HYPERSENSITIVITY PNEUMONITIS PRESENTING AS SEVERE CYSTIC LUNG DISEASE FOLLOWING COVID-19 INFECTION

SESSION TITLE: Dirty Jobs: Occupational Lung Diseases SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Hypersensitivity Pneumonitis (HP) is a group of immunologically mediated lung diseases. It develops in susceptible individuals with exposure to provoking antigens along with influence from genetic and environmental factors. There remains no standardized approach for assessing the various forms of HP and the diverse nature of the disease makes it difficult and often underdiagnosed. Cystic disease is not uncommon in HP, but the advanced cystic disease seen in our young patient was unique and likely compounded by her pregnancy as well as a previous illness with COVID-19. CASE PRESENTATION: A 26-year-old female construction worker at 12 weeks gestation, with a past medical history of polysubstance abuse and previous COVID-19 infection ten months prior, presented with progressively worsening dyspnea of 9 months. She was admitted with acute hypoxic respiratory failure due to recurrent right pneumothorax requiring multiple thoracenteses and eventually chest tube placement. CT Chest demonstrated severe cystic interstitial fibrosis with emphysematous changes. Initial lung biopsy showed interstitial fibrosis as a possible sequela of COVID-19. Due to her pregnancy and medical complications, she was transferred to a transplant center where she continued to have recurrent pneumothoraces requiring video-assisted thoracoscopic surgery. Autoimmune workup, HP panel, and extended myositis panel were negative. However, a repeat lung biopsy pointed to subacute HP. Despite steroid and immunosuppressant initiation, her hospital course was complicated by cardiac arrest and brain death. She went on to become an organ donor. DISCUSSION: Diffuse cystic lung diseases are characterized by parenchymal destruction of the airway walls leading to expansion of the distal airspaces forming multi-lobular cysts. A broad differential diagnosis for this exists including infection, Langerhans histiocytosis, lymphangioleiomyomatosis, interstitial pneumonia, and HP. The first step to evaluate HP is a detailed history of potential exposures. Our patient worked in construction and was exposed to commonly demonstrated antigens used in paint, plastic, and wood manufacture. Pregnancy appears to trigger symptoms in some patients, seen in prior case reports. Our patient's symptoms began after her COVID infection. Though not clearly studied, some studies have proposed that dysregulation of COVID - 19 immune response triggers interstitial fibrosis as a long-term sequela. Early diagnosis and treatment with steroids are vital to the treatment and prevention of complications such as recurrent pneumothorax. CONCLUSIONS: Covid-19 is an emerging risk factor for the propagation of various immune-mediated diseases. Progression of disease may occur even after the infection has been cured and limited data is available regarding its relation. Early recognition and treatment can be effective life-saving measures in these patients. Reference #1: Baldi BG, Carvalho CRR, Dias OM, Marchiori E, Hochhegger B. Diffuse cystic lung diseases: differential diagnosis. J Bras Pneumol. 2017;43(2):140-149. Reference #2: Densem C, Niven R, Barber P, Bishop P. Development of cryptogenic fibrosing alveolitis during pregnancy. J R Soc Med. 1998;91(11):591-593. Reference #3: Ambardar SR, Hightower SL, Huprikar NA, Chung KK, Singhal A, Collen JF. Post-COVID-19 Pulmonary Fibrosis: Novel Sequelae of the Current Pandemic. J Clin Med. 2021;10(11):2452. Published 2021 Jun 1 DISCLOSURES: No relevant relationships by Anastasia Brit No relevant relationships by Steven Colby No relevant relationships by Patrick Koo No relevant relationships by Vishruth Vyata No relevant relationships by Harika Yadav

UPPER EXTREMITY DEEP VENOUS THROMBOSIS AFTER BNT162B2 MRNA COVID-19 VACCINE

CASE: A 60-year-old woman with past medical history including hypertension, nephrolithiasis, and Covid-19 4 months prior presented to the emergency department with 3 days of substernal chest pain radiating toward the back and shoulders 6 days after receiving her second dose of the BNT162b2 mRNA Covid-19 vaccine (Pfizer/BioNTech) in her left deltoid. The patient tested negative for Covid-19 and denied shortness of breath, cough, fever, or dyspnea on exertion. Her ECG was notable for more pronounced t-wave inversions in III and aVF, but further cardiac workup was unremarkable, and she was discharged the next day. The patient re-presented to care 6 days later with left arm pain, erythema, edema, and warmth. Her left bicep circumference was 31cm versus 28cm on the right. Upper extremity duplex ultrasound (US) was remarkable for deep venous thrombosis (DVT) of the left internal jugular, subclavian, axillary, and basilic veins. MRI angiogram was confirmatory. Other than her occupation as a hairdresser, the patient did not have known risk factors for DVT: no personal or family history of thromboembolism, no tobacco use, took no prescription medications, and had received all ageappropriate cancer screening. Her thrombophilia workup was negative. The patient was discharged on apixaban. Eleven days later, a venogram showed persistent clot burden in the left axillary, mid-subclavian, and brachiocephalic veins. Thrombectomy, overnight tPA infusion, and left subclavian vein stenting were performed and the patient was discharged on daily apixaban and aspirin. IMPACT/DISCUSSION: As of December 10th, 2021, the vaccine adverse event reporting system yielded 464 reports of “thrombosis” after the Pfizer/ BioNTech vaccine in individuals with no reported current illness, 32 of which occurred in the upper extremity. To our knowledge, our patient represents the first report of upper extremity deep venous thrombosis (UEDVT) shortly after receipt of the Pfizer vaccine in an otherwise healthy person. UEDVT is relatively rare: it occurs in about 0.4 to 1 per 10,000 people per year and less than 20% of incidents are idiopathic. Given the scarcity of potential causes, our case may simply reflect expected background incidence. Nevertheless, the literature includes multiple case reports of DVT after mRNA Covid-19 vaccination, including cases of lower extremity DVT and DVT with pulmonary embolism (PE) after the Pfizer vaccine, and cases of lower extremity DVT, PE, and UEDVT after the mRNA-1273 (Moderna) vaccine. Given the similar mechanism of action between the Moderna and Pfizer vaccines, it is possible that the same pathophysiology underlies the reports of DVT in these vaccine recipients. CONCLUSION: Upper extremity deep venous thrombosis after Covid-19 mRNA vaccination should remain on the differential as clinicians assess chest and arm pain following vaccination. There is a possible association between the BNT162b2 mRNA Covid-19 vaccine and upper extremity deep venous thrombosis that requires further research.

Why do SMEs switch suppliers?

Purpose>Combining a conceptual framework with empirical evidence, this study aims to offer insights into why small and medium-sized enterprises (SMEs) in the business-to-business beauty sector switch suppliers, due to pricing considerations.Design/methodology/approach>Data gathered from 475 telephone surveys of Spanish hairdressers provide the input for discrete choice models for testing the proposed hypotheses.Findings>The SMEs that change suppliers tend to be sensitive to promotions, express less satisfaction with a current supplier’s offerings and serve fewer customers who buy professional products for their in-home use. If SMEs are satisfied with the supplier’s services though, they are less likely to change and more prone to negotiate with that supplier.Research limitations/implications>This study does not address why dissatisfied SMEs might remain with their current suppliers. Further research might replicate this study using additional pricing data from suppliers.Practical implications>Suppliers in business-to-business (B2B) sectors can leverage these findings to allocate their marketing budgets optimally and establish service strategies that will enable them to retain buyers and reduce their switching risk.Originality/value>As an extension of extant literature, this study specifies switching drivers for SMEs in the B2B beauty sector. The findings should apply throughout this worldwide service sector, as well as to similar markets such as health, beauty and personal care and well-being services.

Socio-occupational inequalities in potential work-related exposure to SARS-COV-2

Introduction The risk of contracting COVID-19 is not uniform across occupations. Certain workers, exposed to diseases/infections, interfacing with the public/colleagues, unable to work from home, and without appropriate personal protective equipment are likely to experience higher workplace exposure to SARS-CoV-2. Objective To describe the proportion of workers potentially exposed to coronavirus in each occupation under 'routine' working conditions, as well as a baseline socio-demographic profile of these workers in France. Methods We combined two French cross-sectional population-based surveys: 'Working Conditions' (CT-2013) and 'Medical Surveillance of Occupational Risk Exposure' (Sumer-2017) to quantify 'exposure to infectious agents', 'face-to-face contact with the public' and 'working with colleagues'. We then identified the most exposed occupations before the first lockdown and built an exposure matrix. Finally, we described other socio-demographic characteristics (age, sex, occupational group, educational level, income level, origin) of the workers with the highest potential exposure to COVID-19. Results Before the first lockdown, 42% (11 million) of French workers were exposed to at least two COVID-19 occupational exposure factors. While most exposed workers are in the health care sector, other occupations such as social workers, hotel/restaurant employees, army/police officers, firefighters, hairdressers, and teachers also have a high proportion of exposed workers. Middle age participants, females, unskilled employees, those with post-secondary non-tertiary education, those with lower income level, French-born in overseas departments, and descendants of non-European immigrants faced a greater risk of occupational exposure to coronavirus before the first lockdown. Conclusions Our exposure matrix can now be used as an input in ongoing French cohorts to attribute a baseline level of work-related exposure and adjust it based on actual working arrangements during the epidemic. Surveillance of occupational exposure to coronavirus and the socio-demographic characteristics of the workers vulnerable to this virus is key to the implementation of occupation-specific public health response to Covid-19.

To be or not to beintensive: Internal Medicine unit role during and after CoViD-19 pandemic

Background and Aim: CoViD-19 causes major changes in daily hospital activity, both in clinician and organizational aspects. Aim of this research is investigated a new model of Internal Medicine Unit. ASL Roma 6 is a local health facilities where hospital, territorial medicine and low-care facilities are integrated. Materials and Methods: Initially, Delphi method (by six experts with clinician, statistic, health economic and public health expertise) allowed to analyze bad outcome causes in Ospedale dei Castelli's CoViD wards cohort (Lazio, Italy) via Ishikawa diagram and to create a SWOT analysis table. At the least, a Barber-Johnson's nomogram has been made with performances of MC (Medicine- CoViD) and MCF (Medicine-CoViD-free) units considering: length of the stay, bed occupation ratio, turn over interval and bed rotation index. CoViD-three-waves have been considered alone and overall. Results: MCF hospitalized 790 patients (-23,90% compared to 2019 Internal Medicine admission), MC hospitalized 350 patients (M 199/F151). Main risk factor for mortality: patients admitted from local facilities (+7%, 57,14% of overall CoViD deaths) and presence of comorbidities (>3: 100%, =5: 24,7%). 197 (25%) patients have been treated with non-invasive ventilation (NIV). Conclusions: CoViD Medicine wards show higher complexity and demand compared to non-CoViD ones, comparable to Sub-Intensive Therapy units;it is necessary to promote the NIV usage in such setting and to use CoViD expertise to build a new hospital model, where Internal Medicine is the core of care, integrated with territorial medicine.