REACTIVATION MILIARY TB IN THE SETTING OF POSTINFECTIOUS COVID-19 LUNGS

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Tuberculosis, caused from infection by M. tuberculosis, affects 2.7 per 100,000 people in the United States. 1 Miliary, or disseminated, TB is a progressive disease characterized by lymphohematogenous dissemination of TB infection that occurs in only 1-2% of TB cases. Little research has gone into pulmonary complications post recovery from COVID-19 infection, especially reactivation of latent TB. Here we present a case of reactivation of latent TB and progression to miliary TB in the setting of post COVID infection. CASE PRESENTATION: A 49-year-old male presented to the ER with fever, shortness of breath, and chest pain. His CXR showed diffuse bilateral, multifocal infiltrates and laboratory testing later came back positive for COVID-19. Two days later, he came back to the ED with acute respiratory failure with 87% oxygen saturation with ambulation. A CT chest done that showed diffuse lung disease consistent with COVID-19 infection, and a right upper lobe lesion likely a granuloma (image 1). He was treated for COVID pneumonia for ten days in the hospital with Decadron, Lasix, and tocilizumab. He required high flow nasal canula during the hospitalization and was discharged when his respiratory status had improved. One year later, he returns with few days of hemoptysis, fever, and chills. He had a progressive cough and 19 pound weight loss overt the last month. Clinically, he appeared mildly diaphoretic without acute distress. He had a room-air oxygen saturation of 95% without labored respiration and did not have increased oxygen demand. CT of the showed diffuse pulmonary parenchymal abnormalities and uniform nodular consolidative changes in the upper lobes bilaterally with areas of cavitation and multiple areas of lung parenchymal changes consistent with miliary TB (image 2). Sputum culture was positive for acid-fast bacilli, and he was started on RIPE therapy with rifampin, isoniazid, pyrazinamide, and ethambutol. He was symptomatically improved within one week of admission and was hospitalized until three negative sputum cultures were drawn. DISCUSSION: This case report gives us novel understanding of the extent of possible complications post recovery from COVID-19 infection. We have already started to see many patients who have recovered from an initial COVID infection, but progressed to secondary lung disease due to this. In our patient particularly, during his initial presentation he was seen to have upper lobe granulomatous disease with concern for latent TB. It is likely that due to the extent of damage done to his lung parenchyma over time it led to reactivation of his latent TB. As we see more patients recovering from COVID infections, we are likely to see more of similar cases of latent infection reactivation. CONCLUSIONS: Patients with latent TB are likely at a high risk of reactivation post recovering from COVID-19 infection, due to immunosuppression and lung parenchymal damage Reference #1: Trends 2019 ;Data & Statistics ;TB ;CDC. Cdc.gov. https://www.cdc.gov/tb/publications/factsheets/statistics/tbtrends.htm. Published 2021. Accessed September 25, 2021. Reference #2: Rodriquez-Morales AJ et al. Clinical, laboratory, and imaging features of COVID-19: a systemic review and meta-analysis. Travel Med Infect Dis. 34: 101623 Reference #3: Colditz GA, Brewer TF, Berkey CS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature. JAMA. 1994;271(9):698-702 DISCLOSURES: No relevant relationships by Sharmin Asha No relevant relationships by Heather Bernstein no disclosure on file for zachary brittingham;no disclosure on file for Vedee Ramdass;

AN UNCOMMON CONCURRENCE OF BABESIOSIS AND ACETAMINOPHEN OVERDOSE: CASE REPORT

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Babesiosis is a tick-borne illness caused by B. microti and other species and transmitted by the Ixodes tick. Acute respiratory distress syndrome (ARDS) can be a manifestation of babesiosis. CASE PRESENTATION: A 69 year old female with the past medical history of HTN, HLD and hypothyroidism who presented to hospital for 1 week of intermittent fever and generalized body aches. Patient denied any tick bites. She started to have intermittent fever around 40°C, nonproductive cough and generalized body aches, associated with night sweats, nausea, diarrhea. She took 1000mg Tylenol every 4 hours for fever and body aches for 1 week without improvement.Upon admission laboratory values were significant for hemolytic anemia (Hgb 9.4 g/dL, reticulocyte count 1.2%, LDH 4896 U/L, haptoglobin < 8mg/dL, total bilirubin 2.3 mg/dL), thrombocytopenia (platelet 38× 103/mm3) and leukopenia (WBC 2.7× 103/mm3), significantly elevated acetaminophen level (22.6), transaminitis (ALT 365 IU/L, AST 579 IU/L) and elevated INR (1.4). Blood parasite smear was positive for blood parasites (Malaria/Babesia: 9.6% RBC infected). Babesia Microti DNA RT-PCR was positive, Babesia Microti Ab (IgM) ≥ 1:320, Babesia Microti Ab (IgG) was 1:512, E. Chaffeensis Ab Ig G <1:64, E. Chaffeensis Ab Ig M <1:20, Lyme Ab Scr-Q <0.90. HIV and blood culture was negative. SARS-CoV-2 RNA was negative.Patient was admitted and received Acetylcysteine for acetaminophen toxicity, atovaquone, azithromycin, doxycycline for Babesia and borreliosis coverage. On day 2 of admission, acetaminophen level decreased to less than 10, transaminitis slowly improved. But patient developed shortness of breath, cough and hypoxia. Concerning severe babesiosis induced ARDS, chest CT angiogram was ordered and showed no evidence of pulmonary embolism but mild pulmonary interstitial edema. 2D Echo showed normal left ventricular systolic function and mild diastolic dysfunction. Patient received IV Lasix, symptoms improved and the CXR on day 6 showed pulmonary edema resolved.In the following days, patient continued to receive treatment for babesiosis, blood parasitemia cleared but Hgb decreased to 6.7 g/dL, patient received transfusion and Hgb level remained 7.9 g/dL on the day of discharge. 5 days after discharge, patient's Hgb level increased to 9 g/dL. 1 month after discharge, Hgb level increased to 12g/dL and transaminase level returned to normal. DISCUSSION: ARDS is a life-threatening condition characterized by severe hypoxemia due to pulmonary gas exchange failure. Though uncommon, tick-borne diseases could present with ARDS. Moreover, acetaminophen toxicity has also been linked to acute lung injury, making the correct diagnosis challenging. Early recognition and intervention led to a favorable outcome. CONCLUSIONS: ARDS can be an early onset manifestation after initiation of treatment for babesiosis and usually resolves with supportive treatment. REFERENCE #1: Autoimmune hemolytic anemia associated with babesiosis.Roshni Narurkar, Aleksandra Mamorska-Dyga, John C. Nelson and Delong Liu.Biomarker Research (2017) 5:14. REFERENCE #2: Yousef Nassar, Seth Richter. Babesiosis Presenting as Acute Liver Failure. Case Rep Gastroenterol 2017;11:769–773. REFERENCE #3: Boustani MR, Lepore TJ, Gelfand JA, Lazarus DS. Acute respiratory failure in patients treated for babesiosis. Am J Respir Crit Care Med. 1994 Jun;149(6):1689-91. doi: 10.1164/ajrccm.149.6.8004331.PMID: 8004331 Review. DISCLOSURES: No relevant relationships by Heather Bernstein, source=Web Response No relevant relationships by ALKA FARMER, source=Web Response No relevant relationships by CUIPING LI, source=Web Response No relevant relationships by Vinay Nakhate, source=Admin input No relevant relationships by kiritkumar parmar, source=Web Response No relevant relationships by Lin Zheng, source=Web Response

Using telehealth to support expectant and breastfeeding momsduring the COVID-19 pandemic

Program Goals: Since the COVID-19 pandemic began in March 2020, an increased number of healthy, full-termnewborns are being discharged 24 hours after delivery. No study has demonstrated the presence of SARS-CoV-2 in breast milk, so breastfeeding promotion and education are still of the utmost importance. Withshelter-at-home recommendations in place, mothers face challenges with finding lactation guidance.Telehealth allows this gap to be filled by providing breastfeeding support virtually when in-person contact islimited. Telehealth breastfeeding support initiatives were piloted for expectant and new mothers (andfamilies). The objective is to provide breastfeeding education by establishing interactive, support groupsfacilitated by lactation professionals using telehealth services. Evaluation: Two models were established basedon experiences with the prior in-person sessions, as well as those of local and national colleagues. Model A:Small group teaching Several 1-hour IBCLC-led sessions (one in Spanish) were offered weekly online on aHIPAA-compliant videoconferencing platform through a consistent link. A toll-free number was provided if no internet access was available. English and Spanish flyers with link, instructions for joining, and email to answertechnology questions were distributed to 150+ partners electronically. Each session was structured aroundopportunity for individualized questions on video chat or chatbox, with additional resources provided onslides. A separate team member managed technology, slides, attendance and the chatbox, which freed theIBCLC to serve solely as subject matter expert. Challenges addressed are listed in Table. This model'sattendance was initially limited but increased each week with additional promotional efforts. Ultimately 29expectant and breastfeeding mothers joined across 10 sessions, including several repeaters. Mothers foundthe sessions helpful and informative, and offered to spread the word. Model B: Traditional didactic teaching A1-hour webinar, led by IBCLCs (including Spanish), was offered weekly with unique themes on a differentHIPAA-compliant videoconferencing platform. The weekly theme was sent to a listerv with a registration linkfor attendance tracking and for distribution of the attendee link to address security concerns. A formal slidepresentation (45 minutes) was given, followed by Q+A (15 minutes) via chatbox. Presentation slides and videorecording were sent to registrants with an access code for security. This model had consistently highattendance -- 110 mothers across 4 sessions, including several repeaters. Each session had a different theme,which allowed for women to select a session specific to their needs. Discussion: Establishing virtual lactationsupport groups is realistic and important. Our 5-week pilot initiative successfully created telelactation sessionsfacilitated by IBCLCs and CLCs. Notable challenges faced in transitioning to a virtual support environment were able to be quickly met, resulting in increased attendance and engagement. Using telehealth servicesallowed vital accessibility to essential breastfeeding support for mothers during this public health crisis.