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SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: High Flow Nasal Cannula (HFNC) is a non-invasive ventilation (NIV) device widely used to manage hypoxemic respiratory failure. Data about optimal flow rate and time length for safety is lacking. Cases of spontaneous pneumomediastinum (SP) during HFNC oxygen therapy in COVID-19 patients have been recently reported. A study in airway models suggests a non-linear increase in PEEP up to 10 cmH2O in adults on maximum tested flows. Prolonged use of NIV could also delay escalation to invasive ventilation and use of lung-protective volumes (LPV). The ROX-index is a predictive tool for NIV failure and continuous evaluation of intubation indications. This study aimed to identify risk factors associated with the development of SP in COVID-19 ARDS on HFNC support and establish mitigating behavior that will aid in safer COVID-19 treatment modalities. METHODS: Cases from 2020 to 2022 were reviewed. Patients with SP while on HFNC were included as cases. Age and gender-matched patients who received HFNC and did not develop SP were controls. Baseline characteristics between groups were compared using t-test for continuous variables and chi-square for categorical values. Longitudinal ROX scores were calculated until the last day (day of pneumomediastinum development for SP group, and death or MV commencement for controls). Nominal logistic regression was performed to identify variables associated with SP development. Parameter Estimates were used to construct a prediction model, and a ROC curve was implemented to assess the accuracy of the prediction of SP events. RESULTS: Total 61 patients enrolled, 52% (32/61) developed SP on HFNC and 48% (29/61) were control group (CG). No statistical significance found on baseline demographics. Median HFNC days-to-SP was 7 [standard deviation (SD), 6.8 days]. Median days from COVID-19 diagnosis-to-SP was 9 (SD, 5 days). Use of MV was greater in SP group (29 vs 3, p-value < 0.001) and use of vassopresor support (28 vs 3, p-value < 0.001). SP-group had an increased mortality compared to CG, with 88% (28/32) vs.12% (3) (p-value, <0.001). Median ROX scores on Day 1 were 5.45 for SP group and 18.2 for CG (p<0.001). Median ROX scores on last day (day-to-event) were 4.08 and 9.4 in CG (p<0.001). Nominal logistic regression identified number of days on HFNC, ROX score on day 1, and cumulative amount of Flow rate, as independent variables associated with SP development. ROC of the Prediction model using parameter estimates from these 3 variables had an AUC of 0.922. CONCLUSIONS: Development of SP is associated with increased mortality. Patients with lower ROX scores at initiation of therapy, prolonged days of HFNC and increased cumulative flow rates are associated with the development of SP. CLINICAL IMPLICATIONS: HFNC has the potential to cause alveolar damage, however a larger patient population size is needed to further analyze the relationship of HFNC use and the development of SP. DISCLOSURES: No relevant relationships by Sofia Durscki Vianna No relevant relationships by Cynthia Espinosa No relevant relationships by Hernando Garcia No relevant relationships by Ephraim Mansour No relevant relationships by Laura Mendez Morente No relevant relationships by Zuleikha Muzaffarr No relevant relationships by Sergio Poli No relevant relationships by Luisa Quesada No relevant relationships by Douglas Salguero No relevant relationships by Michelle Yousefzadeh
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SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumocystis Pneumonia (PCP) is an opportunistic infection caused by a yeast-like fungus pneumocystis jirovecii. It is characterized by hypoxemia and increased inflammatory markers with elevated lactate dehydrogenase (LDH) often used as a clinical indicator of possible infection. COVID-19 is a viral infection caused by severe acute respiratory syndrome coronavirus and presents with a variety of symptoms, pneumonia being the most frequent and serious manifestation. Common laboratory markers include lymphopenia, elevated LDH and inflammatory markers. CASE PRESENTATION: Our patient is a 54 yo African American male with an unremarkable history who presented to our facility from an outside hospital (OH) for worsening respiratory failure in the setting of a large left pulmonary artery thrombosis. He was infected with COVID-19, four months prior and had experienced worsening weakness, SOB and anorexia two months before admission. Work up at OH revealed the large pulmonary emboli as well as extensive multifocal opacities consistent with prior COVID infection and described as post- COVID fibrosis. His sputum also tested positive for pseudomonas aeruginosa and mycoplasma pneumoniae for which he was treated. Unfortunately his hypoxemia worsened and he required intubation;prompting transfer to our facility for hopes of thrombectomy. He continued with hypoxemic, hypercarbic respiratory failure and underwent a bronchoscopy which was grossly normal. As serology indicated lymphopenia and paraprotein gap > 4, we decided to order HIV RNA PCR, which came back positive (CD4 count 11cells/ mm3). One week later, pneumocystis jirovecii was identified from an immunohistochemical stain from bronchial alveolar lavage (BAL). DISCUSSION: PCP is a common opportunistic infection in patients with human immunodeficiency virus, generally presenting when CD4 counts decrease below 200 cells/ mm3. Along with similar symptoms and elevated inflammatory markers, COVID-19 and PCP share common radiographic findings of ground glass opacities. In addition to his compromised lung (from COVID-19) and prolonged hospitalization, the positive cultures of m. pneumoniae and p.aeruginosa were originally misleading. Although cases of co-infection of PJP and COVID-19 exist, our case demonstrates that having a broad differential after recovery from COVID-19 continues to be necessary. CONCLUSIONS: PCP and COVID-19 pneumonia share similarities in radiographic and laboratory findings proving difficult to differentiate from each other. This case highlights the importance of assessing the immunological status of patients with unknown HIV history especially in a time where considering different etiologies of pneumonia have taken the backseat in the height of the COVID-19 pandemic Reference #1: Anggraeni AT, Soedarsono S, Soeprijanto B. Concurrent COVID-19 and Pneumocystis jirovecii pneumonia: The importance of radiological diagnostic and HIV testing. Radiol Case Rep. 2021;16(12):3685-3689. Published 2021 Oct 2. doi:10.1016/j.radcr.2021.09.002 Reference #2: Analysis of underlying diseases and prognosis factors associated with Pneumocystis carinii pneumonia in immunocompromised HIV-negative patients. Roblot F, Godet C, Le Moal G, Garo B, Faouzi Souala M, Dary M, De Gentile L, Gandji JA, Guimard Y, Lacroix C, Roblot P, Becq-Giraudon B. Eur J Clin Microbiol Infect Dis. 2002;21(7):523. DISCLOSURES: No relevant relationships by Cynthia Espinosa No relevant relationships by Jason Kovacevic No relevant relationships by Laura Mendez Morente No relevant relationships by Zuleikha Muzaffarr
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Introduction The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has been linked with many sequelae not typical of other respiratory viruses. One of the unique features of this virus, known as COVID coagulopathy, has been associated with bleeding and/or clotting diathesis in the setting of a prothrombotic state. This has put patients at risk for hemorrhagic complications such as frank disseminated intravascular coagulation, and antiphospholipid syndrome activation. This is a case of hemothorax as a rare complication of COVID-19 infection. Case Presentation This is the case of a 48 year old male with a history of ESRD requiring dialysis, who presented to our facility with shortness of breath. He was recently admitted a month prior to an outside facility for a dialysis catheter infection and was found to be COVID-19 positive. He received IV antibiotics and supplemental oxygen. He was discharged home with plans for IV antibiotics. He presented to our facility with five days of shortness of breath. In the ED he was afebrile, tachypneic and tested negative for COVID-19. Computed Tomography of the chest was significant for a moderate to large right pleural effusion with loculated components. The next day he underwent a thoracentesis and 600 cc of bloody pleural fluid was aspirated. He then underwent a VATS, decortication, pleurodesis a few days later as the effusion failed to resolve. Cytology of the initial thoracentesis was negative for malignant cells and pathology from the VATS was positive for fibrosis, hemorrhage with fibrin deposition and acute and chronic inflammation. Discussion Hemothorax as a complication of COVID -19 has yet to be described in the literature. Altered markers such as D-dimer and fibrinogen were associated with increased coagulation and thrombotic complications respectively. Furthermore, studies have reported intra-alveolar hemorrhages and GI bleeding in post-mortem analysis of COVID patients. This case highlights the uniqueness of this novel virus and the vast array of complications that can result from infection.
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RationaleThe novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the greatest challenges in modern medicine. As the pandemic has progressed throughout the globe it has revealed vulnerable populations;one of these being obese patients. Obesity has been associated with an increased risk of hospitalization along with other co-morbid conditions such as hypertension, diabetes, cardiovascular disease and chronic lung disease. We sought to investigate the mortality associated with COVID-19 positive obese patients in the inpatient setting. MethodsThis observational retrospective study included patients who were admitted to the hospital with confirmed SARS-CoV-2 RNA qualitative polymerase chain reaction assay from March 1, 2020 until May 20, 2020. The primary outcome of this study was the mortality of patients who were admitted to the hospital. Other outcomes included: hospital length of stay, need for intensive care, mechanical ventilation, continuous renal replacement therapy and secondary bacterial infection. Primary Statistical analysis of data was performed using Microsoft Excel and R 4.0.2. Quantitative variables were compared using a t-test and categorical variables with chi-squared testing. Time to event analysis was evaluated with a log-rank test. ResultsAmong the 178 patients hospitalized COVID-19 positive patients, the average BMI was 28.90 (SD 6.48). There were 40 in hospital deaths with an average BMI of those alive 28.80 (SD 6.16) and among those who expired of 29.26 (SD 7.56). Multivariate logistic regression of the full variable model of mortality demonstrated that age, intensive unit care, mechanical ventilation and days of hospitalization were statistically significant and correlated with mortality (p-values 0.007, 0.031, 0.020, and 0.0001). Kaplan Meier analysis comparing obese and non obese individuals to number of days of hospitalization until time of death with censoring demonstrated an absence of statistically significant difference (p-value 0.696). Backward stepwise reduction of the multivariate linear regression model demonstrated multivariate statistical significance for age (pvalue 1.58 E -09), gender (p-value 0.01), hypertension (p-value 0.003), and smoking status (p-value 0.005). Conclusion Advanced age, intensive care, mechanical ventilation and days of hospitalization increased the risk of mortality. We also confirmed that hypertensive and patients with a history of smoking also had an increased risk of mortality.
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Introduction: Amiodarone is one of the most commonly prescribed antiarrhythmic medications in the United States. Adverse effects have been shown to affect multiple organ systems including cardiac, thyroid, hepatic, ocular and pulmonary. Pulmonary toxicity can vary in presentation from interstitial pneumonitis, eosinophilic pneumonia, organizing pneumonia and acute respiratory distress syndrome (ARDS)1. This is a case of ARDS caused by Amiodarone. Case Presentation: This is a case of an 81 yo male with a history of atrial fibrillation (on Amiodarone 200 mg daily), mechanical aortic valve replacement and diabetes who presented to the hospital with a four week history of dry cough and one week of dyspnea on exertion. He was treated for community acquired pneumonia prior to admission with steroids, Azithromycin, Ceftriaxone and Levofloxacin. On arrival he was afebrile, but hypoxic requiring oxygen support with nasal cannula. Physical exam was concerning for an ill appearing, lethargic elderly gentleman with extensive crackles throughout both lung fields more concentrated in the upper lobes. Laboratory was significant for negative SARS Coronavirus RNA PCR and Leukocytosis 14.7. Computed-tomography revealed extensive bilateral consolidations with air bronchograms worse in the upper lobes. As his clinical status worsened requiring use of non-invasive ventilation and transfer to the intensive care unit, it became clear that this was not an infectious process;work up thus far had been negative. Amiodarone was discontinued and the patient was started on Diltiazem and pulse dose steroids. Within four days, his respiratory and mental status improved. Discussion: Amiodarone pulmonary toxicity has been associated with higher doses of 400 mg, but 1.6% of cases are reported with less, making this case unique. The pathology appears to be related to direct cytotoxic effect and indirect immunological reaction. Patients will usually present with a nonproductive cough and shortness of breath. Imaging is key for diagnosis, demonstrating diffuse patchy infiltrates;with a preference to the right lung and upper lobes. Treatment centers on discontinuation of the drug and 40-60 mg of Prednisone per day tapered over the period of a few months2.
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SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Castleman’s disease (CD) is a rare group of lymphoproliferative disorders characterized by non-neoplastic lymph node hypertrophy, clinically classified as multicentric (MCD) if the disease involves multiple regions of lymph nodes. It manifests as constitutional symptoms due to cytokine dysregulation and systemic inflammation. Human Herpesvirus 8 Associated MCD (HHV-8 MCD), is a subtype of MCD, linked to uncontrolled HHV8 infection known to cause cytokine dysregulation in immunocompromised patients, especially those with HIV. We present a case of HHV-8 MCD which mirrored the clinical presentation and cytokine dysregulation of SARS-COV-2 (COVID-19) infection amidst the current pandemic. CASE PRESENTATION: A 54 year old male with a history of well controlled HIV (CD4+ > 400, undetectable viral load), Kaposi’s Sarcoma, and recent travel within the United States in the past month, presented to the ICU with fever, dry cough, and shortness of breath for two weeks. He presented febrile (T Max 101F), tachycardic, and hypoxic requiring high flow nasal cannula. Physical exam was notable for cervical lymphadenopathy, diffuse rhonchi, and hepatosplenomegaly. Laboratory data revealed WBC 8k with lymphopenia, elevated inflammatory markers (Ferritin 2740, CRP 157), D-Dimer 8.4, LDH 222. There was high clinical suspicion for COVID-19, however, the patient had 2 negative tests. CT chest showed bilateral ground glass opacities with numerous pulmonary nodules up to 1cm with diffuse hilar and mediastinal lymphadenopathy and massive splenomegaly. The patient underwent excisional biopsy of a cervical lymph node with pathology revealing interfollicular areas with mature plasma cells positive for CD138, kappa, and lambda light chains. Lymphoid follicles contained small clusters of CD20 and HHV-8 positive, lambda light chain plasmablasts consistent with the diagnosis of HHV-8 MCD. The patient was started on chemotherapy with Doxorubicin and Rituximab. DISCUSSION: Patients with HHV-8 MCD often manifest with constitutional symptoms, lymphadenopathy, hepatosplenomegaly and pulmonary manifestations. This is caused by upregulation of pro-inflammatory cytokines particularly IL-6 and TNF-alpha, similar to the dysregulation associated with poorer outcomes in COVID-19 patients. Our case demonstrates that established treatments of pro-inflammatory illness such as MCD may play a role in managing COVID-19 patients. The shared aspects of the clinical presentations of COVID-19 and MCD further emphasize the importance of developing a broad differential. CONCLUSIONS: Our patient represents a common presentation of a rare disease during a global health crisis. We maintain the importance of resisting inherent biases when formulating a differential diagnosis. Reference #1: Wang HW, Pittaluga S, Jaffe ES. Multicentric Castleman disease: Where are we now?. Semin Diagn Pathol. 2016;33(5):294-306. doi:10.1053/j.semdp.2016.05.006 Reference #2: England JT, Abdulla A, Biggs CM, et al. Weathering the COVID-19 storm: Lessons from hematologic cytokine syndromes [published online ahead of print, 2020 May 15]. Blood Rev. 2020;100707. doi:10.1016/j.blre.2020.100707 Reference #3: Lurain K, Yarchoan R, Uldrick TS. Treatment of Kaposi Sarcoma Herpesvirus-Associated Multicentric Castleman Disease. Hematol Oncol Clin North Am. 2018;32(1):75-88. doi:10.1016/j.hoc.2017.09.007 DISCLOSURES: No relevant relationships by Ephraim Mansour, source=Web Response No relevant relationships by Zuleikha Muzaffarr, source=Web Response No relevant relationships by Ayoola Olayiwola, source=Web Response No relevant relationships by Anita Singh, source=Web Response