Non-Hodgkin's lymphoma complicated with human coronavirus HKU1 pneumonia: A case report and literature review.

Objective: To analyze the clinical manifestations, diagnostic methods and treatment process of the patients with non-Hodgkin's lymphoma complicated with human coronavirus(HCoV)-HKU1 pneumonia and improve the clinical medical staff's awareness of the disease, and to reduce the occurrence of clinical adverse events. Method(s): The clinical data of a patient with non-Hodgkin's lymphoma complicated with HCoV-HKU1 pneumonia with hot flashes and night sweats, dry cough and dry throat as the main clinical features who were hospitalized in the hospital in January 2021 were analyzed, and the relevant literatures were reviewed and the clinical manifestations and diagnosis of HCoV-HKU1 were analyzed. Result(s): The female patient was admitted to the hospital due to diagnosed non-Hodgkin's lymphoma for more than 2 months. The physical examination results showed Karnofsky score was 90 points;there was no palpable enlargement of systemic superfical lymph nodes;mild tenderness in the right lower abdomen, no rebound tenderness, and slightly thicker breath sounds in both lungs were found, and a few moist rales were heard in both lower lungs. The chest CT results showed diffuse exudative foci in both lungs, and the number of white blood cells in the urine analysis was 158 muL-1;next generation sequencing technique(NGS) was used the detect the bronchoalveolar lavage fluid, and HCoV-HKU1 pneumonia was diagnosed. At admission, the patient had symptoms such as dull pain in the right lower abdomen, nighttime cough, and night sweats;antiviral treatment with oseltamivir was ineffective. After treatment with Compound Sulfamethoxazole Tablets and Lianhua Qingwen Granules, the respiratory symptoms of the patient disappeared. The re-examination chest CT results showed the exudation was absorbed. Conclusion(s): The clinical symptoms of the patients with non-Hodgkin's lymphoma complicated with HCoV-HKU1 pneumonia are non-specific. When the diffuse shadow changes in the lungs are found in clinic, and the new coronavirus nucleic acid test is negative, attention should still be paid to the possibility of other HCoV infections. The NGS can efficiently screen the infectious pathogens, which is beneficial to guide the diagnosis and treatment of pulmonary infectious diseases more accurately.Copyright © 2023 Jilin University Press. All rights reserved.

Role of telemedicine in anesthesia: Are we ready yet?

Telemedicine is a modality which utilizes technology to provide and support health care across large distances. It has redefined the practices of medicine in many specialties and continues to be a boon for clinicians on many frontiers. Its role in the branch of anesthesia remains largely unexplored but has shown to be beneficial in all the three phases: pre-operative, intra-operative, and post-operative. Now time has come that anesthesiologists across the globe reassess their strategies and utilize the telemedicine facilities in the field of anesthesia.Copyright © 2021 EDP Sciences. All rights reserved.

Report of the Association Between Multisystem Inflammatory Syndrome and Severe Myocarditis

Introduction: The people worldwide have been affected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection since its appearance in December, 2019. Kawasaki disease-like hyperinflammatory shock associated with SARS-CoV-2 infection in previously healthy children has been reported in the literature, which is now referred to as a multisystem inflammatory syndrome in children (MIS-C). Some aspects of MIS-C are similar to those of Kawasaki disease, toxic shock syndrome, secondary hemophagocytic syndrome, and macrophage activation syndrome. Case Presentation: This study reported an 11-year-old boy with MIS-C presented with periorbital and peripheral edema, abdominal pain, elevated liver enzymes, severe right pleural effusion, moderate ascites, and severe failure of right and left ventricles. Conclusion(s): Due to the increasing number of reported cases of critically ill patients afflicted with MIS-C and its life-threatening complications, it was recommended that further studies should be carried out in order to provide screening tests for myocardial dysfunction. Adopting a multidisciplinary approach was found inevitable.Copyright © 2023, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

Real Time Implementation of Robust Sound based Respiratory Disease Classification using Spectrogram and Deep Convolutional Neural Networks

Respiratory diseases become burden to affect health of the people and five lung related diseases namely COPD, Asthma, Tuberculosis, Lower respiratory tract infection and Lung cancer are leading causes of death worldwide. X-ray or CT scan images of lungs of patients are analysed for prediction of any lung related respiratory diseases clinically. Respiratory sounds also can be analysed to diagnose the respiratory illness prevailing among humans. Sound based respiratory disease classification against healthy subjects is done by extracting spectrogram from the respiratory sound signal and Convolutional neural network (CNN) templates are created by applying the extracted features on the layered CNN architecture. Test sound is classified to be associated with respiratory disease or healthy subjects by applying the testing procedure on the test feature frames of spectrogram. Evaluation of the respiratory disease binary classification is performed by considering 80% and 20% of the extracted spectrogram features for training and testing. An automated system is developed to classify the respiratory diseases namely upper respiratory tract infection (URTI), pneumonia, bronchitis, bronchiectasis, and coronary obstructive pulmonary disease (COPD) against healthy subjects from breathing & wheezing sounds. Decision level fusion of spectrogram, Melspectrogram and Gammatone gram features with CNN for modelling & classification is done and the system has deliberated the accuracy of 98%. Combination of Gammatone gram and CNN has provided very good results for binary classification of pulmonary diseases against healthy subjects. This system is realized in real time by using Raspberry Pi hardware and this system provides the validation error of 14%. This automated system would be useful for COVID testing using breathing sounds if respiratory sound database with breathing sound recordings from COVID patients would be available.Copyright © 2023 North Atlantic University Union NAUN. All rights reserved.

Occlusive Explosion

Clinical Information Patient Initials or Identifier Number: A Relevant Clinical History and Physical Exam: 47yr old man, suffered a blast injury at the workplace after an O2 tank exploded while he was transferring liquid gas into a tank for welding purposes. The impact has caused him to temporary loss of consciousness. Upon awakening, he had severe chest pain associated with shortness of breath. On examination, superficial partial thickness injury on the chest wall, and lungs: reduced breath sound bi-basally, no murmur heard. BP:106/77mmHg, HR:100/min, SPO2 100% on HFM 15L/min. [Formula presented] [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: Serial ECGs were done and showed dynamic changes in the anterior leads Bedside echo before invasive coronary angiograms shows mild LVSD, normal valves, and no pericardial effusion [Formula presented] [Formula presented] Relevant Catheterization Findings: Right radial approach 6F system Opitorque catheter for diagnostic angiogram LMS: smooth LAD: ATO mid LAD, DG1 prox ATO LCx: smooth RCA: smooth Impression: ATO to LAD and Diagonal 1 ( Dual ATO) [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: Right radial coronary angiogram via 6F system EBU 3.0 engaged with good support Sion blue wired into LAD, export catheter delivered, and aspirated red thrombus Pre-dilated with Sapphire 3 SC 2.5x15mm @ 6-10ATM Flow established in LAD, however, decided to interrogate DG1 as it shows ATO BMW wired into the DG1 and pre-dilated with Sapphire 3 SC 2.0x15mm Noted nonflow limiting dissection and decided to stent DG1 with 2.25x34mm@12ATM, dissection sealed and TIMI III flow established Stented mid LAD with 2.5x30mm @12ATM just before LAD/DG1 bifurcation, then stented proximal LAD with 2.5x 26mm@ 12ATM. Post-dilated LAD with 2.75x15mm@ 14-20ATM TIMI II-III flow IV Tirofiban has been given a loading dose due to a high thrombus burden and sluggish flow [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Myocardial infarction is a rare complication of blunt chest trauma. This case demonstrates how blast shock waves result in the dissection of the coronary vessel leading to total occlusion of the two vessels. It also promotes red thrombus within the coronary vessels. Percutaneous coronary intervention is the most suitable way to treat this condition. Intravascular imaging such as IVUS or OCT would be beneficial to demonstrate the physiology behind this MI and would also be helpful in planning and optimizing the lesions. Unfortunately, intravascular imaging was not used for this patient to reduce procedural time as he was treated during the height of the COVID pandemic.Copyright © 2023

The diagnosis of spontaneous secondary tension pneumothorax following apparentrecovery from COVID19 pneumonitis

Background: Coronavirus disease 19 has been associated with a plethora of different manifestations of systems affected (including pulmonary, gastro-intestinal, and thrombotic disease) and time to presentation of complications. Pneumothorax has been established as a complication in the literature. However, tension pneumothorax remains a rare presentation with higher mortality. We report a case of secondary tension pneumothorax in a patient following apparent recovery from COVID-19 pneumonitis. Case presentation: Eight days after resolution of COVID-19 pneumonitis symptoms a 51-year-old Caucasian man with no pre-existing pulmonary disease was brought into the emergency department following 48 hours of progressive shortness of breath. Further clinical assessment revealed reduced breath sounds in the right lung, BP was 116/95 mmHg and jugular venous pressure was not elevated. Chest x-ray showed right-sided tension pneumothorax with mediastinal shift. Insertion of a chest drain led to rapid resolution of symptoms and the patient was discharged following full re-expansion of the lung. Conclusion(s): The period of recovery from COVID-19 is variable. Clinicians should consider tension pneumothorax as a possible complication of COVID-19 pneumonitis in patients presenting with type 1 respiratory failure, even after resolution of pneumonitis symptoms and a considerable time period following initial contraction of COVID-19.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

Pancreaticopleural fistula presenting as respiratory distress in previously healthy adolescent

Case Report: Respiratory distress is one of the most common complaints evaluated by pediatric providers in the office and emergency department setting. While primary cardiopulmonary processes represent the majority of cases of respiratory distress, pleural effusions of extravascular origin remain a rare but important differential. In this case, we present a previously healthy adolescent female who presented to our institution with respiratory distress and was subsequently found to have a pancreatic pleural effusion in the setting of a pancreaticopleural fistula. A 13 year old female with no chronic past medical history presented to the emergency department for three weeks of progressively worsening shortness of breath. History was notable for SARS-CoV-2 infection 6 months prior and intermittent night sweats and fevers for previous 4 weeks. She denied trauma, abdominal pain, nausea, vomiting, diarrhea, or anorexia. Her exam was notable for tachycardia, tachypnea, tripod positioning and absent breath sounds on her left. Chest computed tomography (CT) revealed left pleural effusion of entire left hemithorax with midline shift in addition to right sided pulmonary thromboembolism, small right sided pleural effusion and venous thromboses of the left internal jugular, subclavian, and proximal innominate veins. A left thoracentesis was performed, and patient was admitted to the PICU on a heparin infusion with subsequent left chest tube placement. Follow-up CT imaging revealed bilateral renal infarcts, iliac vein thrombosis, and a pancreatic fluid collection extending into the mediastinum with pancreatic ductal dilation. Magnetic resonance cholangiopancreatography further characterized the pancreatic lesion as a cystic tract traversing from the inferior mediastinum into the retroperitoneum and replacing the majority of the pancreatic gland suggesting a pancreaticopleural fistula as the source of a pancreatic pleural effusion. Serum amylase was 256 U/L and serum lipase was 575 U/L. Pleural fluid amylase was 1702 U/L and pleural fluid lipase was >2400 U/L, exceeding detection limit of this institution's lab. An extensive diagnostic work-up included infectious, hematologic, oncologic, autoimmune and rheumatologic etiologies and was largely unremarkable. Given concern for pancreaticopleural fistula, patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) which was diagnostic for pancreatic divisum. A pancreatic duct stent was placed with normalization of serumpancreatic enzymes prior to discharge and resolution of pleural effusion at one month post ERCP Although an initial episode of acute pancreatitis usually resolves with supportive care, this case is a reminder that pancreatitis can present with local and systemic complications including pulmonary effusion or venous thromboses and keeping a high index of suspicionfor it is crucial toavoid delaying diagnosis and care. Copyright © 2023 Southern Society for Clinical Investigation.

Protein losing enteropathy (PLE) secondary to norovirus infection in a 4 year old patient

Case Report: Protein losing enteropathy (PLE) occurs when proteins leak from the gastrointestinal (GI) system more rapidly than they are produced. Inflammation of the GI tract facilitates increased membrane permeability of gastric mucosa, leading to excess protein leakage. 1 PLE in children has been associated with CMV, rotavirus, COVID-19, HIV, C. difficile, and autoimmune diseases like Crohn's Disease. 2-6 Norovirus is a known cause of PLE in immunocompromised pediatric patients. 7-8 However, to our knowledge, there are no case reports about PLE precipitated by norovirus in immunocompetent pediatric patients. The purpose of this case report is to present a case of PLE precipitated by a norovirus infection in a 4- year-old previously healthy child. While the above gastrointestinal viruses have been proposed as precipitators for this disease, PLE precipitated by norovirus infection has not been well described. This case also highlights the importance of early diagnosis and management to avoid complications. Method(s): Our patient initially presented with two days of abdominal pain, diarrhea, emesis, reduced urine output, and swelling of the lower extremities. He was exposed to several sick family members-his sister had upper respiratory symptoms and his grandmother had gastrointestinal symptoms. Physical exam was notable for diminished breath sounds in the right lower lobe, abdominal distension with diffuse tenderness and dullness to percussion, significant scrotal and penile edema, and bilateral lower extremity pitting edema. Laboratory results revealed leukocytosis, hypoalbuminemia, hyponatremia, elevated aspartate aminotransferase (AST), and elevated serum alpha-1-antitrypsin, as well as low Immunoglobulins G and M. CD3 and CD4 levels were low reflecting cellular immune dysregulation seen in patients with PLE. IgA and Tissue Transglutaminase (TTF) were within normal limits. Ebstein Barr Virus and cytomegalovirus IgM antibodies were negative. COVID IgG was negative as well. His Polymerase chain reaction (PCR) gastrointestinal panel was positive for norovirus. A chest X-ray showed a large right pleural effusion. Abdominal CT revealed large ascites slightly more predominant in the upper abdomen, mesenteric lymphadenitis, and bilateral pleural effusions. Echocardiogram showed small anterior and apical pericardial effusions. Result(s): Based on the patient's elevated serum alpha-1 antitrypsin levels, hypoalbuminemia, low levels of immunoglobulins and lymphocytes, and clinical manifestations of ascites, bilateral pleural effusions, pericardial effusion, and dependent edema, along with a positive PCR for norovirus, the diagnosis of PLE secondary to Norovirus was made. Conclusion(s): This case demonstrates the importance of recognizing viruses like Norovirus as potential causes of PLE to avoid a delay in diagnosis and initiation of therapy, and to avoid unnecessary additional testing. Copyright © 2023 Southern Society for Clinical Investigation.

Infective Endocarditis Pulmonary Septic Emboli Due to Mrsa in a Patient with Chronic End Stage Kidney Disease on Maintenance Hemodialysis a Case Report and Few Learning Points

BACKGROUND: Small percentage of catheter-related bloodstream infection may present atypically with persistent low-grade fever without chills and rigor and in some of these cases blood culture can be negative. These may lead to diagnostic confusion and delay in detection of the common entity of catheter-related blood stream infections. AIM OF THE STUDY: Case discussion with learning points METHODS: We report a case with multiple pictorial images and discuss differential diagnosis with few learning points. RESULT(S): 42-year-old male patient, a known case of end-stage chronic kidney disease on maintenance hemodialysis through a tunneled catheter, presented with a history of intermittent, low-to-moderate fever for 3 weeks. The fever associated with generalized weakness, night sweats but was not associated with chill and rigor. His past medical history included endstage chronic kidney disease due to chronic glomerulonephritis and was on maintenance hemodialysis thrice weekly for last 6 months through tunneled catheter in right IJV. On physical examination, the patient had tachycardia, normotension with a blood pressure of 120/70.mmHg, normal saturation at room air with respiratory rate of 20 /minute. On auscultation, there was reduced breath sounds on left side and normal heart sounds. The catheter site showed no heat, erythema, swelling, tenderness. Chest radiograph revealed left hydropneumothorax with multiple focal pulmonary nodular opacities. CECT chest showed left loculated hydropneumothorax with multiple cavitary nodules with reverse halo sign (Figures 1 and 2). Lab investigations showed significant leukocytosis with neurophilia, random serum glucose of 250.mg/dL, and D-dimer of 3624.ng/mL. Blood cultures from hemodialysis catheter and contralateral peripheral vein were negative for pathogenic bacteria, mycobacteria, and fungal etiology. Urine analysis was sterile and did not have pus cells. On day 4 of admission, patient had left axillary pain. On clinical examination, there was focal tenderness on examination in the left axilla. On ultrasonography, there was a small collection which was aspirated under ultrasound guidance and showed gram-positive bacteria on microscopy. Trans esophageal echocardiography revealed multiple tiny vegetations on right side of interatrial septum on tricuspid valve (Figure 3). Subsequent culture results showed methicillin resistant staphylococcus sensitive to clindamyin, vancomycin, linezolid, ciprofloxacin (Figure 4 and 5). The patient was started on vancomycin and ceftazidine on empirical basis for microscopic findings, and after subsequent culture revealed methicillin-resistant Staphylococcus aureus, he was treated with vancomycin. Permanent catheter was removed. Hemodialysis was continued through temporary right IJV catheter. Blood cultures were cleared from MRSA on hospital day ten. She got discharged home on intravenous Vancomycin for 6-8 weeks and was reported doing well on follow-up. CONCLUSION(S): The learning points are- 1. MRSA infection is common in chronic kidney disease patient on hemodialysis. 2. Clinical presentation of metastatic MRSA infection with infective endocarditis may be indolent with cardiovascular and respiratory stability with absence of fever spikes, chill, and rigor. 3. Common infective causes of cavitary nodules in lung are typical and atypical mycobacterial infection, fungal infection, and pyogenic septic emboli. 4. Uncommon infective causes of reverse halo sign on CT chest need to be remembered and include bacterial pneumonia, septic embolism, mycobacterial infection, invasive aspergillosis, in addition to common infective etiology of reverse halo sign like mucormycosis infection and COVID19 infection.

An Unwelcome House Guest: Coronary Aneurysms and Evolving Stemi

Case Description: 54-year-old man presented to the Emergency Department (ED) three weeks after Covid-19 infection for progressively worsening dyspnea and hypoxemia. Dexamethasone and prophylactic apixaban (2.5mg twice a day) were initiated and he was discharged 48 hours later. A week after discharge he re-presented to the ED requiring 6L of oxygen (O ) despite uninterrupted dexamethasone and apixaban therapy. His past medical history was significant for quiescent IgG4 disease on Rituximab and Type 1 Diabetes. He was afebrile, tachycardic and tachypneic with decreased right lower lobe breath sounds. He had an elevated erythrocyte sedimentation rate and C-reactive protein, no leukocytosis and no pulmonary embolism of CT. He was admitted and vancomycin and cefepime antibiotic therapy for a superimposed bacterial pneumonia was begun. On day 12 of the hospital stay, he experienced new onset chest pain. Evaluation showed an elevated troponin and submillimeter ST segment elevation concerning for an evolving STEMI. Coronary angiography demonstrated an 90% diffuse mid LAD stenosis and two large coronary aneurysms of the left circumflex artery (LCx). The mid-LAD was stented using a 3.0 x 38 mm and 2.75 x 26 mm Onyx drug eluting stents with resolution of his chest pain. IgG4 serum level was normal and imaging did not demonstrate active IgG4 disease. He was discharged on aspirin and clopidogrel. Due to concern for a hypercoagulable state in the setting of Covid 19 infection, IgG4 disease and the large coronary aneurysms for thrombus formation, warfarin anticoagulation was also initiated. On review of his coronary imaging, the largest LCx aneurysm was 9mm on admission and 12mm three weeks later with evidence of diffuse coronary inflammation. CT Fractional Flow Reserve (abnormal <= 0.80) demonstrated decreased flow at the distal aneurysm with no focal stenosis to account for flow reduction. Conclusion(s): 54-year-old man with IgG4 disease presenting with prolonged Covid-19 infection and acute NSTEMI. He was found to have large, flow limiting coronary aneurysms and inflamed coronary arteries all consistent with his IgG4 disease. Management of these aneurysms will be discussed.

Mortality risk model validation in a prospective cohort of patients from the sixth wave of the COVID-19 pandemic in a hospital emergency department

Objective. To validate risk factors for mortality in patients treated for COVID-19 in a hospital emergency department during the sixth wave of the pandemic. Method. Prospective observational noninterventional study. We included patients over the age of 18 years with a confirmed diagnosis of COVID-19 between December 1, 2021, and February 28, 2022. For each patient we calculated a risk score based on age 50 years or older (2 points) plus 1 point each for the presence of the following predictors: Barthel index less than 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen less than 400, abnormal breath sounds, platelet concentration less than 100 x 109/L, C-reactive protein level of 5 mg/dL or more, and glomerular filtration rate less than 45 mL/min. The model was assessed with the area under the receiver operating characteristic curve (AUC). Results. Of the 1156 patients included, 790 (68%) had received at least 2 vaccine doses. The probability of 30-day survival was 96%. A risk score was calculated for 609 patients. Four hundred seventeen patients were at low risk of death, 180 were at intermediate risk, and 10 were at high risk. The probability of death within 30 days was 1%, 13%, and 50% for patients in the 3 risk groups, respectively. The sensitivity, specificity, and positive and negative predictive values of a risk score of 3 points or less were 88%, 72%, 19%, 99%, respectively.The AUC for the model was 0.87. Conclusion. The risk model identified low risk of mortality and allowed us to safely discharge patients treated for COVID-19 in our tertiary-care hospital emergency department. Copyright © 2023, Saned. All rights reserved.

Cefepime-Induced Neurotoxicity in the Setting of AKI Requiring Renal Replacement Therapy

Introduction: Cefepime is a commonly used parenteral antibiotic for severe infections.85% of the drug is excreted renally and crosses the blood-brain barrier. Cefepime-induced neurotoxicity (CIN) manifests as encephalopathy, myoclonus and seizures. It is reported in patients with renal impairment if administered in high dosage. CIN is reversible after drug discontinuation and faster clinical recovery is achieved by intermittent hemodialysis (IHD). Case Description: A 53-year-old female with a history of sleep apnea, obesity, recent COVID pneumonia presented with worsening dyspnea on exertion for 5 days. Physical examination revealed tachycardia, tachypnea, diminished breath sounds at lung bases. Admission laboratory results were a creatinine (Cr), 0.96 mg/dl;BUN, 18 mg/dl. Chest x-ray showed bilateral ground glass pulmonary opacities. Patient was started on Vancomycin 2 g IV every 12 hours and Cefepime 2 g IV every 8 hours. On day 2 she was in septic shock due to E.Coli bacteremia, intubated and started on pressors. Vancomycin was discontinued. On day 8 Cr increased to 1.49 mg/dl. Patient remained on Cefepime without dosage change for six more days despite glomerular filtration rate decreased to 20 ml/min/1.73 m2. On day 18 patient was noted to have altered mental status and jerking movements of upper extremities and head. Cefepime was stopped, Cr peaked at 3.95 mg/dl, BUN was 130 mg/dl at that time. CT scan of head was negative for acute findings. EEG showed focal cortical hyperexcitability, no seizure activity. Cr increased to 4.41 mg/dl, IHD was started. After two IHD sessions jerking movements disappeared, and consciousness improved. Work up for acute kidney injury (AKI) revealed negative Hepatitis B,C, HIV serology. ANA, ANCA serology was negative. Patient regained renal function within 1 week after six IHD sessions. Discussion(s): CIN is a known complication in patients with renal dysfunction but remains challenging to recognize in critically ill patients. Our patient had various causes of altered mental status: shock, hypoxemia, uremia. Despite decline in renal function cefepime dose was not adjusted and patient developed CIN which required emergent hemodialysis initiation. A high index of suspicion for CIN is critical when evaluating a patient with AKI. Discontinuation of cefepime and emergent IHD initiation leads to resolution of neurological symptoms within 48 hours.

A Special Case of Acute Myocarditis with Left Ventricular Thrombus

Introduction. Acute myocarditis is a potential life-threatening disease and left ventricular thrombus could be a complication. Nowadays, myocarditis has been observed after SARS-CoV-2 vaccination. We report the case of a young adult female with left ventricular thrombus secondary to COVID19 mRNA vaccine-related acute myocarditis. Case report A 33-year-old afro-descendant female was admitted to the ED with dyspnea, heart-pounding and chest pain. The EKG showed sinus tachycardia with diffuse changes in repolarization. The lab tests showed: TnHS 8437 ng/mL, C-reactive protein 3,8 mg/dL, normal white blood cell count, NTproBNP 3800 pg/mL, GOT 171 UI/l, GPT 57 UI/l. She received the first dose of mRNA SARS-CoV-2 vaccine 21 days earlier. The PCR swab test for SARS-CoV-2 was negative. Clinical examination revealed HR 110 bpm, BP 105/75 mmHg, normal lung sounds, tachycardic heart sounds. Transthoracic echocardiogram showed EF 25%, massive apical adherent thrombus and mild diffuse pericardial effusion. Serological analysis for viral and bacterial infection were negative. Coronary angiography, cardiac- MRI, myocardial biopsy were not performed because of patient refuse and claustrophobia. LMWH 8000 UI bid, Ibuprofen 600 mg tid and Colchicine 0,5 mg/die were administered. The patient was discharged after 14 days with no symptoms, no residual thrombus and total EF recovery. The alleged adverse event was reported to the National Pharmacovigilance Network. Conclusions Myocarditis is a potential consequence of both COVID-19 and its mRNA vaccines. Post-vaccine myocarditis is usually self-limiting with a low rate of consequences.

Pulmonary palytoxin poisoning on CT imaging

Background: Palytoxin poisoning is an uncommon exposure in the US, and is most frequently encountered amongst hobbiests and professionals in the aquarium industry. The toxin is produced by the microalgae Ostreopsis as well as the coral Palythoa toxica. Discovered in Hawaii, the name limu-make-o-Hana translates to "seaweed of death from Hana." Palytoxin interrupts Na+/ K+ ATPase pump, resulting in widespread cellular dysfunction. Persons are at highest risk when cleaning a fish tank housing the coral that produces palytoxin, resulting in cutaneous or inhalational exposure. We present a case of palytoxin inhalational exposure with computed tomography (CT) imaging. Case report: A 41-year-old male presented to the emergency department (ED) with dyspnea, cough, and wheezing after cleaning his saltwater fish tank. He reported that he maintains Zoanthid corals in his home saltwater fish tank and typically wears personal protective equipment when cleaning the tank. He had taken off his mask directly after using hot water to clean the tank, and quickly developed shortness of breath. He contacted Poison Control and was instructed to take loratadine with initial improvement in his symptoms. He then developed decreased appetite, nausea, and chills. The following day, in addition to these symptoms, he developed a fever of 102.5 degreeF and an oxygen saturation of 88% measured with an at-home pulse oximeter. He then proceeded to the ED where he was found to be hypoxic to 91% on room air, tachycardic to 120 bpm, hypotensive to 93/ 70mmHg, febrile to 100.9 degreeF and tachypneic at a respiratory rate of 30. Physical exam revealed clear lung sounds. Application of supplemental oxygen at 2 L resulted in improvement in his oxygen saturation and his hypotension and tachycardia responded to intravenous fluids. Significant laboratory results included WBC count of 20.4 with bands of 14%, elevated lactate of 2.4mmol/L, elevated D-dimer of 0.48 mug/mL and a negative COVID PCR test. CTA thorax revealed patchy ground-glass opacities in the bilateral upper and lower lobes with mosaicism. The patient received doxycycline in addition to broad spectrum antibiotics due to concern for inhalational marine toxicity. He was also started on 60mg prednisone, inhaled steroids, and bronchodilators for symptomatic treatment, with improvement in his symptoms. During his hospitalization, a respiratory viral panel was negative for common viruses associated with atypical pneumonia including influenza, coronavirus, metapneumovirus, rhinovirus, enterovirus, adenovirus, parainfluenza, bocavirus, Chlamydophila pneumoniae, and Mycoplasma pneumonia. His dyspnea gradually improved and he was weaned off supplemental oxygen prior to discharge home on hospital day 2. Discussion(s): It is unclear what changes are expected on thoracic imaging in patients with inhalational palytoxin exposure. Chest radiographs in two previous cases displayed scattered infiltrates, and a chest CT in another case showed pleural based consolidations. The ground-glass mosaicism suggests that a more diffuse reactive airway process after an inhalational palytoxin insult. Conclusion(s): Patients with inhalational palytoxin exposure may be found to have reactive airway symptoms along with ground glass opacities with mosaicism on CT imaging.

A RARE CASE OF PLEURODYNIA AFTER THE COVID-19 VACCINE

SESSION TITLE: Rare Cases with Masquerading Pulmonary Symptoms SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: COVID vaccinations have been encouraged by many healthcare providers but many adverse effects have also been reported. The adverse effects of the vaccine can vary based on each individual. Common adverse effects of the vaccine included fatigue, fever, chills, sore throat, muscle pain, headache, rash at injection site. Pleurodynia, also known as Devil's Grip, is a viral myalgia which causes sharp chest pain or the sensation of a grip around one's chest. Pleurodynia treatment is mostly supportive like anti-inflammatories (NSAIDS), pain management, and antibiotics (if bacterial inflammation is suspected). CASE PRESENTATION: We present a case report of a 63-year-old female who presented with complaints of pleuritic chest pain worse with inspiration. She had a history of atrial fibrillation and HTN. Patient had received the Pfizer COVID booster vaccine a few days prior to onset of the pleuritic chest pain. She was obese and had a 40 pack year smoking history. She was on room air saturating 92% with no increased work of breathing. Lung sounds were diminished due to body habitus but clear. Chest x-ray showed low lung volumes with no evidence of acute pulmonary disease. Computed Tomography Angiography (CTA) chest showed no pulmonary embolism and small left partially loculated pleural effusion with peripheral airspace opacities abutting the pleura. Acute coronary syndrome was ruled out and other cardiac workup was negative. COVID PCR was negative. Patient was treated empirically for bacterial infection with ceftriaxone and azithromycin. She was given NSAIDS to decrease inflammation and pain. Patient's symptoms improved significantly with treatment. She was discharged on NSAIDS and advised to follow up outpatient with her primary care and pulmonology. DISCUSSION: Research studies have indicated that the COVID vaccines (like Pfizer) can cause exacerbation of inflammatory or autoimmune conditions. Multiple mechanisms may be responsible for myocarditis, pericarditis, and other inflammatory conditions post vaccines. One mechanism describes that lipid particles of SARS mRNA vaccines can induce inflammation by activating the NLR pyrin domain containing 3 inflammasome of mRNA which are recognized by toll like receptors and cytosolic inflammasome components leading to inflammation. Another mechanism explains that viral proteins can cause immune cross reactivity with self-antigens expressed in the myocardium leading to an inflammatory process. CONCLUSIONS: As per current literature review there are no case reports about pleurodynia post COVID vaccination but pericarditis and myocarditis have been described. Further research studies are indicated to assess the cause and pathophysiology of pleurodynia post COVID vaccine. Physicians should have a high index of clinical suspicion for pleurodynia when assessing a patient with pleuritic chest pain with a recent history of COVID vaccination. Reference #1: 1. Analysis of COVID 19 Vaccine Type and Adverse Effects Following Vaccination. Beatthy, A;Peyser, N;Butcher, X. AMA Netw Open. 2021;4(12):e2140364. doi:10.1001/jamanetworkopen.2021.40364 Reference #2: 1. Association of Group B Coxsackieviruses with Cases of Pericarditis Myocarditis, or Pleurodynia by Demonstration of Immunoglobulin M Antibody. Schmidt, N;Magoffin, R;& Lennette, E. Infection and Immunty Journal. 1973 Sep;8(3): 341–348. PMCID: PMC422854 Reference #3: 3. Autoimmune phenomena following SARS-CoV-2 vaccination. Ishay, Y;Kenig, A;Toren, T;Amer, R;et. al. International Journal of Immuno-pharmacology. 2021 Oct;99: 107970. DISCLOSURES: No relevant relationships by Olufunmilola Ajala No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by iran Zaman

ANTISYNTHETASE SYNDROME PRESENTING AS INTERSTITIAL LUNG DISEASE: A CASE OF ANCHORING BIAS DURING THE COVID-19 PANDEMIC

SESSION TITLE: Dyspne Mysteries SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Anti-synthetase (AS) syndrome is characterized by interstitial lung disease (ILD), arthritis, myositis, fever, or Raynaud's phenomenon in the presence of an AS autoantibody (1). At least 70% of patients with AS syndrome develop ILD (2), and it represents the major cause of mortality in these patients with a 10 year survival rate of 73%. In a small cohort study, the anti-PL-12 antibody subtype was found to be strongly associated with ILD (3). CASE PRESENTATION: A 35 year old female with a history of tobacco use disorder presented to the hospital with three months of recurrent subjective fevers, non-productive cough, and dyspnea on exertion. She denied arthralgias, muscle weakness and hemoptysis. She initially presented to her primary care physician with these symptoms and was prescribed amoxicillin for streptococcal pharyngitis. The patient continued to be symptomatic and was treated empirically for COVID-19 pneumonia twice despite two negative COVID-19 tests and without any significant clinical improvement in her respiratory status. On admission, she was febrile, tachycardic, and had a new oxygen requirement with bilateral coarse breath sounds on exam. She had no leukocytosis and her COVID-19 test was negative. CT angiography of the chest showed extensive mixed reticular and airspace opacities with peribronchial predilection and peripheral sparing (figure 1). A bronchial alveolar lavage was notable only for neutrophilia (19%) and eosinophilia (4%). Rheumatological workup revealed elevated rheumatoid factor, positive antinuclear antibody (1:40), weakly positive anti–Sjögren's-syndrome-related antigen A antibody (50 AU/ml), undetectable anti-Jo-1 antibody and positive anti-PL-12 antibody. Pulmonary function testing revealed a TLC of 40% and DLCO of 28%, consistent with a restrictive pattern. Considering the patient's organizing pneumonia, positive antibodies, and findings of "mechanic's hands,” the patient was diagnosed with anti-synthetase syndrome with ILD. She was started on oral prednisone and mycophenolate mofetil. On follow-up, she was noted to have symptomatic improvement and stable hypoxia without clinical signs of disease progression. DISCUSSION: During the coronavirus pandemic, the resemblance of COVID-19 pneumonia to other diseases, in the absence of conscious suspicion for other etiologies, can lead to anchoring and availability bias thereby delaying diagnosis and appropriate treatment. Additionally, anti-synthetase syndrome should be considered in the differential diagnosis of ILD even in the absence of arthritis and myositis, as respiratory symptoms are often the first presenting signs. CONCLUSIONS: Increased responsibility is required of diagnosticians to exercise due diligence and active recognition of COVID availability and anchor bias to avoid missing crucial diagnoses. Reference #1: Cojocaru, Manole, Inimioara Mihaela Cojocaru, and Bogdan Chicos. "New insights into antisynthetase syndrome.” Maedica 11.2 (2016): 130. Reference #2: Marco, Joanna L., and Bridget F. Collins. "Clinical manifestations and treatment of antisynthetase syndrome.” Best Practice & Research Clinical Rheumatology 34.4 (2020): 101503. Reference #3: Kalluri, Meena, et al. "Clinical profile of anti-PL-12 autoantibody: cohort study and review of the literature.” Chest 135.6 (2009): 1550-1556. DISCLOSURES: No relevant relationships by Mario Flores No relevant relationships by David Jackson No relevant relationships by Lisa Saa No relevant relationships by Abu Baker Sheikh

PFIZER COVID-19 VACCINE CAUSES SHORTNESS OF BREATH IN A 24-YEAR-OLD PATIENT: A CASE REPORT

SESSION TITLE: Variety in Risk Factors and Treatment of VTE SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The year of 2020 will be a year never forgotten when the COVID-19 pandemic began. The healthcare system is going into a crisis facing a disease that is unknown and overwhelming. Companies were frantic to find a solution to help prevent so many unnecessary deaths. Pfizer mRNA COVID-19 vaccine was granted emergency use by the FDA after proving efficacy in early trials. Many side effects were unknown and discovered as time went on. Unprovoked isolated pulmonary embolisms are rare. CASE PRESENTATION: A 24 year old male with no significant past medical history presented to the emergency department due to shortness of breath, hemoptysis and chest pain. He denied any family history or personal history of clotting disorders. He received the mRNA COVID-19 Pfizer vaccine 5 days prior to symptom onset. He describes it as constant sharp pain with varying intensity that he rates a 6/10 and can reach a 10/10 pain exacerbated with lying flat and deep breathing. He also states he has been coughing up a teaspoon amount of blood with this chest pain. Physical examination revealed reduced breath sounds in the left lower lobe. Patient was hemodynamically stable. Labs were stable and hemoglobin was stable throughout the hospital course. Fibrinogen was elevated and hypercoagulable work-up was negative. CTA of chest was performed and revealed left-sided pulmonary emboli involving the left lower lobe with pulmonary infarction. Therefore, he was managed by Eliquis. DISCUSSION: Pfizer released a safety and efficacy report of the BNT162b2 mRNA Covid-19 Vaccine. Many of the common side effects reported were pain at the injection site, fatigue, headache, and fever [1]. Adverse events that were reported were shoulder injury, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia [1]. Isolated PE in a young healthy patient was never reported as an adverse event from the Pfizer safety and efficacy report. Severe acute respiratory syndrome-coronavirus-2 has been proven to increase the risk of venous thromboembolism because it is a prothrombotic virus [2]. Vaccination reports of pulmonary embolism are increasing, however, isolated PE without a DVT is still very underreported and rare. The literature states that a lot of patients that are having PE after mRNA vaccine also have associated thrombocytopenia, however, this is not what this patient demonstrates [3]. A total of 43, 548 participants were observed for the safety and efficacy report of the Pfizer COVID-19 report and not a single patient demonstrated an isolated pulmonary embolism event [1]. CONCLUSIONS: This case is a demonstration of a rare occurrence of isolated PE with no evidence of DVT in such close proximity to receiving the mRNA COVID-19 Pfizer vaccination.There are few reports of pulmonary embolism in healthy patients with no history of clotting disorders and further data are needed to support this association. Reference #1: Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 Reference #2: Hesam-Shariati S, Fatehi P, Abouzaripour M, Fathi F, Hesam-Shariati N, Hesam Shariati MB. Increased pulmonary embolism in patients with COVID-19: a case series and literature review. Trop Dis Travel Med Vaccines. 2021;7(1):16. Published 2021 Jun 12. doi:10.1186/s40794-021-00145-3 Reference #3: Muster V, Gary T, Raggam RB, Wölfler A, Brodmann M. Pulmonary embolism and thrombocytopenia following ChAdOx1 vaccination. Lancet. 2021;397(10287):1842. doi:10.1016/S0140-6736(21)00871-0 DISCLOSURES: No relevant relationships by Muhammad Azaz Cheema No relevant relationships by Morcos Fahmy No relevant relationships by Christina Gearges No relevant relationships by Asma Iftikhar

CHLORINE GAS EXPOSURE AND OBSTRUCTIVE AIRWAY DISEASE: A CASE REPORT AND CASE-BASED DISCUSSION

SESSION TITLE: Occupational and Environmental Lung Disease Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Chlorine gas is a pulmonary irritant with pungent odor that damages the respiratory tract. Chlorine gas exposure occurs in industrial or household exposures,Chlorine gas has two forms either a liquid or gas, toxicity of chlorine gas depends on the dose and duration of exposure. Chlorine gas used in manufacturing products like paper, insecticides, Chlorine is used to treat bottled and swiming pool water. CASE PRESENTATION: A 37 Y.O Male, no PMH presents with progressive dyspnea for three days worse with activity,decreases with rest, denied cough fever or chest pain he is vaccinated for COVID,no smoking history. The patient worked at a chlorine gas factory in the Dominican Republic for 15 years. Exam: Vitals: BP 124/72 mmHg. HR 100 BPM. RR 21 BPM. SpO2 84%. General: acute distress. Heart: normal S1, S2. RRR. Lung: wheeze bilaterally. Abdomen: Soft. Musculoskeletal: no pitting edema. he was placed on 6 LPM NC saturation improved to 90%. CBC and Chemistry were unremarkable, he was started on steroid, breathing treatment with antibiotics. ABG showed hypoxemia. he was placed on Venturi mask and his saturation improved to 95%.CTA was negative for PE. EKG, troponin were unremarkable. A proBNP normal. The antibiotics were discontinued because of a negative workup. A TTE study was normal. HRCT scan of the chest, showed atelectasis and infiltrates of lower lobes. No interstitial fibrosis.A PFT showed obstructive airway disease. He was discharged on oral and inhaled steroids.Hi new onset obstructive airway could be due to chlorine gas exposure. DISCUSSION: Chlorine gas causes cellular injury through oxidative damage but further damage results from activation and recruitment of inflammatory cells with subsequent release of oxidants and proteolytic enzymes. Humans can detect chlorine gas odor at a concentration between 0.1-0.3 ppm. At 1-3 ppm,it causes irritation of oral,eye mucosal membranes. At 30-40 ppm causes cough, chest pain, and SOB. At 40-60 ppm, toxic pneumonitis and pulmonary edema and can be fatal at 430 ppm concentration or higher within thirty minutes. Chronic exposure to chlorine gas lead to chest pain, cough, sore throat, hemoptysis, recurrent asthma. Physical exam findings include tachypnea cyanosis, wheezing, intercostal retractions, decreased breath sounds. Pulmonary function tests may reveal obstructive lung function disease. Chronic exposure to a low level was found to be associated with an increased risk of asthma in swimmers. CONCLUSIONS: Chlorine exposure results in direct chemical toxicity to the airways with acute airways obstruction or airways hyperreactivity, presentation varies from acute overwhelming intoxication with acute lung injury and or death, occupational exposure increase the likelihood of chronic bronchitis or isolated wheezing attacks. Treatment for chlorine exposure is largely supportive. Reference #1: 1- Center of disease control and prevention website/emergency preparedness and response/ https://emergency.cdc.gov/agent/chlorine/basics/facts.asp Reference #2: 2- C- Morim A, Guldner GT. Chlorine Gas Toxicity. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537213/. Reference #3: A- Gummin DD, Mowry JB, Beuhler MC, et al. 2020 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021;59(12):1282-1501. doi:10.1080/15563650.2021.1989785 DISCLOSURES: No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib no disclosure on file for Matthew Yotsuya;