LIVER ABSCESS DEVELOPMENT IN THE POSTACUTE COVID-19 PHASE

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 is a systemic infectious and inflammatory disease, with multifactorial immunosuppression during the recovery phase which predisposes to serious infections. Although the gastrointestinal (GI) system is often affected in post-acute COVID-19 patients, liver abscess formation is rare. Here, we present a case of septic shock caused by a bacterial liver abscess in a survivor of severe COVID-19. CASE PRESENTATION: 78-year-old man with no past medical or surgical history was admitted to an outside hospital (OSH) with severe COVID-19 pneumonia and discharged after 14 days. He required high flow nasal cannula and was treated with Remdesevir, Dexamethasone, and Baricitinib. D-dimer was elevated without evidence of acute venous thromboembolism. Four weeks later he returned to the OSH due to dyspnea and was found to be hypotensive and hypoxemic. Laboratories showed leukocytosis, hyperlactatemia, and mild elevation of total bilirubin and transaminases. Whole-body CT scan revealed a small RUL pulmonary embolus and a 7cm multifocal loculated complex fluid collection indicative of a left hepatic lobe abscess. He was managed with supplemental oxygen, anticoagulation, broad-spectrum antibiotics, IV fluids, and vasopressors and transferred to our hospital for abscess drainage. The liver abscess was aspirated after an abdominal MR confirmed the findings and the septic shock subsequently resolved. Body fluid and blood cultures grew pan-sensitive Klebsiella pneumoniae. Antibiotics were narrowed to levofloxacin. He remained hemodynamically stable and was discharged home. DISCUSSION: In our patient, the underlying cause of bacterial inoculation of the liver and abscess formation remains unclear and is not fully explained by drug-induced immunosuppression given the frequency with which these medications are used. Hepatic abscesses often develop after liver injury and, in COVID-19, multiple mechanisms of liver injury have been proposed which may predispose to abscess formation. Specifically, in our case, it is likely that hypoxic hepatitis and arterial/venous thrombosis from hypercoagulability played a role in abscess formation given the need for supplemental oxygen and the presence of a pulmonary embolism. Additionally, in COVID-19, increased hepatobiliary expression of ACE2 may contribute to direct viral cytotoxicity of the liver and substantial dysbiosis may lead to cholestasis and bacterial translocation. CONCLUSIONS: Our case is unique and underlines the importance of having a high index of suspicion and monitoring for "occult infections,” such as liver abscesses in the COVID-19 recovery phase, even in those without prior GI medical history and with non-specific signs and symptoms. Further elucidation of the cause of liver injury and abscess formation are warranted;however, early identification and treatment can reduce morbidity and mortality. Reference #1: Nalbandian, A., et al, 2021. Post-acute COVID-19 syndrome. Nat Med, 27(4): 601–615. Reference #2: Liemarto, A.K., et al, 2021. Liver abscess with necrosis in post COVID-19: A case report. Ann Med Surg (Lond), 72: 103107. Reference #3: Alhaddad O., et al, 2022. A case report of COVID-19 evoked cholangitic liver abscess. Egypt Liver J, 12(1):5. DISCLOSURES: No relevant relationships by Christian Ascoli No relevant relationships by Anna Duchnowska No relevant relationships by Tirsa Ferrer Marrero No relevant relationships by Manasa Reddy

Severe Hypertriglyceridemia as a Cause of Arterial Thrombosis with Peripheral Embolic Complications

Lead Author's Financial Disclosures: Nothing to disclose. Study Funding: None. Background/Synopsis: Extensive evidence exists in support of a causal association of elevated triglyceride-rich lipoprotein (TRL) levels with the risk of atherosclerosis progression. Hypertriglyceridemia has been established as a risk factor for venous thrombosis, including a 2- fold increase in the risk of venous thrombosis in postmenopausal women. However, there is limited data on the role of hypertriglyceridemia in the arterial thrombosis. Objective/Purpose: Not Applicable. Methods: Case description: A 51-year-old white female with hypertension and type 2 diabetes (hemoglobin A1C, 7.4%) was transferred for further management of newly diagnosed bilateral renal and splenic infarcts. No risky habits were elicited except for the use of combined hormonal contraceptives over the past two years to control menorrhagia. Family history was significant for hypertriglyceridemia. Her physical exam was unremarkable. Testing for COVID-19 was negative. An extensive hypercoagulable and autoimmune work-up was unremarkable. Fasting lipid profile was significant for elevated levels of triglycerides, 1,274 mg/dL (replicated on two separate occasions), very low-density lipoprotein-cholesterol, 255 mg/dL, and non-high-density lipoprotein-cholesterol, 214 mg/dL, directly measured low-density lipoprotein cholesterol, 39 mg/dL and lipoprotein(a), 6 mg/dL. There was no structural pathology on the echocardiogram, including no interatrial shunt or intracardiac thrombus. Her whole-body computed tomography angiography revealed a focal calcified protruding thrombus in the distal thoracic aorta. No significant plaque was seen elsewhere in the aorta. Results: Decision-making. The posterior thrombus in the distal thoracic and proximal abdominal aorta was determined as a culprit for the visceral organ infarcts. Over the course of the hospital stay her abdominal pain gradually resolved. Treatment with low dose aspirin and therapeutic dose of low-molecular weight heparin was initiated followed by apixaban and aspirin on discharge. She was started on atorvastatin 40 mg, fenofibrate 145 mg, icosapent ethyl 4 g, resulting in a 70% reduction in the triglycerides levels (306 mg/dL). In 3 months, her repeat CT angiography showed significant resolution of the aortic atherothrombosis with no signs of aortic wall inflammation. At the 6-month follow-up visit she was switched to dual antiplatelet therapy with a plan to repeat imaging in 6 months. Conclusions: This case illustrates challenges in managing patients with arterial thrombosis in the setting of familial hypertriglyceridemia. Apart from severely elevated triglycerides no other etiology was evident. We propose further investigation of the prothrombotic properties of TRL and the role of targeted triglyceride-lowering therapies on atherothrombotic outcomes.

Beware of TB amid COVID 19 pandemic

Background: Tubercolosis has a worrisome connection with novel corona virus.Lingering respiratory symptoms in people who have recovered from Covid could well be mistaken as residual issues of Covid or secondary bacterial infections, missing TB diagnosis totally. Methods: A 28 year old female doctor by profession, initially asymptomatic tested Covid -19 positive as a part of contact tracing. On the 15th day, she developed fever, dry cough and fatigue which persisted even after taking symptomatic treatment. Repeat Covid testing was negative.HRCT chest was normal.Sputum CBNAAT was negative and other relevant blood investigations were normal. On examination she was febrile and matted subcentimetric right cervical lyphnodes(LN) were palpable.Excision Biopsy of cervical LN was done and report suggested Kikuchi's disease.As a part of work up of Pyrexia of Unknown Origin, she undertwent 18-FDG PET whole body CT scan and showed mediastinal lymph node uptake(2R,4R LN station). Mediastinoscopic biopsy report showed tuberculosis and Gene Expert showed mycobacterium complex with Rifampicin resistance. Results: Based on clinical, radiological and laboratory findings, MDR LN tuberculosis was diagnosed.Patient wad started on MDR TB regimen and symptoms got improved. Conclusion: There is an increased likelihood of tuberculosis in post COVID patients due to many factors like lung inflammation, altered immunity and stress due to COVID, use of steroids and uncontrolled diabetes.Therefore active tuberculosis should be vigorously ruled out in any post covid patients with continuous fever.

Systematic review and meta-analysis of whole-body computed tomography compared to conventional radiological procedures of trauma patients.

PURPOSE: The superior diagnostic accuracy of CT makes it an attractive tool for initial trauma imaging. This meta-analysis aimed to assess the evidence regarding the value of whole-body CT (WBCT) as part of the primary survey, in comparison to conventional radiological procedures. METHODS: A comprehensive systematic search of the literature was conducted using keywords applied in Scopus, Cochrane and PubMed databases. Articles were eligible if they contained original data comparing the use of WBCT in the primary survey, with conventional radiological procedures. Outcomes included overall and 24 -h mortality, emergency department (ED) time, intensive care unit (ICU) and hospital length of stay (LOS), and multiple organ dysfunction syndrome/failure (MODS/MOF) incidence. Radiation dose, mechanical ventilation duration and cost were evaluated qualitatively. Analysis was performed with Covidence, MedCalc Version 19.1.3. and Meta-Essentials. RESULTS: Fourteen studies were included. Statistical pooling demonstrated comparable rates between conventional procedures and WBCT (OR = 0.854, CI = 0.715-1.021, p = 0.083) in 63,529 patients across 11 studies. A significant finding favouring WBCT was discovered for ED time (SMD = -0.709, CI -1.198 to -0.220, p = 0.004). Patients experienced similar 24 -h mortality rates (p = 0.450), MODS/MOF incidence (p = 0.274), and hospital (p = 0.541) and ICU LOS (p = 0.457). WBCT is associated with increased radiation dose and mechanical ventilation duration. CONCLUSION: This review demonstrates that WBCT markedly reduces time spent in ED. No significant differences in mortality rate are suggested. WBCT currently entails greater radiation dose and mechanical ventilation time. Further research is necessitated to address limitations of predominately retrospective observational data available.

An evaluation of venous thromboembolism by whole-body enhanced CT scan for critical COVID-19 pneumonia with markedly rises of coagulopathy related factors: a case series study.

BACKGROUND: Coronavirus disease (COVID-19) pneumonitis associated with severe respiratory failure has a high mortality rate. Based on recent reports, the most severely ill patients present with coagulopathy, and disseminated intravascular coagulation (DIC)-like massive intravascular clot formation is frequently observed. Coagulopathy has emerged as a significant contributor to thrombotic complications. Although recommendations have been made for anticoagulant use for COVID-19, no guidelines have been specified. We describe four cases of critical COVID-19 with thrombosis detected by enhanced CT scan. The CT findings of all cases demonstrated typical findings of COVID-19 and pulmonary embolism or deep venous thrombus without critical exacerbation. Two patients died of respiratory failure due to COVID-19. DISCUSSION: Previous reports have suggested coagulopathy with thrombotic signs as the main pathological feature of COVID-19, but no previous reports have focused on coagulopathy evaluated by whole-body enhanced CT scan. Changes in hemostatic biomarkers, represented by an increase in D-dimer and fibrin/fibrinogen degradation products, indicated that the essence of coagulopathy was massive fibrin formation. Although there were no clinical symptoms related to their prognosis, critical COVID-19-induced systemic thrombus formation was observed. CONCLUSIONS: Therapeutic dose anticoagulants should be considered for critical COVID-19 because of induced coagulopathy, and aggressive follow-up by whole body enhanced CT scan for systemic venous thromboembolism (VTE) is necessary.