AORTIC ROOT ABSCESS: A RARE COMPLICATION OF STAPHYLOCOCCUS EPIDERMIDIS PROSTHETIC VALVE ENDOCARDITIS

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Aortic root abscess is a lethal complication of infective endocarditis. Here, we report a case of aortic root abscess that occurred as a complication of S. epidermidis prosthetic valve endocarditis, which is a rare cause of aortic abscess. CASE PRESENTATION: 71-year-old woman with complex cardiac history including a bioprosthetic aortic valve replacement, ascending aorta aneurysm repair, and coronary artery bypass graft x4 presented to the ER with worsening chest pain, fevers, chills and rigors. On arrival, temperature was 97.5°F heart rate was 61 beats/min, respiratory rate was 20 per minute and blood pressure was 139/82 mm Hg. On exam, she had a grade 4/6 ejection systolic murmur, heard best at the right upper sternal border radiating to carotids. Laboratory investigations showed hemoglobin, 10.5 g/ dL;total leukocyte count, 10 k/uL with 80% neutrophils;platelet count, 311 k/uL;and sedimentation rate, 74 mm/hr. Rest of the labs were normal. She tested negative for SARS-Cov-2 by polymerase chain reaction (PCR). Blood cultures grew isolated Staphylococcus epidermidis. She was persistently bacteremic on vancomycin monotherapy and required ceftaroline and daptomycin combination therapy for clearance of bacteremia. Transesophageal echo cardiography was obtained which showed an area of echolucency adjacent to the posterior aortic valve annulus suggestive of abscess. PET CT was obtained, confirmed the diagnosis of aortic abscess. She was referred to Mayo Clinic. She underwent, extensive debridement of previously implanted tissue aortic valve and entire root complex, coronary artery bypass grafting and aortic root replacement. DISCUSSION: Aortic root abscess is a life-threatening complication of aortic valve endocarditis, known to occur in patients with native and prosthetic aortic valves. Staphylococcus aureus is the reported as most common cause. Persistent fever, shortness of breath, chest pain and other signs of severe aortic regurgitations are the most common presentation. Aggressive surgical debridement and medical therapy are the key to treatment. If untreated, can result in severe valvular dysfunction, fistula formation, perforation of cusps, pseudoaneurysm, obstruction of coronary flow or fatal arrhythmia. Even with surgery, reported mortality remains high 12.2-30%. CONCLUSIONS: Aortic root abscess should be considered as a diagnosis in persistently febrile and bacteremic patients with prosthetic valve endocarditis and should be treated promptly with surgical debridement and reconstruction. REFERENCE #1: Chen G-J, Lo W-C, Tseng H-W, Pan S-C, Chen Y-S, Chang S-C. Outcome of surgical intervention for aortic root abscess: a meta-analysis. Eur J Cardiothorac Surg 2018;53:807–14 DISCLOSURES: No relevant relationships by Rosa Cruz Torres, source=Web Response No relevant relationships by Dorothy Kenny, source=Web Response No relevant relationships by Sanu Rajendraprasad, source=Web Response No relevant relationships by Manasa Velagapudi, source=Web Response

CASE OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C) PRESENTING WITH RASH AND SHOCK

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Multisystem inflammatory syndrome in children (MIS-C) is a multisystem inflammatory disorder sharing the clinical features of Kawasaki disease (KD) and toxic shock syndrome. CASE PRESENTATION: A 19-year-old male with no known past medical history presented to the emergency room with myalgia, headache, fever, photophobia, and rash on bilateral upper and lower extremities for more than one week. He tested positive for SARS-CoV-2 by RT-PCR 6 weeks prior to the presentation. Symptoms worsened with the development of a maculopapular skin rash, high-grade fevers, diarrhea, and vomiting. On admission he was afebrile (97.6 °F), had tachycardia (133/min) and tachypnea (48/min) along with hypotension (78/33 mmHg), and saturating 85% on 4L/min. Lab abnormalities included WBC of 28.2 k/uL with 55% bands, procalcitonin 42.91 ng/mL, lactic acid 4 mmol/L, BUN 65 mg/dl, serum creatinine 7 mg/dl and elevated D-dimer of 3.1 mg/L. Cardiac labs were remarkable for proBNP 76,275 pg/mL, and peak troponin 31.10ng/mL in 12 hours. EKG consistent with myopericarditis. CT scan of the abdomen/pelvis found edema of the cecum and ascending colon with pericolonic fat stranding of ascending colon possible mesenteric adenitis. He initially required 3 vasopressors to maintain his MAP>65mmHg. Echocardiography revealed a left ventricle ejection fraction (LVEF) of 20% with moderate global hypokinesis of the left ventricle. Cardiac catheterization revealed elevated wedge pressure and had clean coronaries with no aneurysms. MIS-C was suspected and was started on 1g/kg IVIG, high dose aspirin, methylprednisolone, and anakinra. Rash dissipated in days after starting steroids. His LVEF recovered to 55-60% prior to discharge from the hospital. He was kept on Anakinra, continued for 4 weeks till normalization of ferritin. DISCUSSION: MIS-C is a rare sequela of COVID-19 manifesting 2-8 weeks after the initial SARS-CoV-2 infection. In severe cases, cardiac involvement leads to cardiogenic shock. The echocardiographic findings of myocarditis and pericarditis have been frequently reported[1]. Inflammatory markers including ESR, C-reactive protein, ferritin, and IL-6 are reported to be elevated in all the cases [2]. Though its pathogenesis is not well defined, proposed hypotheses include hyper-immune response, macrophage activation, and T cell stimulation with a delayed cytokine storm. Various case have reported clinical outcomes with the use of intravenous immunoglobulin, corticosteroids, IL-1 inhibitor (anakinra), or IL-6 receptor inhibitor (tocilizumab) [3]. However, further research is needed to define clinical predictors and treatment modalities to manage MIS-C. CONCLUSIONS: Our case emphasizes the complexity of MIS-C with multisystem involvement, and it highlights a timely use of IVIG, high dose aspirin, anakinra, and methylprednisolone as potential therapeutics for this hyperinflammatory condition. REFERENCE #1: Alsaied T, Tremoulet AH, Burns JC, et al. Review of Cardiac Involvement in Multisystem Inflammatory Syndrome in Children. Circulation. 2021;143(1):78-88. doi:10.1161/CIRCULATIONAHA.120.049836 REFERENCE #2: Abrams JY, Godfred-Cato SE, Oster ME, et al. Multisystem Inflammatory Syndrome in Children Associated with Severe Acute Respiratory Syndrome Coronavirus 2: A Systematic Review [published online ahead of print, 2020 Aug 5]. J Pediatr. 2020;226:45-54.e1. doi:10.1016/j.jpeds.2020.08.003 REFERENCE #3: Tanner T, Wahezi DM. Hyperinflammation and the utility of immunomodulatory medications in children with COVID-19. Paediatr Respir Rev. 2020;35:81-87. doi:10.1016/j.prrv.2020.07.003 DISCLOSURES: No relevant relationships by Faran Ahmad, source=Web Response No relevant relationships by Sunil Nair, source=Web Response No relevant relationships by Sanu Rajendraprasad, source=Web Response

SPONTANEOUS CORONARY ARTERY DISSECTION: A RARE SEQUELA OF COVID-19

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare coronary event, mostly associated with autoimmune and inflammatory conditions. We share a case report of a patient admitted to the Creighton University Medical Center, Omaha, Nebraska with the clinical presentation and diagnostics suggestive of SCAD after coronavirus disease 2019 (COVID-19). CASE PRESENTATION: A 43-year-old caucasian woman with a history of atrial fibrillation (AF) during pregnancy, was brought to the hospital after she had a syncopal episode due to ventricular fibrillation (VF) leading to cardiac arrest requiring defibrillation on site. She had been tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by PCR with mild symptoms, about 12 weeks prior to this episode and she recovered within a week after self-quarantine at home. In the emergency room, she had AF with a rapid ventricular response, hypothermia, bilateral decreased breath sounds, a non-tender abdomen, and equal pulses. She required endotracheal intubation for airway protection. Her initial laboratory studies revealed normal complete blood counts, CRP 71.2 mg/L, and initial Troponin I 2.55 ng/mL (with a peak of 21 ng/mL). Subsequently, she progressed to refractory cardiogenic shock necessitating four vasopressor agents. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 20% with new-onset global hypokinesis and myocardial wall thickness. The coronary angiogram revealed SCAD in the left circumflex artery. An Impella device was placed for cardiovascular support initially, but she ultimately required Veno-arterial (VA) ECMO. She was also given pulse dose IV methylprednisone due to concerns for myocarditis as a late inflammatory sequela of COVID-19. She was managed conservatively without coronary intervention. The follow-up TTE one week later showed improvement in her LVEF to 60%. DISCUSSION: SCAD should be kept in the differential diagnosis in the patients who have COVID-19 infections within the past 2-12 weeks and noted to have symptoms of an acute coronary syndrome (ACS) or new-onset cardiac arrhythmias. So far there are very few reported cases of SCAD after COVID-19, all having a variable clinical course (1–3). Overall, SCAD is an underreported coronary event and has a prevalence of around 4%, mostly associated with autoimmune and inflammatory diseases. Various mechanisms of SCAD have been proposed including infection-related endothelial dysfunction and intra-plaque hemorrhage leading to an intra-adventitial hematoma, followed by longitudinal spread along the coronary artery and eventually dissection. Even though SCAD can be due to other contributory factors in critical illness, however, the association of SCAD with COVID-19 needs to be further elaborated. CONCLUSIONS: COVID-19 may lead to various cardiovascular disorders ranging from ACS to SCAD and management protocols need further research. REFERENCE #1: Kumar K, Vogt JC, Divanji PH, Cigarroa JE. Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID-19 infection. Catheter Cardiovasc Interv [Internet] 2021;97(2). Available from: https://onlinelibrary.wiley.com/doi/10.1002/ccd.28960 REFERENCE #2: Aparisi Á, Ybarra-Falcón C, García-Granja PE, Uribarri A, Gutiérrez, and H, Amat-Santos IJ. COVID-19 and spontaneous coronary artery dissection: causality? REC Interv Cardiol (English Ed [Internet] 2021;Available from: https://www.recintervcardiol.org/en/?option=com_content&view=article&id=548&catid=41 REFERENCE #3: Shojaei F, Habibi Z, Goudarzi S, et al. COVID-19: A double threat to takotsubo cardiomyopathy and spontaneous coronary artery dissection? Med Hypotheses [Internet] 2021;146:110410. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0306987720333016 DISCLOSURES: No relevant relationships by Faran Ahmad, source=Web Response No relevant relationships by Arslan Ahmed, source=Web Response No relevant relationships by Austin Loranger, so rce=Web Response Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Pharmaceuticals, Inc. Please note: $5001 - $20000 by Doug Moore, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Genentech Please note: $1001 - $5000 by Doug Moore, source=Web Response, value=Honoraria No relevant relationships by Sanu Rajendraprasad, source=Web Response No relevant relationships by Renuga Vivekanandan, source=Web Response

Influence of health disparities on COVID-19 critical care admissions

INTRODUCTION: COVID-19 has brought attention to the health disparities even in a rural state such as Nebraska. COVID-19 patients admitted to CHI (Catholic Health Initiative) Health Nebraska had data collected concurrently to determine the intensive care unit (ICU) admissions. METHODS: Data from all patients with a positive SARSCoV- 2 polymerase-chain-reaction (PCR) test were collected regarding their health on admission, their progress during hospitalization, and their disposition after dismissal. Data were entered into an Excel spreadsheet and analyzed by SPSS-PC (ver 26.0). Emphasis was placed on critical care admission for patients. Continuous variables were analyzed using Student t-test and discrete variables were analyzed using Chi-square or Fisher's exact test. Apriori significance was p ≤ 0.05. RESULTS: From March 15, 2020, to July 15, 2020, 127 (29%) of 441 total COVID-19 positive patients were admitted to ICU beds in our healthcare system (CHI Health Nebraska;approximately 320 ICU beds). Significantly more male patients (58%;p<0.01) were admitted to ICU. Bodyweight (93.9 ± 32.6 vs. 83.1 ± 23.5 kg) and APACHE II score (12.6 ± 7.6 vs. 8.9 ± 5.6, P<0.01) on admission to ICU were also significantly (p<0.01) higher. Additionally, 50% of patients with COVID-19 positive PCR result belonged to minority race groups (African-American 21%;Asian 11%;Hispanic 68%;p < 0.001) when African-American represent 5%, Asian 2.7%, and Hispanics 10% of the Nebraska general population. For health disparities, significantly more (40%;p<0.03) ICU admissions were due to occupational exposure to COVID-19 (meatpacking plants). Total hospitalization length was significantly longer for ICU patients (18.6 ± 12.1 days) compared to non-ICU patients (12.5 ± 12.4 days, p<0.001). CONCLUSIONS: COVID-19 infection has resulted in significant health disparities with greater numbers of ICU admission from occupational exposure in a close workspace with minimal social distancing.

A case of burkholderia gladioli ventilator-associated pneumonia in a patient with COVID-19

INTRODUCTION: Burkholderia gladioli (B. gladioli) is primarily a plant pathogen but has been known to be pathogenic in patients with cystic fibrosis, chronic granulomatous disease or immunocompromised. METHODS: We hereby report a case of B. gladioli causing ventilator-associated pneumonia (VAP) in a patient with COVID-19. 68-year-old Hispanic man with a history of hypertension, type 2 diabetes mellitus, chronic kidney disease, and complete heart block with pacemaker presented to primary care office with fatigue, worsening shortness of breath, and decreased urine output for 2 days. He was found to be in acute respiratory distress with bilateral coarse breath sounds and saturating 60% on room air subsequently sent to ER for further evaluation. Transitioned to 100% high flow in the ER and was admitted to ICU. Pertinent work up showed pH of 7.2, bicarbonate (10 mmol/L), lactate (7.2 mmol/L), creatinine (5.5 mg/dl), d-dimer (2.0 mg/L), LDH (745 u/l), ferritin (5934 ng/mL). Chest x-ray showed bilateral infiltrates. Further increase in oxygen requirements required intubation. Intravenous ceftriaxone and azithromycin were started empirically for community-acquired pneumonia. Given his clinical presentation, PCR for SARS-Cov-2 was positive. He was treated with convalescent plasma and dexamethasone with decreasing ventilatory requirements and inflammatory markers. On day 13 of admission, the patient became febrile, WBC count of 24.4 k/ul, and increasing ventilatory requirements raising concern for VAP. Intravenous vancomycin and cefepime were started. Computed tomography pulmonary angiogram showed extensive pulmonary consolidation. Sputum culture grew B. gladioli. Based on susceptibilities levofloxacin was added to the antibiotic regime and cefepime was later switched to meropenem for double coverage in this critically ill patient. Despite aggressive management, he suffered multi-organ failure including acute respiratory distress syndrome (ARDS), acute renal injury requiring continuous renal replacement therapy, and shock unresponsive to vasopressors. The patient suffered cardiac arrest and died. RESULTS: COVID-19 pneumonia might have predisposed our patient to VAP with this rare organism. In spite of prompt recognition and aggressive treatment of infection, the outcome was fatal.

COVID-19 therapeutics: What works?

INTRODUCTION: SARS-CoV-2 pandemic has brought about a race to determine what is efficacious against this new viral infection that causes COVID-19. We sought to evaluate our therapeutic algorithm for treating patients with SARSCoV- 19. METHODS: Data from patients admitted to our healthcare system with a positive polymerase chain reaction was concurrently reviewed. Demographics, progress during hospitalization, and disposition after discharge from the institutions were entered into an Excel spreadsheet and analyzed by SPSS (ver. 27.0). Continuous variables were analyzed using Student t-test and discrete variables were analyzed using Chi-square or Fisher's exact test. Apriori significance was p ≤ 0.05. Results are presented as percentages or mean (± SD). RESULTS: From March 15, 2020 - July 15, 2020, 127 (29%) of 464 total patients were hospitalized in our healthcare system (CHI Health Nebraska;approximately 1000 hospital beds). A treatment algorithm was developed to determine criteria for COVID-19 therapeutics and shared among the institutions. A total of 66 (14.6%) expired during their hospitalization. Mean age and admission creatinine clearance was significantly different for expired patients (72.2 ± 13.1 vs. 61.6 ± 18.7 years;48.5 ± 33.0 vs. 80.8 ± 50.5 ml/min;p<0.01). Twenty-two percent of patients required an ICU bed. Therapeutics that demonstrated a significant reduction (p<0.01) in mortality included convalescent plasma, proning intubated patients, and dexamethasone. Hydroxychloroquine, azithromycin, and remdesivir use did not reduce mortality. Tocilizumab significantly reduced mortality (13%, p<0.001). CONCLUSIONS: Convalescent plasma, dexamethasone, tocilizumab, and proning intubated patients all positively affected the patient outcome in SARS-CoV-19 infection.