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__NOTOC__
__NOTOC__
{{COVID-19}}
{{SI}}


{{CMG}} {{AE}}{{Arash.M}}
{{CMG}}; {{AE}} {{Arash.M}}, {{Fs}}


{{SK}}  
{{SK}} MFS, fisher syndrome


==Overview==
==Overview==


[[Miller|Miller Fisher Syndrome]] (MFS) is an acute peripheral neuropathy which can develop after exposure to a viral or bacterial infection. It includes triad of [[ophtalmoplegia]], [[areflexia]] and [[ataxia]]. In [[covid-19]] pandemic period, while [[covid-19]] typically presents with fever, SOB and respiratory symptoms, MFS with prior history of covid-19 has been seen in several cases all around the world.  
[[Miller Fisher Syndrome]] (MFS) is an acute [[peripheral neuropathy]] that can develop after exposure to a [[Virus|viral]] or [[bacterial]] infection. It includes triad of [[ophthalmoplegia]], [[areflexia]] and [[ataxia]]. In [[COVID-19]] pandemic period, while [[COVID-19]] typically presents with [[fever]], [[shortness of breath]] (SOB) and [[respiratory]] symptoms, MFS with prior history of [[COVID-19]] has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of [[COVID-19]] patients have reported peripheral [[neurological]] symptoms.
<br> One retrospective study in 214 patients has shown that 8.9 % of [[covid-19]] patients have reported peripheral neurological symptoms.


==Historical Perspective==
==Historical Perspective==


The first reported case of MFS with history of covid-19 was detected on January 2020 in Shanghai, who was a middle-age woman diagnosed with MFS presented with [[areflexia]], acute weakness in both legs and severe fatigue. Further reports were announced by medical groups in Spain and the USA which presented [[neuro-ophtalmological]] symptoms. <ref><nowiki>{{</nowiki>https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619<nowiki>}}</nowiki></ref>
* The first reported case of MFS with a history of [[COVID-19]] was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with [[areflexia]], acute [[weakness]] in both legs and severe [[fatigue]].
* Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. <ref><nowiki>{{</nowiki>https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619<nowiki>}}</nowiki></ref>


==Classification==
==Classification==


MFS is a rare variant of [[Guillain-Barre syndrome]], characterized by [[ophtalmoplegia]], [[areflexia]] and [[ataxia]].
* MFS is a rare variant of [[Guillain-Barre syndrome]], characterized by [[ophtalmoplegia]], [[areflexia]] and [[ataxia]].


==Pathophysiology==
==Pathophysiology==


MFS is related to dysfunction of third, forth and sixth cranial nerves. A typical serological finding in patients with MFS and prior history of [[covid-19]] is antibodies against [[GQ1b ganglioside]], though negative test for antibodies does not rule out the diagnosis. The presence of ophtalmoparesis in MFS is related to a action of [[anti-GQ1b antibodies]] on the neuromuscular junction between the cranial nerves and ocular muscle. [[ELISA test]] is positive in 70% to 90% of patients.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/10695710<nowiki>}}</nowiki></ref>
* [[Miller Fisher Syndrome]] (MFS) is related to dysfunction of third, fourth, and sixth [[cranial nerves]].  
* A typical [[Serology|serological]] finding in patients with MFS and prior history of [[covid-19]] is antibodies against GQ1b [[ganglioside]], though negative test for [[antibodies]] does not rule out the [[diagnosis]].  
* The presence of [[ophthalmoparesis]] in MFS is related to a action of anti-GQ1b [[antibodies]] on the [[neuromuscular junction]] between the [[cranial nerves]] and [[Ocular muscles|ocular muscle]]. [[ELISA test]] is positive in 70% to 90% of patients.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/10695710<nowiki>}}</nowiki></ref>


==Causes==
==Causes==
Although MFS has been detected in some patients with covid-19, other viral and bacterial infections can also cause MFS
 
*[[Influenza virus]]
* Although [[Miller Fisher Syndrome]] (MFS) has been detected in some patients with [[COVID-19]], other viral and [[bacterial]] infections can also cause MFS:
*[[Cytomegalovirus]]
**[[Influenza Virus]]
*[[Zika virus]]
**[[Cytomegalovirus]]
*[[Mycoplasma]]
**[[Zika virus]]
*[[Campylobacter]]
**[[Mycoplasma]]
**[[Campylobacter]]


==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
MFS must be differentiated from other diseases that cause ophthalmoplegia, areflexia, and ataxia, such as [[myasthenia gravis]], [[botulism]], [[diphtheria]], [[brain stem stroke]], [[brain stem encephalitis]] and [[basal meningitis]]. It is essential to rule out emergent neurological disorders like stroke or brain injury in patients with MFS symptoms.<ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>
 
*For further information about the differential diagnosis, [[COVID-19-associated Miller-Fischer syndrome differential diagnosis|click here]].
* To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
While the incidence of MFS is one or two person per million each year, the prevalence of MFS associated with covid-19 is still unknown.
 
* While the [[incidence]] of MFS is one or two-person per million each year, the [[prevalence]] of MFS associated with [[COVID-19]] is still unknown.


==Risk Factors==
==Risk Factors==
There are no established risk factors for MFS associated with covid-19.
 
* There are no established [[Risk factor|risk factors]] for MFS associated with [[COVID-19]].


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for patients with MFS caused by covid-19.
 
* There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for patients with MFS caused by [[COVID-19]].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
There is an increased risk of death in patients over the age of 60 year-old. Hence, the mortality rate is estimated to be 3.6%.  
 
<br> Risk factors for severe illness and poor prognosis include:
* There is an increased risk of death in patients over the age of 60-year-old. Hence, the [[mortality rate]] is estimated to be 3.6%.  
* Old age
* Risk factors for severe illness and poor [[prognosis]] include:
* Male gender
**[[Old age]]
* Patients with  
** Male gender
** [[Diabetes Mellitus]]
** Patients with  
** [[Hypertension]]
***[[Diabetes Mellitus]]
** [[COPD]]
***[[Hypertension]]
** [[CKD]]
***[[COPD]]
***[[CKD]]


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
Although the diagnosis of [[covid-19]] is based on respiratory symptoms, it can be associated with neurological symptoms, of which overlap the diagnosis of MFS. Consequently, in patient with prior history of covid-19, other neurologic diseases should be ruled out and [[anti-GQ1b]] antibody test should be considered. Also, in new patients with suspicious symptoms for covid-19 and neurological symptoms, nasal swab test and neurological examination should be considered.
 
<br> MRI may be performed as a part of diagnostic work up. Although in majority of cases no abnormality is detected, enlargement and prominent enhacement in orbits and retro-orbital region has been reported in some cases.<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>. <ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>
* Although the diagnosis of [[COVID-19]] is based on [[respiratory]] symptoms, it can be associated with [[neurological]] symptoms, which overlap the diagnosis of MFS.  
* Consequently, inpatient with prior history of [[COVID-19]], other [[Neurological|neurologic]] diseases should be ruled out and anti-GQ1b [[antibody]] test should be considered.  
* Also, in new patients with suspicious symptoms for [[COVID-19]] and neurological symptoms, a nasal swab test and neurological examination should be considered.
* [[Magnetic resonance imaging|MRI]] may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>. <ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>


===History and Symptoms===
===History and Symptoms===
Symptoms of covid-19 associated with MFS include:
* Respiratory system symptoms
** [[shortness of breath]]
** [[cough]]
* Neurological symptoms
** [[headache]]
** [[ataxia]]
** [[ophthalmoplegia]]
** [[areflexia]]


<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>
==== Common symptoms ====
 
* Common [[symptoms]] of covid-19 associated with [[MFS]] include:
** [[Shortness of breath]]
**[[Cough]]
**[[Fever]]
**[[Ophthalmoplegia]]
**[[Areflexia]]
**[[Ataxia]]
 
==== Less common symptoms ====
 
* Less common symptoms of covid-19 associated with [[MFS]] include:
** [[Headache]]<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>
**[[Diplopia]]
**[[Blurred vision]]
**[[Ptosis]]
**[[Facial droop]]


===Physical Examination===
===Physical Examination===
Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
 
* Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
====Vitals====
====Vitals====
Abnormal signs associated with covid-19:
Abnormal signs associated with covid-19:
* [[Tachycardia]]
* [[Tachycardia]]
* [[Tachypnea]]
* [[Tachypnea]]
* Fever
*[[Fever]]
====neurological====
 
====Neurological====
* [[Eye dropping]]
* [[Eye dropping]]
* [[Blurry vision]]
* [[Blurry vision]]
Line 88: Line 110:


===Laboratory Findings===
===Laboratory Findings===
Laboratory findings consistent with the diagnosis of covid-19 include positive [[PCR]] nasal swab.
 
<br> Laboratory test for neurological signs are not diagnostic and should be used with other clinical parameters. They are include:
* Laboratory findings consistent with the diagnosis of COVID-19 include positive [[PCR]] nasal swab.
* Ganglioside (GM1) Antibodies, IgG and IgM
* Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:
* GD1b Antibody, IgM
**[[Ganglioside]] (GM1) [[Antibodies]], [[IgG]] and [[IgM]]
* GQ1b Antibody, IgG
** GD1b [[Antibody]], [[IgM]]
** GQ1b Antibody, [[IgG]]


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with covid-19.
 
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19]].


===X-ray===
===X-ray===
CXR is less sensitive in detection of covid-19 in comparison with CT. However, in some cases [[lung consolidation]] and patchy peripheral opacities corresponding to [[ground glass opacities]] has been reported.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/<nowiki>}}</nowiki></ref>
 
* [[Chest X-ray]] is less sensitive in detection of [[COVID-19]] in comparison with [[Computed tomography|CT]].  
* However, in some cases [[lung consolidation]] and patchy peripheral opacities corresponding to [[ground glass opacities]] has been reported.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/<nowiki>}}</nowiki></ref>


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography findings associated with covid-19.
 
<br> [[Lung Ultrasound]] may be helpful in evaluation of patients with covid-19. It indicates :
* Lung [[ultrasound]] may be helpful in the evaluation of patients with COVID-19. It indicates :
* Multiple [[B-lines]]
 
** Ranging from focal to diffuse with spared areas  
* Multiple B-lines
* Irregular and thickened pleural lines
** Ranging from focal to diffuse with spared areas
* Irregular and thickened [[pleural]] lines
* Subpleural consolidations
* Subpleural consolidations
* Alveolar consolidations
*[[Alveolar]] [[Consolidation (medicine)|consolidations]]
* Bilateral [[A-lines]]
* Bilateral [[A-lines]]


===CT scan===
===CT scan===
The preliminary findings of CT in COVID-19 associated with MFS include:
The preliminary findings of [[Computed tomography|CT]] in COVID-19 associated with MFS include:
* Bilateral [[Ground Glass Opacities]]
* Bilateral ground glass opacities
* Air space consolidation  
* Air space [[Consolidation (medicine)|consolidation]]
* Bronchovascular thickening
* Bronchovascular thickening
* Traction bronchiectasis
* Traction [[bronchiectasis]]


===MRI===
===MRI===
Brain MRI may be helpful in the diagnosis of MFS in patients with prior history of covid-19 and neurological manifestations. Although there can be no abnormalities, multiple cranial nerve enhancement has been reported in some patients.
 
* Brain [[Magnetic resonance imaging|MRI]] may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and [[neurological]] manifestations.  
* Although there can be no abnormalities, multiple [[Cranial nerves|cranial nerve]] enhancement has been reported in some patients.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with covid-19 with MFS manifestations.
 
* There are no other diagnostic studies associated with COVID-19 with MFS manifestations.


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
No specific treatment and vaccine exists for covid-19 yet. However, patients with moderate to severe [[ARDS]] and respiratory manifestations can benefit from [[Mechanical ventilation]] and [[extracorporeal membrane oxygenation]] (ECMO). In some patients the combination of antiviral therapies like protease inhibitors, ritonavir, and lopinavir indicated partial success in treatment of covid-19.
 
<br> [[Remdesivir]], a drug originally developed to treat [[Ebola virus]], showed positive results against [[SARS-CoV-2]].
* No specific treatment and vaccine exists for covid-19 yet.  
<br> [[Dexamethasone]] has been announced as an effective treatment in patients with systematic manifestations.
* However, patients with moderate to severe [[ARDS]] and respiratory manifestations can benefit from [[Mechanical ventilation]] and [[extracorporeal membrane oxygenation]] (ECMO).  
* In some patients the combination of antiviral therapies like [[protease inhibitors]], [[Ritonavir clinical pharmacology|ritonavir]], and [[lopinavir]] (100-400mg/day)<ref name="CaoWang2020">{{cite journal|last1=Cao|first1=Bin|last2=Wang|first2=Yeming|last3=Wen|first3=Danning|last4=Liu|first4=Wen|last5=Wang|first5=Jingli|last6=Fan|first6=Guohui|last7=Ruan|first7=Lianguo|last8=Song|first8=Bin|last9=Cai|first9=Yanping|last10=Wei|first10=Ming|last11=Li|first11=Xingwang|last12=Xia|first12=Jiaan|last13=Chen|first13=Nanshan|last14=Xiang|first14=Jie|last15=Yu|first15=Ting|last16=Bai|first16=Tao|last17=Xie|first17=Xuelei|last18=Zhang|first18=Li|last19=Li|first19=Caihong|last20=Yuan|first20=Ye|last21=Chen|first21=Hua|last22=Li|first22=Huadong|last23=Huang|first23=Hanping|last24=Tu|first24=Shengjing|last25=Gong|first25=Fengyun|last26=Liu|first26=Ying|last27=Wei|first27=Yuan|last28=Dong|first28=Chongya|last29=Zhou|first29=Fei|last30=Gu|first30=Xiaoying|last31=Xu|first31=Jiuyang|last32=Liu|first32=Zhibo|last33=Zhang|first33=Yi|last34=Li|first34=Hui|last35=Shang|first35=Lianhan|last36=Wang|first36=Ke|last37=Li|first37=Kunxia|last38=Zhou|first38=Xia|last39=Dong|first39=Xuan|last40=Qu|first40=Zhaohui|last41=Lu|first41=Sixia|last42=Hu|first42=Xujuan|last43=Ruan|first43=Shunan|last44=Luo|first44=Shanshan|last45=Wu|first45=Jing|last46=Peng|first46=Lu|last47=Cheng|first47=Fang|last48=Pan|first48=Lihong|last49=Zou|first49=Jun|last50=Jia|first50=Chunmin|last51=Wang|first51=Juan|last52=Liu|first52=Xia|last53=Wang|first53=Shuzhen|last54=Wu|first54=Xudong|last55=Ge|first55=Qin|last56=He|first56=Jing|last57=Zhan|first57=Haiyan|last58=Qiu|first58=Fang|last59=Guo|first59=Li|last60=Huang|first60=Chaolin|last61=Jaki|first61=Thomas|last62=Hayden|first62=Frederick G.|last63=Horby|first63=Peter W.|last64=Zhang|first64=Dingyu|last65=Wang|first65=Chen|title=A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19|journal=New England Journal of Medicine|volume=382|issue=19|year=2020|pages=1787–1799|issn=0028-4793|doi=10.1056/NEJMoa2001282}}</ref> indicated partial success in treatment of [[COVID-19]].
* [[Remdesivir]] (100-200mg/day)<ref name="urlCoronavirus disease 2019 (COVID-19) investigational drug information for remdesivir">{{cite web |url=https://reference.medscape.com/drug/remdesivir-4000090 |title=Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir |format= |work= |accessdate=}}</ref>, a drug originally developed to treat [[Ebola virus]], showed positive results against [[SARS-CoV-2]].
* [[Dexamethasone]] (6mg/day)<ref name="urlCorticosteroids | Coronavirus Disease COVID-19">{{cite web |url=https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/ |title=Corticosteroids &#124; Coronavirus Disease COVID-19 |format= |work= |accessdate=}}</ref> has been announced as an effective treatment in patients with systematic manifestations.


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of covid-19.
 
* Surgical intervention is not recommended for the management of covid-19.


===Primary Prevention===
===Primary Prevention===
Effective measures for the primary prevention of [[covid-19]] include handwashing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.
 
* Effective measures for the [[primary prevention]] of [[covid-19]] include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2], Fahimeh Shojaei, M.D.

Synonyms and keywords: MFS, fisher syndrome

Overview

Miller Fisher Syndrome (MFS) is an acute peripheral neuropathy that can develop after exposure to a viral or bacterial infection. It includes triad of ophthalmoplegia, areflexia and ataxia. In COVID-19 pandemic period, while COVID-19 typically presents with fever, shortness of breath (SOB) and respiratory symptoms, MFS with prior history of COVID-19 has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of COVID-19 patients have reported peripheral neurological symptoms.

Historical Perspective

  • The first reported case of MFS with a history of COVID-19 was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with areflexia, acute weakness in both legs and severe fatigue.
  • Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. [1]

Classification

Pathophysiology

Causes

Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • While the incidence of MFS is one or two-person per million each year, the prevalence of MFS associated with COVID-19 is still unknown.

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for patients with MFS caused by COVID-19.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • Although the diagnosis of COVID-19 is based on respiratory symptoms, it can be associated with neurological symptoms, which overlap the diagnosis of MFS.
  • Consequently, inpatient with prior history of COVID-19, other neurologic diseases should be ruled out and anti-GQ1b antibody test should be considered.
  • Also, in new patients with suspicious symptoms for COVID-19 and neurological symptoms, a nasal swab test and neurological examination should be considered.
  • MRI may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.[3]. [4]

History and Symptoms

Common symptoms

Less common symptoms

Physical Examination

  • Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:

Vitals

Abnormal signs associated with covid-19:

Neurological

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of COVID-19 include positive PCR nasal swab.
  • Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:

Electrocardiogram

X-ray

Echocardiography or Ultrasound

  • Lung ultrasound may be helpful in the evaluation of patients with COVID-19. It indicates :

CT scan

The preliminary findings of CT in COVID-19 associated with MFS include:

MRI

  • Brain MRI may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and neurological manifestations.
  • Although there can be no abnormalities, multiple cranial nerve enhancement has been reported in some patients.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with COVID-19 with MFS manifestations.

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of covid-19.

Primary Prevention

  • Effective measures for the primary prevention of covid-19 include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.

References

  1. ↑ {{https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619}}
  2. ↑ {{https://pubmed.ncbi.nlm.nih.gov/10695710}}
  3. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  4. ↑ {{https://rarediseases.org/rare-diseases/miller-fisher-syndrome/}}
  5. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  6. ↑ {{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/}}
  7. ↑ Cao, Bin; Wang, Yeming; Wen, Danning; Liu, Wen; Wang, Jingli; Fan, Guohui; Ruan, Lianguo; Song, Bin; Cai, Yanping; Wei, Ming; Li, Xingwang; Xia, Jiaan; Chen, Nanshan; Xiang, Jie; Yu, Ting; Bai, Tao; Xie, Xuelei; Zhang, Li; Li, Caihong; Yuan, Ye; Chen, Hua; Li, Huadong; Huang, Hanping; Tu, Shengjing; Gong, Fengyun; Liu, Ying; Wei, Yuan; Dong, Chongya; Zhou, Fei; Gu, Xiaoying; Xu, Jiuyang; Liu, Zhibo; Zhang, Yi; Li, Hui; Shang, Lianhan; Wang, Ke; Li, Kunxia; Zhou, Xia; Dong, Xuan; Qu, Zhaohui; Lu, Sixia; Hu, Xujuan; Ruan, Shunan; Luo, Shanshan; Wu, Jing; Peng, Lu; Cheng, Fang; Pan, Lihong; Zou, Jun; Jia, Chunmin; Wang, Juan; Liu, Xia; Wang, Shuzhen; Wu, Xudong; Ge, Qin; He, Jing; Zhan, Haiyan; Qiu, Fang; Guo, Li; Huang, Chaolin; Jaki, Thomas; Hayden, Frederick G.; Horby, Peter W.; Zhang, Dingyu; Wang, Chen (2020). "A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19". New England Journal of Medicine. 382 (19): 1787–1799. doi:10.1056/NEJMoa2001282. ISSN 0028-4793.
  8. ↑ "Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir".
  9. ↑ "Corticosteroids | Coronavirus Disease COVID-19".


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