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SESSION TITLE: Critical Renal and Endocrine Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: About 7% of acute pancreatitis (AP) cases are caused by hypertriglyceridemia (HTG). In such cases bowel rest, IV fluids, symptomatic therapy, and triglyceride (TG) lowering interventions are initiated. Plasmapheresis is one of the treatment options, but it has specific indications. We present a case of severe hypertriglyceridemia-induced pancreatitis that required plasmapheresis. CASE PRESENTATION: A 30 y/o man with type 2 diabetes, hyperlipidemia, multiple previous admissions for HTG-AP, presented with severe abdominal pain, nausea, and vomiting x 1 day. On admission, he was tachycardic, hypotensive, afebrile, SpO2 > 96% on RA. Labs: Glu 491 mg/dL, TG > 1000 mg/dL, Cholesterol 509 mg/dL, Lipase 987 U/L, Cr/BUN 2.4 mg/dL /20 mg/dL, VBG pH 7.25/PCO2 36.2 mmHg/PO2 19.4 mmHg/Ca 0.8/lactate 5.6;WBC 13.07 K/cm;COVID PCR positive. CXR: diffuse patchy opacities. CTAP with contrast was deferred because of AKI. He was admitted to the ICU and started on insulin drip with no improvement over 24hrs. He was still acidotic, Ca persistently low, TG still >1000, and kidney function worsened. Plasmapheresis was initiated. After one session his TG lowered to 700. He was restarted on insulin drip and in the next 24hr TG decreased to < 500 and metabolic acidosis resolved. Once AKI resolved, CT abdomen/pelvis with contrast confirmed acute pancreatitis, with focal hypodensities within the uncinate process and the proximal body, concerning infarcts as well as large phlegmon surrounding the pancreas, but no evidence of necrotizing or hemorrhagic pancreatitis. His hospital course was complicated with sepsis and DVT, which resolved with therapy. He was discharged home with TG lowering agents, Apixaban, and his previous T2DM regimen. DISCUSSION: Plasmapheresis is indicated in patients with severe HTG (>1000- 2000 mg/dl), severe HTG-AP, and when standard treatment options are inadequate. It lowers the lipid levels and removes proinflammatory markers and cytokines stopping further inflammation and damage to the pancreas and other organs faster compared to conservative therapy. Most patients need only one session which lowers TG level by 50-80%, as seen in our patient. CONCLUSIONS: Plasmapheresis should be considered in cases of HTGP with worrisome features such as lactic acidosis, hypocalcemia, worsening inflammation, and multi organ failure. Reference #1: Rajat Garg, Tarun Rustagi, "Management of Hypertriglyceridemia Induced Acute Pancreatitis", BioMed Research International, vol. 2018, Article ID 4721357, 12 pages, 2018. https://doi.org/10.1155/2018/4721357 Reference #2: Pothoulakis I, Paragomi P, Tuft M, Lahooti A, Archibugi L, Capurso G, Papachristou GI. Association of Serum Triglyceride Levels with Severity in Acute Pancreatitis: Results from an International, Multicenter Cohort Study. Digestion. 2021;102(5):809-813. doi: 10.1159/000512682. Epub 2021 Jan 21. PMID: 33477149. Reference #3: Gavva C, Sarode R, Agrawal D, Burner J. Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach. Transfus Apher Sci. 2016 Feb;54(1):99-102. doi: 10.1016/j.transci.2016.02.001. Epub 2016 Feb 20. PMID: 26947356. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Vaishali Geedigunta No relevant relationships by Zinobia Khan No relevant relationships by Jelena Stojsavljevic
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INTRODUCTION: Covid- 19 has been associated with various fungal infections in immunocompetent/immunocompromised patients. We report the second case of PCP pneumonia coinfection in a HIV- uninfected man with COVID-19. CASE: A 52 y/o man with PMH of hyperlipidemia, gout, viral myocarditis and no prior immunodeficient conditions was admitted to hospital for COVID-19 SARS (Severe Acute Respiratory Syndrome) CoV- 2 Pneumonia. He was initially treated with Dexamethasone 6mg/day, Remdesivir and Tocilizumab x 2doses and oxygen therapy. On day 4, he was transferred to ICU for acute hypoxemic respiratory failure requiring NIV eventually requiring intubation with Fio2-60-90%. His course was complicated by AKI, septic shock requiring pressor for BP support. He received empiric ceftriaxone and Hydrocortisone for suspected adrenal insufficiency. Despite antibiotics, labs showed increasing WBC count with decreasing procalcitonin. Blood/urine cultures: no growth. Tracheal cultures: Ceftriaxone-sensitive E.coli therefore was continued on ceftriaxone. On ICU day3, he was still febrile so was started on prophylactic Bactrim for PCP suspecting immunosuppression although he was never treated with long term high dose steroids. Fungal cultures, Aspergillus, HIV, Beta-D glucan - negative. He was afebrile after 7days of antibiotics and PCP testing was done to discontinue Bactrim. Tracheal aspirate culture reported positive for PCP diagnosed with IFA stain. LDH - 471 but is an unreliable marker in the setting of covid pneumonia. HRCT was not attained due to unstable hemodynamics. Prophylactic Bactrim was then switched to therapeutic dose and also started on Prednisone 40mg twice daily on tapered dose. DISCUSSION: PCP is an infection commonly seen in immunocompromised individuals but may colonize healthy individuals remaining asymptomatic and serving as a reservoir to transmit and affect immunocompromised hosts with immunodeficiency syndromes/malignancy/organ transplant. Diagnosis is made via identification of organism via staining/PCR. Based on previous case series reported by Mayo Clinic amongst HIV- uninfected individuals, an average dose of steroids was 30mg/ day (minimum-16mg/ day) for an average duration of 12 weeks (minimum-8weeks) to acquire PCP infection. Our subject was treated with Hydrocortisone dose equivalent to a prednisone dose ∼ 75mg/day x 1 week which may have induced immunosuppression or due to COVID-19 infection itself making him susceptible for PCP infection. First case of PCP pneumonia coinfection in COVID-19 (recovered) was reported in March 2021. CONCLUSION: Our case report is unique for two reasons, PCP diagnosis via tracheal aspirate and two, detected in COVID-19 infected patient post prophylaxis. PCP coinfection with COVID-19 should be identified and treated.