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SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal
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SESSION TITLE: Biological Markers in Patients with COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: In December 2019, a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in a global pandemic. The literature has been slowly growing in the subgroup of pregnant women but the metabolic derangements of pregnancy and SARS-CoV-2 have not been well described. METHODS: In this case series, we review 9 patients with severe SARS-CoV-2 infections admitted to the medical ICU at a single institution between 2020-2022, during the delta variant wave. RESULTS: Of the nine critically ill patients, the mean age was 32 ± 6.4 years with fetal age on admission of 27 ±2.81 weeks and 29 ±2.91 weeks at delivery. Average CRP of 114 ± 25 mg/L. In eight of 9 patients (89%), there was an anion gap metabolic acidosis (AGMA) on admission. The average albumin-corrected anion gap was 18±1.93. 75% of patients had mild ketonuria based on urinalysis. However, 50% had documented symptoms of nausea, vomiting, or diarrhea. While betahydroxybutyrate was checked in 2 patients, neither were abnormal. One had lactic acidosis, but none required vasopressors at time of identification. No renal failure or diabetes was noted and only two had abnormal glucose tolerance tests. At delivery, average PEEP was 10± 4 cmH2O with an average respiratory rate of 28 ± 4 breaths per minute. All patients with AGMA delivered early resulting in preterm delivery. 75% of the fetuses showed signs of distress at the time of delivery, which was the primary indication for delivery in 37.5% of deliveries. 37.5% of deliveries were due to significant maternal hypoxia. The only patient without AGMA did not deliver early. CONCLUSIONS: After excluding renal failure, toxin ingestion, and lactic acidosis, only ketosis can weakly explain the AGMA. There have been several studies that highlighted the association between COVID and ketone production. In pregnancy, placental production of glucagon and human placental lactogen and subsequent insulin resistance increases susceptibility to ketosis. A recent study posited that COVID could cause placental abnormalities. Therefore, pregnant women may be more susceptible to significant ketosis because of COVID infection. In one of our cases, the combination of hypoxia and acidosis could not be managed safely by the ventilator and resulted in early delivery. CLINICAL IMPLICATIONS: Ketosis and an elevated anion gap could be a marker for more severe outcomes in pregnant patients with COVID. This case series highlights the challenges of managing the metabolic demands of critically ill pregnant patients infected with SARS-CoV-2. DISCLOSURES: No relevant relationships by Calli Bertschy no disclosure on file for Joey Carlin;No relevant relationships by Jessica Ehrig No relevant relationships by Shekhar Ghamande no disclosure on file for Jordan Gray;No relevant relationships by Abirami Subramanian