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SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cystic fibrosis (CF) often leads to a double-lung transplant, making patients highly vulnerable to viral infections. For instance, the H1N1 influenza pandemic affected many people, with those who incurred it suffering significant morbidity. A recent study published in the Journal of Cystic Fibrosis has shown 40 confirmed cases of CF patients with SARS-CoV-2 worldwide up to April 2020. This is a unique case of a cystic fibrosis patient with ARDS with SARS-CoV-2 that required mechanical ventilation. CASE PRESENTATION: A 23-year-old Caucasian male with double-lung transplant due to cystic fibrosis, complicated by pancreatic insufficiency presented with acute dyspnea, cough, and fever. He was immunosuppressed due to tacrolimus, mycophenolate, and chronic prednisone use. His mycophenolate was held in the setting of presumed sepsis however his tacrolimus and prednisone were continued given the risk of rejection. Subsequently, his respiratory status rapidly declined prompting admission to the Intensive Care Unit for mechanical ventilation. Computed tomography of the chest endorsed worsening acute respiratory distress syndrome-like feature requiring high positive end-expiratory pressure [PEEP] settings. Labs revealed elevated d-dimer, CRP, interleukin-6 (IL-6) and clinical features consistent with cytokine storm. Recent literature suggested a possible role of tocilizumab, an anti-IL-6 antibody. He received 400mg of Tocilizumab, following which the patient drastically improved. ICU care was challenging because of potential pharmacologic variance and adynamic ileus in the setting of cystic fibrosis with sedation and paralytics. Patient was liberated after 5 days of mechanical ventilation. Interestingly, he remained SARS-COV-2 positive post discharge for several weeks afterward. DISCUSSION: This critically ill immunosuppressed patient, unusually, exhibited rapid recovery. From the 40 patients in the study from Journal of Cystic Fibrosis, there was no mortality reported and only one patient reported to require mechanical ventilation associated with SARS-CoV-2. Factors that may have influenced this patient's recovery and lower mortality is the prompt use of Tocilizumab and his young age. Tocilizumab is currently an experimental medication, noted to inhibit further clinical deterioration. CONCLUSION(S): Fortunately, this case did not have long term consequences, however, that may not be the norm. Many CF patients have double lung transplants and the long-term impact of SARS-CoV-2 amongst CF patients is not known. More research may be warranted for the long-term effects of CF patients with SARS-CoV-2. Reference #1: Rebecca Cosgriff, Susannah Ahern, Scott C. Bell, Keith Brownlee, Pierre-Regis Burgel, Cass Byrnes, Harriet Corvol, Stephanie Y. Cheng, Alexander Elbert, Albert Faro, Christopher H. Goss, Vincent Gulmans, Bruce C. Marshall, Edward McKone, Peter G. Middleton, Rasa Ruseckaite, Anne L. Stephenson, Siobhan B Carr, A multinational report to characterise SARS-CoV-2 infection in people with cystic fibrosis,Journal of Cystic Fibrosis,2020 Reference #2: Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24. Erratum in: Lancet. 2020 Jan 30. Reference #3: L. Viviani, B.M. Assael, E. Kerem ECFS (A) H1N1 study group. Impact of the A (H1N1) pandemic influenza (season 2009-2010) on patients with cystic fibrosis J Cyst Fibros, 10 (5) (2011), pp. 370-376, 10.1016/j.jcf.2011.06.004 Epub 2011 Jul 12. PMID: 21752728 DISCLOSURES: No relevant relationships by Shubham Adroja, source=Web Response No relevant relationships by Ansaam Daoud, source=Web Response No r levant relationships by Randall Harris, source=Web Response No relevant relationships by Joseph Michael Lim, source=Web Response No relevant relationships by Sujith Modugula, source=Web ResponseCopyright © 2020 American College of Chest Physicians
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Importance: The coronavirus disease 2019 (COVID-19) pandemic has resulted in severe psychological, social, and economic stress in people's lives. It is not known whether the stress of the pandemic is associated with an increase in the incidence of stress cardiomyopathy. Objective: To determine the incidence and outcomes of stress cardiomyopathy during the COVID-19 pandemic compared with before the pandemic. Design, Setting, and Participants: This retrospective cohort study at cardiac catheterization laboratories with primary percutaneous coronary intervention capability at 2 hospitals in the Cleveland Clinic health system in Northeast Ohio examined the incidence of stress cardiomyopathy (also known as Takotsubo syndrome) in patients presenting with acute coronary syndrome who underwent coronary arteriography. Patients presenting during the COVID-19 pandemic, between March 1 and April 30, 2020, were compared with 4 control groups of patients with acute coronary syndrome presenting prior to the pandemic across 4 distinct timelines: March to April 2018, January to February 2019, March to April 2019, and January to February 2020. Data were analyzed in May 2020. Exposures: Patients were divided into 5 groups based on the date of their clinical presentation in relation to the COVID-19 pandemic. Main Outcomes and Measures: Incidence of stress cardiomyopathy. Results: Among 1914 patient presenting with acute coronary syndrome, 1656 patients (median [interquartile range] age, 67 [59-74]; 1094 [66.1%] men) presented during the pre-COVID-19 period (390 patients in March-April 2018, 309 patients in January-February 2019, 679 patients in March-April 2019, and 278 patients in January-February 2020), and 258 patients (median [interquartile range] age, 67 [57-75]; 175 [67.8%] men) presented during the COVID-19 pandemic period (ie, March-April 2020). There was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with a total of 20 patients with stress cardiomyopathy (incidence proportion, 7.8%), compared with prepandemic timelines, which ranged from 5 to 12 patients with stress cardiomyopathy (incidence proportion range, 1.5%-1.8%). The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI, 4.11-5.11; P < .001). All patients during the COVID-19 pandemic had negative reverse transcription-polymerase chain reaction test results for COVID-19. Patients with stress cardiomyopathy during the COVID-19 pandemic had a longer median (interquartile range) hospital length of stay compared with those hospitalized in the prepandemic period (COVID-19 period: 8 [6-9] days; March-April 2018: 4 [3-4] days; January-February 2019: 5 [3-6] days; March-April 2019: 4 [4-8] days; January-February: 5 [4-5] days; P = .006). There were no significant differences between the COVID-19 period and the overall pre-COVID-19 period in mortality (1 patient [5.0%] vs 1 patient [3.6%], respectively; P = .81) or 30-day rehospitalization (4 patients [22.2%] vs 6 patients [21.4%], respectively; P = .90). Conclusions and Relevance: This study found that there was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 pandemic when compared with prepandemic periods.