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History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.
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The aim - to study was to assess the condition of the lungs and pleural cavities in HIV-infected patients with community-acquired pneumonia by ultrasound examination. Material and methods. During the period from May 2020 to February 2021, 7 HIV-infected patients with community-acquired pneumonia were observed, who underwent ultrasound of the lungs and pleural cavities. Results and discussion. Ultrasound of the lungs is the most affordable method of diagnosis in outpatient settings, at the pre-hospital stage to solve the issue of patient routing. Ultrasound is mandatory for quick triage of patients with suspected pneumonia in the emergency department. Given that ultrasound is not associated with radiation exposure to the patient, the examination of pregnant women, newborns and children with suspected pneumonia of any etiology should begin with ultrasound of the lungs, pleural cavities and mediastinum. Ultrasound of the lungs can be performed after pneumonia in order to monitor rehabilitation to assess the nature of changes in the chest cavity and determine the prognosis of the disease. The article presents a clinical example of lung ultrasound in an HIV-infected patient with pneumonia of unknown etiology.Copyright © 2021 Infectious Diseases: News, Opinions, Training. All rights reserved.
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Background: Although mRNA SARS-CoV-2 vaccines have received emergencyuse- authorization for infants age 6 months and older, vaccine uptake is slow, stressing that questions of safety and durability of vaccine efficacy remain prominent. Method(s): Infant rhesus macaques (RMs) (n=8/group) at 2 months of age, comparable to human toddler age, were immunized intramuscularly at weeks 0 and 4 with 30mug stabilized prefusion SARS-CoV-2 S-2P spike (S) protein (Washington strain) encoded by mRNA encapsulated in lipid nanoparticles (mRNA-LNP) or 15mug S protein mixed with 3M-052 in stable emulsion (Protein). At 1 year, vaccinated and age-matched unvaccinated RM (n=8) were challenged intranasally (106pfu) and intratracheally (2x106pfu) with B.1.617.2. Lung radiographs and pathology were blindly assessed, viral N gene RNA (vRNA) copies were measured by qPCR in pharyngeal swabs and lung, and neutralizing antibody and peripheral blood T cell responses were measured. Result(s): At 1 year, D614G-specific neutralizing antibody (nAb) titers were still detectable in the Protein (ID50=755;range: 359-1,949) and mRNA-LNP groups (ID50=73;range: 41-240). Both vaccines also induced cross-neutralizing antibodies to B.1.617.2. Peripheral blood CD4+ T cell responses to the ancestral spike protein at week 52 did not differ between the groups. However, median CD8+ T cell responses were higher (p=0.002, Mann Whitney) in the mRNA-LNP group (2.8%;range: 0.9%-7.1%) compared to the Protein group (0.8%;range: 0.1%-1.6%). Control RMs had significantly higher median vRNA copies/ml (1.4+/-2.7x108) in day 4 pharyngeal swabs compared to Protein (3.8+/-6.8x103) or mRNA-LNP (4.4+/-9.7x105) vaccinated RMs. Severe lung pathology was observed in 7 of 8 controls compared to 1 of 8 or 0 of 8 RMs in the mRNA-LNP or Protein group respectively. Protection against lung inflammation was associated with nAb titers (r=-0.592, p=0.003) (Figure 1). Conclusion(s): These results demonstrate that despite lower vaccine doses compared to adults, both protein and mRNA vaccines were safe, induced durable immune responses and provided comparable protective efficacy against infection with a heterologous SARS-CoV-2 variant in infants, implying that early life vaccination of human infants may lead to durable immunity. Neutralizing ID50 antibody titers are a correlate of protection in infant RMs challenged with SARS-CoV-2.
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A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.
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Computed tomography has become the main method of early diagnostics of COVID-19 during the pandemic of the novel coronavirus infection. Based on results of computed tomography of the chest it is possible to diagnose viral pneumonia associated with COVIS-19, to quickly assess the lung damage volume and severity of changes, to perform quick routing of patients and to start antiviral treatment. Hence, 2020 was associated with a rapid increase in the number of computed tomography examinations with corresponding changes in the structure of X-ray diagnostics. The aim of the current study was to evaluate the impact of the pandemic of the novel coronavirus infection on the structure of X-ray diagnostics and collective doses from medical exposure in the Russian Federation in 2019-2020. The study was based on the results of analysis of the federal state statistical surveillance forms 3-DOZ and 30 as well as on the data on Covid-19 morbidity in the regions of the Russian Federation. The results of the study indicate that there were no significant changes in the structure of X-ray diagnostics in 2020 compared to 2019 except for the increase in the number of computed tomography examinations. Their contribution to the total number of X-ray examinations has increased to 8,2% in 2020 compared to 4,6% in 2019. Contribution of other imaging modalities to the total number of X-ray examinations has not changed significantly. In 2020 the number of X-ray examinations decreased by 20% in average, varying from 6% for diagnostic nuclear medicine to 42% for interventional examinations. At the same time, the number of computed tomography examinations has rapidly increased by 60%. The structure of collective dose from medical exposure has significantly changed in 2020. Contribution of computed tomography to the collective dose in 2020 accounted for to 74% compared to 57% in 2019. Contribution of other imaging modalities has decreased by the factor of 1,5-2. Contribution of radiography examinations has decreased to 10,5% compared to 19% in 2019. Collective doses have correspondingly decreased by 20-30% for all imaging modalities except for computed tomography. Collective dose from computed tomography has increased by 71% compared to 2019. The number of all X-ray examinations in the Russian Federation has decreased by 12%: from 294 million in 2019 to 258 million in 2020. Collective dose from medical exposure has rapidly increased in 2020 by 30% to 115 thousand man.-Sv compared to 88 thousand man.-Sv in 2019. In average, in regions of the Russian Federation in 2020 each second computed tomography examination has been performed as a part of COVID-19 diagnostics with 2,3 computed tomography examinations per person infected with COVID.Copyright © 2022, Saint-Petersburg Research Institute of Radiation Hygiene after Professor P.V. Ramzaev. All rights reserved.
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Background: Survival Radiology (SR) is a flagship annual full-day in-person radiology workshop targeted at final year medical students in Singapore to prepare them for internship. Previous in-person editions have consistently received positive reviews from 2014 to 2019. However, the COVID-19 pandemic necessitated a rapid online pivot for its sixth edition in 2020. Objective(s): This study aims to (a) identify key success factors of a traditional in-person medical student radiology workshop, (b) describe the rapid online pivot in 2020 and (c) to identify key success factors for online educational initiatives. Method(s): Post-workshop survey responses of SR from 2014 to 2020 were evaluated. Likert-scale data were quantitatively analysed, while free-text responses were qualitatively analysed. Result(s): A total of 1248 post-workshop surveys (2014-2020 workshops) and 266 free-text responses (2020 workshop) were received from 2640 participants over the years. Progressive changes that sustained or improved participant feedback for in-person SR workshops included adoption of a case-based approach, utility of 'live' audience response systems and incorporation of quizzes with a favourable overall feedback rating of 4.42-4.89 from 2014 to 2019. The webinar version of SR in 2020 became the best-rated edition since inception with a rating of 4.9. Qualitative analysis of feedback from SR 2020 showed that the participants preferred the webinar model, online modes of engagement and interactivity. Conclusion(s): Our experience shows that it is not only possible to successfully pivot online for such workshops, but that blended educational formats utilising online engagements supplemented by in-person activities will be well-received by 'Generation Z' learners even after the COVID-19 pandemic.Copyright © The Author(s) 2022.
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Purpose: Knee distraction (KD) treatment for young (<65) patients with end-stage knee osteoarthritis (OA) has previously been shown to successfully postpone a knee arthroplasty for years by reducing pain, improving function, and inducing joint tissue repair. During KD treatment, the tibia and femur are separated ~5 mm for ~6 weeks using an external fixation device. The studies performed thus far have used proof-of-concept medical devices intended for other applications than KD. Recently, the first device specifically designed and intended for KD treatment has been developed. The purpose of the current study was to evaluate the clinical efficacy of this intended device. Method(s): In 5 hospitals, 65 patients with end-stage knee OA, in general practice considered for arthroplasty or high tibial osteotomy, were offered KD treatment by their orthopedic surgeon. Inclusion criteria were judged by the orthopedic surgeon and included age <=65 years, BMI <35 kg/m2 with weight <=110 kg, sufficient knee stability and physical condition, KL grade >=2, malalignment <=10 degrees, no history of inflammatory or septic arthritis. KD was performed according to a standardized protocol. Before and 1 and 2 years after treatment, standardized knee radiographs were performed and patients filled out WOMAC (for pain and function, 0-100, primary clinical outcome) and SF-36 (for quality of life, 0-100, secondary outcome) questionnaires. From the radiographs, minimum joint space width (JSW, mm, primary structural outcome) was measured by one experienced observer and KL grade at baseline was determined. Use of self-reported pain medication (paracetamol, opioids, NSAIDs) and intra-articular injections were registered as well, as were adverse events. Changes over 2 years were evaluated for statistical significance with paired t-tests for continuous variables and McNemar's tests for categorical variables. For the primary clinical outcome (WOMAC), clinical significance was evaluated as well, on group level defined as an increase of >=15 points and on individual level using OARSI-OMERACT response criteria. The influence of adverse effects on 2-year changes in primary outcomes was analyzed with independent t-tests. Result(s): Of the 65 treated patients (age: 53.3+/-6.7;BMI: 28.0+/-3.2;sex: 38 (55%) male;KL grade 0/1/2/3/4: 0 (0%) / 7 (11%) / 26 (40%) / 23 (36%) / 9 (14%)), 50 patients completed 2 years follow-up: 6 patients received partial or total arthroplasty (of which 3 in the 1st year) and 8 patients were lost to follow-up in the 2nd year (primarily due to COVID restrictions). The total WOMAC score (Figure 1A/B) showed a statistically and clinically significant improvement over 1 (+28.4 points;p<0.001) and 2 (+26.2 points;p<0.001) years, as did all the subscales (all p<0.001). After 1 year 72% of patients were OARSI-OMERACT responders, while after 2 years this was 51%. The minimum JSW (Figure 1C/D) significantly improved over 1 (+0.5 mm;p<0.001) and 2 (+0.4 mm;p=0.015) years as well. The physical component scale of the SF36 (Figure 2A/B) showed statistically significant improvement over 1 (+10.5 points;p<0.001) and 2 (+9.8;p<0.001) years, while the mental component scale (Figure 2C/D) did not (both p>0.26). The most common adverse event (Table 1) was pin tract skin infections, experienced by 46 (71%) of patients. In most cases (36;78% of cases) they could be treated with oral antibiotics, while in 3 of the cases (5% of treated patients) hospitalization and/or intravenous antibiotics were needed. Also, 8 (12%) of patients experienced device related complications. Experiencing pin tract infections or device complications did not significantly influence 2-year changes in primary outcomes in these patients (both p>0.05). Before treatment, 39 (60%) of patients used pain medication (Table 2), most often paracetamol (20;31%) or NSAIDs (16;25%). Around half used them daily. After treatment, significantly less patients used pain medication (p<0.001), with 35% at 1 year and 36% at 2 years. In total 12 (18%) patients had received an intra-arti ular injection before KD treatment, of whom 5 (8%) steroids and 3 (5%) hyaluronic acid. Both in the 1st and 2nd year after treatment, 1 patient (2%) received an injection. Conclusion(s): Patients treated with the first device intended for KD treatment showed significant clinical and structural improvement after 1 and 2 years. Importantly, the effect was clinically relevant, as a majority of patients were clinical responders and pain medication use decreased. Long-term evaluation will show whether arthroplasty can be postponed successfully as well. [Formula presented] [Formula presented] [Formula presented] [Formula presented]Copyright © 2023
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Background: The present radiological COVID literature is mainly confined to the CT findings. Using High Resolution Computed tomography (HRCT) as a regular 1st line investigation put a large burden on radiology department and constitute a huge challenge for the infection control in CT suite. Materials and Methods: A prospective study of 700 consecutive COVID positive cases who underwent Chest Xray (CXR) and HRCT thorax were included in the study. Many of these CXR were repeated and followed up over a duration of time to see the progression of disease. Results: 392/700 (56%) were found to be negative for radiological thoracic involvement. 147/700 (21%) COVID positive patients showed lung consolidations, 115/700 (16.5%) presented with GGO, 40/700 (5.7%) with nodules and 42/700 (6%) with reticular–nodular opacities. 150/700 patients (21.4 %) had mild findings with total RALE severity score of 1-2. More extensive involvement was seen in 104/700 (14.8 %) and 43/700 (6.2%) patients, who had severity scores of 3-4 and 5-6 respectively. 11/700 patients had a severity score of >6 on their baseline CXR. Those with severity score of 5 or more than 5 (54/700, 7.7%) required aggressive treatment with mean duration of stay of 14 days, many of them died also (23/54, 42.5%). Conclusion: In cases of high clinical suspicion for COVID-19, a positive CXR may obviate the need for CT. Additionally, CXR utilization for early disease detection and followup may also play a vital role in areas around the world with limited access to CT and RT-PCR test.
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Introduction: Tocilizumab, a monoclonal anti-interleukin- 6 receptor antibody, has been widely used as a treatment for rheumatoid arthritis. Gastrointestinal perforation is a rare but critical complication that occurs in patients treated with tocilizumab. In the COVID-19 pandemic, tocilizumab has been recently highlighted for its beneficial effect in reducing the risk of death in severely ill COVID-19 patients. In this current study, we report the ileal perforation in a COVID-19 confirmed patient who had received tocilizumab for the treatment of rheumatoid arthritis. Case Presentation: A 57-year- old woman with a medical history of rheumatoid arthritis and hypertension presented to our emergency room with abrupt onset of severe abdominal pain and nausea. Physical examination revealed direct and indirect tenderness of the whole abdomen. She had a history of COVID-19 infection 1 month ago and recovered without severe complications. She also has been treated for rheumatoid arthritis, and the disease activity has been maintained low with the administration of tocilizumab since 2019. The latest administration of tocilizumab to the patient was 2 weeks ago. The plain radiograph of the abdomen showed intraperitoneal free air suggesting pneumoperitoneum. The abdominal computed tomography was also conducted to find the origin of free extraluminal air, and it revealed heterogenous wall enhancement of the ileal loop and the mesenteric haziness. The emergency surgery was performed, and the ileal perforation was noted. The small bowel segmental resection was performed through the surgical procedure. Conclusion(s): COVID-19 has been founded to cause gastrointestinal inflammation. The use of tocilizumab in COVID-19 patients should be carefully conducted because it could act as a permissive of gastrointestinal perforation. Furthermore, the physician should be aware of the possible complication of tocilizumab because early diagnosis and timely management are crucial to preventing high mortality complications.
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Lung diseases mainly affect the inner lining of the lungs causing complications in breathing, airway obstruction, and exhalation. Identifying lung diseases such as COVID-19, pneumonia, fibrosis, and tuberculosis at the earlier stage is a great challenge due to the availability of insufficient laboratory kits and image modalities. The rapid progression of the lung disease can be easily identified via Chest X-rays and this serves as a major boon for the terminally ill patients admitted to Intensive Care Units (ICU). To enhance the decision-making capability of the clinicians, a novel lung disease prediction framework is proposed using a hybrid bidirectional Long-Short-Term-Memory (BiDLSTM)-Mask Region-Based Convolutional Neural Network (Mask-RCNN) model. The Crystal algorithm is used to optimize the scalability and convergence issues in the Mask-RCNN model by hyperparameter tuning. The long-range dependencies for lung disease prediction are done using the BiDLSTM architecture which is connected to the fully connected layer of the Mask RCNN model. The efficiency of the proposed methodology is evaluated using three publicly accessible lung disease datasets namely the COVID-19 radiography dataset, Tuberculosis (TB) Chest X-ray Database, and National Institute of Health Chest X-ray Dataset which consists of the images of infected lung disease patients. The efficiency of the proposed technique is evaluated using different performance metrics such as Accuracy, Precision, Recall, F-measure, Specificity, confusion matrix, and sensitivity. The high accuracy obtained when comparing the proposed methodology with conventional techniques shows its efficiency of it in improving lung disease diagnosis. Copyright © 2022 Elsevier Ltd
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Case Report: A 4-year-old African American male presented to an outside emergency department (ED) following sudden inability to move left upper extremity. Past medical history was unremarkable and routine vaccinations were up to date. Radiograph of affected extremity ruled out fractures and patient was discharged to follow up with primary care physician. Two days later mother brought him to our ED due to persistent left upper extremity paralysis, poor appetite, and subjective fever. On exam his left arm was warm and tender to dull and sharp touch;he had definite loss of active movement, hypotonia and absence of deep tendon reflexes. The patient had winging of left scapula and could not shrug left shoulder. MRI of cervical and thoracic spine showed enlargement of spinal cord from C2-C6 level with gray matter hyperintensity, slightly asymmetric to the left. Laboratory studies showed leukocytosis (14 000/mcL) and CSF studies showed pleocytosis of 89 WBC/mcL (93.3% mononuclear cells and 6.7% polymorphonuclear cells), 0 RBCs, normal glucose and protein, and a negative CSF meningoencephalitis multiplex PCR panel. Due to high suspicion of demyelinating or autoimmune condition he was treated with high dose steroids and IVIG. Subsequently neuromyelitis optica was ruled out as aquaporin-4 receptor antibodies (AB) and myelin oligodendrocyte glycoprotein AB were normal. CSF myelin basic protein and oligoclonal bands were absent ruling out demyelinating disorders. CSF arboviruses IgM and West Nile IgM were negative. He showed minimal improvement in left upper extremity movement but repeat spinal cord MRI one week later showed improved cord thickness with less hyperintensity. Respiratory multiplex PCR was negative including enteroviruses. Repeat CSF studies after IVIG showed increased IgG index and IgG synthesis suggestive of recent spinal cord infection, consistent with acute flaccid myelitis (AFM). Pre-IVIG blood PCR was invalid for enteroviruses due to PCR inhibitors found in the sample. Blood post-IVIG was negative for mycoplasma IgM, West Nile IgM, and arboviruses IgM. Enterovirus panel titers (post-IVIG) were positive for coxsackie A (1:32), coxsackie B type 4 (1:80) and 5 (1:320), echovirus type 11 (1:160) and 30 (1:80) as well as positive for poliovirus type 1 and 3. These titers could not distinguish acute infection from patient's immunity or false-positives as a result of IVIG. He was discharged with outpatient follow-up visits with neurology, infectious disease, occupational and physical therapy, showing only mild improvement after discharge. Discussion(s):With the anticipated resurgence of AFM after the peak of COVID-19 pandemic, our case illustrates the need to consider this diagnostic possibility in patients with flaccid paralysis. It is important to remember CSF IgG synthesis is not affected by IVIG. In addition when treatment plans include IVIG, appropriate samples should be collected before IVIG to facilitate accurate work-up for infectious diseases. Copyright © 2023 Southern Society for Clinical Investigation.
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Background: The COVID-19 first surfaced when cluster of pneumonia patients arose in Wuhan, Hubei Province, China. Although the current gold standard for COVID-19 diagnosis is reverse transcriptase-polymerase chain reaction (RT-PCR), chest x-ray (CXR) and computed tomography (CT) play a vital role in sickness diagnosis due to their limited sensitivity and availability. Aim: To evaluate retrospectively the role of CXR, the main radiological findings in it and its diagnostic accuracy in COVID-19 pneumonia. Methods: This is a cross sectional study involving 264 PCR positive COVID-19 patients with their clinical-epidemiological findings admitted at Ziauddin Hospital from May-July 2020. CXRs were taken as digital radiographs in our emergency department's isolation wards using the same portable X-ray device, according to local norms. CXRs were taken in two directions: antero-posterior (AP) and postero-anterior (PA). The hospitals' database had all of the images. To determine the number of radiological findings, multiple radiologists on duty completed an independent and retrospective examination of each CXR. In the event of disagreement, a mutual agreement was reached. SPSS version 20 was used for statistical analysis. Results: We were able to find 264 patients who met our criteria. With a mean age of 56.4214.89, the majority of individuals were determined to be males 189(71.6%) and females 75(28.4%). (Range of 16 to 87 years). 127 patients (48.1%) had severe illness symptoms and were admitted to the ICU, while the remaining 102(38.6%) had mild to moderate disease 35(13.3%). Diffuse (29.2%) and middle and lower co-existing distribution (25.8%) whereas just lower lobe (13.3%) were the most common predominance in severity. Peripheral involvement was also seen in (8.7%) cases. Conclusion: Both lungs are equally affected with the disease having the consolidation and opacifications while the effusion is the major complication in the severe cases. Diffuse involvement of the lung lobes is seen in the study followed by the middle and lower lobe involvement.
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SESSION TITLE: Imaging, ECMO, and other Procedures in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Inhalation of various organic and non-organic compounds like toxic fumes, batteries, and dust can result in lung irritation called chemical pneumonitis (1). Chemical Pneumonitis can cause acute complications like secondary pneumonia or long-term complications like bronchiectasis or lung destruction (2). Classical radiograph findings of chemical pneumonitis show pulmonary edema or radiographic opacities (3). This type of injury can initially present as no damage in radiograph scans, and the extent of damage can be difficult to determine initially. Chemical pneumonitis can also be difficult to distinguish from pneumonia caused by bacteria or a virus. CASE PRESENTATION: A 40-year-old male presented to the emergency department with an 18% total body surface area burn to his upper extremities from an oil pump battery explosion that released chemicals he likely aspirated. The patient was intubated and transferred to the Burn ICU where a bedside bronchoscopy was performed. It revealed no soot or signs of inhalation injury. On the day of admission, he had a 100% oxygen dependence. A CT scan was done and showed no lung damage. The patient was extubated and moved to a high-flow nasal cannula of 40 liters per minute. A repeat CT scan was performed of his chest on hospital day 4. The results appeared to be multifocal pneumonia eliciting a possible diagnosis of Covid 19 pneumonia. This delayed his excision and grafting by 5 days. Through aggressive respiratory therapy intervention, oxygen dependence was reduced until the patient was on room air. The patient was discharged to inpatient rehab on hospital day 21. DISCUSSION: There are several factors presented in this case that should be kept in mind when treating a patient exposed to compounds that can cause chemical pneumonitis. Chemical pneumonitis likely has no findings on bronchoscopy. Furthermore, previous literature has suggested that CT chest scans of chemical pneumonitis may initially present with no apparent injury. Regardless of these initial findings, it is important that patients receive intense pulmonary hygiene to avoid delays in other interventions. Chemical pneumonitis injuries can be associated with chemical burns, and it is imperative to avoid delays in interventions including excision and skin grafting. Findings from a chemical pneumonitis injury may present on a CT scan later in a patient's course of injury. The findings of the CT scan could resemble multifocal pneumonia. This may complicate treatment plans as SARS-CoV-2 is also known to cause multifocal pneumonia. CONCLUSIONS: This case highlights the complexity that chemical pneumonitis traumatic injury may present, and the various factors providers should keep in mind. In the aftermath of the COVID-19 pandemic, another factor has emerged: the resemblance of chemical pneumonitis to SARS-CoV-2 multifocal pneumonia. Reference #1: Andujar, P., & Nemery, B. (2009). Pathologies respiratoires aiguës et subaiguës d'origine toxique [Acute and subacute chemical pneumonitis]. Revue des maladies respiratoires, 26(8), 867–885. https://doi.org/10.1016/s0761-8425(09)73682-4 Reference #2: Neill, S., & Dean, N. (2019). Aspiration pneumonia and pneumonitis: a spectrum of infectious/noninfectious diseases affecting the lung. Current opinion in infectious diseases, 32(2), 152–157. https://doi.org/10.1097/QCO.0000000000000524 Reference #3:.White, C. S., & Templeton, P. A. (1992). Chemical pneumonitis. Radiologic clinics of North America, 30(6), 1231–1243. DISCLOSURES: No relevant relationships by Genesy Aickareth No relevant relationships by Deepak Bharadia No relevant relationships by John Griswold No relevant relationships by Alan Pang No relevant relationships by Jad Zeitouni
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SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Tuberculosis (TB) rates in the USA are currently at the lowest in history. During 2010-17, only 5175 TB cases occurred in children in the USA. Even in Hidalgo County on the Texas-Mexico border there were only 36 cases of TB among all age groups in 2020. CASE PRESENTATION: An asymptomatic 3-year-old male presented to the PICU with a positive PPD and an infiltrate in the right lower lobe on chest x-ray. Once three morning gastric aspirates were obtained child was started on a 4 drug regimen recommended by the health department, and sent to the pulmonology clinic for further care awaiting identification and sensitivity of an organism. Child was born at 35 weeks gestation, spent 8 days in NICU for unclear reasons requiring intubation and oxygen. Upon review of patient history and chest x-ray, diagnosis of TB became less likely. This was further confirmed by gastric aspirate revealing no organisms and negative QuantiFERON Gold. CT with oral and IV contrast revealed a right-sided congenital diaphragmatic hernia (CDH) in the foramen of Morgagni. Patient received definitive outpatient surgery in October 2021. At 3-month follow-up there were no surgical complaints and patient reported increased exercise tolerance. DISCUSSION: TB is very rare in the US, even in the Rio Grande Valley where the proportion of cases are higher. This child received 42 doses of TB treatment after a positive PPD and consolidation on chest x-ray. However, x-ray did not clearly indicate TB infection and in fact was suspicious for bowel in the chest cavity. This case clearly indicates the need for careful examination of radiographs and ordering more tests such as the QuantiFERON Gold as needed before jumping to what may seem to be the obvious conclusion. Even though CDH are uncommon and Morgagni hernias are rare making up only 2-3% of CDH, a closer look at the case was warranted. This child's misdiagnosis led to more than simply unnecessary medical treatment, it also led to social stigma for the family that culminated in the father being terminated from his job. This child's surgical repair was delayed due to missed diagnosis of Morgagni hernia in NICU, PICU, and health department and delayed ordering of confirmatory TB tests. Furthermore, patient was referred to surgery in March 2020 but was delayed by 19 months due to COVID-19. The pandemic was also the stimulus for the outpatient nature of the complicated surgery. It is unclear why patient's PPD was positive. It is of note that mother's PPD was also positive due to contact with active TB years prior to child's birth. One hypothesis is this may have caused positive PPD in child and is a future question to pursue. CONCLUSIONS: We want to emphasize to look before you leap and investigate before you treat. There was harm to the child and family done by treating aggressively that could have been prevented and an opportunity to help the child that was delayed. Reference #1: Cowger TL, Wortham JM, Burton DC. Epidemiology of tuberculosis among children and adolescents in the USA, 2007–17: An Analysis of National Surveillance Data. The Lancet Public Health. 2019;4(10). doi:10.1016/s2468-2667(19)30134-3 Reference #2: Leeuwen L, Fitzgerald DA. Congenital diaphragmatic hernia. Journal of Paediatrics and Child Health. 2014;50(9):667-673. doi:10.1111/jpc.12508 Reference #3: Mohamed M, Al-Hillan A, Shah J, Zurkovsky E, Asif A, Hossain M. Symptomatic congenital Morgagni hernia presenting as a chest pain: A case report. Journal of Medical Case Reports. 2020;14(1). doi:10.1186/s13256-019-2336-9 DISCLOSURES: No relevant relationships by Isha Mittal No relevant relationships by Barbara Stewart
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SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We present two cases of symptomatic post-COVID eosinophilic pneumonia responsive to steroids. CASE PRESENTATION: Case 1: A 73-year-old gentleman with underlying asymptomatic rheumatoid arthritis (RA), was admitted with COVID pneumonia for which he received tocilizumab, remdesivir, and 12 days of dexamethasone. His course was complicated by MRSA pneumonia and bacteremia, so was discharged on IV Vancomycin. Six days post discharge, he redeveloped respiratory distress. Labs showed a WBC 18,000 and proBNP 2828. A chest CT revealed bilateral ground-glass opacities, worsening right upper lung airspace disease and bilateral pleural effusions. Despite receiving Furosemide, Vancomycin, and Ceftazidime, he required high-flow nasal cannula oxygenation (HFNC). Bronchoscopy demonstrated thick right bronchial secretions. BAL fluid revealed 7% eosinophils and grew MRSA. Case 2: A 70-year-old gentleman with extensive smoking history, emphysema, psoriasis, Guillain-Barré syndrome and a recent hospitalization for COVID pneumonia was discharged on a steroid taper. He returned 23 days post discharge in respiratory distress requiring HFNC, 5 days after discontinuing steroids. The chest CT revealed worsening fibrosis and bronchiectasis. Intravenous Levofloxacin and Vancomycin resulted in no clinical improvement. Bronchoscopy showed inflamed bronchi with secretions and BAL analysis revealed 6% eosinophils. For both patients, BAL was negative for fungi and PJP and CTA ruled out PE. Both patients were started on Prednisone with a prolonged taper. They improved clinically with decreased oxygen requirements to 4L nasal cannula and dramatic decrease in subjective dyspnea within 48 hours of starting steroids. DISCUSSION: The differential diagnosis for the clinical deterioration and worsening radiographs in both patients includes bacterial/fungal superinfection, PE, post-COVID-ILD and eosinophilic pneumonia. For the first patient, his RA was inactive. His BAL was positive for MRSA but did not improve until steroids were initiated. Neither of the patients were stable for VATS biopsy. Eosinophilic pneumonia is defined as pulmonary infiltrates with peripheral blood eosinophilia =500/ml, BAL eosinophils > 5% or eosinophilic infiltration on lung biopsy [1]. Both of our patients had >5% BAL eosinophils. Potentially, prolonged COVID-ILD stimulates T-Helper-2 cells, causing the release of IL-4/5/13 with recruitment of eosinophils. Studies report post-COVID-ILD biopsies show organizing pneumonia and fibrosis but have not yet been associated with eosinophilia. In both patients, we observed eosinophilia on BAL. It can be hypothesized that a delayed inflammatory response mediated by eosinophils play a role. CONCLUSIONS: Pulmonary eosinophilic pneumonia is a complication of post-COVID-ILD and can be successfully managed with steroids. Reference #1: De Giacomi F, Vassallo R, Yi ES, Ryu JH. Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management. Am J Respir Crit Care Med. 2018 Mar 15;197(6):728-736. doi: 10.1164/rccm.201710-1967CI. PMID: 29206477. DISCLOSURES: No relevant relationships by farrukh ahmad No relevant relationships by Deborah Markowitz No relevant relationships by Dhiraj Shah No relevant relationships by Garima Singh No relevant relationships by Aakriti Soni
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Aim: Amid COVID pressures, standards of surgical practices need constant reviewing to maintain patient safety and streamline care pathways. Newly published BOAST (British Orthopaedic Association Standards for Trauma and Orthopaedics) guidelines for paediatric supracondylar fractures became a benchmark against which a restructured DGH trauma unit's performance can be appraised. Method: Theatre records were analysed between April-2020 and September-2020. Data were collected to reveal time to theatre, operative techniques, documentations of ulnar nerve protection, complications, follow-up plans, time to first post-op radiograph and to wire removal. Results: 90% of patients underwent operations within 24-48 hour. Although there was no incidence of iatrogenic nerve injury, documentation of ulnar nerve protection was not identified in 45% of crossed wire fixations. Wire size was not mentioned in 14%. 33% did not have first follow-up with radiograph within 4-10 days, and 43% of patients did not have the wires removed till 4 weeks post op. Conclusion: This re-audit highlights the need to improve in documentation for ulnar nerve protection and to identify the delays in follow-up appointments. Although BOAST no longer recommends a fixed timeframe for follow-up plan, first radiograph within 4-10 days and wire removal within 4 weeks are still reasonable locally.
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Deep learning approach for detecting various respiratory diseases hasbeen challenging and mostdemanding research area. Withrapidly increase in number of patients suffering from respiratory diseases quick method hasbecome necessary for classification and detection of respiratory diseases. This survey paper offers a comparative study of various deep learning techniques that can use chest X-raysfordetection of various thoracic diseases.There is possibility of severe respiratory failure in some thoracic diseases if they are not treated in initial stages. Many digital image processing techniques,machine learning and deep learning models have been developed for this purpose[17]. Different forms of existing deep learning techniques including convolutional neural network (CNN), visual geometry group based neural network (VGG-16 and VGG-19) have been developed for respiratory disease prediction. But these all models have some limitations that they do not cover all respiratory diseases including Covid-19, Viral pneumonia and Tuberoculosis on single platform. Therefore, we propose our customized new deep learning model Clx-Net by using data augmentation technique to enlarge the area of available dataset[1][2] to make model more efficient with less time consumption per epoch and provide localization to identify infected region by examining chest X-ray images. Our focus is to develop a new unique deep learning based model Clx-Net which will be able to detect almost all major respiratorydiseases including Covid-19. It will simplify the detection of respiratory diseases and also find the location of infected chest area to make task easy for radiologists.
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Background: According to 2019 updated EULAR recommendations, therapy of Early Rheumatoid Arthritis (ERA) with biological disease-modifying antirheu-matic drugs(bDMARDs) is adviced in presence of poor prognostic factors,I.e. persistently moderate/high disease activity, high acute phase reactants, high swollen joint count, autoantibody positivity, presence of early erosions, failure of two/more conventional synthetic DMARD. Objectives: To evaluate over time prevalence of bDMARD therapy and factors associated to rapid initiation in our EA Clinic (EAC), comparing two different periods: from 2004 to 2012 and from 2012 to 2020. The last two years were not considered because of the adverse influence of COVID19 pandemia on early access to EAC and on timely scheduled visits. Methods: A total of 281 ERA patients with less than 12 months of disease duration (53.9 years mean age, 75% female, 77% seropositive), followed according to the treat-to-target (T2T) strategy, were enrolled in the study. At baseline, and every three months, the ACR/EULAR core data set variables were recorded. At baseline and every year, hand and foot radiographs were examined according to modifed Total Sharp score (mTSS). At each visit, clinical improvement and remission were evaluated according to EULAR criteria. The achievement of Comprehensive Disease Control (CDC) (28-joint Disease Activity Score using C reactive protein <2.6, Health Assessment Questionnaire <0.5 and change from baseline in mTSS ≤0.5) was assessed every year. Results: We examined 164 patients from 2004 to 2012 and 117 subjects from 2012 to 2020. In the frst group 72 patients (43.9%) initiated bDMARDs during the 8-year FU, with a mean delay of 41.8 months. In the second group 37 patients (31.6%) started biotechnological drugs over time, with a mean delay of 50.4 months. Analyzing the period from 2004 to 2012, ERA patients starting bDMARDs were younger (p<0.0001), had longer disease duration (p=0.02) and higher body mass index (BMI) (p=0.01) compared to subjects not undergoing to biological therapy. Moreover, ERA patients in bDMARDs were in higher percentage anti-citrullinated peptide antibody (ACPA) positive (80.6%) and reached to a lesser extent CDC at 12months of FU (26.1%) compared to patients that didn't initiate bDMARDs (60.9% ACPA positive, p=0.01;63% achieving CDC, p<0.0001, respectively). Examining the period from 2012 to 2020, bDMARD-treated ERA patients were younger (p=0.06),in higher percentage ACPA positive (81.1%) and erosive at baseline (35.1%) compared to patients that didn't initiate bDMARDs (64% ACPA positive, p=0.02;17.5% erosive, p=0.04, respectively). As previously, patients in bDMARD reached to a lesser extent CDC at 12 month of FU (35.1%) compared to subjects not undergoing to biological therapy (55% achieving CDC, p=0.05). On multivariate analysis, ACPA positivity was associated with initiation of bDMARD in both patient groups (p=0.02), whereas older age at onset and reaching CDC at 12 month were inversely associated (p=0.001;p<0.0001, respectively). Conclusion: Despite the widest choice of bDMARDs currently available in the last 8 years, we did not observe an increase in the prescription of these drugs from 2012 to 2020. As in other ERA cohorts, bDMARD initiation is associated to poor prognostic factors, in particular ACPA positivity, presence of erosions at baseline and not achieving CDC at 12 months of FU. In the last 8 years, the decreased influence of disease duration at onset and of BMI could be a consequence of the improvement in strategies of early referral and control of modifable risk factors.