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Introduction: In the US there has been a recent outbreak of adenovirus hepatitis in the pediatric population. However, to our knowledge, there has been only one reported case of adenovirus hepatitis in an immunocompetent adult. We have identified another such case. Case Description/Methods: A 25 year old female with no medical history presented with abdominal pain, nausea, vomiting, diarrhea, and subjective fevers for two weeks and was found to have transaminitis 25-30x the upper limit of normal, which were: AST 791, ALT 542, ALP 92, and total bilirubin of 2.9. The patient reported no prior history of liver disease. She denied alcohol, tobacco, illicit drugs, or herbal medications, but did report taking acetaminophen 1500 mg daily for two weeks. Serum acetaminophen levels were normal and serum and urine toxicology were negative. US with doppler was unremarkable, CT showed cholelithiasis, MRCP showed a normal common bile duct without obstructive calculus. Autoimmune causes of hepatitis, ceruloplasmin and alpha-1 antitrypsin were all unremarkable. HAV, HBV, HCV, HDV, HEV, CMV, HSV, VZV, EBV, HIV, and COVID19 were all negative. Ultimately, the serology for adenovirus was positive. After a week of supportive treatment, the patient's labs trended down and symptoms resolved. Discussion(s): Adenovirus is confirmed by a rise in antibody titer or by virus detection. Coagulative necrosis in histopathology is a finding in liver biopsies if they are pursued in unexplained cases of liver injury. Ultimately, adenovirus hepatitis can be diagnosed once all common causes of hepatitis have been excluded. In the current outbreak, only children have been getting adenovirus hepatitis. In adults, a high prevalence of neutralizing antibodies contributes to immunity, and therefore only in immunocompromised states, do adults get such an infection. Supportive care with IV fluids, electrolyte correction, and antiemetics usually is enough with eventual symptomatic and laboratory improvement as it was for our patient. Studies have shown that extensive disease can be treated with antiviral drugs, cidofovir, and ribavirin. Our patient's history of acetaminophen use is a confounder, however, her normal serum level and her symptoms suggestive of an infectious cause made acetaminophen less of a culprit. We hypothesize that our patient's use of acetaminophen when she was initially exposed to the virus is what made her susceptible to developing adenovirus hepatitis and we hope this case adds insight for clinicians dealing with future adult cases.
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The novel coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), first appeared in December 2019 and was declared a pandemic by the World Health Organization on March 11, 2020 (World Health Organization. WHO director-general's opening remarks at the media briefing on COVID-19—11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19%2D%2D-11-march-2020. Accessed 2020). By September 9, 2020, 27.7 million cases and 0.9 million deaths were confirmed globally (Center for Systems Science and Engineering – Johns Hopkins Coronavirus Resource Center: COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. https://coronavirus.jhu.edu/map.html. Accessed 2020). This disease placed an unprecedented strain on healthcare systems around the world (Remuzzi and Remuzzi. Lancet. 395(10231):1225–8, 2020) and had a substantial effect on clinical practice across all surgical specialties, with neurosurgery being no exception (Bernstein. J Neurosurg. 2020:1–2. https://doi.org/10.3171/2020.4.JNS201031). Many hospitals implemented no-visitor policies and COVID-19 testing for all inpatients in order to prevent spread and protect patients and healthcare workers (Calderwood. Infect Control Hosp Epidemiol. 2020:1–9. https://doi.org/10.1017/ice.2020.303). To conserve beds, workforce, and valuable resources such as masks, gowns, and ventilators, surgeons had to restrict operations to emergency and essential interventions. Some neurosurgeons were redeployed to new intradepartmental roles, others lateralized to provide care for coronavirus patients. In order to limit in-person interactions and contagion, there was a surge in telehealth and digital innovation for remote monitoring and management. Research laboratories were closed for prolonged periods. Medical education and residency training were also substantially altered, with cancellation of many in-person events and a transformation to online meetings and educational sessions. In this chapter, we discuss the impact of COVID-19 on the global neurosurgery community with respect to clinical care, education, and research. While the pandemic has caused tremendous disruption in global neurosurgery already, there is hope that many of the lessons learned during this time have contributed to our resilience and preparedness for the future, be it a second wave of COVID-19 or a new unexpected challenge. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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Background: The introduction of the novel COVID-19 vaccination raised concerns regarding side effects from patients who had undergone breast cancer treatment. Lymph node swelling after the mRNA vaccines (Moderna, Pfizer) is a distressing side effect for women treated for breast cancer as it may indicate cancer progression or recurrence. Patients at risk of breast cancer-related lymphedema (BCRL) are fearful that lymph node swelling from the vaccine could incite or worsen BCRL. Data investigating associated side effects in this population is essential for patient education and future self-advocacy. Purpose(s): The purpose of this study was to elicit side effects associated with the COVID vaccine in women treated for breast cancer. Method(s): 4,945 surveys were sent to women over the age of 18 who had received breast cancer treatment and had been prospectively screened for BCRL with perometry. 621 participants who received an mRNA vaccine and responded to the survey were included in analysis, 469 of whom completed booster dose surveys. Participants were asked about type and duration of side effects after each vaccine dose. Solicited side effects included injection site soreness, swelling, or redness;swelling, numbness, or heaviness of the arm;generalized muscle soreness (GMS);fatigue;headache;joint pain;chills;nausea;vomiting;fever;Bell's palsy;axillary or supraclavicular lymph node swelling;other;or none of the above. We computed frequencies and the median duration of side effects for each dose. To investigate predictors of side effects, we fit multivariable logistic regression models separately for each side effect, with random effects for participants to account for clustered responses. We considered significant predictors those with p < 0.05. Result(s): Of the 621 participants, the median follow-up time between breast surgery and date of first vaccine dose was 69 months. The distribution of the top 5 side effects is presented in Table 1. Of note, the majority of participants who reported lymph node swelling (9.8% dose 1, 12.9% dose 2, 11.3% dose 3) reported it in the axilla ipsilateral to the vaccine (54.1% D1, 61.3% D2, 71.7% D3). Lymph node swelling was also reported in the axilla contralateral to the vaccine (45.9% D1, 45% D2, 24.5% D3), supraclavicular region ipsilateral (29.5% D1, 26.3% D2, 32.1% D3) and contralateral (18% D1, 18.8% D2, 9.4% D3) to the vaccine. Older patients reported each side effect significantly less frequently. Those who had received neoadjuvant chemotherapy reported significantly more GMS and headache than those who did not. Those who had received regional lymph node radiation were less likely to report GMS, as were patients who had sentinel lymph node biopsies (vs. no lymph node surgery). The median duration of side effects for all three doses was 48 hours or less, with the plurality (41.0% D1, 38.7% D2, 44.1% D3) of participants reporting side effects lasting 24 hours or less. While all side effects apart from injection site soreness were significantly more common in the second than the first doses, the duration of side effects only increased for 28.1% of participants. Conclusion(s): Over 86% of women treated for breast cancer may experience at least one side effect after any dose of the COVID-19 vaccine. This data, collected specifically for patients with breast cancer, will help enhance guidelines for structured and universal education regarding additional doses of the vaccine in the future. This will allow patients to better understand COVID vaccine side effect profiles after breast cancer treatment and self-advocate prior to future doses. (Table Presented).
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INTRODUCTION: Acquired Hemophagocytic lymphohistiocytosis (HLH) is rare with an incidence of 1.2 per 1,000,000 individuals. It can be caused by infection, malignancy, autoimmune disorders or can be idiopathic. To our knowledge, we present the third case of a patient clinically diagnosed with HLH associated with isolated Hepatitis B. CASE DESCRIPTION/METHODS: A 49 year-old-male from Tajikistan with no past medical history presented with persistent fevers for 3 months associated with non-productive cough, unintentional weight loss and night sweats. Vitals were stable and physical exam was remarkable for pallor and hepatosplenomegaly. Labs: Hgb 7.8 g/dl, PLT 133 mcl, WBC 2.68 mcl, Ferritin 2717ng/ml, Triglycerides 421mg/dl. His pancytopenia was suggestive of an underlying hematological malignancy, and a bone marrow biopsy was performed;it was non-diagnostic, with minimal evidence of RBC phagocytosis. Extensive work up was obtained and negative (Figure 1). Serum soluble IL-2 level was elevated, 10972 units/mL. The patient was diagnosed with HLH secondary to chronic hepatitis B infection and treated with high dose dexamethasone, Etoposide and Tenofovir with significant improvement. DISCUSSION: HLH is a fatal, rare condition characterized by fever, hyperferritinemia, hepatosplenomegaly, hepatic dysfunction, and uncontrolled hemophagocytosis throughout the reticuloendothelial system caused by immune hyperactivation and hypercytokinemia. Acquired HLH is usually associated with malignancy, viral infection, autoimmune disorder, or can be idiopathic. Lymphoma is the most common malignancy to cause acquired HLH and Epstein-Barr virus the most common infection. Isolated Hepatitis B is an extremely rare cause of HLH, with 2 other cases reported. Despite having a non-diagnostic bone marrow biopsy, he met multiple diagnostic criteria for HLH;fever >7 days, splenomegaly, cytopenia involving >2 cell lines, hyperferritinemia, and elevated soluble interleukin-2. He was treated with Tenofovir, high-dose dexamethasone and Etoposide in order to prevent reactivation of Hepatitis B. This case highlights the urgency to establish the cause of HLH, with Hepatitis being a differential, as initiating chemotherapy without treating his Hepatitis B may have led to unwanted complications including delay in chemotherapy, hepatic failure, and death. HLH caused by isolated Hepatitis B is rare and this case serves to increase awareness of diagnosis and management, especially since there is now reported association with SARS-CoV-2 and HLH.