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SESSION TITLE: Genetic and Developmental Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Glucose-6-phosphate-dehydrogenase (G6PD) deficiency is one of the more common hematologic disorders. Many individuals are asymptomatic until a triggering event. Events that lead to hemolysis in the setting of G6PD include certain medications, infections, and specific foods. We discuss a case of G6PD deficiency diagnosed in a hospitalized adult with COVID infection. CASE PRESENTATION: A 41 year old male presented to the hospital with altered mental status. On admission he was found to be in diabetic ketoacidosis and was COVID positive. He was admitted to the ICU and his acidosis was corrected with insulin. He did not require intubation but was treated with steroids, remdesivir, and supplemental oxygen for his COVID pneumonia. His hospitalization was complicated by hemolytic anemia. Testing for autoimmune hemolytic anemia and HIT (heparin induced thrombocytopenia) were negative. Genetic testing for G6PD deficiency came back positive. The patient was discharged and referred to hematology for follow up. DISCUSSION: Interestingly, our patient was asymptomatic prior to his COVID infection. It is likely that the stress from his COVID infection triggered worsening hemolysis. G6PD can be worsened with specific medications or foods but we cannot exclude infection. The inflammatory response secondary to COVID is the probable cause for the patient's hemolytic anemia presentation and subsequent G6PD deficiency diagnosis. CONCLUSIONS: G6PD deficiency should be included in the differential diagnosis for patients presenting with COVID infection and labs consistent with hemolytic anemia. Reference #1: Buinitskaya Y, Gurinovich R, Wlodaver CG, Kastsiuchenka S. Centrality of G6PD in COVID-19: The Biochemical Rationale and Clinical Implications. Front Med (Lausanne). 2020;7:584112. Published 2020 Oct 22. doi:10.3389/fmed.2020.584112 DISCLOSURES: No relevant relationships by Sarin Atam No relevant relationships by Kathleen Coppola No relevant relationships by Malik Muhammad Uzair Khan No relevant relationships by Mackenzie Kramer No relevant relationships by Rameesha Mehreen No relevant relationships by Stephanie Tzarnas No relevant relationships by Laura Walters
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SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Lazarus Phenomenon, also known as auto-resuscitation, is a rare event where cessation of CPR results in a delayed return of spontaneous circulation (ROSC). The phenomenon was named after the story of Lazarus, who was restored to life four days after death. We present a case of a 78-year-old male who presented to the hospital for septic shock and had intra-hospital cardiac arrest with ROSC after cessation of CPR. CASE PRESENTATION: 78 year old male with a medical history of paroxysmal atrial fibrillation, stage IIIA NSCLC and COPD, presented for progressive dyspnea. He complains of feeling weak with loss of appetite and had a recent mechanical fall. Initial vital signs were temperature 96F, BP 141/78, HR 75 bpm, RR 18/min, SaO2 100% on 2LNC. Initial labs showed lactic acid 11.6, BUN 55, creatinine 3.7, CO2 9, anion gap 25, AST 2654, ALT 2120, ALP 159, total bilirubin 0.8, troponin <0.1, CK 399, INR 4.2, PTT 36, WBC 16.5, Hb 10.8, and plt 202. COVID-19 testing was negative. CXR demonstrated a retro-cardiac opacity consistent with previous diagnosis of lung cancer versus a dense consolidation. He was started on antibiotics for sepsis and admitted to the ICU for his metabolic status and shock liver. He remained hemodynamically stable for a few hours until a he had sudden onset of unresponsiveness with asystole. Code blue was called. Repeat labs demonstrated lactic acid 15.5, potassium 6.3, CO2 9. He underwent resuscitation for 32 minutes when compressions were stopped. Within 5 minutes post arrest, sinus activity was noted on the cardiac monitor. The patient had a radial pulse on evaluation. Manual blood pressure measurement was 119/71 with a HR of 99. Arterial blood gas after ROSC showed a pH 7.0, pCO2 68, pO2 273, HCO3 16, lactic acid 19. A few hours later, the patient rapidly de-compensated and underwent resuscitation for a second time. Efforts were deemed futile and the patient expired. DISCUSSION: The physiologic description of the Lazarus phenomenon is yet to be fully elucidated. Hypotheses include auto-PEEP due to rapid manual ventilation generating increased intrathoracic pressure and decreased venous return, delayed drug effect and stunned myocardium during active chest compressions (1). Once chest compressions and positive pressure ventilation via manual bag-mask stops, sudden decrease in intrathoracic pressure allows for sudden venous return and re-perfusion of cardiac tissue, resulting in ROSC in some cases. A recent literature review cited 65 published cases over the past 30 years with the most common rhythm being asystole (2). Most cases of auto-resuscitation occurred between 5-10 minutes post stopping of chest compressions (2). Mortality of these cases were 70% post resuscitation (2). CONCLUSIONS: It is important for clinicians to be aware of the Lazarus phenomenon post resuscitative efforts and to observe patients carefully post resuscitation. Reference #1: Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. J R Soc Med. 2007;100(12):552-557. doi:10.1177/0141076807100012013 Reference #2: Gordon, L., Pasquier, M., Brugger, H. et al. Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review. Scand J Trauma Resusc Emerg Med 28, 14 (2020). https://doi.org/10.1186/s13049-019-0685-4 DISCLOSURES: No relevant relationships by Vincent Chan No relevant relationships by Mackenzie Kramer No relevant relationships by Nathaniel Rosal No relevant relationships by Laura Walters No relevant relationships by William Ward
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SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Herpes simplex type 1 (HSV-1) related respiratory tract infections have been described in critically ill or immunocompromised patients. We present a case of HSV-1 pneumonia in a mechanically ventilated and immunocompromised patient in the setting of SARS CoV-2 infection. CASE PRESENTATION: A 54-year-old female on Rituximab for Rheumatoid arthritis presented with shortness of breath and cough. She was afebrile, tachypneic and hypoxic. She was discharged 1 week prior after a 3 weeklong treatment for COVID-19 pneumonia. CT Angiogram showed extensive bilateral patchy consolidations with ground-glass infiltrates and subsegmental pulmonary emboli. Patient was initiated on heparin and broad-spectrum IV antibiotics with steroids for presumed ARDS with superimposed bacterial pneumonia. Her respiratory failure worsened requiring invasive mechanical ventilation. Failing oxygenation despite aggressive therapy prompted further workup that showed a normal echo and negative blood cultures. Sputum was negative for Pneumocystis pneumonia and Tuberculosis. Cytology from tracheal aspirate showed bronchial cells with inclusions and multinucleations consistent with HSV-associated cytopathic changes. A positive serum HSV-1 IgG and serum quantitative PCR of HSV-1 DNA solidified the diagnosis. Ganciclovir therapy was initiated to cover for HSV and Cytomegalovirus (CMV), however, a serum CMV PCR was negative. Within a day, her clinical course took a downward spiral. CT chest was repeated which showed worsening airspace disease. Despite ganciclovir therapy, the severity of lung disease led to eventual failure of oxygenation and patient demise. DISCUSSION: Prolonged mechanical ventilation due to ARDS is a risk factor for HSV bronchopneumonia in patients with COVID-19 and has shown an increased mortality 1,2. Diagnosis can be achieved by viral culture or observing cytopathic effects of HSV on cells in tracheobronchial aspirates, bronchoalveolar lavage, or biopsy3. In critically ill patients early treatment has been shown to prolong the ICU time to death and improved oxygenation4. It is important to test for co-infections as about 65% of HSV pneumonia cases are associated with pathogens like CMV and Pneumocystis5. CONCLUSIONS: Worsening respiratory disease in mechanically ventilated COVID-19 patients despite antibiotic therapy for suspected superimposed bacterial infection warrants a workup for secondary viral infections like HSV. Increased mortality is seen if not promptly treated. Reference #1: 1. Meyer A, Buetti N, Houhou-Fidouh N, et al. HSV-1 reactivation is associated with an increased risk of mortality and pneumonia in critically ill COVID-19 patients. Critical Care. 2021/12/06 2021;25(1):417. doi:10.1186/s13054-021-03843-8 Reference #2: Le Balc'h P, Pinceaux K, Pronier C, Seguin P, Tadié J-M, Reizine F. Herpes simplex virus and cytomegalovirus reactivations among severe COVID-19 patients. Critical Care. 2020/08/28 2020;24(1):530. doi:10.1186/s13054-020-03252-3 Reference #3: Shah JN, Chemaly RF. Herpes Simplex Virus Pneumonia in Patients with Hematologic Malignancies. Pulmonary Involvement in Patients with Hematological Malignancies. 2010:301-311. doi:10.1007/978-3-642-15742-4_24 DISCLOSURES: No relevant relationships by Andrew Cox No relevant relationships by Syeda Hassan No relevant relationships by Maria Khan No relevant relationships by Malik Muhammad Uzair Khan No relevant relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Ifrah Naeem No relevant relationships by Laura Walters
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SESSION TITLE: Critical Diffuse Lung Disease Cases 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Recurrent episodes of community acquired pneumonia (CAP) have been shown to be common in elderly patients. Cryptogenic organizing pneumonia (COP) is an interstitial lung disease that is often mistaken for pneumonia, especially in the older population. Here, we present a 100-year-old woman diagnosed with COP after multiple failed courses of antibiotics for CAP. CASE PRESENTATION: A 100-year-old female with a history of cardiomyopathy, pulmonary hypertension, and autoimmune hemolytic anemia previously on prednisone, who presented with shortness of breath and non-productive cough. CT of the chest showed dense left upper and lower lobe consolidations. She was admitted 2 months prior with similar symptoms and found to have extensive right sided consolidations with concerns of CAP. She was treated with antibiotics without resolution of her symptoms. CXR from two years prior revealed right upper and right lower lobe consolidations. This admission, she was started on antibiotics with no improvement and required supplemental oxygen. She had no leukocytosis. COVID-19 testing was negative and she was unable to produce any sputum for culture. The patient declined bronchoscopy. She was seen by speech and swallow with no concern for aspiration. Prednisone was started empirically for COP and the patient experienced rapid improvement in symptoms and oxygenation. Ultimately, she was discharged on 20 mg of prednisone daily as well as Bactrim for PCP prophylaxis. She continued a slow taper as an outpatient with overall improvement in her clinical symptoms. Serial CT scans demonstrate complete resolution of the infiltrates with no recurrence or new infiltrates. DISCUSSION: Cryptogenic organizing pneumonia is a rare interstitial lung disease known to affect bronchioles and alveoli. Its etiology is unclear and symptoms often mimic other types of infectious pneumonia leading to frequent mis-diagnosis. The average age of onset is typically 50-60. Establishing this diagnosis can be difficult due to the non-specific symptomatology of dry cough and dyspnea. Bronchoscopy with lavage and transbronchial biopsies can be performed to rule out infectious and non-infectious etiologies but is not necessary for diagnosis. The most common radiographic pattern is multifocal asymmetrical parenchymal consolidations with air bronchograms that tend to migrate and appear in different sites over time. Less common presentations include ground glass opacities, nodular densities, and progressive fibrotic patterns. Steroids with a slow taper as outpatient are mainstay of therapy and the majority of patients respond with symptom and radiographic improvement. CONCLUSIONS: While elderly patients are particularly susceptible to recurrent CAP, the diagnosis of COP should be considered part of the differential diagnosis in those with recurrent unexplained consolidations on chest radiography without an infectious etiology. Reference #1: Hedlund J, Kalin M, Ortqvist A. Recurrence of pneumonia in middle-aged and elderly adults after hospital-treated pneumonia: aetiology and predisposing conditions. Scand J Infect Dis. 1997;29(4):387-92. doi: 10.3109/00365549709011836. PMID: 9360255. Reference #2: Tiralongo F, Palermo M, Distefano G, et al. Cryptogenic Organizing Pneumonia: Evolution of Morphological Patterns Assessed by HRCT. Diagnostics (Basel). 2020;10(5):262. Published 2020 Apr 29. doi:10.3390/diagnostics10050262 Reference #3: Lee JW, Lee KS, Lee HY, Chung MP, Yi CA, Kim TS, Chung MJ. Cryptogenic organizing pneumonia: serial high-resolution CT findings in 22 patients. AJR Am J Roentgenol. 2010 Oct;195(4):916-22. doi: 10.2214/AJR.09.3940. PMID: 20858818. DISCLOSURES: No relevant relationships by Vincent Chan No relevant relationships by Mackenzie Kramer No relevant relationships by John Madara No relevant relationships by Stephanie Tzarnas No relevant relationships by Laura Walters
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SESSION TITLE: Complications of Thoracic Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Serratia marcescens is a gram negative bacteria known to colonize the human GI tract. While infections of urinary tract, respiratory tract, and CNS can occur, it is usually associated with immunocompromised hosts or patients who undergo invasive procedures or surgeries. Here, we present a 21-year-old immunocompetent male with Serratia marcescens cavitary pneumonia following COVID-19 infection. CASE PRESENTATION: A 21-year-old obese male with no past medical history presented with shortness of breath, cough and fevers for one week. In the emergency department (ED), he was febrile to 38.8°C, tachycardic, saturating 90% on room air. He was recently admitted to an outside hospital two weeks prior with COVID-19 pneumonia. He was treated with Remdesivir and decadron and discharged after five days. No invasive procedures were performed during his hospital stay and he never required advanced oxygen support other than simple nasal cannula. CTA of his chest in the ED showed thick walled bilateral lower lobe cavitary lesions and multifocal ground glass alveolar opacities. No pulmonary embolism was seen. Sputum cultures were collected but inadequate. Bronchoscopy with bronchoalveolar lavage (BAL) was performed and fluid studies showed white blood cell count of 70,029 cell/uL, with 94% neutrophils. BAL fluid cultures grew Serratia marcescens. He was originally placed on vancomycin and cefepime and discharged on oral Levaquin for four weeks based on sensitivities. HIV testing was negative. DISCUSSION: Serratia is a rod shaped gram negative bacteria found in soil, water, and human gut flora. It is known to be an opportunistic pathogen that can cause urinary, respiratory, CNS and blood stream infections in immunocompromised patients. Infections in immunocompetent are usually associated with invasive devices such as mechanical ventilation or central venous catheters. While superimposed bacterial infections in COVID-19 illness are well known, they are usually seen in patients with severe disease requiring mechanical ventilation and prolonged hospitalization. Those with underlying systemic illness, advanced age and impaired immune systems are particularly susceptible. Our patient was young, immunocompetent and only required minimal oxygen support while hospitalized for COVID-19. CONCLUSIONS: Serratia marcescens pneumonia is rarely seen in immunocompetent hosts, but should remain on the differential in patients with recent hospitalization and COVID-19 infection, regardless of severity of disease. Reference #1: Hidron, A., Quiceno, W., Cardeño, J. J., Roncancio, G., & García, C. (2021). Post-COVID-19 Necrotizing Pneumonia in Patients on Invasive Mechanical Ventilation. Infectious Disease Reports, 13(3), 835–842. https://doi.org/10.3390/idr13030075 Reference #2: Fazio, G., Galioto, F., Ferlito, A., Coronella, M., Palmucci, S., & Basile, A. (2021). Cavitated pulmonary nodules in a female patient with breast cancer: Keep in mind Serratia marcescens’ infections. Respiratory Medicine Case Reports, 33, 101441. https://doi.org/10.1016/j.rmcr.2021.101441 Reference #3: Jose, M., & Desai, K. (2020). Fatal Superimposed Bacterial Sepsis in a Healthy Coronavirus (COVID-19) Patient. Cureus. https://doi.org/10.7759/cureus.8350 DISCLOSURES: No relevant relationships by Lucy Checchio No relevant relationships by Syeda Hassan No relevant relationships by Jaclyn Rosenzweig No relevant relationships by Stephanie Tzarnas No relevant relationships by Laura Walters
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This article highlights the logistical challenges posed by the COVID-19 pandemic for the U.S. food supply chain and reviews emergency support provided through the transportation sector given specific regulatory exemptions.