A Quality Improvement Project Impacts Resident Satisfaction with the Depart Process

Purpose of Study The current depart process resulted in slow work-flow and patient safety and equity concerns. The QI project aimed to improve resident satisfaction with the hospital discharge process. Methods Used The QI project was designed using the Model for Improvement. Starting April 2020, Plan-Do-Study-Act cycles included: hiring clinical team coordinators;creating standard depart instructions for diabetic ketoacidosis, pyelonephritis, seizures, croup and dehydration;uploading instructions to Powerchart;and clinician reminders to use instructions with families. Measures examined monthly, included resident satisfaction and patient readmissions. Summary of Results Resident satisfaction improved from 4.8 (February 2020) to 7.8 (August 2020) for the overall discharge process;from 5.3 to 7.9 for family education on all key points;from 6.0 to 7.7 for smooth transition of care;from 3.0 to 7.4 for no language barriers;and from 3.0 to 6.7 for no unnecessary delays, on a scale of 0/strongly disagree/ terrible to 10/strongly agree/excellent. Readmissions also trended downward. Conclusions During this QI project to address the depart process, resident satisfaction improved and readmissions declined. These results are encouraging, but should be interpreted in the context of decreased patient census due to COVID-19 and non-respiratory season, which may have decreased workload and increased education time and interpreter access. Next steps include PDSAs related to health literacy and Spanish translation.

Principles of glucocorticosteroid administration in patients with COVID-19

Introduction. This article discusses the treatment of coronavirus infection (COVID-19) with glucocorticosteroid drugs (GCS), side effects of drugs and their prevention, transfer from intravenous to intramuscular and then to oral administration, and the development of withdrawal syndrome. The article describes the conditions under which antibiotic therapy is prescribed, as well as the conditions under which the combined use of corticosteroids and antibiotics is necessary. Aim. The aim to analyze the basic principles of corticosteroids prescribing in the treatment of COVID-19: indications for corticosteroids administration, administration regimens and required dosages, side effects of corticosteroids administration. Material and methods. The article uses data from the Interim Guidelines for the Prevention, Diagnosis and Treatment of New Coronavirus Infection (COVID-19), the Federal Clinical Guidelines for the Specialty "Rheumatology", as well as using the literature on basic and clinical endocrinology, cardiology and pharmacology. The work was written using a systems approach, methods of analysis, induction and observation. Results and discussion. Systemic corticosteroids are used in cases of severe and critical course of the disease COVID-19 (confirmation may be an increase in ferritin, procalcitonin, C-reactive protein (CRP), decreased cognitive functions, development of sopor). Their appointment is also justified when the initial course of the disease was not diagnosed as severe, but suddenly the patient's condition deteriorated. The use of antibiotic therapy is advisable when a bacterial infection is attached - (procalcitonin (PCT) > 0.5 ng / ml, purulent sputum, leukocytosis> 12 x 109 / L (in the absence of previous use of glucocorticoids), an increase in band neutrophils of more than 10%). In the presence of chronic infectious diseases in patients with COVID-19 (for example, chronic obstructive pulmonary disease-COPD, chronic pyelonephritis, etc.), antibiotics are prescribed to prevent exacerbations of these diseases. Conclusion. In the course of the study, the authors of the article formulated the following principles of glucocorticoid therapy: drugs should be prescribed according to strict indications;maximum doses are applied in a short course;when the patient's condition is stabilized, it is necessary to reduce the dose in a timely manner and gradually to complete withdrawal to prevent the development of "withdrawal" syndrome, adrenal insufficiency of central genesis, sympathoadrenal crises;during and after treatment, prevention of complications of glucocorticoid therapy (hyperglycemia, hypocalcemia, osteopenia, inflammatory diseases of the urinary system) is recommended;collegial management of patients by infectious diseases and endocrinologists is mandatory.

Treatment of asymptomatic bacteriuria in the first 2 months after kidney transplant: A controlled clinical trial.

BACKGROUND: The incidence of urinary tract infections (UTIs) in the first 2 months postrenal transplantation (pRT) is very high. We evaluate the efficacy of asymptomatic bacteriuria (AB) screening and treatment on the incidence of UTI in the first 2 months pRT METHODS: We conducted a randomized controlled clinical trial. A urine culture was obtained in all patients on the day of the bladder catheter removal, on week three, and before removal of the ureteral catheter. The intervention group received treatment for AB. The control group did not receive treatment. The primary outcomes were the cumulative incidence of UTI and/or graft pyelonephritis and the time to the first episode of UTI and/or graft pyelonephritis RESULTS: Eighty patients were randomized, 40 in each group, and the median follow-up was 63 days (IQR 54-70). The average age was 29.8 years and 33.7% (n = 27) were women. The incidences of UTI (n = 10, 25 % vs. n = 4, 10%, p = .07) and pyelonephritis (n = 6, 15% vs. n = 1, 2.5%, p = .04) were greater in the intervention group, as also shown in the survival analysis: UTI (HR2.8, 95% CI 0.8-9.1, p = .07) and pyelonephritis (HR 6.5, 95% CI 0.8-54.7, p = .08), respectively. The most commonly isolated bacterium was Escherichia coli (n = 28, 59.5%), and over half were E. coli with extended-spectrum beta-lactamases (n = 15). A major limitation was not obtaining the calculated sample size due to a delay in patient recruitment resulting from the COVID-19 pandemic CONCLUSION: Treatment of AB in the first 2 months pRT does not decrease the incidence of UTI or graft pyelonephritis and may actually increase their frequency. Routine treatment of AB during the first months after renal transplantation should not be a standard procedure.

A CASE OF LONG-TERM TOLERANCE AFTER KIDNEY TRANSPLANTATION.

We present a case of long-term organ functioning (ca.10 years) after allografting of a cadaveric kidney without usage of immunosuppressing drugs. In 2005, a patient suffering from a hypertensive form of chronic glomerulonephritis, have received an allogeneic graft of cadaveric kidney compatible for AB0 system, HLA antigens (A19, B07, DR04), and negative results of cross-match test. The graft function was immediately restored, with normalization of creatinine levels achieved 4-5 days after surgery. Immunosuppression with cyclosporine, solumedrol, cellcept, metypred and simulect was performed in the hospital. Pulse therapy with solumedrol was performed on the day +20 due to the development of initial rejection signs. The postoperative period proceeded without infectious complications. The patient was discharged being recommended to take cyclosporine, Cell-Sept and Metypred. Within a year after transplantation, the patient claimed for pain in the hip joint, and, therefore, metypred was completely canceled. Subsequently, the Cellcept was replaced with a Mayfortic. In 2007, the signs of coxarthrosis were revealed at computed tomography, followed by aseptic necrosis of the the right femur head. Deforming osteoarthritis of the right hip joint was detected, and the hip replacement surgery was suggested. In 2010, due to risk of side effects from ongoing immunosuppressive therapy, e.g., joint damage, the Mayfortic was canceled. In 2012, being in fear of original Sandimmun Neoral replacement by a generic drug, the patient completely refused cyclosporine therapy. In 2021, the endoprosthetics of the right hip joint was performed, and the surgical wound healed initially. Since 2012, the patient has not completely taken immunosuppressive therapy. Over this time period, the patient has never been admitted to the hospital for impaired functioning of the organ graft. Meanwhile, he monitored his graft function on regular basis undergoing biochemical analyses, clinical examination, ultrasound studies of the graft and made regular visits to the outpatient department. In 2021, a week after hip replacement, there was a slight increase in serum creatinine, followed by further increase to 230 mmol/L in 2021, and to 310 mmol/L in March 2022. In February 2022, the patient suffered mild respiratory infection (confirmed COVID-19). In March 2022, the first clinical signs of increasing nephropathy appeared, i.e., swelling of both lower extremities, with leukocytes in urine upon routine analysis, increased blood flow resistance in the main artery of the transplant shown by ultrasound study. Due to worsening of the patient's condition, he resumed taking the prescribed immunosuppressants. Copyright © 2022, SPb RAACI.

Conservative Management of a COVID-19-positive Patient With Emphysematous Pyelonephritis: A Case Report.

Herein, we present a case of emphysematous pyelonephritis with septic shock that was treated conservatively. A 44-year-old woman with diabetes mellitus presented to the emergency department with acute abdominal discomfort. Clinical examination revealed that the patient was conscious but vitally unstable. Therefore, the patient required inotropic support. A computed tomography scan revealed gas in the left kidney, suggestive of emphysematous pyelonephritis. Subsequently, the patient was treated conservatively and stabilized with broad-spectrum antibiotics, strict blood glucose management, and drainage.

A CASE OF LONG-TERM TOLERANCE AFTER KIDNEY TRANSPLANTATION

We present a case of long-term organ functioning (ca.10 years) after allografting of a cadaveric kidney without usage of immunosuppressing drugs. In 2005, a patient suffering from a hypertensive form of chronic glomerulonephritis, have received an allogeneic graft of cadaveric kidney compatible for AB0 system, HLA antigens (A19, B07, DR04), and negative results of cross-match test. The graft function was immediately restored, with normalization of creatinine levels achieved 4-5 days after surgery. Immunosuppression with cyclosporine, solumedrol, cellсept, metypred and simulect was performed in the hospital. Pulse therapy with solumedrol was performed on the day +20 due to the development of initial rejection signs. The postoperative period proceeded without infectious complications. The patient was discharged being recommended to take cyclosporine, Cell-Sept and Metypred. Within a year after transplantation, the patient claimed for pain in the hip joint, and, therefore, metypred was completely canceled. Subsequently, the Cellcept was replaced with a Mayfortic. In 2007, the signs of coxarthrosis were revealed at computed tomography, followed by aseptic necrosis of the the right femur head. Deforming osteoarthritis of the right hip joint was detected, and the hip replacement surgery was suggested. In 2010, due to risk of side effects from ongoing immunosuppressive therapy, e.g., joint damage, the Mayfortic was canceled. In 2012, being in fear of original Sandimmun Neoral replacement by a generic drug, the patient completely refused cyclosporine therapy. In 2021, the endoprosthetics of the right hip joint was performed, and the surgical wound healed initially. Since 2012, the patient has not completely taken immunosuppressive therapy. Over this time period, the patient has never been admitted to the hospital for impaired functioning of the organ graft. Meanwhile, he monitored his graft function on regular basis undergoing biochemical analyses, clinical examination, ultrasound studies of the graft and made regular visits to the outpatient department. In 2021, a week after hip replacement, there was a slight increase in serum creatinine, followed by further increase to 230 mmol/L in 2021, and to 310 mmol/L in March 2022. In February 2022, the patient suffered mild respiratory infection (confirmed COVID-19). In March 2022, the first clinical signs of increasing nephropathy appeared, i.e., swelling of both lower extremities, with leukocytes in urine upon routine analysis, increased blood flow resistance in the main artery of the transplant shown by ultrasound study. Due to worsening of the patient's condition, he resumed taking the prescribed immunosuppressants. © 2022, SPb RAACI.

Infections in people with diabetes

People with diabetes mellitus have an increased risk of many common infections, such as urinary tract infections, lower respiratory tract infections and skin/soft tissue infections. This is caused by a combination of systemic and local host factors, and also specific organism characteristics. Individuals with diabetes mellitus also tend to acquire more complex infections, such as emphysematous cholecystitis and emphysematous pyelonephritis. Some conditions, such as malignant otitis externa and rhinocerebral mucormycosis, occur almost exclusively in people with diabetes. Despite greater susceptibility to infections and worse outcomes, there is little guidance regarding prevention and treatment measures for infections in those with diabetes. Comprehensive longitudinal studies are needed to further investigate the complex relationship between glycaemic control and infections. Copyright © 2022

Emphysematous Pyelonephritis, Emphysematous Cystitis, and Emphysematous Ureteritis: A Case Report.

Emphysematous urinary tract infections (EUTIs) are rare, severe, and suppurative infections affecting various parts of the urinary tract. We report a case of a 75-year-old male presenting with hematuria and generalized weakness with uncontrolled diabetes mellitus (DM) and hypertension. He tested positive for COVID-19 on the second day of hospital admission. A non-contrast-enhanced CT of the abdomen and pelvis revealed gas within the left renal parenchyma, walls of the left ureter, and urinary bladder, establishing the diagnosis of EUTIs. The patient was treated using intravenous antibiotics without any surgical intervention, and four weeks later was stable and transported to long-term acute care (LTAC) facility. DM is the most common risk factor for the development of EUTIs and Escherichia coli is the most common causative pathogen.

A CASE OF SARS-COV-2 ASSOCIATED WITH QUADRUPLE BACTERIAL COINFECTION

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: SARS-CoV-2 has been associated with co-infecting pathogens, such as bacteria, viruses, and fungi. Little has been reported about community acquired atypical bacterial co-infections with SARS-CoV-2. We present a case of a patient with recent COVID-19 pneumonia and diagnosis of Legionella and Mycoplasma pneumonia, in addition of E. coli and C. perfringens bacteremia, that emphasizes SARS-CoV-2 impact in human immunity and the need to consider community acquired infections. CASE PRESENTATION: A 64-year-old male with history of hypertension, alcohol use disorder, iron deficiency anemia, and recent COVID-19 pneumonia presented to the ED with shortness of breath, dark urine, and increased confusion. The patient was admitted to the hospital a week prior with COVID-19 pneumonia and acute kidney injury. He received dexamethasone, remdesivir, and IV fluids. After 8 days, he was discharged home. Upon evaluation, he was afebrile and normotensive, but tachycardic, 129/min, on 4 L of nasal cannula sating 100%. On exam, the patient was oriented only to person and had decreased breath sounds bilaterally. Labs revealed an elevated WBC, 15.3 K/mcL, with left shift, low Hgb, 7.8 g/dL, with low MCV, 61 fL, increased BUN/Cr, 56 mg/dL and 2.8 mg/dL, and an abnormal hepatic panel, AST 121 U/L, ALT 45 U/L, alkaline phosphatase 153 U/L. Ammonia, GGT, CPK and lactic acid were within normal range;but the D-dimer and procalcitonin were elevated, 4618 ng/mL and 25.12 ng/mL, respectively. A urinalysis showed gross pyuria, positive leukocyte esterase and mild proteinuria. CT head showed no acute abnormalities, but the chest X-Ray revealed a hazy opacity in the left mid and lower lung, followed by a CT chest that demonstrated peripheral and lower lobe ground glass opacities and a CT abdomen that showed right sided perinephric and periureteral stranding. Given increased risk for thromboembolism, a VQ scan was done being negative for pulmonary embolism. The patient was admitted with acute metabolic encephalopathy, acute kidney injury, transaminitis, pyelonephritis and concern for hospital acquired pneumonia. Vancomycin, cefepime and metronidazole were ordered. HIV screen was negative. COVID-19 PCR, Legionella urine antigen and Mycoplasma IgG and IgM serologies were positive. Blood cultures grew E. coli and C. perfringens. Infectious Disease and Gastroenterology were consulted. The patient was started on azithromycin and a colonoscopy was done showing only diverticulosis. After an extended hospital course, the patient was cleared for discharge, without oxygen needs, to a nursing home with appropriate follow up. DISCUSSION: Co-infection with bacteria causing atypical pneumonia and bacteremia should be considered in patients with recent or current SARS-CoV-2. CONCLUSIONS: Prompt identification of co-existing pathogens can promote a safe and evidence-based approach to the treatment of patients with SARS-CoV-2. Reference #1: Alhuofie S. (2021). An Elderly COVID-19 Patient with Community-Acquired Legionella and Mycoplasma Coinfections: A Rare Case Report. Healthcare (Basel, Switzerland), 9(11), 1598. https://doi.org/10.3390/healthcare9111598 Reference #2: Hoque, M. N., Akter, S., Mishu, I. D., Islam, M. R., Rahman, M. S., Akhter, M., Islam, I., Hasan, M. M., Rahaman, M. M., Sultana, M., Islam, T., & Hossain, M. A. (2021). Microbial co-infections in COVID-19: Associated microbiota and underlying mechanisms of pathogenesis. Microbial pathogenesis, 156, 104941. https://doi.org/10.1016/j.micpath.2021.104941 Reference #3: Zhu, X., Ge, Y., Wu, T., Zhao, K., Chen, Y., Wu, B., Zhu, F., Zhu, B., & Cui, L. (2020). Co-infection with respiratory pathogens among COVID-2019 cases. Virus research, 285, 198005. https://doi.org/10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Albert Chang No relevant relationships by Eric Chang No relevant relationships by KOMAL KAUR No relevant relationships by Katiria Pintor Jime ez

Severe maternal infectious morbidity during the second half of pregnancy is an independent risk factor for a small for gestational age neonate.

OBJECTIVE: The effect of severe maternal infectious morbidity on fetal growth during the second half of pregnancy is under debate. Preliminary evidence suggests that such association may be plausible. The objectives of this study were to determine: 1) The association between severe maternal infectious morbidity and adverse pregnancy outcome; and 2) The effect of maternal infection during pregnancy on fetal growth. STUDY DESIGN: This retrospective population - based cohort study included 4771 women who gave birth at our medical center during the study period. Parturients were allocated into two groups: 1) patients with severe maternal infection during the second half of pregnancy (n = 368); and 2) control group comprised of normal pregnant women who were matched to the study group by maternal age, gravidity and parity (n = 4403). RESULTS: The severe maternal infection group included women with pneumonia (n = 198), pyelonephritis (n = 131), and viral pneumonitis (n = 39). In comparison to the normal patients group: 1) having had pneumonia during the second half of pregnancy was associated with increased rates of fetal growth restriction, placental abruption, fetal demise (P < 0.001, for all comparisons) and preeclampsia (P = 0.041); 2) Pyelonephritis during the second half of gestation was associated with higher rates of fetal growth restriction (P < 0.001), placental abruption (P = 0.006) and labor induction (P = 0.039). As a group, women with severe maternal infection had higher rates of small for gestational age neonates compared to normal parturients (P < 0.001). Among women with infections, only those who had pyelonephritis (P = 0.032) or pneumonia (P = 0.008), had a higher rate of small for gestational age neonates than those in the control group. After adjustment to confounding factors, maternal infection (OR = 1.42, 95% CI 1.085-1.85) and previous delivery of a small for gestational age neonate (OR = 2.54, 95% CI 2.02-3.19), were independent risk factors for the delivery of a small for gestational age neonate. CONCLUSION: Severe maternal infectious morbidity during the second half of pregnancy is an independent risk factor for the delivery of a small for gestational age neonate and is associated with adverse pregnancy outcomes. Both, pneumonia and pyelonephritis, during the second half of gestation affect fetal growth and are related to higher rates of small for gestational age neonates.

ACUTE INTERSTITIAL NEPHRITIS AS A PRIMARY PRESENTATION OF CANDIDA INFECTIVE ENDOCARDITIS

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

INFECTIOUS PATHOLOGIES AFFECTING KIDNEY TRANSPLANT RECEPIENTS: A SINGLE CENTRE PROSPECTIVE OBSERVATIONAL STUDY

Introduction: Kidney transplant recipients (KTRs) have to receive lifelong immunosuppressive therapy. Consequently they are predisposed to life threatening infections. Even though the data on infectious pathologies have been described in KTRs, the data on long term sequalae of such diseases is lacking. Methods: In this single high volume centre we followed up 100 KTRs, who presented to us with signs of infections. Patients presenting with acute drug reaction or toxicity, malignancy, and auto-immune disorders were excluded. Results: Majority of the patients were male (80%) with a median age of 47years and the median duration of follow up is 34 months. Comorbidites were present in majority of patients in the form of hypertension (83%), Diabetes (11%), heart disease (7%). Amongst infections prior to kidney transplant, TB (28%), HCV (11%) and HBV (1%) were the predominant. 33% patients had acute graft dysfunction, which on biopsy showed mostly ATN and was managed conservatively. However one patient had features of CMV viremia, which was managed with iv Valganciclovir. During follow up 57% of patients presented to us with at least one episode of infection, while 24% patients had 3 more episodes of infection during the follow up period. First episode of infection occurred after a median duration of 10 months. The most common infections were UTI (40%), acute gastroenteritis (35%), CMV infections (10%),pyelonephritis (5%), bacterial pneumonia (5%) protozoal infections (2%), COVID (2%). Most of the infections were managed successfully however 10% patients had graft dysfunction and are on maintenance hemodialysis. Conclusions: Infections in KTRs are a serious debilitating condition which affect graft function. Prompt and aggressive treatment is warranted for graft survival. No conflict of interest

EMPHYSEMATOUS PYELONEPHRITIS IN THE COVID & CANCER ERA- CASE SERIES FROM A TERTIARY CARE HOSPITAL IN CHENNAI, SOUTH INDIA

Introduction: Emphysematous pyelonephritis (EPN) is a rare yet life threatening, necrotizing renal parenchymal infection with a mortality rate of 20-25%. With advent of CT, early goal directed therapy with antibiotics, aggressive treatment of sepsis and percutaneous drainage techniques, the mortality and morbidity rates are not as grim as earlier reports. Nephrectomy, treatment of the past has been replaced with nephron sparing surgery with better patient outcomes. A retrospective study was conducted at Government Kilpauk Medical College Hospital between January 2020 and April 2022. Diabetes, obstructive uropathy, structural abnormalities of the urinary tract and immunosuppression are well known risk factors for EPN. Malignancy and associated chemotherapy can make the vulnerable even more susceptible to EPN. The COVID19 pandemic, which was rampant for the past two years, with steroids being the cornerstone of management of COVID pneumonia also contributed to significant immunosuppression and poor glycemic control in many. This study wants to highlight along with traditional risk factors, the impact of COVID19 and Cancer on EPN. Methods: Demographic, clinical, radiological, and microbiological data of 33 patients were recorded. The data were analyzed to study risk factors, treatment modalities, need for hemodialysis, prognostic factors contributing to morbidity and mortality and patient outcome.The initial diagnosis of EPN at presentation was made by ultrasound evidence of gas in renal parenchyma, which was confirmed by CT imaging. Results: Out of a total 33 patients, 64% were females and the median age was 57.5 years. At presentation, common symptoms were abdominal pain (93%), renal angle tenderness (87%), fever (82%), vomiting (75%), dysuria (74%) and oliguria (65.9%). 81.8% (n=27) patients were diabetic. Urinary tract obstruction was present in 33.3% (n=11), Solid organ malignancy related EPN in 21.2% (n=7), with cancers involving kidney and urinary tract predominantly, concomitant COVID infection in 18.2% (n=6) patients, renal transplant EPN in 9% (n=3) of patients respectively. Most common organism was E.coli (60%) followed by Klebsiella spp.(10%), Pseudomonas (8%), Candida spp. (5.6%), Proteus mirabilis (1.4%) and culture negative EPN (15%). CT scoring was done by Huang and Tseng classification. Class I was documented in 28%, Class 2 in 58.8%, Class 3 in 11.8% and Class 4 in 2% of patients. DJ stenting was done in 55% of patients, percutaneous nephrostomy in 3% and the remaining patients improved with antibiotics alone. 35.7% (n=12) required dialysis,10.7% (n=4) were dialysis dependent at the end of three months with 9%(n=3) requiring dialysis indefinitely. Gender, glycemic status or uremic symptoms showed no statistical significance. Sepsis, shock, altered sensorium, higher serum creatinine and hemodialysis dependency had significant impact on patient's outcome. Conclusions: Early diagnosis and treatment with broad-spectrum antibiotics and properly timed interventions decreased mortality. Abdominal pain, renal angle tenderness and fever were the most common symptoms. E. coli was the commonest organism encountered. Solid organ malignancy contributed to a sizable portion of EPN in our study secondary to susceptibility to infections and obstruction. COVID19 infection is a risk factor for EPN due to worsening glycemic status and immunosuppression caused by steroid administration. No conflict of interest

CASE REPORT of A HARD to TREAT DERMATOMYOSITIS after A COVID-19 INFECTION and SUBSEQUENT VACCINATION

Background: A 50 years old woman, a medical doctor, came to our department with symmetrical proximal muscular weakness, several months after Covid-19 infection and three weeks after a second dose of Covid-19 mRNA vaccine. The patient had no prior or family history of autoimmune diseases and take no medicines. In the past she undergone an operation for double-kidney with frequent urinary infections. Objective fndings have shown symmetrical proximal muscular weakness and classic sings of dermatomyositis-Gottron's papules, shawl and holster signs, periungual vasculitis. Objectives: We present a case of a 50 old woman with clinical and laboratory proven dermatomyositis, starting three weeks after a second dose of a Covid1-19 mRNA vaccine without other reasons. Methods: The laboratory tests showed elevated CPK, lactate dehydroge-nase, aspartate aminotransferase and alanine aminotransferase, high ANA-1:1280 and myositis specifc autoantibodies-anti-NXP2 and anti-Mi-2-beta. The electromyography showed myopathic changes and the muscle MRI-symmetrical edema of mm.obturator and mm.adductor brevis. We exclude diseases that may mimic infammatory myopathies. We made a cancer screening-whole body MRI, colonoscopy, gastroscopy, mammography and gynecological exam, immunoblot for detection of paraneoplastic syndrome-associated neuronal antibodies, with no detection of cancer. Muscle biopsy of m.vastus lateralis showed attenuating muscle infammation with advancing muscle atrophy and fbrosis. Results: The diagnose dermatomyositis was made according Bohan and Peter criteria and we start a high dose (1mg/kg/day) glucocorticoid therapy with good initial clinical and laboratory effect. Two months after starting a therapy muscle weakness worsened together with difficulty of swallowing. We excluded steroid myopathy after second EMG and lack of improvement when tapering the GS dose. Methotrexate 20 mg/weekly was added as a steroid sparing drug with good response, but was stopped because fare of pyelonephritis. Accordning to the opinion of dermatologist hydroxychloroquine was started for a couple of weeks, because of active skin manifestations. Muscle weakness worsened on the background of treatment, which was stopped. We started a therapy with intravenous immunoglobulins and considered therapy with cyclophosphamide or azathio-prine after urinary infection. Because the patient was infected for a second time with covid-19, although vaccine, we continued only with glucocorticoids and anti-osteoporotic therapy. Conclusion: The etiology and pathogenesis of infammatory myopathies are not fully clarifed so far. We speculate that the infection with Covid-19 as well as mRNA vaccine trigger infammatory myopathy and compromise the patient's immunity for poor treatment response with glucocorticoids and immunosuppres-sives. On the other hand advanced muscle atrophy and fbrosis within a short period show that suspected triggering factors could be a reason for difficult to treat such type of dermatomyiositis.

Clinical Presentation of Melioidosis: A Case Series

Introduction: Melioidosis is an infectious disease caused by Gramnegative bacterium Burkholderia pseudomallei. It is a potentially fatal disease endemic to tropical and subtropical regions. Bacteria spread by contact with contaminated water and soil. The presentation of this disease is variable ranging from localized infection to fulminant septicemia and multi-organ dysfunction. Objective: The purpose of this study is to look into clinical presentation, treatment, and outcomes of confirmed melioidosis cases in a tertiary care hospital. Materials and methods: This is a retrospective case series of patients in a single tertiary care center between January 2018 and September 2021. We present a series of 19 cases admitted with a confirmed diagnosis of melioidosis. Three of 19 cases discontinued treatment in between but were included in the analysis. Results: We report 19 cases of melioidosis admitted to our hospital in a span of 3 years (17 males and 2 females). The median age of presentation was 47 years. The disease had varied presentation with lung involvement in 11 cases (57%), solid organ abscesses in 8 cases (42%), osteomyelitis and septic arthritis in 5 (26%), and acute pyelonephritis in 2 cases (10%). Lung involvement was seen as consolidation, septic emboli, and solid nodular lesions. Most common risk factor associated with disseminated disease was diabetes. Diabetes was seen in 17 cases (89.4%). All patients had uncontrolled blood sugars and 2 cases presented in DKA. Other comorbidities seen were systemic hypertension (16%), coronary artery disease (10%), chronic liver disease (10%), post COVID (10%), and SLE (5%). ARDS complicating lung condition was seen in 6 patients (54%) of which 3 patients were managed with NIV and 3 patients required invasive mechanical ventilation. AKI was seen in 11 patients (57.8%) of which 8 patients recovered from AKI and 3 patients required renal replacement therapy. One patient with associated lupus nephritis required long-term hemodialysis. Altered liver function test was seen in 11 patients (57.8%). Bone marrow suppression is common. Three patients had pancytopenia and 10 patients had thrombocytopenia. Hyponatremia was the most common electrolyte abnormality seen in 7 patients (36.8%). Of the 19 cases admitted three patients did not continue treatment. Median hospital stay for the remaining 16 cases was 16 days. 15 out of 16 cases survived with a survival rate of 93.7% and one mortality (6.2%). Conclusion: Melioidosis is a potentially fatal disease. High index of suspicion is required for diagnosing this condition due to its varied presentation. Early diagnosis and appropriate treatment is the cornerstone in improving the outcome. Though mortality was less than 6%, they have significant morbidity with prolonged ICU and hospital stay leading to increased economic burden.

Immune-mediated Acute Limb Ischemia: A Rare Complication of SARS-CoV-19 Infection

Occurrence of acute limb ischaemia (ALI) in patients with SARS-CoV-2 is an uncommon complication. COVID-19 has been associated with thrombotic disease secondary to a hypercoagulable state. COVID-19 appears to cause a hypercoagulable state through mechanisms unique to SARS-CoV-2 and centres on the cross-talk between thrombosis and inflammation. The proposed hypothesis includes a severely heightened inflammatory response that leads to thrombotic inflammation, through a mechanism such as cytokine storm, complement activation, and endothelitis. The innate and adaptive immune responses result in immunemediated thrombosis, leading to thrombotic complications, such as myocardial infarction, pulmonary embolism, deep vein thrombosis, and stroke. The activation of coagulation (D-dimer) and thrombocytopenia are important prognostic markers in SARSCoV- 19 infections. At our institution, we found six patients to have ALI and reviewed their characteristics and outcomes. Our findings showed that in severe COVID-19 disease, the association of ALI had high mortality. Materials and methods: It is a retrospective observational study performed at Bangalore Baptist hospital during the COVID-19 pandemic (August 2020 to August 2021). We report a case series of 6 ALI patients aged between 30 and 55 years. All the patients were tested positive for SARS-CoV-2 disease. All our patients received standard treatment care as per institution protocol for SARS-CoV-2 disease. They were all commenced on therapeutic anticoagulation at admission to ICU. Baseline coagulation profile and inflammatory markers and their trends were followed in all patients. The diagnosis of ALI in all ventilated patients was done clinically by the presence of pallor, pulselessness, acrocyanosis, blisters, and dry care unit with SARS-CoV-2 disease, 6 patients had developed limb ischemia (1.4%). Male and female preponderance was equal. Among 6 patients, 1 was newly detected diabetes mellitus, 2 were diabetic and hypertensive of which one had right upper limb post-polio paralytic sequelae, and the rest had no co-morbidities. The mean duration of ICU stay and mechanical ventilation days was 22 days and 17.8 days, respectively. All the patients had lower limb ischemia of which 3 were unilateral. Discoloration extended up to the ankle joint in almost all cases. As these patients were on the ventilator secondary to severe hypoxemia or vasopressor support, they were managed conservatively. Two patients presented with stroke, pyelonephritis with acute kidney injury, and septic shock requiring high vasopressor support. 5 of 6 patients died during the course of treatment (mortality 83%). All patients showed high inflammatory markers especially D-dimer during the initial development phase of limb ischemia. 1 survived patient required bilateral foot amputation due to dry gangrene. Conclusion: Limb ischemia with tissue necrosis is a dreadful complication and is associated with high mortality. High incidence of thrombosis despite therapeutic anticoagulation raises a question about pathophysiology unique to COVID-19. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for the treatment of thrombotic events. Further insight into the cause and management of thrombosis is needed.

Analysis of the Epidemiological Situation on the Pneumonia with Signs of Coronavirus Infection among the Population of the Republic of Kazakhstan

BACKGROUND: New coronavirus infection caused by SARS-CoV-2 (COVID-19), as well as pneumonia with signs of coronavirus infection, continues to spread around the world, but the epidemiological situation is not the same in different countries. AIM: The aim of the study was to analyze the epidemiological situation of coronavirus infection and pneumonia with signs of coronavirus infection in the Republic of Kazakhstan. MATERIALS AND METHODS: Retrospective epidemiological analysis of the incidence of coronavirus infection and pneumonia with signs of coronavirus infection in the republic according to official statistical reporting, as well as a statistical analysis of discharge records of patients diagnosed with coronavirus infection (no virus identified) in a small town of Karaganda region was carried out. RESULTS: An increase in cases, sick persons, recovered persons, and lethal cases in population with positive PCR for COVID-19, as well as pneumonia with signs of coronavirus infection in the Republic of Kazakhstan was registered for the period from January 8, 2020, to December 31, 2021. The number of cases of coronavirus increased in 10.93 times those who recovered – in 15.78 times and deaths – in 16.4 times, respectively. The increase in the number of cases of pneumonia with signs of coronavirus infection also increased in 16.24 time, the number of those who recovered at the beginning of the observation was not established, by the end the number of recovered was 76,989 people, the number of deaths increased in 173.83 time. CONCLUSION: An analysis of the discharge records of patients with pneumonia with signs of coronavirus infection revealed that 54.2% of the patients were females and 45.8% were males. The disease was registered in 21.8% of patients older than 60 years in the presence of concomitant diseases. Concomitant diseases were represented in 42% by arterial hypertension, in 26% by ischemic heart disease, and in 14% by pyelonephritis. The same percentage of cases (12%) was chronic obstructive pulmonary disease and iron deficiency anemia, 11% – diabetes mellitus. Among all patients, 69.4% were urban residents and 30.6% were rural areas.

Indium 111 White Blood Cell Scan to Diagnose Acute Interstitial Nephritis

Drug- Induced Acute Interstitial Nephritis is a known cause of AKI commonly caused by NSAIDS, PPI and antibiotics which have been well documented in the literature. The hallmark presentation is fever, rash and eosinophilia, although this is only seen in a minority of cases. Half of cases do not present with AKI and therefore the clinician must have a high index of suspicion for further workup. Early detection can lead to early treatment which should result in improved outcomes. 67 Gallium renal scan Scintigraphy has been used over the last 30 years to help diagnose AIN, however no known use of Indium-111 WBC Scan has been used to in the diagnosis of AIN. A 71-year-old male presented with fevers and generalized weakness for 4 days, endorsing associated paresthesias in both lower extremities as well as visual hallucinations. After a primary care physician outpatient visit, a WBC Scan showed localization to bilateral kidneys and the colon. He was sent to the hospital for IV antibiotics as bilateral pyelonephritis was suspected. Initial labs was significant for WBC of 11.4k (without Eosinophilia), serum creatinine of 1.73 (Baseline 1.1). Urinalysis was negative for infection however with trace proteinuria. Covid test was negative. Three sets of blood cultures were negative. Imaging was negative for acute pathology. IV antibiotics were started without resolution of symptoms. Transthoracic Echo was negative for any vegetations. Patient continued to have fevers. He stated that he was started on hydralazine three weeks prior to admission. After cessation of Hydralazine he ceased to have fevers. Case was discussed with Radiology and he had a renal biopsy. Biopsy results confirmed mild AIN, 45% global sclerosis, severe arterial and arteriolar sclerosis, tubular atrophy and interstitial fibrosis. He was started on Prednisone and tapered over 2 months. Renal function returned to baseline. AIN was suspected because of recent initiation of Hydralazine even though neither rash nor eosinophilia was present. A positive Indium-111 WBC Scan in the setting of fever, AKI and elevated WBC count encouraged us to proceed with the biopsy even though the patients' AKI had “resolved.” Here we aim to show that Indium-111 WBC assisted in the diagnosis of AIN and could be used in the future for clinicians as an indication for biopsy.

ATYPICAL PRESENTATION OF LEGIONNAIRES DISEASE WITH DIVERTICULITIS IN IMMUNOSUPPRESSED PATIENT

CASE: A 69-year-old male smoker with stage 3b prostate cancer managed with abiraterone and prednisone, prior severe COVID-19 pneumonia requiring mechanical ventilation, and history of perforated sigmoid diverticulitis presented with 3 days of anorexia, watery diarrhea, and left lower abdominal pain. Two weeks earlier he developed a mild dry cough without fever, dyspnea, or chest pain. There were no sick contacts or recent travel. He was afebrile, and initial routine chemistries and a complete blood count were unremarkable. An abdomino-pelvic CT revealed acute diverticulitis of the distal descending and sigmoid colon. A consolidation at the right lung base was also incidentally noted. Follow up imaging confirmed a multifocal pneumonia on chest Xray. Legionella antigen was detected in the urine. Metronidazole and levofloxacin were initiated with clinical improvement and the patient was discharged home to complete a 10-day course of antibiotics IMPACT/DISCUSSION: Legionella bacteria are gram negative organisms found widespread in soil and bodies of water including lakes, streams, and artificial reservoirs. Transmission is via inhalation of aerosols and a high innoculum is typically needed to cause infection. Host risk factors for infection include older age, impaired cellular immunity, smoking, male sex, and medical co-morbidities such as diabetes mellitus, renal, lung and cardiovascular disease. The two most commonly known syndromes associated with Legionella infection are Legionnaire's disease, a pneumonia occurring typically in the late summer or early autumn months (as in our patient), and Pontiac fever, an acute self- limited febrile illness. The mortality rate for hospitalized Legionnaire's is up to 10%. Extra-pulmonary manifestations are rare and can include skin and soft tissue infections, septic arthritis, endocarditis, myocarditis, peritonitis, pyelonephritis, meningitis, brain abscesses, and surgical site infections. The diagnosis of extra-pulmonary disease requires detection of Legionella at the affected site by culture or polymerase chain reaction. In the absence of a known local Legionella outbreak, our patient's age, sex, smoking status, and underlying immune suppression most likely increased his risk for this sporadic infection. We postulate that the acute diarrhea associated with Legionnaire's disease may have triggered inflammation of his diverticula or the acute diverticulitis was an extra-pulmonary manifestation. To our knowledge, we are the first to report a case of Legionnaire's disease presenting as acute diverticulitis. CONCLUSION: Legionnaire's is a typical disease with many atypical and extra-pulmonary presentations. We present a case of Legionnaire's disease masquerading as acute diverticulitis and urge timely consideration and testing for Legionella in at-risk patients presenting with predominantly GI symptoms and subtle or no respiratory complaints, as it can be life-saving.

THE GREAT IMITATOR: A CASE OF RENAL SQUAMOUS CELL CARCINOMA DISGUISED AS CHRONIC PYELONEPHRITIS

CASE: A 78-year-old female with a history of recurrent nephrolithiasis and left ureteral reconstruction presented to our institution with hematuria, flank pain, anorexia and weight loss. 3-4 months prior, she had similar symptoms in her home country and was treated with multiple courses of antibiotics. She attempted to present to the US for evaluation earlier, but was unable to due to COVID. She first presented to a nearby US hospital and was diagnosed with an atrophic kidney with a superimposed infection based on imaging and labs. An EGD/ Colonoscopy done for her weight loss was unrevealing. She was discharged on antibiotics and told to follow up for possible nephrectomy. 1 days later, she presented to our institution with continued symptoms. Repeat CT was concerning for emphysematous pyelonephritis. Vital signs were unremarkable. Labs showed no leukocytosis, normal creatinine, hypercalcemia to 13.0 and urinalysis showed hematuria, pyuria and proteinuria. She was initially treated with IV antibiotics and a percutaneous nephrostomy for source control. To continue work up for her weight loss, a CT chest was done that showed multiple lung nodules and a re-review of the CT abdomen noted a T12 lytic lesion. 2 weeks into her admission, she had a left nephrectomy. Pathology revealed an invasive, grade 3, poorly differentiated squamous cell carcinoma arising from the renal pelvis, with lymphovascular invasion. A biopsy of the T12 lesion was consistent with metastasis. Due to her functional status and aggressive nature of her malignancy, palliative therapies were recommended. Patient's course was further complicated by ileus, massive aspiration and spinal cord compression from the T12 lesion. She passed away on hospital day 45. IMPACT/DISCUSSION: Squamous cell carcinoma of the renal pelvis is a rare malignancy. Most present at an advanced stage with a long history of nonspecific symptoms, such as hematuria and/or flank pain, which are typically attributed to recurrent nephrolithiasis;one of the most well-documented risk factors. Additionally, there are no characteristic findings on imaging, making radiological differentiation between renal SCC and other chronic infectious processes difficult. Often there is no suspicion for malignancy until the pathology results. For these reasons, renal SCC should be considered in patients who have underlying risk factors. One may also benefit from a renal biopsy, which can be done before a nephrectomy and has been shown to have a high degree of diagnostic accuracy. Adding to this diagnostic challenge, our patient's care was delayed due to COVID, demonstrating the importance of considering alternative diagnoses when patients have deferred presentations and fractured workups. CONCLUSION: Consider the diagnosis of renal SCC in patients with recurrent nephrolithiasis, UTIs, unexplained hematuria and/or flank pain and refer for a renal biopsy if appropriate. Be mindful of the impact of fragmented and delayed medical care on vulnerable patients.