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1.
Chest ; 162(4):A1535, 2022.
Article in English | EMBASE | ID: covidwho-2060837

ABSTRACT

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

2.
Chest ; 162(4):A412-A413, 2022.
Article in English | EMBASE | ID: covidwho-2060589

ABSTRACT

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

3.
Chest ; 162(4):A390, 2022.
Article in English | EMBASE | ID: covidwho-2060580

ABSTRACT

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

4.
Thyroid ; 31(SUPPL 1):A136, 2021.
Article in English | EMBASE | ID: covidwho-1483386

ABSTRACT

Subacute thyroiditis is an acute inflammatory response in the thyroid which usually follows a viral infection. This report highlights a case of subacute thyroiditis in a patient with a history of benign COVID 19 infection without indication for supplemental oxygen or hospitalization. This case is unique in the fact that the patient required multiple doses of steroids for symptom control. A 36-year-old female with a past medical history of hyperlipidemia, essential hypertension, obesity, type two diabetes, and recent COVID-19 infection six months prior presented to the hospital for evaluation of persistent anterior neck pain, fevers up to 100.9- F, ten pound weight loss, and palpitations. Two months before presentation she developed anterior neck pain that radiated into the left side of her neck and jaw. This was evaluated by an outpatient otolaryngologist who performed a nasopharyngeal laryngoscopy with unremarkable findings. She was placed on a muscle relaxant, ibuprofen, and a course of steroids. She saw another physician who trialed an additional course of steroids shortly after. Unfortunately she continued to experience excruciating discomfort prompting this hospitalization. Admission labs revealed that the patient's TSH was less than 0.01 uIU/mL. Her free T4 was 1.9 ng/dL and her free T3 was 3.6 pg/mL. A CT scan of the neck showed a 1.9 x 1.0 cm hypodense lesion. Further imaging with a thyroid ultrasound showed a heterogenous thyroid with generalized hypo echogenicity, decreased blood flow, without discrete nodules, cysts, or calcifications concerning for acute thyroiditis. The patient was started on intravenous methylprednisolone with improvement in symptoms. She was subsequently transitioned to oral prednisone on discharge. Subacute thyroiditis most commonly follows a viral infection. With our patient, symptoms developed shortly after her COVID19 infection. Once a diagnosis of subacute thyroiditis is made, patients are treated with a short course of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and occasionally oral steroids which resolves most symptoms. This case was unique in that our patient required three regimens of steroids before her symptoms improved. Given these findings, a prolonged course of steroids may be indicated for covid-19 induced subacute thyroiditis.

5.
Chest ; 160(4):A735, 2021.
Article in English | EMBASE | ID: covidwho-1458273

ABSTRACT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: BRASH Syndrome is a phenomenon characterized by bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia. Literature on this syndrome is limited given its under-recognition. CASE PRESENTATION: A 77-year-old female with a past medical history of atrial fibrillation, coronary artery disease, diastolic heart failure, and chronic kidney disease (CKD) III presented with dyspnea. Her home medications included furosemide, metoprolol, spironolactone, warfarin, and rosuvastatin. Comprehensive metabolic panel was significant for an elevated creatinine from baseline. Cardiac BNP was elevated, chest X-ray demonstrated cardiomegaly, and physical exam was significant for jugular venous distention. Electrocardiogram (EKG) revealed atrial fibrillation with rapid ventricular response (Image 1). Diltiazem was added for rate control however the patient was ultimately electrically cardioverted. Post procedure EKG revealed a junctional rhythm (Image 2). Hypotension persisted however. The patient soon developed oliguric renal failure and hyperkalemia, prompting upgrade to the medical intensive care unit (ICU) for shock. The patient had persistent bradycardia with heart rates as low as 32 beats per minute (bpm). Hemodialysis was initiated the following morning and the patient's shock, bradycardia, and hyperkalemia resolved. DISCUSSION: Transient abnormal rhythms have been reported post cardioversion, however the persistence of bradycardia with our patient's other abnormal lab findings raised concerns for different etiologies. BRASH syndrome is an under recognized pathophysiological phenomenon. Patients with congestive heart failure and CKD are at risk when in an inpatient setting. Different triggers are noted in recent reports, including medications such as Ranolazine and Bactrim, anaphylaxis, and even COVID-19. These cases varied in clinical severity, ranging from asymptomatic bradycardia to multiorgan failure. The hallmark mechanism of BRASH syndrome is a synergistic effect of AV nodal blocking medications and hyperkalemia promoting bradycardia. This, in conjunction with renal injury, produces the cycle of objective findings that define BRASH syndrome. Acute kidney injury caused by renal hypoperfusion can exacerbate the effects of AV nodal blocking medications as well as worsen hyperkalemia. Profound hyperkalemia and AV nodal blockade will in turn synergistically promote and prolong bradycardia. Bradycardia can depress cardiac output and further worsen renal hypoperfusion, continuing this viscous cycle. CONCLUSIONS: We believe electrical cardioversion into a junctional rhythm caused BRASH syndrome in our patient. Treatment is tailored to correcting the individual abnormalities. Many of these case reports had favorable outcomes. This case suggests that BRASH syndrome can often go undiagnosed yet still successfully be managed with supportive care. REFERENCE #1: Farkas, J., Long, B., Koyfman, A., et al. BRASH SYNDROME: BRADYCARDIA, RENAL FAILURE, AV BLOCKADE, SHOCK, AND HYPERKALEMIA. The Journal of Emergency Medicine, 59(2):216-223, pp. 1–8, 2020. DOI: 10.1016/j.jemermed.2020.05.001 REFERENCE #2: Cakulev, I., Efimov, I., Waldo, A., et al. Cardioversion: Past, Present, and Future. Circulation. Oct 20;120(16):1623-32. 2009. DOI:10.1161/circulationaha.109.865535 REFERENCE #3: Flores, S., Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: A-BRASH in the emergency department, American Journal of Emergency Medicine 38(9), P1987.E1-1987.E3. 2020. DOI: 10.1016/j.ajem.2020.05.033 DISCLOSURES: No relevant relationships by John Madara, source=Web Response No relevant relationships by Nathaniel Rosal, source=Web Response No relevant relationships by Franklin Thelmo, source=Web Response No relevant relationships by Stephanie Tzarnas, source=Web Response

6.
Critical Care Medicine ; 49(1):76-76, 2021.
Article in English | Web of Science | ID: covidwho-1326666
7.
Critical Care Medicine ; 49(1):112-112, 2021.
Article in English | Web of Science | ID: covidwho-1326604
8.
Critical Care Medicine ; 49(1 SUPPL 1):112, 2021.
Article in English | EMBASE | ID: covidwho-1193936

ABSTRACT

INTRODUCTION: Remdesivir is an antiviral medication that has demonstrated improvement in time to symptom resolution in Covid-19. The side effect profile documented in literature is still developing. To date, there have been no wide scale demonstrated cardiac toxicities noted. We present a case of COVID-19 who developed ventricular ectopy suspected to be due to Remdesivir. METHODS: A 70-year-old male with a past medical history of coronary artery disease, hypertension, and recurrent aspiration events presented from a nursing home in respiratory distress. The patient initially presented with findings consistent with aspiration pneumonia, however was also found to be positive for Covid-19. Vital signs were positive for fever, tachycardia, tachypnea, and an oxygen saturation of 90% on Non-Rebreather, requiring intubation. Metabolic panel on admission showed a slightly elevated ALT, but no electrolyte abnormalities or altered renal function. A leukocytosis and mild anemia were noted on complete blood count. Admission electrocardiogram was negative for ectopy. Remdesivir therapy for COVID-19 was planned. During infusion of the first dose, the patient had multiple premature ventricular complexes (PVCs) that developed into a short run of non-sustained ventricular tachycardia. During the second dose, PVCs again were noted, and Remdesivir was stopped. After infusion was held, ectopy resolved. Echocardiogram showed an ejection fraction of 60 - 65%, mild tricuspid and mitral regurgitation, and no evidence of wall motion abnormalities. After 48 hours, ectopy was no longer observed. RESULTS: A preliminary report of the Adaptive COVID-19 Treatment Trial evaluated Remdesivir's efficacy and safety. Of the patients receiving it, 29% had grade 3 or 4 adverse reactions, though none were cardiac in nature. In our patient, the onset of ectopy was noted immediately upon infusion and resolved upon abortion of infusion. Postulated mechanisms were drug interactions (carvedilol, atorvastatin, and sertraline were considered), CAD, or underlying disease of the conduction system. Further studies investigating the association of underlying conditions and medications with Remdesivir may shed light on this occurrence.

9.
Critical Care Medicine ; 49(1 SUPPL 1):76, 2021.
Article in English | EMBASE | ID: covidwho-1193868

ABSTRACT

INTRODUCTION: Convalescent plasma therapy (CPT) is a relatively new treatment option offered for COVID 19 pneumonia. Both the side effects and disease course after treatment with CPT have not been thoroughly investigated. CPT is primarily reserved for those participating in FDA approved clinical trials, however this case highlights an immunocompromised patient who benefited from CPT although was excluded from the clinical trial. METHODS: A 60-year-old female with a past medical history of rheumatoid arthritis (RA) was admitted for COVID 19 pneumonia on 6/18/2020. Her current management of her RA included Rituximab infusions which she received most recently one week prior to admission. On presentation she was noted to be febrile and in hypoxic respiratory failure requiring HFNC for oxygen support. She was treated with a 5-day course of dexamethasone and Remdesivir during her hospitalization. She initially had a great clinical response and was afebrile and weaned off of supplemental oxygen by the time of discharge. Patient was re-admitted three weeks later with fevers and SOB. COVID swab remained positive and coronavirus antibodies were negative. Patient was admitted to the ICU for high oxygen O2 requirements and required intubation. Bronchoscipt with alveolar lavage was performed which revealed no bacterial or fungal source of infection. Due to continued elevation of inflammatory markers, oxygen requirement and clinical symptoms, the patient was started on a second course of Remdesivir which was extended to 10 days. The patient was approved for CPT and received transfusion two weeks after admission with no adverse effects. Patient was discharged on room air 4 days after treatment and inflammatory markers markedly trended down. Her repeat COVID swab prior to discharge was negative. RESULTS: Research surrounding CPT in immunocompromised patients infected with COVID-19 is limited. With no vaccine available, CPT has been shown to be beneficial with clearance of viral load. Our case demonstrated the successful use of CPT in an immunocompromised individual. Further research needs to be done to evaluate the effectiveness of CPT in immunocompromised patients infected with COVID 19.

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