Exacerbation of Erythema Nodosum Leprosum Possibly Triggered by COVID-19 Vaccine: A Case Report

Erythema nodosum leprosum (ENL) is an immune complex mediated type III hypersensitivity reaction seen in patients of borderline lepromatous and lepromatous leprosy. It can be caused by a wide array of triggers and can be seen before, during, or after completion of anti-leprosy therapy. There are multiple well-known triggers for type 2 reactions like the initiation of multidrug therapy, Mantoux testing, vaccination, mental and physical stress, and physiological states like pregnancy. Herein, we report a case of exacerbation of ENL in a middle-aged woman, probably due to COVID-19 vaccine while she was well-controlled on immunosuppressive therapy. The episode was treated with non-steroid anti-inflammatory drugs and oral steroids and the symptoms resolved within 2 weeks. Although causality was highly possible between the occurrence of ENL and COVID-19 vaccine, physicians should be aware that it can be easily managed with proper care and medicines and this should not be a basis for deferring the vaccine. Copyright © Hind Kusht Nivaran Sangh, New Delhi.

THE PANDEMIC'S FUNGAL REVENGE: COVID-19 ASSOCIATED PULMONARY ASPERGILLOSIS (CAPA)

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: Since the start of the COVID-19 pandemic, COVID-19 Associated Pulmonary Aspergillosis (CAPA) has been on the rise. This superinfection, if not properly identified and treated, has shown to increase mortality up to 67% in COVID-19 patients. We are presenting a late presentation of CAPA after 4-month of COVID-19 infection and treated successfully. CASE PRESENTATION: A 57-year-old female patient with past medical history type 2 diabetes mellitus, hypertension and cardiomyopathy in addition to COVID-19 pneumonia treated for months ago with azithromycin, Bamlanivimab/Etesevimab, and Dexamethasone who presents to the hospital with massive hemoptysis and shortness of breath requiring intubation and mechanical ventilation. There was no reported history of recent travel, smoking, alcohol, or illicit drug use. Physical exam showed diminished lung sounds at the right lower lobe. Her labs showed mild leukocytosis, lactic acidosis and negative COVID-19 PCR. CT scan showed dense consolidation on right lower lobe consistent with lobar pneumonia and centrilobular ground glass opacities in the right upper lobe. Bronchoscopy showed complete obstruction of right bronchus intermedius and minimal blood clots in LLL. BAL respiratory culture, fungal smear, acid fast bacilli were non-diagnostic and negative for malignancy. Patient continued to have hemoptysis and bronchoscopy was repeated with negative cytology and cultures. The patient continued to have hemoptysis and she was transferred to tertiary center were bronchoscopy was repeated and confirmed right bronchus intermedius stenosis, blood clots, and suspicious right mainstem nodules with mucosal lesion. Biopsy results from bronchoscopy came back positive for the morphologic features of Aspergillus species. The patient was started on voriconazole with significant improvement in her symptoms. DISCUSSION: The recent literature of COVID-19 suggest association between COVID infection and invasive pulmonary Aspergillosis. COVID-19 virus causes damage in the airway epithelium and enable aspergillus to invade the pulmonary tract leading to serious infections with Aspergillus. It has also been known that Aspergillus infections are associated with diabetes mellitus and immune suppression which can be precipitated by steroid use and other treatments for COVID-19 infection like IL-6 inhibitors. Here in our patient with help of tissue biopsy we diagnosed CAPA, started treatment early and treated successfully. CONCLUSIONS: CAPA can be difficult to diagnose and needs high index of suspicion in the appropriate clinical scenario when dealing with post COVID respiratory complaints like hemoptysis. Bronchoalveolar lavage alone without tissue biopsy might miss the diagnosis in the context of invasive aspergillosis like the scenario we observed in our case. Doing tissue biopsy through bronchoscopy might add more clinical benefit when Aspergillus infections are suspected. Reference #1: Chih-Cheng Lai, Weng-Liang Yu, COVID-19 associated with pulmonary aspergillosis: A literature review, https://doi.org/10.1016/j.jmii.2020.09.004 DISCLOSURES: No relevant relationships by Haytham Adada No relevant relationships by Mahmoud Amarna No relevant relationships by Rishika Bajaj No relevant relationships by Camelia Chirculescu No relevant relationships by Sonia Dogra No relevant relationships by Azad Patel

Challenges faced by people affected with leprosy during the COVID-19 pandemic: a questionnaire based study

This study aims to assess the continuity of medical care, the impact on disease condition and to highlight the major challenges faced by people affected by leprosy during the pandemic. Telephonic questionnaire-based survey was conducted among previously registered patients of leprosy at referral hospitals in India. Leprosy affected people aged >18 years, either on treatment or who had completed treatment with access to phone and willingness to participate were included. The questions were asked pertaining to demographic details, baseline disease characteristics and various problems faced during lockdown relating to livelihood, finances, treatment, and mental status. A total of 196 patients consented to participate in the study. Mean age of study participants was 37.31 (13.86) years, male participants (n=123, 62.7%) were more than females (n=73, 37.2%). Overall, 101 patients (51.5%) experienced exacerbation, 21 patients (10.7%) reported improvement and 74 patients (37.8%) reported no change in disease status during the pandemic. Most common difficulty faced was the procurement of medicines (115 patients, 58.6%) followed by difficulty in diagnostic testing (61 patients, 31.1%). Course of treatment was interrupted in 16 patients. Most of the patients (n=147, 75%), agreed that teleconsultation services would aid in management of their disease. The majority of patients (88.2%) were able to continue some form of treatment. Two patients (1%) tested positive for COVID-19. Nearly all patients (n=189, 96.4%) were informed regarding the risks and preventive measures related to COVID-19. Fifty percent of the patients reported deterioration in mental health due to the pandemic. The present study highlights the gaps in healthcare delivery and social inequalities along with their impact on the health, livelihood and mental status of people affected by leprosy during the current COVID-19 pandemic.

Low – Cost Portable Smart Ventilator

Ventilators are one of the most important and complex devices in the intensive care unit (ICU). These devices are used to handle the patients in critical conditions like lungs collapse, comma, transplant surgeries, etc. But due to COVID-19 pandemic, there is a very large need of the ventilators. This paper focuses on the development of a prototype of portable ventilators with remote control. These ventilators are based on the slider-crank mechanism operated remotely as well as manually. The slider-crank mechanism compresses resuscitator (AMBU bag) and delivers the compressed air to lungs through a pipe and face mask. These ventilators are capable of controlling breath per minute (BPM) and Tidal volume (volume of the oxygen compulsory in the lungs). The range of BPM can be controlled 10-45 BPM where deliverable tidal volume is 250–750 mL. To deliver the contactless treatment to a patient and save the doctor from the disease transmission, we have developed the android application to operate ventilator remotely. Arduino-based Wi-Fi controller is used to create control over BPM. Wi-Fi controller integrates the mobile application with ventilators to establish remote and contactless control. There is the provision of emergency cut-off in antagonistic condition. The overall cost of the prototyping is only 4000 INR and can be assembled within minutes on an assembly line. Because of the ventilator’s compact size and light weight it can be used in remote locations and ambulances. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

Serial Imaging of Virus-Associated Necrotizing Disseminated Acute Leukoencephalopathy (VANDAL) in COVID-19.

BACKGROUND AND PURPOSE: Various patterns of leukoencephalopathy have been described in coronavirus disease 2019 (COVID-19). In this article, we aimed to describe the clinical and imaging features of acute disseminated leukoencephalopathy in critically ill patients with COVID-19 and the imaging evolution during a short-term follow-up. MATERIALS AND METHODS: We identified and reviewed the clinical data, laboratory results, imaging findings, and outcomes for 8 critically ill patients with COVID-19 with acute disseminated leukoencephalopathy. RESULTS: All patients demonstrated multiple areas of white matter changes in both cerebral hemispheres; 87.5% (7/8) of patients had a posterior predilection. Four patients (50%) had short-term follow-up imaging within a median of 17 days after the first MR imaging; they developed brain atrophy, and their white matter lesions evolved into necrotizing cystic cavitations. All (8/8) patients had inflammatory cytokine release syndrome as demonstrated by elevated interleukin-6, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, and ferritin levels. Most (7/8; 87.5%) patients were on prolonged ventilator support (median, 44.5 days; interquartile range, 20.5 days). These patients had poor functional outcomes (6/8 [75%] patients were discharged with mRS 5) and high mortality (2/8, 25%). CONCLUSIONS: Critically ill patients with COVID-19 can develop acute disseminated leukoencephalopathy that evolves into cystic degeneration of white matter lesions with brain atrophy during a short period, which we dubbed virus-associated necrotizing disseminated acute leukoencephalopathy. This may be the result of COVID-19-related endothelial injury, cytokine storm, or thrombotic microangiopathy.

BIO-MECHANICS OF ARDS IN COVID-19: A PROSPECTIVE OBSERVATIONAL STUDY

SESSION TITLE: Respiratory Infections: What have We Learned About COVID-19 and New Trial Data for Management of Aspergilloma SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Early clinical observations of novel coronavirus-associated Acute Respiratory Distress Syndrome (C-ARDS) reported a higher than expected compliance discordant to the degree of hypoxemia. Our goal was to evaluate survival of patients with C-ARDS according to different lung mechanical parameters. METHODS: We conducted a prospective, observational study of C-ARDS patients admitted to the ICU at a tertiary care hospital in Michigan (March 1st to May 1st, 2020). Subjects were enrolled at the time of intubation and followed until death or discharge. The average lung compliance (AvC) measured in ml/cm H2O and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) were calculated daily over the first 7 days post-intubation. Median differences in AvC and P/F ratio between alive and deceased participants were calculated using Wilcoxon Rank Sum. Pearson correlation was used to describe the relationship between AvC and P/F ratio. Multivariate logistic regression was performed to explain co-variate effect after adjustment. Survival function was performed using the Kaplan-Meier estimator for different levels of AvC. RESULTS: 135 patients were included;mortality was 41.4% (n=56). Baseline demographics were similar between the survivor and deceased groups, except for hypertension and coronary artery disease (CAD) trending towards significance in the latter. Survivors had longer length of stay (34.7 days vs. 17.6 days;p = 0.001). There was no significant correlation between AvC and P/F ratio (Pearson's r 0.09;p=0.31). Surviving and deceased patients had different median P/F values (185 [IQR 242 to 135] vs 150 [IQR 196 to 109];p=0.01), but did not differ significantly in terms of median AvC (29 [IQR 35 to 26] vs 31 [IQR 37 to 24];p 0.69). There was no difference in survival curves between AvC levels of 35, 40 and 45. A multivariate logistic regression analysis was done to adjust for gender, BMI, hypertension, coronary artery disease and ventilator length of stay. Only age [OR =1.05, 95% CI: 1.02, 1.08, p 0.003] and PF value [OR = 0.98, 95% CI: 0.98, 0.99, p 0.001] were significant risk factors for mortality. CONCLUSIONS: Our results suggest that low P/F ratio and advanced age are the most significant independent predictors of mortality in C-ARDS. The severity of hypoxemia did not correlate significantly with lung elasticity, and lung compliance was not predictive of mortality. Our findings are consistent with other reports on lung mechanics in C-ARDS (Schenck et al). CLINICAL IMPLICATIONS: As with typical ARDS, degree of hypoxemia at the onset of respiratory failure may have prognostic implications in patients with C-ARDS. Pulmonary compliance by itself does not predict risk of mortality. DISCLOSURES: No relevant relationships by Abdulgadir Adam, source=Web Response No relevant relationships by Paul Bozyk, source=Web Response No relevant relationships by Enrique Calvo Ayala, source=Web Response No relevant relationships by Edward Castillo, source=Web Response No relevant relationships by christopher Dado, source=Web Response No relevant relationships by Bhavinkumar Dalal, source=Web Response Removed 04/27/2020 by Bhavinkumar Dalal, source=Web Response No relevant relationships by Bhavinkumar Dalal, source=Web Response Removed 04/27/2020 by Bhavinkumar Dalal, source=Web Response No relevant relationships by Bhavinkumar Dalal, source=Web Response Removed 04/27/2020 by Bhavinkumar Dalal, source=Web Response No relevant relationships by Bhavinkumar Dalal, source=Web Response Removed 04/27/2020 by Bhavinkumar Dalal, source=Web Response No relevant relationships by Sanjay Dogra, source=Web Response No relevant relationships by Giovi Grasso-Knight, source=Web Response No relevant relationships by Zaid Imam, source=Web Response No relevant relationships by Filip Ionescu, source=Web Response No relevan relationships by Daniel Keena, source=Web Response No relevant relationships by Nader Mina, source=Web Response No relevant relationships by Ehsun Naeem, source=Web Response Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 by Girish Nair, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with GlaxoSmithKline Please note: $20001 - $100000 Added 05/31/2020 by Vishal Patel, source=Web Response, value=Consulting fee

Surprise Diagnosis of COVID-19 following Neuroimaging Evaluation for Unrelated Reasons during the Pandemic in Hot Spots.

During the height of the recent outbreak of coronavirus 19 (COVID-19) in New York City, almost all the hospital emergency departments were inundated with patients with COVID-19, who presented with typical fever, cough, and dyspnea. A small number of patients also presented with either unrelated conditions (such as trauma) or other emergencies, and some of which are now known to be associated with COVID-19 (such as stroke). We report such a scenario in 17 patients who were admitted and investigated with CT spine imaging and CT angiography for nonpulmonary reasons (trauma = 13, stroke = 4). Their initial work-up did not suggest COVID-19 as a diagnosis but showed unsuspected/incidental lung findings, which led to further investigations and a diagnosis of COVID-19.