Esophageal Mucosal Calcinosis: A Rare Site of Calcium Deposition in End-Stage Renal Disease

Introduction: Calciphylaxis, otherwise known as calcium uremic arteriolopathy, is defined as calcium deposition around blood vessels in skin and fat tissue which occurs in 1-4% of patients with end-stage renal disease (ESRD). Calcium deposition in the esophagus is extremely rare;to date, there have been only 4 cases reported worldwide. We report the fifth case of esophageal mucosal calcinosis occurring in a young male with ESRD. Case Description/Methods: A 37-year-old Thai man with ESRD on peritoneal dialysis since 2005 presented with generalized weakness and odynophagia due to oral ulcers, resulting in poor PO intake. He denied drinking alcohol, illicit drug use, or smoking. On exam his abdomen was soft, non-distended, non-tender, without any guarding. Past medical history included hypertension and COVID-19 in January 2022. Laboratory tests revealed neutropenia and pancytopenia, hyperphosphatemia, and hypocalcemia. EGD revealed distal esophageal esophagitis and hemorrhagic erosive gastropathy. Biopsy showed ulcerative esophagitis with dystrophic calcification, consistent with esophageal mucosal calcinosis .No intestinal metaplasia was noted. Immunohistochemistry was negative for CMV, HSV1, and HSV2. The patient was treated with pantoprazole 40mg IV every 12 hours, Magic Mouthwash 5ml qid, and Carafate 10mg qid. He was transferred to a cancer center where he had a bone marrow biopsy formed which was negative. His symptoms resolved and the patient was discharged to home (Figure). Discussion(s): Esophageal mucosal calcinosis is extremely rare. It is due to a combination of factors involving acidosis and the phenotypic differentiation (and apoptosis) of vascular smooth muscle cells (VSMC) into chondrocytes or osteoblast-like cells. These changes, along with the passive accumulation of calcium and phosphate, induce calcification. Acidosis is well-known to promote inflammation of the arterial walls, releasing cytokines that induce vascular calcification. The benefits of treatment with sodium thiosulfate remain unclear. An ample collection of cases should help devise standardized treatment options and establish management guidelines for this condition.

Vitamin-D deficiency, the hidden pandemic in sunshine sufficient countries, exacerbating hypocalcaemia in a health worker undergoing thyroidectomy - a global perspective and review of literature

Introduction: Vitamin D deficiency (VDD) is common in young adults even in sunlight sufficient countries. It manifests with subtle and trivial symptoms that are often ignored. Nutritional deficiency due to improper dietary habits, poverty, long hours at work and study are factors. The lockdown during COVID has exacerbated the incidence. We had a patient with VDD who became symptomatic after routine thyroidectomy prompting our review into literature on the global health perspective of VDD. Material and method: - A 21-year-old nursing student developed hypocalcaemia within 24 hours after a routine thyroidectomy. VDD was detected and patient improved after supplementation. Literature was reviewed from Pubmed database for the medical aspects of the problem, from Government archives like the Scientific Advisory Committee on Nutrition, ICMR etc for cause and medical archives including those of paediatric and general health for the impact of disease at the state, national and global level. A global health problem list was prepared and data was reviewed. Discussion: Vitamin D is protective against respiratory infections due to viral aetiology including COVID. However, complete lockdown to prevent spread of COVID, online learning, and work from home culture has reduced sunlight exposure and increased incidence of VDD. Post thyroidectomy hypocalcaemia is common in VDD. Conclusion: Since there is a high prevalence of asymptomatic VDD even in sunshine sufficient countries, it is recommended to screen all patients especially young adults for VDD during routine preoperative work up.

Epidemiological shift of paediatric fracture characteristics during COVID-19 in Hong Kong - a reflection on bone health crisis

Introduction: Since the beginning of Coronavirus disease 2019 (COVID-19) pandemic, schools in Hong Kong were suspended intermittently as part of the anti-epidemic measure. This study aims to investigate the impact of COVID-19 pandemic on the epidemiology of paediatric fracture and bone health of children. Method(s): We recruited patients aged 3-17 admitted to tertiary paediatric orthopaedic trauma centres for fractures from 1st February 2020 till 4th March 2021 during COVID-19 period as study group and compared with patients admitted from 1st February 2019 till 31st January 2020 before COVID-19 as control group. Result(s): Total number of admissions due to fracture was reduced by 49% (pre-COVID period: 345, COVID period: 177). Demographic data such as age, age group distribution, sex, location of fractures, energy of injury, prior history of fracture were comparable in the two groups. There was no statistically significant difference in the proportion of patients requiring operative treatment. Significant change was found in injury mechanisms, with injury related to body-powered vehicles (33.7%, n = 58) becoming the leading cause of injury during COVID period (p < 0.001). There was significant drop in proportion of patient with injury from level ground fall (p < 0.001) and sports (p < 0.001). The percentage of obese children increased significantly (p = 0.009) during the COVID period (32.7%, n = 48) than pre-COVID period (21.0%, n = 67). The proportion of patients with hypocalcaemia was found to be higher (p = 0.002) during COVID period. Conclusion(s): This study reflects paediatric bone health issues during COVID-19 pandemic. We postulate the reduction in fracture incidence, change in the distribution of injury mechanisms, and more obesity could be related to a more sedentary lifestyle during COVID period. Hypocalcaemia can be associated with reduced sunlight exposure, obesity, and lack of physical activities. If the problem is left neglected, it can lead to long-term bone health problems.Copyright © The Author(s) 2023.

Perinatal Transmission of SARS-CoV-2 Infection and Its Clinical Attributes: A Single-Center Study From Western Uttar Pradesh.

Background Globally, severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) has infected millions of people to date. The morbidity and mortality associated with SARS-CoV-2 are higher in diabetics than those with chronic kidney disease and in the elderly. In pregnant women, it causes an increased risk for preeclampsia/eclampsia, infections, intensive care unit (ICU) admission, maternal mortality, and preterm birth. In neonates, SARS­CoV­2 infection has been found to cause stillbirths, growth retardation, premature delivery, increased neonatal intensive care unit (NICU) admission, and need for oxygen support. The neonate can get infected by vertical or horizontal transmission. As most studies have focussed on transmission at the time of birth only, in this study, we explored both vertical and horizontal transmission along with the clinical attributes of those born to mothers with SARS­CoV­2 infection. Methodology A prospective observational study was conducted in the Department of Pediatrics of a tertiary care hospital over 12 months from October 2020 to October 2021. All reverse transcription-polymerase chain reaction (RT-PCR) SARS-CoV-2-positive pregnant females admitted to the facility during the study duration were included. The enrolled mothers were followed till delivery. The mothers and neonates were managed per standard guidelines. Delivery details and neonatal outcomes were recorded. Coronavirus disease 2019 sampling in newborn babies was done at birth (within 24 hours) using a nasopharyngeal swab sample for RTPCR along with cord blood for SARS-CoV-2 immunoglobulin M (IgM). Complete blood count, C-reactive protein, serum electrolytes, random blood sugar, and chest X-ray were obtained for all babies at birth and thereafter according to requirement. In those roomed in with their mother, RT-PCR was repeated at the time of discharge or if they became symptomatic. Results A total of 44 mother-neonate dyads were included in the study. Cord blood IgM for SARS­CoV­2 was negative for all neonates, while throat swab RT-PCR was positive for two (4.5%) neonates immediately after birth. Overall, 13.6% of the neonates were premature, 27.2% of the neonates had low birth weight (<2,500 g), and 6.8% had very low birth weight (<1,500 g). Among those admitted to the NICU, 18.2% had respiratory distress; 4.5% had fever, lethargy, and poor feeding; and hyperbilirubinemia requiring phototherapy was observed in 11.3% of the neonates. Moreover, 4.5% of the neonates had hypocalcemia on initial investigations. Mortality was seen in 2.2% (1/44) of the neonates. Rooming-in and breastfeeding were seen in 68.2% of the neonates. The horizontal transmission was seen in one (3.3%) roomed-in neonate. Conclusions Perinatal transmission of SARS­CoV­2 infection does occur but its rate is not significant. Furthermore, with proper infection prevention and control measures, the risk of perinatal transmission can be decreased. Breastfeeding and rooming-in do not increase infection transmission if the mother takes all precautions.

Association of Hemoperfusion Disease Progression among Patients with Severe-to-Critical Covid-19

Introduction: Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) which can lead to respiratory failure, acute respiratory distress syndrome (ARDS), pneumonia, and sepsis1. The symptoms of severe COVID-19 usually occur after a few days when viral replication is decreasing and excessive inflammation in the lung alveoli are present. Subsequently, excessive inflammation led to abnormalities in gas exchange, abnormalities in ventilation, and abnormalities in blood perfusion in the lungs2. Severe disease also has the characteristics present in Cytokine Release Syndrome (CRS) such as high fever, and elevated levels of ferritin and C-reactive protein2. Hemoperfusion has been offered to patients with severe COVID-19 who continue to have disease progression and increased inflammatory markers despite maximizing medical therapy. Our main objective is to determine the association of hemoperfusion with the development of disease progression among patients with at least severe COVID-19 in Asian Hospital and Medical Center from March 2020 to March 2021. Method(s): This is a retrospective cohort of patients aged-19 and older with a diagnosis of at least severe COVID-19 who were grouped according to whether they received hemoperfusion or not. These patients were monitored throughout their hospital course for the development of disease progression (i.e., mortality or need for mechanical ventilation). Multivariate analysis was used to determine the association of hemoperfusion with disease progression. Result(s): A total of 267 patients were included in the study, 128 (47.9%) underwent hemoperfusion, and 139 (52.1%) did not. Those who underwent hemoperfusion were older, had more co-morbidities (hypertension, diabetes, and chronic kidney disease), and had more severe disease. Disease progression occurred in 127 patients (47.5%), which was higher in those who underwent hemoperfusion (94 patients). On multivariate analysis, hemoperfusion was significantly associated with the need for intubation (RR 11.94, CI 5.3-26.8;p<0.0001), in-hospital mortality (RR 4.56, CI 2.2-9.4, p<0.0001), and the composite of disease progression (RR 7.44, CI 3.9-14.2, p<0.0001). Thrombocytopenia and hypocalcemia were also significantly more common among those who received hemoperfusion (p<0.0001). [Formula presented] [Formula presented] Conclusion(s): Our cohort showed that hemoperfusion was associated with the development of disease progression and more adverse events. However, those who received hemoperfusion had more co-morbidities and had more severe disease at the onset, which may explain our findings. Based on this study, hemoperfusion could not be recommended in the routine management of patients with at least severe COVID-19;however, a randomized controlled trial is highly recommended to verify our findings. No conflict of interestCopyright © 2023

Hypocalcemia is associated with adverse outcomes in patients hospitalized with COVID-19.

PURPOSE: Calcium ions are involved in the regulation of several cellular processes and may also influence viral replication. Hypocalcemia has been frequently reported during infectious diseases and in critically ill patients, including also COVID-19 patients, significantly related with the pro-inflammatory state and mortality. The aim of this study is to investigate the prevalence of hypocalcemia at admission in patients hospitalized for COVID-19 (Coronavirus disease 2019) and to evaluate association of hypocalcemia with in-hospital COVID-19 outcomes. METHODS: Retrospective analysis on 118 consecutive patients, hospitalized for COVID-19 between March and May 2020. Clinical characteristics, inflammation markers, biochemical routine and mineral metabolism parameters at admission were collected. Hypocalcemia was defined as total serum calcium <2.2 mmol/L. Population was stratified by tertiles of total serum calcium. Primary outcome was the composite of in-hospital death or admission to intensive care unit (ICU). Secondary outcomes included in-hospital death, admission to ICU and need for non-invasive ventilation as separate events. Associations were tested by logistic regression and Cox-regression analysis with survival curves. RESULTS: Overall prevalence of hypocalcemia was 76.6%, with just 6.7% of patients reporting levels of 25-(OH)-vitamin D > 30 ng/ml. Total serum calcium was inversely related with selected inflammatory biomarkers (p < 0.05) and poorer outcome of COVID-19 during hospitalization. Lower tertile of total calcium (≤2.02 mmol/L) had increased risk of in-hospital mortality (HR 2.77; 1.28-6.03, p = 0.01) compared with other groups. CONCLUSION: Total serum calcium detected on admission is inversely related with proinflammatory biomarkers of severe COVID-19 and is useful to better define risk stratification for adverse in-hospital outcome.

Hypocalcemia: A key biomarker in hospitalized COVID-19 patients.

BACKGROUND: At the end of 2019 a new respiratory syndrome emerged in China named Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 infection. Considering the severity of the disease in adult subjects with one or more chronic pathologies, it was mandatory to find simple and effective biomarkers for negative prognosis of the disease easily available at the admission to the hospital. METHODS: To identify possible parameters showing association with the outcome in COVID-19 patients with pre-existing chronic diseases, blood biochemical profiles of 511 patients, enrolled from March to June 2020, were retrospectively evaluated. The pathological conditions taken into consideration were diabetes, arterial hypertension, chronic kidney disease, cardiovascular diseases, chronic obstructive pulmonary disease, obesity, and cancer. All the data were collected upon admission to the emergency room (ER) during the indicated period. RESULTS: We observed that serum and ionized calcium were prevalently altered in our cohort. We determined that hypocalcemia was a major parameter associated with mechanical ventilation and poor prognosis, correlating also with the presence of comorbidities such as cardiovascular diseases, chronic kidney disease, and cancer. In addition, we found a positive correlation between hypocalcemia and clinical complications during hospitalizations. CONCLUSIONS: Our results strengthen the relevance of serum calcium concentration as a useful prognostic biomarker in hospitalized COVID-19 patients.

Is there any link between Hyperphosphatemia, Hypoalbuminemia, and Hypocalcemia with Hospital Outcomes in COVID-19 Patients?

Background: Disturbed biochemical factors have been observed in viral infections including SARS, Ebola virus, and now COVID-19. This study aimed to evaluate the association between Calcium axis' derangements and hospital duration, ICU admission, mechanical ventilation, and death in patients with COVID-19. Methods: 428 hospitalized patients with COVID-19 were included in this study. On the first day of admission, the patients were extensively evaluated for biochemical and hormonal factors and followed up until discharge/death. The association between hyperphosphatemia, hypoalbuminemia, and hypocalcemia and major outcomes, including hospital duration, ICU admission, mechanical ventilation, and death, was investigated by logistic regression analysis. Results: Hyperphosphatemia and hypoalbuminemia were present in 27 (6.3%) and 59 (13.8%) cases, respectively in the study population. The results of the present study reveal the relation of these factors with worse outcomes in COVID-19 patients; such as hospital duration, ICU admission, mechanical ventilation, and death. On the other hand, high frequency of hypocalcemia (59.1%, 253 subject) has no significant influence on the mentioned outcomes (All P values were greater than 0.05). Conclusions: Poor outcomes were associated with hyperphosphatemia and hypoalbuminemia. It seems that we should evaluate the patients for derangements of phosphate, albumin, and calcium and try to treat them for all COVID-19 patients.

The Role of Calcium and Calcium Regulating Hormonal System in the Mechanisms of Covid-19 Contagiousness and Severity

Calcium is involved in all vital processes of the body: synaptic transmission, memory development, immunity, blood clotting, heart contractions, etc. In this regard, it is important to understand the involvement of calcium in the development of SARS-CoV-2 virus infection and COVID-19 disease. We have studied the existing scientific literature, looking for the involvement of both calcium and calcium-regulating hormones (parathyroid hormone, calcitonin, vitamin D) in COVID contagiousness and severity of disease. Separately, both hypocalcemia and vitamin D deficiency have been identified in a number of large clinical trials as a predictor of mortality in patients hospitalized with COVID-19. Angiotensin-converting enzyme-2 plays a key role in contagiousness with the SARS-CoV-2 virus, and its formation is a calciumcalmodulin-dependent process. In our opinion, in order to prevent the penetration and spreading of the virus in the body, this link should be targeted with the usage of drugs that activate the calcium calmodulin system. Calcium blockers used parallel with hypocalcemia, to some extent, reduce the spreading of the virus in the body in the acute phase of the disease, but it is possible that in the future they lead to deeper and long-term complications-cognitive dysfunction. However, we did not find any study in the literature that aimed to identify calcium-dependent mechanisms in a complex, dynamic study of the same patients. Therefore, this question is still open in science, because without understanding how the amount of calcium-regulating hormones changes during the disease, without understanding how much phosphorus changes in parallel with calcium, it is impossible to get a complete picture of the disease on the role of calcium-dependent mechanisms in development. Only a summary of such combined data will allow us to reach a scientifically based conclusion, to explain the mechanisms by which hypocalcemia occurs, and by what possible mechanisms it can be prevented. Copyright © 2022, Yerevan State Medical University. All rights reserved.

Lower Serum Calcium Levels In Covid-19 Patients: A Case-Control Study In A Tertiary Care Centre

Background: The novel coronavirus disease (COVID-19) has affected over 50 million people and has inflicted more than 1.2 million casualties ever since its inception in December 2019. Besides, multiple hematological and biochemical parameters have emerged as potential biomarkers to predict severe disease and mortality in COVID-19. One such biochemical biomarker is hypocalcemia. Hypocalcemia is associated with severe disease, organ failure, increased likelihood of hospitalization, admission to the intensive care unit, need for mechanical ventilation, and death from COVID-19. Hence, the present study was undertaken to compare the serum total calcium in patients infected with COVID-19 and a normal healthy population. Aim(s): To compare serum total calcium in patients infected with COVID-19 and normal healthy populations. Material(s) and Method(s): This is a case-control study with 50 COVID-19 patients and 50 normal healthy individuals as controls. Serum calcium was determined by Arsenazo III method using Vitros 5600 autoanalyser. Result(s): Chi-square analysis was done and the p-value between cases and control was < 0.05 which is significant. 20% of the COVID -19 patients had very severe hypocalcemia ranging between 4.5-6 mg/dl, 47% of the COVID-19 patients had moderate to severe hypocalcemia with values between 6.6-8.5 mg/dl, and 33% of the COVID -19 patients had normal calcium levels ranging from 8.6-10 mg/dl. Conclusion(s): Hypocalcemia is highly prevalent in COVID-19 patients implying that hypocalcemia is intrinsic to the disease. Prospective studies with a larger number of patients are required to prove this hypothesis and unravel the underlying pathophysiological mechanisms. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Biochemical and Anthropometric Nutritional Assessment in Children Infected with COVID-19: A Cross-sectional Study

BACKGROUND: Severe acute respiratory syndrome has led to a pandemic of coronavirus disease 2019 (COVID-19). Malnutrition either biochemically or anthropometrically is a well-known risk factor for COVID-19 and may be the vice versa AIM: The objectives of this study were to investigate the prevalence of malnutrition in children infected with COVID-19 through evaluating the nutritional biomarkers such as serum electrolytes, serum albumin, and hemoglobin together with the anthropometric assessment. METHODS: A cross-sectional study that was conducted at El-Matria Teaching Hospital for all children admitted with confirmed COVID-19 for 6 months from February 1, 2021 to the end of July, 2021. Nutritional biochemical evaluation included serum electrolytes particularly the potassium and other nutritional biomarkers such as serum albumin and hemoglobin. Nutritional anthropometric evaluation depended on body mass index, the height/length, weight for length, and weight for height. The prevalence of malnutrition esp. hypokalemia was the main outcome. RESULTS: Hypokalemia was present in 21.8% of the study participants. Other nutritional biomarkers were found as hyponatremia, hypocalcemia, hypophosphatemia, and hypomagnesemia were detected in 49.1%, 38.2%, 21.8%, and 34.5% of the study subjects, respectively. Anthropometric malnutrition was present in most of the enrolled children with COVID-19 in the study (65.5 % [n = 36]) through which overweight and obese children occupied a greater percentage. CONCLUSION: Malnutrition either biochemically or anthropometrically could be linked to COVID-19 in children. COVID-19 could have negative outcomes on the nutritional status such as electrolytes disturbances. Both malnutrition and COVID-19 are considered synergistic associations.

Accidental prolonged aerosol exposure to 1.5% glycine solution via inhalation

Background: Glycine is an endogenous, non-essential, simple amino acid produced in the human body. A 1.5% solution is commonly used for irrigation in gynecologic and urologic procedures as it is a sterile, clear, non-irritating liquid. It is neutral, mildly acidic and nonpyrogenic, and as it is produced by the human body it does not cause allergic reactions. If an excessive amount is absorbed during a procedure it can result in electrolyte abnormalities, such as hyponatremia or hypocalcemia. It can also result in transient vision disturbances, changes in heart rate, hypotension, hyperammonemia, or encephalopathy. Glycine has been used as a diluent in certain inhaled therapies for COVID-19 infections, such as epoprostenol. We describe a case where a 1.5% glycine solution was inadvertently used for humidified oxygen via high flow nasal cannula as opposed to distilled water. Case report: The patient was a 70-year-old male who was admitted to the hospital for hypoxia related to a COVID-19 infection with O2 saturations in the 70-80% range. He was placed on high flow nasal cannula to improve his oxygen levels. During his inpatient stay it was discovered that a 3-L bag of 1.5% glycine solution had been connected to the high flow nasal cannula instead of distilled water. This ran from Friday evening to the following Monday morning before the error was discovered. There was only 100mL of the glycine solution remaining in the bag when it was found. The patient continued to do well and had no new complaints during his stay. The case was called to the regional poison center which recommended monitoring electrolytes, watching for any possible respiratory symptoms and continuing supportive care. Initial lab work on admission showed a chemistry panel of Na 146, K 3.6, Cl 102, CO2 25.3, BUN 9, Cr 0.70, Glucose 106, Ca 9.3. Repeat lab work immediately after the mistake was found showed: Na 137, K 4.8 Cl 100, CO2 28, BUN 15, Cr 0.70, Glucose 129, Ca 9.0. On recommendations from poison control, electrolytes were monitored with repeat lab work 10 h after discontinuation of the glycine solution, showing: Na 135, K 4.3, Cl 97, CO2 26.8, Glucose 175, Ca 9.2. The patient did not develop any new complaints, had no reported altered mental status, epistaxis, nasal irritation or other symptoms related to the inhalation. He was eventually discharged home on oxygen for his persistent hypoxia related to his COVID-19 lung infection. Discussion(s): This case demonstrates that prolonged continuous inhalational exposure to a 1.5% glycine irrigation solution does not result in any mucosal irritation, metabolic or systemic toxic reactions, even though its pH is reportedly between 4.5 and 6.5. Thus, glycine solutions up to this concentration appear to be safely tolerated for its increasing use as an excipient for aerosolized medications. Conclusion(s): We describe a case where 1.5% glycine solution was inadvertently used in place of distilled water for humidified oxygen via high flow nasal cannula for approximately 3 days in a patient being treated for COVID-19 related pneumonia with no notable adverse effects.

PLASMAPHERESIS FOR HYPERTRIGLYCERIDEMIA-INDUCED PANCREATITIS

SESSION TITLE: Critical Renal and Endocrine Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: About 7% of acute pancreatitis (AP) cases are caused by hypertriglyceridemia (HTG). In such cases bowel rest, IV fluids, symptomatic therapy, and triglyceride (TG) lowering interventions are initiated. Plasmapheresis is one of the treatment options, but it has specific indications. We present a case of severe hypertriglyceridemia-induced pancreatitis that required plasmapheresis. CASE PRESENTATION: A 30 y/o man with type 2 diabetes, hyperlipidemia, multiple previous admissions for HTG-AP, presented with severe abdominal pain, nausea, and vomiting x 1 day. On admission, he was tachycardic, hypotensive, afebrile, SpO2 > 96% on RA. Labs: Glu 491 mg/dL, TG > 1000 mg/dL, Cholesterol 509 mg/dL, Lipase 987 U/L, Cr/BUN 2.4 mg/dL /20 mg/dL, VBG pH 7.25/PCO2 36.2 mmHg/PO2 19.4 mmHg/Ca 0.8/lactate 5.6;WBC 13.07 K/cm;COVID PCR positive. CXR: diffuse patchy opacities. CTAP with contrast was deferred because of AKI. He was admitted to the ICU and started on insulin drip with no improvement over 24hrs. He was still acidotic, Ca persistently low, TG still >1000, and kidney function worsened. Plasmapheresis was initiated. After one session his TG lowered to 700. He was restarted on insulin drip and in the next 24hr TG decreased to < 500 and metabolic acidosis resolved. Once AKI resolved, CT abdomen/pelvis with contrast confirmed acute pancreatitis, with focal hypodensities within the uncinate process and the proximal body, concerning infarcts as well as large phlegmon surrounding the pancreas, but no evidence of necrotizing or hemorrhagic pancreatitis. His hospital course was complicated with sepsis and DVT, which resolved with therapy. He was discharged home with TG lowering agents, Apixaban, and his previous T2DM regimen. DISCUSSION: Plasmapheresis is indicated in patients with severe HTG (>1000- 2000 mg/dl), severe HTG-AP, and when standard treatment options are inadequate. It lowers the lipid levels and removes proinflammatory markers and cytokines stopping further inflammation and damage to the pancreas and other organs faster compared to conservative therapy. Most patients need only one session which lowers TG level by 50-80%, as seen in our patient. CONCLUSIONS: Plasmapheresis should be considered in cases of HTGP with worrisome features such as lactic acidosis, hypocalcemia, worsening inflammation, and multi organ failure. Reference #1: Rajat Garg, Tarun Rustagi, "Management of Hypertriglyceridemia Induced Acute Pancreatitis", BioMed Research International, vol. 2018, Article ID 4721357, 12 pages, 2018. https://doi.org/10.1155/2018/4721357 Reference #2: Pothoulakis I, Paragomi P, Tuft M, Lahooti A, Archibugi L, Capurso G, Papachristou GI. Association of Serum Triglyceride Levels with Severity in Acute Pancreatitis: Results from an International, Multicenter Cohort Study. Digestion. 2021;102(5):809-813. doi: 10.1159/000512682. Epub 2021 Jan 21. PMID: 33477149. Reference #3: Gavva C, Sarode R, Agrawal D, Burner J. Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach. Transfus Apher Sci. 2016 Feb;54(1):99-102. doi: 10.1016/j.transci.2016.02.001. Epub 2016 Feb 20. PMID: 26947356. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Vaishali Geedigunta No relevant relationships by Zinobia Khan No relevant relationships by Jelena Stojsavljevic

RHABDOMYOLYSIS AS A VARIANT OF COVID-19 MYOSITIS

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Myalgias are one of the most common manifestations of a COVID infection. Myositis is much less reported with the spectrum of presentation ranging from asymptomatic elevation of creatinine kinase (CK) to rhabdomyolysis. Further understanding is required to formulate evidence based protocols for management and prognostication. CASE PRESENTATION: A 25-year-old male smoker, unvaccinated for COVID presented to the hospital with fever, weakness and myalgias and tested positive for COVID. Examination showed mild tenderness in the proximal muscles of the lower extremities. Labs were significant for metabolic acidosis, hypocalcemia, hyperkalemia, acute kidney injury, AST 6178, ALT 1340, CK > 36000 and CPK > 60000 and gross hematuria. Electrolyte abnormalities were corrected and he received aggressive hydration with intravenous fluids containing bicarbonate. Oxygen requirements increased and he received dexamethasone and Baricitinib for COVID. His creatinine continued to increase despite downtrending transaminases and CK. Ultrasound liver was normal. He developed bilateral pleural effusions and mild ascites suspected secondary to volume overload in the setting of acute renal failure. Hemodialysis was initiated and he received a total of 6 sessions of hemodialysis over the next week. Creatinine, BUN and GFR significantly improved. AntiJo1 Ab ordered to rule out polymyositis was negative. Transaminitis and raised CK levels downtrended alongside the COVID inflammatory markers and oxygen requirements as the patient was weaned to room air. DISCUSSION: The spectrum of COVID myositis reported thus far covers asymptomatic elevation of muscle enzymes, myasthenia, paraspinal myositis, dermatomyositis and rhabdomyolysis (1). The pathophysiology of COVID myositis has been hypothesized to be through ACE2 receptor mediated viral entry into muscle fibers leading to activation of innate and adaptive immunity. Other proposed mechanisms include the release of inflammatory cytokines and molecular mimicry with cross reaction of the antiviral antibodies. Myositis was most reported most commonly among males aged 33–87 (1). Symptoms when present include fevers, cough, shortness of breath, myalgias and proximal, lower limb–dominant, acute, and symmetric weakness. Peak CK values as high as 33,000 U/L have been reported (2). In general, patients diagnosed with rhabdomyolysis appear to have negative myositis-specific autoantibodies and higher CK levels than those without, highlighting the need for close monitoring of CK levels. Rhabdomyolysis associated fatality was reported to be as high as 45% (4 of 9 reported) over a short follow-up duration (1). Our case documents a recovery period in days-weeks with hydration and hemodialysis (3). CONCLUSIONS: Areas for exploration include factors predisposing patients to rhabdomyolysis, utility of checking enzyme levels and impact of vaccination on disease severity. Reference #1: Saud A, Naveen R, Aggarwal R, Gupta L. COVID-19 and Myositis: What We Know So Far. Curr Rheumatol Rep. 2021 Jul 3;23(8):63. doi: 10.1007/s11926-021-01023-9. PMID: 34216297;PMCID: PMC8254439. Reference #2: Husain R, Corcuera-Solano I, Dayan E, Jacobi AH, Huang M. Rhabdomyolysis as a manifestation of a severe case of COVID-19: A case report. Radiol Case Rep. 2020 Jul 7;15(9):1633-1637. doi: 10.1016/j.radcr.2020.07.003. PMID: 32690987;PMCID: PMC7340044. Reference #3: Byler J, Harrison R, Fell LL. Rhabdomyolysis Following Recovery from Severe COVID-19: A Case Report. Am J Case Rep. 2021 May 8;22:e931616. doi: 10.12659/AJCR.931616. PMID: 33963170;PMCID: PMC8127859. DISCLOSURES: No relevant relationships by Asim Amjad No relevant relationships by Sarasija Natarajan No relevant relationships by Pius Ochieng No relevant relationships by Yamini Patel

Lenvatinib-induced hypocalcaemia due to transient primary hypoparathyroidism.

CONTEXT: Radioiodine refractory differentiated thyroid cancer can be effectively treated with multi-tyrosine-kinase inhibitors (MKIs). Hypocalcaemia has been reported among the side effects of these drugs, but little is known about its pathophysiology and clinical relevance. CASE REPORT: We report the case of a 78-years-old woman with an aggressive papillary thyroid cancer infiltrating perithyroidal structures. The extent of surgery was limited to hemithyroidectomy, RAI treatment could not be performed, and she started lenvatinib treatment. After 4 months of therapy, the patient accessed the Emergency Department for a grade III hypocalcaemia (corrected serum calcium: 6.6 mg/dL, n.v. 8.1-10.4 mg/dL), due to primary hypoparathyroidism (serum PTH: 12.6 ng/L, n.v. 13-64 ng/L). The patient was treated with intravenous calcium infusions and vitamin D supplementation. After discharge, the oral dose of carbonate calcium (CaCO3) was of 6 g/day, and was titrated according to blood exams. Two weeks after discharge, while taking CaCO3 at the dose of 3 g/day, the patient experienced symptomatic grade II hypercalcemia (corrected serum calcium: 11.6 mg/dL), associated to the spontaneous reprise of PTH secretion, and leading to oral calcium withdrawal. During the subsequent follow-up, the patient remained eucalcemic without calcium supplementation. CONCLUSIONS: Though hypocalcaemia has been described as potential side effect of MKI treatment, this is the first report of a lenvatinib-induced primary hypoparathyroidism, in a patient with a documented normal parathyroid function after surgery. The periodical assessment of calcium-phosphorus metabolism is thus warranted to prevent this potentially lethal side effect, in both post-surgical hypoparathyroid and euparathyroid patients.

The Prevalence of Electrolyte Imbalances and Their Relationship with Disease Severity in Hospitalized COVID-19 Patients

Since the identification of COVID-19, its various manifestations have been reported in numerous studies. However, few studies have specifically examined the electrolyte imbalances seen in this disease. Patients with a definitive diagnosis of COVID-19 admitted to our hospital entered this retrospective cross-sectional study. Upon admission of the patients, a blood sample was sent for the analysis of the electrolytes. The relationship between electrolyte imbalances and disease severity, ICU admission, and mortality was also stated. Of 1072 hospitalized patients studied, 657 were men, and 415 were women. The prevalence of hypocalcemia (47.7%), hypophosphatemia (21.1%), hypomagnesemia (15.8%), and hyponatremia (13%) was higher compared to other electrolyte imbalances in these patients. Lower levels of sodium, calcium, and magnesium were seen in severe cases, while higher serum levels of potassium and phosphorus were detected in severe cases and ICU hospitalized patients. Causes such as albumin decrease in inflammation, the role of PTH, and the effect of vitamin D can play a role in hypocalcemia in these patients. In addition, electrolyte loss from the digestive tract can contribute to electrolyte imbalances. Because of the high prevalence of electrolyte imbalance in these patients, electrolyte monitoring is recommended in COVID-19 patients to ensure better care. © 2022, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

COVID-19 HAD AN ADVERSE IMPACT on DENOSUMAB TREATMENT PROVISION-COMPARISON with PRE-PANDEMIC WAITING TIMES at A UK-BASED RHEUMATOLOGY DEPARTMENT

Background: Denosumab treatment is licensed for prevention of osteoporo-tic fractures. It can cause hypocalcaemia, so bone profile blood tests must be checked prior to treatment. In our department, we have a Standard that patients have blood tests within 1 month before their denosumab injection, and that they receive the injection within 1 month from its due date. A customized MS Access database to record this information and generate a date for the next dose was established in 2015 after a quality improvement project (QIP)1. At the onset of the COVID-19 pandemic, UK national guidance recommended continued provision of denosumab as an essential service. Objectives: 1. To re-audit delay from due date to actual injection date after establishment of our database. To compare delay from due date to actual injection date before and after onset of COVID-19. To compare the time between blood tests and actual injection date, before and after onset of COVID-19. Methods: Data for 2 time-periods were extracted from the database: Time Period 1 (pre-COVID-19) 01-03-2019-29-02-2020;Time Period 2 (post-COVID-19 onset) 01-03-2020-28-02-2021. For each patient attendance, dates of blood test, due date and actual injection date were extracted. All patient details were anonymised, with a decryption key to identifers held on a secure server at the host Trust. It was manually determined whether blood tests and injections were within 1 month of when they were due. Statistical analyses were carried out in Stata v.14.0. The Kolmogorov-Smirnov test was used to compare distributions between Time Periods 1 and 2. Results: TIME PERIOD 1: 100 appointments were audited from 68 patients. 20% of blood tests were within 1 month of actual injection date. Median time between blood tests and actual injection was 45 days [IQR 35-59]. 52% of actual injections were given within 1 month from due date. (This compares favourably with our 2015 QIP, when 40% of actual injections were within 1 month from due date1). Median time between due date and actual injection was 29.5 days [IQR 13-50.5]. TIME PERIOD 2: 77 appointments were audited from 66 individual patients. 24.7% of blood tests were within 1 month of actual injection. Median time between blood tests and actual injection was 45 days [IQR 35-59]. 16.6% of actual injections were given within 1 month of due date. Median time between due date and actual injection was 82 days [IQR 40-141]. There were no signifcant differences in time between blood tests and actual injection between Time Periods 1 and 2. However, the time between due date and actual injection date was signifcantly longer in Time Period 2 (p<0.005). Conclusion: The introduction of our customized database promoted an improvement in time between due date and actual injection date of denosumab. However, this improvement signifcantly declined after the onset of the COVID-19 pandemic. Resources may need to be increased and processes adapted to minimise the impact of future emergencies on denosumab provision.

SCARED INTO SCURVY: NUTRITIONAL DEFICIENCIES DUE TO FEAR OF COVID-19

CASE: A 26-year-old male presented to the hospital with 2 weeks of difficulty ambulating, bilateral lower extremity rash, and diffuse myalgia with arthralgia. Symptoms began suddenly with lower extremity pain and difficulty getting up from his chair. He denied sensory changes, and pain was most prominent at the hips and knees. He also noticed a new rash on his thighs and mild bleeding from his gums. All other review of systems were negative. He denied family history of autoimmune disease and was without any personal chronic medical conditions. He was the primary caretaker of his grandmother and had stayed isolated at home throughout the COVID-19 pandemic. Vital signs were normal, and physical exam revealed 3/5 right hip flexion, 4/5 left hip flexion, and 4/5 right knee flexion and extension. Inspection of his rash demonstrated follicular hyperkeratosis, perifollicular erythema, and corkscrew hairs. Initial lab work revealed anemia, hypothyroidism, hypotonic hyponatremia, hypocalcemia, an elevated CK, ESR, and CRP. Extensive infectious and autoimmune workup was unrevealing. Further interview revealed that his diet consisted of soy milk, potato chips, crackers, peanut butter, and water in the preceding 6 months. This was intentionally done to reduce exposure to SARS- CoV-2. Further evaluation revealed Vitamin C, Vitamin D, Zinc, and Iron deficiencies. His presenting symptoms and rash were ultimately attributed to hypothyroid myopathy and Scurvy. Following thyroid replacement therapy, dietary education, and nutritional supplementation, he experienced improvement in his symptoms and rash. IMPACT/DISCUSSION: It has become evident that the COVID-19 pandemic has had significant psychosocial impact on the public, with substantial portions of our population experiencing increased fear and anxiety. Interestingly, a longitudinal study by Pan et al. found that Dutch patients without prior mental health disorders, such as our patient, had a more significant increase in depression, anxiety, and worry during the pandemic. To add to this, a study by Izzo et al. found that a substantial part of their study population had turned to unhealthy nutritional behaviors during the pandemic. Furthermore, Nguyen et al. demonstrated that increased health literacy was protective against the negative psychological impacts of the COVID-19 pandemic. Our case presents an outcome of merging pandemic fears with poor health literacy. It also highlights the critical role of the clinician as historian. Conceptualizing the patient's clinical presentation with their daily life ultimately led to appropriate diagnostic workup and treatment. CONCLUSION: As the COVID-19 pandemic continues, its broader and less apparent effects will continue to be seen. Clinicians must remain vigilant in assessing the changes in their patients' daily lives with open and invested communication. Early identification of potentially harmful changes and improved health education could prevent potential complications.

Unrecognized Primary Hypoparathyroidism with Severe Hypocalcemia in the Presence of COVID-19 Infection.

Primary hypoparathyroidism (PHPT) is a rare disease most commonly caused by surgical parathyroid glands destruction or genetic disorders. PHPT manifestation varies from subclinical to acute or even lethal symptoms. In atypical presentation the signs of hypocalcemia could be missed, and asymptotic chronic hypocalcemia could manifest only in the presence of exacerbated comorbidities, infections, hypomagnesemia or certain medications. We present a case of PHPT with severe hypocalcemia manifesting as seizures and delirium in a presence of COVID-19 infection.

The osteo-metabolic phenotype of COVID-19: an update.

CONTEXT: In the multifaceted COVID-19 clinical scenario characterized by a multi-system disorder with negative implications not only on respiratory function but also on cardiac, hematological, neurological and endocrine-metabolic systems, a distinctive osteo-metabolic phenotype with an independent influence on disease severity and recovery of patients affected was early reported. AIM: To summarize and update the main evidences regarding the distinct components of this phenotype in acute and Long COVID-19, reinforcing its clinical relevance and discussing the main pathophysiological and clinical-therapeutic implications of the most recent reported findings. RESULTS: This emerging phenotype is characterized by a widespread acute hypocalcemia and hypovitaminosis D with an impaired compensatory parathyroid hormone response, and a high prevalence of skeletal complications such as vertebral fractures. The clinical relevance of this osteo-metabolic phenotype on acute COVID-19 is well characterized, and novel seminal evidences are progressively highlighting its importance also in predicting patient's long-term outcomes and Long COVID-19 occurrence. CONCLUSIONS: These findings reinforced the central role of a multidisciplinary team, including endocrinologists, in evaluating these patients for a proactive search of each aspect of the osteo-metabolic phenotype components since they may represent suitable therapeutic targets to prevent SARS-CoV-2 infection, poor COVID-19 outcomes, Long COVID-19 occurrence and even possibly better responses to COVID-19 vaccination.