Bilateral Spontaneous Pneumothorax in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19

Introduction: Spontaneous pneumothorax is a rare complication of coronavirus disease 2019 (COVID-19), primarily reported in adults. Pediatric cases with bilateral pneumothorax are much less reported. Case Presentation: We presented the case of a five-year-old previously healthy boy who developed persistent fever, abdominal pain, generalized maculopapular rash, and dyspnea before admission. His chest computed tomography (CT) showed a viral involvement pattern of pneumonia suggestive of COVID-19. Subsequently, he was confirmed with multisystem inflammatory syndrome in children (MIS-C). While he responded well to the therapies, on the fifth day of admission, he developed respiratory distress again. A chest roentgenogram showed bilateral spontaneous pneumothorax. Bilateral chest tubes were inserted, and his condition improved sig-nificantly after five days of admission to the intensive care unit. Two weeks later, he was discharged in good condition. Conclusion(s): Children with MIS-C associated with COVID-19 may develop primary spontaneous pneumothorax. Owing to the clinical picture overlapping with MIS-C associated with COVID-19, the timely diagnosis of pneumothorax may be challenging in such patients.Copyright © 2022, Author(s).

Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

Oxygen flow: How much do we know?

Introduction: Since the advent of Covid, oxygen has been the centre of discussion despite being the most important entity for the survival of human life. As various modes of its delivery has been in practice for a long time, using the non-rebreather mask has been a part of most guidelines for emergencies and hypoxia. This requires a higher flowrate of up to 15 l/min. Most flowmeters can deliver upto 75 l/min over the maximum calibrated mark.1 What may appear as a small rise from the maximum labelled mark can deliver more oxygen than required and result in wastage of oxygen or hide the severity of the patient's condition. Using this audit/ QIP we are trying to determine if the flowrates delivered are as per the prescription/protocol. Aim(s): To find out if the oxygen administration when it is prescribed at 15L/min is at the prescribed value and therefore quantify the amount of oxygen that is being wasted. Method(s): Data was collected randomly, observing the flow rates that the patients were receiving as prescribed or over the prescribed rate for those on non rebreather mask. Result(s): 54 observations were recorded from ED, ITU, AMU and theatre recovery across two hospitals. It was found that 57.4% of the patients were on flowrates more than the prescribed value. Conclusion & Discussion: More than half the patients requiring high flow rate of oxygen were on rates more than prescribed. This is potentially due to the lack of understanding of the calibration of the flowmeter. This results in the wastage of oxygen causing significant financial loss and an increase in the carbon dioxide emission impacting the environmental pollution. We plan to run an educational intervention for staff in these departments to emphasise the importance of administering drugs (including oxygen) as they are prescribed, and how easy it is to over administer oxygen.

Respiratory support for adult patients with COVID-19

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).Copyright © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

Sarilumab use in severe Coronavirus Disease 2019 pneumonia

Background Interleukin-6 (IL-6) signal blockers have an important role in the management of Coronavirus Disease 2019 (COVID-19) and prevent progression of inflammation. Many studies have evaluated the efficacy of Sarilumab in severe COVID-19 pneumonia. Aim Evaluation of sarilumab efficacy in severe COVID-19 pneumonia. Patients and methods In all, 40 patients with severe acute respiratory syndrome coronavirus 2 severe pneumonia received intravenous sarilumab 400 mg. Results Patients were admitted to the ICU with a mean duration of 18.17 +/- 8.75 days. Eighteen (45%) patients on high-flow oxygen with nonrebreather masks and 22 (55%) patients on mechanical ventilation received sarilumab. IL-6 level is with a mean of 62.50 +/- 23.01 before sarilumab and a mean of 31.35 +/- 33.30 after sarilumab. Thirteen (32.5%) patients improved and 27 (67.5%) patients died. No sarilumab serious adverse effects were detected in this study. Patient oxygen saturation on discharge mean was 95.75+/-.97%. Concerning serum IL-6 levels among the recruited patients, there was statistically significant difference between the mean baseline level compared with the follow-up levels, 62.50 +/- 23.01 and 31.35 +/- 33.30 ng/ml, respectively, with a P value of 0.001. Conclusion Sarilumab improves IL-6 level in COVID-19 patients with severe pneumonia with no serious adverse effects. Mortality rate increased in severe COVID-19 cases, so early use of sarilumab in moderate cases may decrease disease progression and decrease mortality rate.Copyright © 2023 The Egyptian Journal of Chest Diseases and Tuberculosis.

AKI and Its Relation with Outcome in Patients with COVID-19

Background: Coronavirus disease 2019 (COVID-19) is currently spreading fast around the world. The rate of acute kidney damage (AKI) in patients hospitalized with Covid-19, as well as the outcomes related with it, are unknown. The goal of this study was to see if having acute kidney damage (AKI) increased the risk of severe infection and death in COVID-19 patients. It also described the symptoms, risk factors, and outcomes of AKI in Covid-19 patients. Material(s) and Method(s): We undertook a retrospective cohort from June 2020 and March 2021 to examine the connection between AKI and patient outcomes COVID-19. Result(s): The most common comorbid condition was hypertension and diabetes followed by chronic kidney disease and ischemic heart disease. Most of the patients who required low dose oxygen with nasal prongs, face masks, or rebreathing masks were in control groups (76.2% vs. 50.6%;p <.001). More patients in AKI group needed non-invasive ventilation and invasive mechanical ventilation compared to control group (33.8% vs. 19.9%;p .001, 15.6% vs. 3.9%;p <.001 respectively. Patients in the AKI group had higher levels of C-reactive protein, lactate dehydrogenase, D-dimer, and serum. Of 145 patients who developed AKI, 29 (20%) needed hemodialysis. Of 29 patients who needed hemodialysis, 18 (62%) expired. A higher number of patients in the control group were discharged than patients in the AKI group (82.1% vs. 56.9%;p <.001). One hundred five patients were expired, with higher mortality in the AKI group (41.7% vs. 12.4%;p <.001). Conclusion(s): COVID-19 patients admitted to the hospital, AKI is associated with a shockingly high fatality rate.Copyright © 2022 Lahore Medical And Dental College. All rights reserved.

Successful Treatment of Encephalitis Following SARS-Cov-2 Infection: A Case Report

Background: The SARS-CoV-2 invades the cells by attachment of virus spike proteins (S1, S2) to cell membrane and engages angiotensin-converting enzyme 2 (ACE2), which is highly expressed in the epithelium of cerebral vasculature. Here, we describe a patient with encephalitis following SARS-CoV-2 infection. Case presentation: A 77-year-old male patient presented with mild cough and coryza lasting for eight days without a prior history of underlying disease or neurologic disorder. Oxygen saturation (SatO2) was decreased and behavioral changes, confusion, and headaches were started within three days prior to admission. Bilateral ground glass opacifications and consolidations were noted on chest CT scan. Lymphopenia, highly elevated D-Dimer and ferritin were noted in laboratory results. Brain CT and MRI showed no changes regarding encephalitis. Cerebrospinal fluid was collected as the symptoms persisted. The results of SARS-CoV-2 RNA RT-PCR from CSF and nasopharyngeal samples were positive. The combination therapy with remdesivir, interferon beta-1alpha and methylprednisolone was started. Due to deterioration of the patient's status and SatO2, he was admitted to the ICU and intubated. Tocilizumab, dexamethasone, and mannitol were started. The patient was extubated on the 16th day of ICU admission. The patient's level of consciousness and SatO2 were improved. He was discharged from the hospital a week later. Conclusion(s): RT-PCR of CSF sample along with brain imaging can help with diagnosis when encephalitis due to SARS-CoV-2 is suspected. However, no changes regarding encephalitis may be seen on brain CT or MRI. Combination therapy with antivirals, interferon beta, corticosteroids, and tocilizumab can help patients recover in these conditions.Copyright © 2022 NRITLD, National Research Institute of Tuberculosis and Lung Disease, Iran.

A randomised controlled trial of high-flow nasal oxygen versus non-rebreathing oxygen face mask therapy in acute hypoxaemic respiratory failure.

Background and Aims: A major limitation to providing oxygen therapy by high flow nasal oxygen (HFNO) delivery devices is its availability and therefore as an alternative many clinicians use a standard non rebreathing face mask (NRBM) in order to oxygenate their patients where low-flow nasal oxygen or simple facemask oxygen is not providing adequate respiratory support to achieve the target peripheral oxygen saturation (SpO2). We aimed to determine the clinical effectiveness of HFNO versus NRBM in terms of improving patient outcome among patients admitted to our intensive care unit (ICU) during coronavirus disease-2019 (COVID-19) outbreak. Methods: In this prospective open labelled study, 122 COVID-19 patients presenting with acute hypoxaemic respiratory failure (AHRF) were randomised to receive either HFNO or NRBM to achieve the target SpO2. The primary clinical outcome measured was device failure rate and secondary outcome was all-cause 28-day mortality rate. Results: The device failure rate was significantly higher in HFNO group (39% versus 21%, P = 0.030). Oxygen support with NRBM resulted in a reduced all mortality rate over HFNO (26.2% versus 45%) but the mortality rate after treatment failure in either group (HFNO or NRBM) remained high (91% versus 92%). Conclusion: Oxygen support with NRBM results in both reduced device failure rate and higher survival among patients of COVID-19 with AHRF.

"Tranq dope" in infancy: A 19- day-old with life-threatening poisoning due to fentanyl/xylazine

Background: More and more, young children are victims of the ongoing epidemic of opioid use disorder. Xylazine, an alpha-2 adrenergic agonist with notorious use as a veterinary tranquilizer, is an increasingly encountered component of the illicit opioid supply in the US, but has been rarely documented in biological samples obtained from children. We report a 19-day-old infant with classic manifestations of central nervous system and respiratory depression associated with fentanyl and xylazine poisoning. Case report: A 19-day-old boy was taken to the emergency department (ED) by his parents for episodes of straining, breathholding, and his eyes rolling backwards. The formula-fed boy was born of an uncomplicated full-term spontaneous vaginal delivery and had previously been thriving. During ED triage assessment he had a period of apnea, then bradypnea, with pulse-oximetric oxygen saturation drop to 55%. He was supported with stimulation and supplemental oxygen via nonrebreather mask but remained lethargic, with temperature 96F, heart rate 166/min, and brisk capillary refill. Point of care blood dextrose testing was 88mg/dL. Analysis of respiratory secretions for common viruses by polymerase chain reaction was negative for respiratory syncytial virus, influenza, or SARS-CoV-2. Computed tomography imaging of the brain was unremarkable. A urine drug immunoassay (Vitros 4600 Chemistry , Ortho- Clinical Diagnostics) resulted positive for fentanyl (cutoff 1 ng/ mL), but negative for amphetamine, barbiturate, benzodiazepine, cannabinoids, cocaine, heroin, morphine, buprenorphine, methadone, or oxycodone. Liquid chromatography tandem mass spectroscopy analysis of the urine confirmed the presence of fentanyl (25 ng/mL) and norfentanyl (245 ng/mL). Gas chromatography with mass spectrometry also detected the presence of xylazine (qualitative result based on spectra matching). Over the ensuing hours the boy recovered fully and the family was connected with child protection services;an exposure route was not identified. Discussion(s): This 19-day-old infant suffered fentanyl/xylazine poisoning. The infant's age and urine fentanyl concentrations exclude pre-natal exposure as an explanation for the drug test findings, and the baby was bottle-fed excluding drug transmission through breast milk. Xylazine has been known to be in this hospital's regional heroin supply since the early 2000s, and in 2019 xylazine was implicated in more than 31% of opioid-associated deaths at the city's medical examiner's office. In 2022, many fentanyl samples tested by regional law enforcement find more xylazine than fentanyl. Until recently, xylazine was an uncommon finding in our testing of pediatric opioid poisoning victims. Similar to fentanyl, xylazine may cause pupillary miosis and CNS depression;unfortunately it may be resistant to reversal with naloxone. Conclusion(s): This case is remarkable for the young age of this infant ill from post-natal fentanyl poisoning and for the detection of xylazine in his urine. Healthcare providers may not immediately consider opioid poisoning in the differential diagnosis of infants with altered mental status, and proper toxicological testing is important for appropriate child protection support. Detection of xylazine is a marker for a non-medical, or "street," source of fentanyl.

AN UNUSUAL PRESENTATION OF CHRONIC LYMPHOCYTIC LEUKEMIA AS ORGANIZING PNEUMONIA

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Organizing pneumonia (OP) is a form of interstitial lung disease with a distinct histopathological pattern where bronchioles and alveoli become inflamed. It is associated with many clinical conditions including infections and connective tissue disease. OP has also been seen in patients with hematologic malignancies, however, primary pulmonary presentation of chronic lymphocytic leukemia (CLL) is uncommon. We present a rare case of OP as an initial presentation of CLL. CASE PRESENTATION: A 62 year-old male with a sixty pack year smoking history and COVID-19 infection one month ago presents with complaints of worsening dyspnea, headaches, productive cough, and congestion of 10 days duration. Patient is unvaccinated and did not require hospitalization for his COVID-19 infection. His vital signs on admission were significant for tachypnea with respiratory rate of 35 and hypoxia with oxygen saturation of 84% on room air. He initially required oxygen supplementation via non-rebreather mask to maintain oxygen saturation >88%. A chest tomography (CT) scan was completed and revealed bilateral dense consolidations with ground-glass opacities and air bronchograms consistent with OP. The scan was also significant for bulky mediastinal lymphadenopathy. The patient denied any personal or family history of autoimmune disease, occupational exposures, and recent travel. Evaluation for infection and for underlying connective tissue disease was unremarkable. He was started on broad spectrum antibiotics and high dose steroids. Due to fluctuating lymphocytosis, bulky lymphadenopathy, and negative infectious workup despite clinical improvement, he underwent a bronchoscopy with endobronchial ultrasound guided transbronchial needle aspiration of lymph nodes. Immunohistochemical (IHC) stains of these samples were compatible with CLL. Additionally, peripheral blood flow cytometry was also diagnostic of CLL. Oncology was consulted for further evaluation and treatment of CLL. The patient's respiratory symptoms improved and oxygen requirements decreased with steroid treatment and he was discharged home. DISCUSSION: OP occurring in patients with hematologic malignancies has multiple etiologies. Most case reports describe patients with previous exposure to chemotherapy, radiotherapy, or bone marrow transplant. However, our patient had no such exposure history and no prior diagnosis of a hematologic malignancy. Infectious and autoimmune etiology were considered, but serologic evaluation was unremarkable. Flow cytometric analysis of lymph node tissue along with lymphocytic bronchoalveolar lavage was consistent with initial diagnosis of CLL. CONCLUSIONS: Despite the low incidence, hematologic malignancy should be considered as a differential diagnosis in all patients who present with organizing pneumonia. Prednisone therapy for 6-12 month duration has been shown to reduce respiratory symptoms and may improve survival. Reference #1: Craig E. Daniels, Jeffrey L. Myers, James P. Utz, Svetomir N. Markovic, Jay H. Ryu. Organizing pneumonia in patients with hematologic malignancies: A steroid-responsive lesion. Respiratory Medicine, 101 (1) (2007), pp. 162-168. Reference #2: M. Mokhtari, P.B. Bach, P.A. Tietjen, D.E. Stover. Bronchiolitis obliterans organizing pneumonia in cancer: a case series. Respiratory Medicine, 96 (4) (2002), pp. 280-286. DISCLOSURES: no disclosure on file for Guillermo Garrido;No relevant relationships by Anita Gopalakrishnan No relevant relationships by Rameez Rao No relevant relationships by Mohammad Salimian

WHEN NOTHING HELPS: A RARE CASE OF COVID-19 EMPYEMA IN A YOUNG HEALTHY MALE

SESSION TITLE: Problems in the Pleura Case Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Severe COVID 19 has now been known to cause devastating damage to the lungs. The manifestations include severe pneumonia, acute respiratory distress syndrome, spontaneous pneumothorax, etc. As we were learning about the pathogenesis of the infection, we were also learning rapidly about the therapeutics targeted against it. A report a case of severe COVID 19 ARDS in a non-vaccinated young male, who later developed empyema during his hospital course. CASE PRESENTATION: A 29-year-old male with no past medical history presented to the emergency department complaining of chest pain and shortness of breath. He was not vaccinated against COVID-19. He was discharged from the hospital on 2 liters of supplemental oxygen two days ago after undergoing treatment for COVID-19 pneumonia with dexamethasone and remdesivir. Physical examination revealed bilateral diminished lung sounds on auscultation. His blood pressure was 112/75 mm Hg, heart rate (HR) 120 per minute, respiratory rate 25 per minute, the temperature of 38.5 Celsius and he was saturating 91% on 15 L of oxygen via a non-rebreather mask. Initial CT scan revealed bilateral ground-glass opacities (figure 1.). Due to high oxygen requirements and CRP of 10.5 MG/DL, the patient was started on Sarilumab. Given his escalating oxygen requirements and worsening respiratory distress, he was intubated and transferred to the intensive care unit. Despite intermittent prone positioning, he became progressively hypoxemic and eventually required Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO). One week later he developed intermittent fever spikes up to 39.5 C with HR of 120 per minute and leukocytosis of 40.8 K/µL. Bedside point of care ultrasound revealed new bilateral complex pleural effusions. Chest CT-scan showed moderate bilateral pleural effusions with new cystic changes and worsening consolidations (figure 2). Pleural fluid analysis showed lactate dehydrogenase of 2798, pH of 7.11, and cell count of 100 with 98% neutrophils. Despite aggressive therapy with chest tube placements and broad-spectrum antibiotics his condition continued to worsen over the next month with the development of hydropneumothoraxes and traction bronchiectasis (figure 3). Given the clinical deterioration despite aggressive care, his family decided to pursue a comfort-oriented treatment approach and he eventually passed away. DISCUSSION: COVID-19 related pleural effusion is a reported complication of COVID-19 pneumonia in up to 2-11% of the cases [1]. Most cases are associated with comorbid conditions, such as heart failure, superimposed bacterial infections, and pulmonary embolism [2]. CONCLUSIONS: Our case indicates that bacterial empyema may complicate COVID-19 pneumonia later in the disease course even in young immune-competent patients, it is unclear if empyema is directly related to the disease process itself r the therapeutic used to treat the COVID 19 infection. Reference #1: Chong WH, Saha BK, Conuel E, Chopra A. The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review. Heart Lung. 2021;50(4):481-490. doi:10.1016/j.hrtlng.2021.02.015 Reference #2: Zhang L, Kong X, Li X, et al. CT imaging features of 34 patients infected with COVID-19. Clin Imaging. 2020;68:226-231. doi:10.1016/j.clinimag.2020.05.016 DISCLOSURES: No relevant relationships by Rimsha Ali No relevant relationships by Konstantin Golubykh No relevant relationships by Iuliia Kovalenko No relevant relationships by Maidah Malik No relevant relationships by Taaha Mirza No relevant relationships by Navitha Ramesh

CEFAZOLIN-INDUCED COAGULOPATHY

SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Cephalosporins have been known to cause hypo-prothrombinemia and prothrombin prolongation (1). The proposed mechanism of this coagulopathy is secondary to a N-methylthiotetrazole side chain interfering with vitamin-k metabolism (1). Current literature supporting the association between cefazolin and hypo-prothombinemia have only been reported through case reports. As cefazolin is a commonly used antibiotic, it is important that healthcare professionals are aware of its potential bleeding risk. We present a case of a 72 year old female with cefazolin-induced hypo-prothrombinemia. CASE PRESENTATION: A malnourished 72-year old female with a past medical history of recent methicillin-susceptible Staphyloccocus aureus (MSSA) bacteremia and COVID-19 pneumonia presented to the emergency department from a skilled nursing facility (SNF) due to shortness of breath. The patient was previously discharged to SNF to complete a 14 day course of IV cefazolin due to her MSSA bacteremia. On admission, vital signs were significant for a respiratory rate of 22 and a pulse oximetry reading of 78% on room air. Laboratory findings were significant for an elevated prothrombin time of >100 seconds, an INR >15, and a D-dimer of 42,344 ng/mlL. A computed tomography angiography (CTA) of the chest revealed a small segmental pulmonary embolus in the right lower lobe of the lung. The patient was started on a heparin drip, placed on a non-rebreather mask, and admitted to the ICU for closer monitoring. Infectious disease was consulted and cefazolin was discontinued. Due to the patient's risk of bleeding her heparin drip was stopped. It was decided not to reverse the patient's coagulopathy with vitamin K as there were no signs of an acute bleed in the setting of an acute pulmonary embolus. The patient was started on nafcillin in place of cefazolin. Four days after discontinuation of cefazolin, the patient's INR had trended down from >15 to 1.6 and she was started on Lovenox 1mg/kg for the treatment of her acute PE. DISCUSSION: Due to the timing of the discontinuation of cefazolin and the correction of the hypo-prothrombinemia, a clear association between the two can be made. It has been proposed that cefazolin's side chain, heterocyclic thiol, 2-methyl-1,3,4-thiadiazole-5-thiol (MTD), causes a similar reaction that other cephalosporins have on the metabolism of Vitamin K (2). This altered Vitamin K metabolism was also likely exacerbated due to the patient's malnourishment and likely depleted vitamin k reserves (2). CONCLUSIONS: Although rare, this case demonstrates the need for clinicians to be aware of the potential bleeding risk associated with cephalosporins and cefazolin in particular. In the future, routine monitoring of PT/INR levels may be recommended when initiating cephalosporins. Reference #1: Park GH, Kim S, Kim MS, Yu YM, Kim GH, Lee JS, Lee E. The Association Between Cephalosporin and Hypoprothrombinemia: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2019 Oct 16;16(20):3937 Reference #2: Shearer, M. J., Bechtold, H., Andrassy, K., Koderisch, J., McCarthy, P. T., Trenk, D., Jähnchen, E., & Ritz, E. (1988). Mechanism of cephalosporin-induced hypoprothrombinemia: relation to cephalosporin side chain, vitamin K metabolism, and vitamin K status. Journal of clinical pharmacology, 28(1), 88–95 DISCLOSURES: no disclosure on file for John Abernathy;No relevant relationships by Ethan Goldberg No relevant relationships by Renee Miu No relevant relationships by Luis Osorio no disclosure on file for Satesh Saroop;no disclosure on file for Oliver Sevilla;no disclosure on file for Kristen Zubel;

AORTIC THROMBUS DESPITE THERAPEUTIC DOSE OF ANTICOAGULATION IN A PATIENT POSITIVE FOR COVID-19

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Hypercoagulability is a well-known complication of COVID-19, with the most common vascular events being pulmonary embolism and deep vein thrombosis (1). Arterial thrombotic events, specifically aortic thrombosis, are rarely observed in COVID-19 infections. Literature review reveals less than 10 cases of aortic thrombosis have been reported in patients with COVID-19 infection. Here, we report a unique case of acute aortic thrombosis despite administration of therapeutic anticoagulation. CASE PRESENTATION: A 77 y.o. female with no known medical history presented to the hospital after a diagnosis of COVID-19 five days prior. Upon arrival, she was hypoxic requiring supplemental oxygen via non-rebreather (NRB) mask. CT chest with contrast revealed bilateral ground-glass opacities without evidence of pulmonary embolism or aortic thrombus. She was treated with remdesivir, dexamethasone, baricitinib and enoxaparin 40mg BID (essentially therapeutic dosing based on patient's body weight of 45kg). Adequate oxygenation was maintained with nasal cannula and NRB. However, on day eight of admission she was noted to desaturate to 80% requiring BiPAP. D-dimer and CRP drastically increased from 0.36ug/ml to 1.75ug/ml and 13.0 to 102.2, respectively. Repeat CT chest with contrast revealed multiple intraluminal thrombi in the distal thoracic aorta. Treatment with clopidogrel was initiated, however patient remained BiPAP dependent. Due to DNR/DNI status, intubation was not pursued. Ultimately, patient was transitioned to comfort care and expired. DISCUSSION: Thrombotic events are poorly understood but remain a well-documented sequela of COVID-19 infection. The pathophysiology of thrombosis in COVID-19 patients has not been fully elucidated, however, it likely involves amplification of the hypercoagulable state due to viral infection. Some of the proposed theories regarding this effect include endothelial dysfunction secondary to direct virus invasion and immuno-thrombosis due to viral mediated endothelial inflammation with resultant platelet activation (2,3). Regarding COVID-19 associated arterial thrombi, myocardial infarction and stroke are the most commonly encountered events. The few reported cases of aortic thrombi occurred almost exclusively in males with significant cardiovascular risk factors and not on anticoagulation (1,3). CONCLUSIONS: Due to the increased risk of venous thromboembolic events, prophylaxis is routinely used in patients with COVID-19. However, in our case, the patient developed multiple aortic thrombi without any typical risk factors for endothelial lesions despite being fully anticoagulated. This case highlights the need for continued research and trials related to appropriate anticoagulation therapies in hospitalized patients with COVID-19. Additionally, physicians should be aware of potential arterial thrombi in patients infected with COVID-19. Reference #1: de Carranza M, Salazar DE, Troya J, et al. Aortic thrombus in patients with severe COVID-19: review of three cases. J Thromb Thrombolysis. 2021;51(1):237-242. doi:10.1007/s11239-020-02219-z Reference #2: Loo J, Spittle DA, Newnham MCOVID-19, immunothrombosis and venous thromboembolism: biological mechanismsThorax 2021;76:412-420. doi:10.1136/ thoraxjnl-2020-216243 Reference #3: Woehl B, Lawson B, Jambert L, Tousch J, Ghassani A, Hamade A. 4 Cases of Aortic Thrombosis in Patients With COVID-19. JACC Case Rep. 2020;2(9):1397-1401. doi:10.1016/j.jaccas.2020.06.003 DISCLOSURES: No relevant relationships by Chelsey Bertrand- Hemmings No relevant relationships by Alyssa Foster No relevant relationships by Kyle Foster No relevant relationships by Yelena Galumyan No relevant relationships by Veronica Jacome No relevant relationships by Viet Nguyen

LIFE CYCLE OF A COVID-19-INDUCED LUNG CYST

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: COVID-19 has affected over 200 million people worldwide. Clinicians continue to observe unusual manifestations of this disease. In an attempt to improve our understanding of COVID-19 pneumonia, we present the details of one patient who developed large bilateral pulmonary cysts. CASE PRESENTATION: A 40-year-old woman with no known medical problems presented with the chief complaint of fever, nausea, vomiting, generalized weakness followed by difficulty breathing that developed over a few days. Her vital signs on admission included temperature 98.4° F, heart rate 104 beats/minute, respiratory rate 48 breaths/minute, O2 saturation 88 percent on 15 liters of oxygen through a non-rebreather mask, and Body Mass Index 42 kg/m2. The patient tested positive for COVID-19. Computed tomography (CT) of the chest to rule out a pulmonary embolism showed bilateral extensive ground-glass opacities and reticular and nodular opacities. She was intubated for acute hypoxic respiratory failure. Twenty days into the hospital admission, she was noted to have a bulla in the right lower lobe. A repeat CT chest on day 45 revealed an increase in the number and size of cysts bilaterally. Patient was discharged to rehab and later readmitted for worsening respiratory status. This time she tested positive for human metapneumovirus. A CT chest showed increase in the size of the right sided lung cysts;the left sided lung cysts had resolved. DISCUSSION: The first COVID-19 related pulmonary cystic lesions were reported in May 2020(1). Since then, several reports have now established a relationship between an infection and cyst formation. The most common distribution is peripheral in the lower lobes. The pathogenesis remains uncertain, but several mechanisms have been proposed. Microthrombi in the pulmonary circulation could lead to ischemia and subsequent remodeling of interstitial matrix and bronchial obstruction with distal hyperinflation due to check valve mechanism. (1,2). Hamad et al. propose that pneumatoceles are formed by air leaked in to the interstitium which causes stripping and separation of a thin layer of lung parenchyma with further injury to the small blood vessels and bronchioles. The rate of barotrauma in non-COVID-19 related ARDS is 0.5%;the rate in COVID-19 ARDS is 15% (3). This suggests a close relation between COVID-19 pneumonia and subsequent development of pulmonary cysts. Our patient had no preexisting pulmonary disease and was noted to have pulmonary cysts after being on mechanical ventilation for almost 2 weeks. The patient later contracted the human metapneumovirus infection and CT showed that the right-sided lung cysts had become bigger in size. However, the left-sided cysts which had a maximum diameter of 4.8 cm had resolved. CONCLUSIONS: We need to follow patients with COVID 19 induced lung cysts clinically and radiologically to understand the clinical course and best management strategies. Reference #1: Kefu Liu et al. COVID 19 with cystic features on Computed tomography;Medicine (Baltimore) 2020May;99(18): e20175. PMCID: PMC7486878 Reference #2: Galindo J, Jimenez L, Lutz J et al. Spontaneous pneumothorax with or without pulmonary cysts, in patients with COVID 19 Pneumonia. Journal of infections in developing countries 2021;15(10);1404-1407 Reference #3: McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, Thomas KM, Moore WH. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology. 2020;297(2): E252–E262. doi: 10.1148/radiol.2020202352 DISCLOSURES: No relevant relationships by Arunee Motes No relevant relationships by Kenneth Nugent No relevant relationships by Tushi Singh No relevant relationships by Myrian Vinan Vega

FINGERNAIL CLIPPING AS A FOREIGN BODY CAUSING SEVERE EMPYEMA

SESSION TITLE: Chest Infections with Pleural Involvement Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration (FBA) is an uncommon cause of dyspnea and respiratory infection. 80% of cases occur in children under 15-years-old, with the highest mortality in children under 1 and adults over 75. We present an unusual case of a fingernail clipping causing severe empyema in a middle-aged male. CASE PRESENTATION: A 44-year-old male with diabetes mellitus presented with a 3-day history of dyspnea, productive cough, and anorexia, and a 1-day history of fevers and substernal chest pain. Exam was notable for fever, tachypnea, tachycardia, and hypoxemia requiring a non-rebreather mask. Labs were significant for a negative COVID-19 polymerase chain reaction (PCR) test, white blood cell (WBC) count 17,000 μL, and lactate 3.4 mmol/L. He was given albuterol-ipratropium nebulizer treatments and methylprednisolone 125 mg. Chest x-ray revealed a large right-sided air-fluid level, dense consolidation of the lung base, and complicated pleural effusion. Computed Tomography (CT) of the chest revealed a large right mid-lung abscess, right middle lobe (RML) and right lower lobe (RLL) consolidations, and loculated pleural effusion with hydropneumothorax. A surgical chest tube was placed that drained purulent fluid. The effusion grew Klebsiella pneumoniae, which was treated with ampicillin-sulbactam. Repeat CT chest revealed improved loculated effusion, but persistent RML and RLL consolidations with concern for endobronchial obstruction. Flexible bronchoscopy was performed, which identified and removed a human fingernail clipping obstructing the RML. Post-procedure, his oxygen requirements, cough, and dyspnea improved remarkably. He was discharged with a 4-week course of amoxicillin-clavulanate. On outpatient follow-up 6 weeks later, he was asymptomatic. DISCUSSION: In our patient, a fingernail clipping was lodged in the opening of the RML, resulting in a post-obstructive pneumonia complicated by empyema. Post-bronchoscopy, the patient admitted to anxiety-induced nail-biting. FBA most commonly occurs in the right bronchial tree (71.5%) as compared to the left bronchial tree (22.8%) and trachea (5.7%). Objects were most commonly lodged in the bronchus intermedius (27%) and right lower lobe (33%). Foreign bodies can be removed via rigid or flexible bronchoscopy, with a 90% success rate in the latter. Instruments such as forceps and baskets can be used to remove the foreign body, and Trendelenberg positioning can be useful in moving the object proximally. In up to 76% of cases, granulation tissue caused by a localized reaction to the foreign body may occur and can be minimized with systemic steroids for 24 hours. CONCLUSIONS: FBA in a middle-aged patient is an unusual cause of respiratory infection, but should be on the differential diagnosis for post-obstructive pneumonia. Reference #1: Hsu Wc, Sheen Ts, Lin Cd, Tan Ct, Yeh Th, Lee Sy. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg. 2000 Mar;122(3):450-4. doi: 10.1067/mhn.2000.98321. PMID: 10699826. Reference #2: Blanco Ramos M, Botana-Rial M, García-Fontán E, Fernández-Villar A, Gallas Torreira M. Update in the extraction of airway foreign bodies in adults. J Thorac Dis. 2016;8(11):3452-3456. doi:10.21037/jtd.2016.11.32. Reference #3: Fang YF, Hsieh MH, Chung FT, Huang YK, Chen GY, Lin SM, Lin HC, Wang CH, Kuo HP. Flexible bronchoscopy with multiple modalities for foreign body removal in adults. PLoS One. 2015 Mar 13;10(3):e0118993. doi: 10.1371/journal.pone.0118993. PMID: 25768933;PMCID: PMC4358882. DISCLOSURES: No relevant relationships by Nuzhat Batool No relevant relationships by Lisa Glass No relevant relationships by Alice Mei No relevant relationships by Daisy Young

INTERSTITIAL LUNG DISEASE EXACERBATED BY NON-NOVEL SARS-COV-2

SESSION TITLE: Variety in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Viruses are thought to trigger acute exacerbation of interstitial lung disease (AE-ILD) [1]. AE-ILD results in significant morbidity and mortality [1]. We report a case of AE-ILD due to non-SARS CoV2 viral infection in the era of the COVID-19 pandemic. CASE PRESENTATION: A 61 year-old African-American male with a history of hypertension, diabetes mellitus, and smoking crack cocaine presented with acute onset of dyspnea, fever, and worsening of his chronic cough. He was diagnosed with ILD suspected to be idiopathic pulmonary fibrosis (IPF) 9 months prior to hospitalization and needed 3 L supplemental oxygen at baseline. He had received 3 doses of COVID-19 vaccination. He was tachycardic, tachypneic, hypoxemic and arrived on a non-rebreather mask to the ED. Physical examination revealed bilateral coarse inspiratory crackles. Laboratory workup revealed leukocytosis, neutrophilia, and lymphopenia. Procalcitonin, lactic acid, BNP, and troponin were normal. CXR showed significantly increased bilateral interstitial markings compared to prior imaging. The patient was not stable for a chest CT. Respiratory pathogen panel was negative for SARS-CoV2, but positive for Coronavirus OC43. Sputum culture grew normal respiratory flora. He continued to have increased work of breathing and was placed on NIV support. He received methylprednisolone, bronchodilators, and ceftriaxone with azithromycin. Antibiotics were discontinued after negative sputum cultures. The patient continued to worsen despite supportive care, he wished to transition the goals of care to comfort only. He was transitioned to hospice care and died within 24 hours. DISCUSSION: Viruses are identified in 10-20% of cases of AE-ILD, in which the virus may be acting as an extrinsic trigger [2]. Efficacious antiviral agents are lacking. Currently, there are no strong evidence based guidelines for the treatment of AE-ILD. Corticosteroids are empirically used to manage exacerbation, however response is variable and particularly worse in the IPF variant of ILD [3]. An effort should be made to identify a treatable infectious etiology in all cases of AE-ILD with any worsening symptoms. Our case highlights that the "common cold” may have fatal consequences for at-risk patients. Care for patients with AE-ILD often goes beyond medications and should encompass emotional and family support. CONCLUSIONS: Hand hygiene and mask wearing are beneficial for ILD patients, in addition to pneumococcal, COVID-19, and influenza vaccinations. In patients with IPF, antifibrotics may help prevent exacerbations [2]. There remains a need for clinical trials to aid in establishing efficacious treatment in AE-ILD. Reference #1: Charokopos A, Moua T, Ryu JH, Smischney NJ. Acute exacerbation of interstitial lung disease in the intensive care unit. World J Crit Care Med 2022;11(1): 22-32 [DOI: 10.5492/wjccm.v11.i1.22] Reference #2: Kreuter M, Polke M, Walsh SLF, et al. Acute exacerbation of idiopathic pulmonary fibrosis: international survey and call for harmonisation. Eur Respir J 2020;55: 1901760 [https://doi.org/ 10.1183/13993003.01760-2019 Reference #3: Jang HJ, Yong SH, Leem AY, et al. Corticosteroid responsiveness in patients with acute exacerbation of interstitial lung disease admitted to the emergency department. Sci Rep. 2021;11(1):5762. Published 2021 Mar 11. doi:10.1038/s41598-021-85539-1 DISCLOSURES: No relevant relationships by Ibukun Fakunle No relevant relationships by Prajwal Shanker No relevant relationships by Aashish Valvani

TIGECYCLINE INDUCED ACUTE PANCREATITIS: A RARE CASE PRESENTATION

CASE: An 81-year-old female with multiple co-morbidities including recent covid-19, presented to the emergency room with shortness of breath. On arrival, she was febrile with a temperature of 101F, pulse 100 beats/min, respiratory rate 14, blood pressure 196/163 and saturating at 75% on 10 L non-rebreather mask. Initial blood work showed WBC 10.9, lactic acid 1.7, BUN/creatinine 27/1.7 (consistent with her baseline), ABG showed pH 7.37, PCO2 49, PO2 88, HCO3 27.9. Chest x-ray demonstrated volume loss in the left hemithorax, airspace disease in the left mid lung and lung base. Due to suspicion for superimposed bacterial pneumonia and positive blood cultures for staphylococcus haemolyticus, she was started on vancomycin and azithromycin. Choice of antibiotics was challenging as she was allergic to penicillin and cephalosporins. During hospitalization, her kidney function deteriorated, vancomycin was substituted with tigecycline on day 3. Day 5 of treatment, she developed multiple episodes of vomiting with epigastric pain, lipase was 4523. Acute pancreatitis was diagnosed with tigecycline presumed to be the inciting agent in the absence of other risk factors such as gall stones, chronic alcohol use, elevated triglycerides, previous known episodes of pancreatitis or any other causative medications. Tigecycline was switched back to vancomycin and she received aggressive IV fluid hydration which also improved her kidney function. Within 48 hours, the patient had improved oxygen saturation, resolution of her abdominal pain, and good oral intake marking significant overall clinical progress. She was discharged on home oxygen and few more days of IV vancomycin for bacteremia. IMPACT/DISCUSSION: Tigecycline is a broad-spectrum glycylcycline antimicrobial agent belonging to the tetracycline class of antibiotics. Tetracyclines have been associated with acute pancreatitis in literature, and concerns about tigecycline-induced acute pancreatitis have been raised over the past decade in post marketing surveys, we described one such case above. Using the Naranjo Adverse Drug reaction probability scale, a score of 6 was achieved, indicating that the patient's pancreatitis was probably related to tigecycline. CONCLUSION: We recommend physicians monitor patients for signs and symptoms of pancreatitis including abdominal pain after initiating treatment with tigecycline. There should be a low threshold for ordering lipase levels and abdominal CT imaging where indicated. If the patient has symptoms concerning for acute pancreatitis, consider stopping tigecycline and switching to a different class of antibiotics immediately.

Effect of Tocilizumab on Clinical Outcome in Patients with Severe COVID-19 Pneumonia

In severe Covid-19 pneumonia, acute respiratory distress syndrome (ARDS) associated with cytokine storm is the leading cause of death. Tocilizumab was approved for chimeric antigen receptor T-cell therapy induced cytokine release syndrome and it may provide clinical benefit in these severe covid-19 pneumonia. In this retrospective cohort study, we evaluated patients with severe COVID-19 pneumonia admitted between May 2021 and June, 2021. Patients who were received tocilizumab during treatment, were enrolled for the study. Systemic steroids, hydroxychloroquine, and azithromycin were concomitantly used for the patients. The outcome was measured as an improvement in peripheral oxygen saturation by change in mode of oxygen therapy and improvement in laboratory parameters after tocilizumab administration. Out of 23 treated patients (18 Male, 5 Females), 19 patients received a single dose of tocilizumab and another four patients received two doses of it. Of these 23 patients, 3/3 with NRBM (non-rebreather mask) showed improvement and shifted to nasal cannula for oxygenation. 11/12 patients with NIV(non-invasive) showed improvement. 5/8 patients with invasive ventilation showed gradual improvement and shifted to NIV. A total of 4/23 (17%) patients didn’t show any improvement and died. Inflammatory markers like CRP, percentage of lymphocytes, and ferritin also showed significant improvement after administration of tocilizumab. Our study showed that in patients with severe COVID-19, tocilizumab was associated with significant improvement in clinical and laboratory parameters. These findings require further validation from ongoing clinical trials of Tocilizumab in COVID-19 patients.

REMOTE SIM: RECONFIGURING EDUCATION TO MEDICAL OFFICERS WITH TELE-ENABLED SIMULATION

Background: Public health restrictions during the COVID-19 pandemic create a need to restructure education delivery to health professionals. Simulation is a fundamental education mode for teams and individuals.1 An Australian scoping review published by Heffernan and colleagues in 2021 suggests the remote delivery of simulation may be both feasible and effective for participants and facilitators.2 The education unit of a tertiary hospital in Perth, Western Australia, sought to develop a method to deliver remote tele-simulation using existing local resources. There are similarly equipped units across Australasia with dedicated simulation suites that could benefit from the REMOTE Sim framework. Aim: The aim of the project was to develop a tele-simulation method that preserved the benefits of simulation education for medical staff when inperson delivery was not possible. A secondary objective was to leverage existing simulation suite infrastructure to enhance the tele-simulation format. Method: Authors reviewed an existing, locally evaluated, in-person simulation program designed to improve multidisciplinary collaboration in recognising and responding to ward-based acute clinical deterioration. By applying principles from established simulation frameworks, authors adapted in-person delivery to a tele-simulation format. Key frameworks included advocacy-inquiry, tag-team, and stop-and-go simulation.3-5 Results: The existing in-person simulation programme divided participants into two groups. One group participated as responders to a simulated scenario, while the other observed via a live audio-visual feed. Observers viewed live audio and video of the simulation, as well the simulated patient's clinical monitoring. In REMOTE Sim, this existing audio-visual feed is shared via video conferencing software. This enables remote participants to observe the simulated patient room and clinical monitoring in real time. Faculty members are located in the simulation suite and participants connect via video conferencing individually in their own environment. Faculty comprises of four or more members allocated to the roles of simulation director, manikin operator, confederate first responder, confederate second responder and so on. Participants are divided into two groups, and undertake a pre-brief that includes an overview of the format and video-conferencing etiquette. During scenarios participants are asked to direct confederate faculty to perform tasks at intervals guided by the simulation director. For example, when the first responder enters the room, group one would be asked by the simulation director to provide direction. Participants might identify the patient is speaking but in respiratory distress, and direct the relevant faculty member to apply 15L of oxygen via a non-rebreather mask. At the next interval, group two would be asked to provide direction to confederate faculty. This maintains the engagement of both groups of participants, using principles of stop-and-go and tag-team simulation.3,4 During these intervals learning points can also be discussed. Following each scenario a simulation debrief is performed with all participants via video-conference. Conclusion: The adapted tele-simulation format described aims to maintain the beneficial use of simulation suite infrastructure when in-person delivery is not possible. Validation of the format is developing, with particular focus on the impact of technology on participant engagement, critical thinking, psychological safety, and learning and reflection during the simulation and debrief.