The First Reported Case of Lorlatinib-Associated Diabetic Ketoacidosis

Introduction: Lorlatinib is a third-generation tyrosine kinase inhibitor that inhibits anaplastic lymphoma kinase (ALK) and c-ros oncogene 1 (ROS1). Although 2-10% of patients with non-small cell lung cancer developed hyperglycemia in phase 2 and 3 studies of lorlatinib, only one case has subsequently reported hyperglycemia >500 mg/dL, and no cases of diabetic ketoacidosis (DKA) have been previously reported. Phase 1 trials in neuroblastoma are ongoing. Case Description: A 34-year-old woman with ALK-mutated paraspinal neuroblastoma presented with DKA 14 months after initiation of lorlatinib. Prior to starting lorlatinib, her hemoglobin A1c had been 5.0% (n: < 5.7%). After 12 months of therapy, her A1c increased to 7.8%, prompting the initiation of metformin 500 mg daily. However, two months later she was admitted for DKA with a blood glucose of 591 mg/dL (n: 65-99 mg/dL), CO2 17 mmol/L (n: 20-30 mmol/L), anion gap 18 (n: 8-12), moderate serum ketones, and 3+ ketonuria. Her A1c was 14.8%, C-peptide was 1.2 ng/mL (n: 1.1-4.3 ng/mL), and her glutamic acid decarboxylase-65 and islet antigen-2 autoantibodies were negative. She was also found to be incidentally positive for COVID-19 but was asymptomatic without any oxygen requirement. The patient's DKA was successfully treated with IV insulin infusion, and she was discharged after 3 days with insulin glargine 27 units twice daily and insulin aspart 16 units with meals. One month later, her hemoglobin A1c had improved to 9.4%, and the patient's oncologist discontinued lorlatinib due to sustained remission of her neuroblastoma and her complication of DKA. After stopping lorlatinib, her blood glucose rapidly improved, and she self-discontinued all her insulin in the following 3 weeks. One month later, she was seen in endocrine clinic only taking metformin 500 mg twice daily with fasting and post-prandial blood glucose ranging 86-107 mg/dL. Discussion(s): This is the first reported case of DKA associated with lorlatinib. This case highlights the importance of close glucose monitoring and the risk of severe hyperglycemia and DKA while on lorlatinib therapy. Discontinuation of lorlatinib results in rapid improvement of glycemic control, and glucose-lowering treatments should be promptly deescalated to avoid hypoglycemia.Copyright © 2023

COVID-19 Viral Infection Presenting With Diabetic Ketoacidosis, Hyperosmolar Hyperglycemic Syndrome, or Mixed Hyperglycemic Crisis: A Case Series.

Cardiovascular disease, COPD, and diabetes (DM) are associated with increased complications with COVID-19. A correlation between COVID-19 and diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic Syndrome (HHS) has been suggested; however, the precise mechanism remains unclear. We present a case series of six patients with COVID-19 infections who were found to have DKA, HHS, or mixed picture. Wedescribe an association between COVID-19 and hyperglycemic emergencies. Six patients (50% male, 50% female, mean age 47.667 ± 18.747) were identified from November 2021 to February 2022. Comorbidities included DM (83.3%), HTN (50%), as well as ESRD, A-Fib, ISLD, HIV, and dementia (each 16.7%). Common review of systems included nausea and vomiting (50%), abdominal pain (33.3%), dyspnea (33.3%), and decreased appetite (33.3%). Additional findings were dysarthria, facial droop, generalized weakness, productive cough, myalgias, and increased urinary frequency (16.7%). Patients were diagnosed with DKA (50%), mixed process (33.3%), andHHS(16.7%). In terms of COVID-19 symptoms, most patients were asymptomatic (83.3%), with one patient developing hypoxia. The survival rate was 100%. Infections can incite DKA/HHS; yet, COVID-19 may have factors that amplify this process, in the setting of pancreatic beta-cell dysfunction from the virus itself. This may contribute to why diabetic patients have a ten times higher risk of death if they develop COVID-19. This virus binds to ACE2 receptors in the pancreas and damages the islets, ultimately decreasing insulin release. Here, we introduce cases of DKA/HHS in the setting of COVID-19, to understand the relationship between how COVID-19 infections may exacerbate diabetic complications.

Hypernatremia in Diabetic Ketoacidosis: A Rare Metabolic Derangement Requiring a Cautionary Approach in Fluid Resuscitation.

Diabetic ketoacidosis (DKA) with hypernatremia is an atypical metabolic derangement that warrants additional consideration in choosing IV fluids. Our patient, a middle-aged male with a history of insulin-dependent diabetes mellitus type 2 and hypertension, presented with DKA and hypernatremia in the setting of poor intake, community-acquired pneumonia (CAP), and COVID-19. DKA and hypernatremia led to a meticulous approach to fluid resuscitation, where a crystalloid solution was the choice in treating and preventing exacerbation of either condition. Successful treatment of these conditions requires understanding the unique pathophysiology, which demands further research on management.

A Case Report of Nearly Missed Renal Tubular Acidosis in the Setting of Sjögren's Syndrome.

The association of renal tubular acidosis (RTA) and Sjögren's syndrome (SS) has been well-documented in the literature previously but is often undiagnosed in clinical practice. In this case report, we present a case of a woman with distal RTA who presented with nausea, vomiting, and confusion. The case shows the diagnostic value of urine studies when evaluating a patient who has exaggerated and unexplained electrolyte losses and how this will change management. Recognizing the extra glandular manifestations of patients with SS is important for patient care to prevent delays in care and treatment.

Cholera in the Time of Covid

INTRODUCTION: Cholera is endemic to 50 countries with most US cases acquired during international travel. However, several cases have occurred from the ingestion of local oysters, crabs, and shrimp with resident Vibrio cholerae strains on the Gulf Coast. DESCRIPTION: A 52-year-old man with insulin dependent diabetes mellitus and well controlled HIV presented with hypovolemic shock. He reported 4 days of non-bloody diarrhea, poor oral intake, and oliguria. Before symptom onset, he ate crabs and tasted the water they were boiled in. He was prescribed azithromycin outpatient which mildly improved his diarrhea but presented to the hospital due to dizziness. He was initially hypotensive but this improved with 2 liters of normal saline without needing vasopressors. He had a blood glucose of 417 mg/dL, sodium bicarbonate of 13 mmol/L, anion gap of 29, creatinine of 10.5 mg/dL, calcium 8.3 mg/dL and corrected sodium of 124 mmol/L. Lactate and beta-hydroxybutyric acid levels were normal. Prior to admission, he took his insulin despite little oral intake. Given his glucose level and anion gap acidosis, he was placed on an insulin drip for concern of diabetic ketoacidosis (DKA). Stool PCR was positive for Vibrio cholerae and Salmonella enterica. Blood cultures were also positive for S. enterica. He received doxycycline for cholera and 14 days of ciprofloxacin for salmonella bacteremia. During his hospitalization, he got 14 liters of fluids with resolution of electrolyte abnormalities by discharge. DISCUSSION: In this patient, the anion gap acidosis was concerning for DKA but normal ketones made this diagnosis less likely. Cholera infection leads to "rice water" stool outputs up to 200cc/kg/hour in the first 2 days then ending after 4-6 days with profound electrolyte abnormalities. Due to rapid volume loss, patients present in hypovolemic shock with hyponatremia, hypocalcemia and hypoglycemia. Anion gap metabolic acidosis occurs due to acute tubular necrosis as in this patient. Stool culture is the gold standard for diagnosis. Treatment with doxycycline, ciprofloxacin or azithromycin decreases the duration of illness and reduces stool volume by 50%. Despite its rarity in the US, cholera should be considered and promptly treated in patients presenting with copious diarrhea, hypovolemia, and renal failure.

Ingestion of Alcohol-Based Hand Sanitizer: A case report

Introduction: Alcohol-based hand sanitizers containing ethanol or is opropanol are being used in order to prevent person-to-person transmission during the COVID-19. Early signs and symptoms of this ingestion include nausea, vomiting, headache, abdominal pain, blurred vision, loss of coordination, and decreased level of consciousness. After hand sanitizer ingestion we have to suspect about methanol poisoning, monitoring the start of anion-gap metabolic acidosis, seizures, and blindness is essential. Treatment includes supportive care, acidosis correction, and the administration of an alcohol dehydrogenase inhibitor. In servere cases hemodialysis may be required. Objective(s): To present a case of an 29-year-old woman who was taken to the emergency department after voluntary ingestion of alcohol-based hand sanitizer in a suicide attempt. To describe the most common side effects of hand sanitizer ingestion and the literature review. Method(s): Clinical case presentation and literature review of similar cases. Result(s): A 29-year-old woman, with diagnosis of borderline personality disorder and previous suicide attempts was taken to the emergency department after 3 hours of voluntary ingestion of an unknown quantity of alcohol-based hand sanitizer. Initial laboratory findings showed laboratory a blood methanol concentration of 66 mg/dL, with an anion gap of 30 mEq/L, arterial blood pH of 7.2, serum bicarbonate concentration of 12 mEq/L. Patient complained of abdominal pain and nervoussness. Conclusion(s): Most common signs and symptoms of alcohol-based hand sanitizer ingestion include nausea, vomiting, headache, abdominal pain, blurred vision, loss of coordination, and decreased level of consciousness. Treatment includes supportive care, acidosis correction, the administration of an alcohol dehydrogenase inhibitor and sometimes may be required.

Laboratory Findings in Fatal Ingestion of Hand Sanitizer

Introduction: Alcohol-based hand sanitizer is typically composed of ethanol or 2-propanol, as recommended by the Center for Disease Control and Prevention. However, since the start of the SARS-CoV-2 pandemic, the demand has increased exponentially, leading to the increased circulation of products that do not meet regulatory standards. This case describes a patient who ingested hand sanitizer;however, based on the laboratory findings, it likely contained more toxic alcohols than ethanol. Case Description: A 53-year-old male presented to the emergency department (ED) via emergency medical services (EMS). Patient reportedly had ingested hand sanitizer and become unresponsive. EMS found him pulseless upon arrival, and advanced cardiac life support (ACLS) was initiated, resulting in return of spontaneous circulation (ROSC). He arrested again in the ED and ACLS was initiated, resulting in ROSC again. No family was present, but per chart review, patient had a history of a seizure disorder, polysubstance abuse, and cirrhosis. Patient was admitted to the intensive care unit for further management. Labs indicated an anion gap metabolic acidosis, significant for anion gap of 48 mmol/L, sodium 151 mmol/L, potassium 5.7 mmol/L, bicarbonate 8 mmol/L, creatinine 4.96 mg/dL, blood urea nitrogen (BUN) 74 mg/dL, glucose 196 mg/dL, and lactate 30.48 mmol/L. Serum osmolality was measured at 407 mOsm/kg with a calculated osmolality of 389 mOsm/L (including ethanol level of 216 mg/dL). Venous blood gas showed a pH of 6.86 on admission. Upon discussion with Poison Control, fomepizole or ethanol treatment was not recommended, as hand sanitizers are typically made from ethanol and his level was not severely elevated, so only supportive care was necessary. Continuous renal replacement therapy (CRRT) was initiated. However, he began to demonstrate decorticate posturing. Following discussion of prognosis with family, they decided to pursue comfort care. Discussion(s): Since the beginning of the SARS-CoV-2 pandemic, hand sanitizer production has increased, with some being manufactured outside of typical regulatory standards. As indicated by the osmolar gap and severe anion gap metabolic acidosis, the hand sanitizer ingested in this case may have contained methanol or ethylene glycol. Consequently, it is essential to have a high index of suspicion for alcohols other than ethanol in hand sanitizer ingestion.

ELEVATED ANION GAP AS A MARKER OF SEVERE SARS-COV-2 INFECTION IN PREGNANT PATIENTS WITHOUT DIABETES: A CASE SERIES

SESSION TITLE: Biological Markers in Patients with COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: In December 2019, a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in a global pandemic. The literature has been slowly growing in the subgroup of pregnant women but the metabolic derangements of pregnancy and SARS-CoV-2 have not been well described. METHODS: In this case series, we review 9 patients with severe SARS-CoV-2 infections admitted to the medical ICU at a single institution between 2020-2022, during the delta variant wave. RESULTS: Of the nine critically ill patients, the mean age was 32 ± 6.4 years with fetal age on admission of 27 ±2.81 weeks and 29 ±2.91 weeks at delivery. Average CRP of 114 ± 25 mg/L. In eight of 9 patients (89%), there was an anion gap metabolic acidosis (AGMA) on admission. The average albumin-corrected anion gap was 18±1.93. 75% of patients had mild ketonuria based on urinalysis. However, 50% had documented symptoms of nausea, vomiting, or diarrhea. While betahydroxybutyrate was checked in 2 patients, neither were abnormal. One had lactic acidosis, but none required vasopressors at time of identification. No renal failure or diabetes was noted and only two had abnormal glucose tolerance tests. At delivery, average PEEP was 10± 4 cmH2O with an average respiratory rate of 28 ± 4 breaths per minute. All patients with AGMA delivered early resulting in preterm delivery. 75% of the fetuses showed signs of distress at the time of delivery, which was the primary indication for delivery in 37.5% of deliveries. 37.5% of deliveries were due to significant maternal hypoxia. The only patient without AGMA did not deliver early. CONCLUSIONS: After excluding renal failure, toxin ingestion, and lactic acidosis, only ketosis can weakly explain the AGMA. There have been several studies that highlighted the association between COVID and ketone production. In pregnancy, placental production of glucagon and human placental lactogen and subsequent insulin resistance increases susceptibility to ketosis. A recent study posited that COVID could cause placental abnormalities. Therefore, pregnant women may be more susceptible to significant ketosis because of COVID infection. In one of our cases, the combination of hypoxia and acidosis could not be managed safely by the ventilator and resulted in early delivery. CLINICAL IMPLICATIONS: Ketosis and an elevated anion gap could be a marker for more severe outcomes in pregnant patients with COVID. This case series highlights the challenges of managing the metabolic demands of critically ill pregnant patients infected with SARS-CoV-2. DISCLOSURES: No relevant relationships by Calli Bertschy no disclosure on file for Joey Carlin;No relevant relationships by Jessica Ehrig No relevant relationships by Shekhar Ghamande no disclosure on file for Jordan Gray;No relevant relationships by Abirami Subramanian

RETURN TO LIFE: A CASE OF THE LAZARUS PHENOMENON

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Lazarus Phenomenon, also known as auto-resuscitation, is a rare event where cessation of CPR results in a delayed return of spontaneous circulation (ROSC). The phenomenon was named after the story of Lazarus, who was restored to life four days after death. We present a case of a 78-year-old male who presented to the hospital for septic shock and had intra-hospital cardiac arrest with ROSC after cessation of CPR. CASE PRESENTATION: 78 year old male with a medical history of paroxysmal atrial fibrillation, stage IIIA NSCLC and COPD, presented for progressive dyspnea. He complains of feeling weak with loss of appetite and had a recent mechanical fall. Initial vital signs were temperature 96F, BP 141/78, HR 75 bpm, RR 18/min, SaO2 100% on 2LNC. Initial labs showed lactic acid 11.6, BUN 55, creatinine 3.7, CO2 9, anion gap 25, AST 2654, ALT 2120, ALP 159, total bilirubin 0.8, troponin <0.1, CK 399, INR 4.2, PTT 36, WBC 16.5, Hb 10.8, and plt 202. COVID-19 testing was negative. CXR demonstrated a retro-cardiac opacity consistent with previous diagnosis of lung cancer versus a dense consolidation. He was started on antibiotics for sepsis and admitted to the ICU for his metabolic status and shock liver. He remained hemodynamically stable for a few hours until a he had sudden onset of unresponsiveness with asystole. Code blue was called. Repeat labs demonstrated lactic acid 15.5, potassium 6.3, CO2 9. He underwent resuscitation for 32 minutes when compressions were stopped. Within 5 minutes post arrest, sinus activity was noted on the cardiac monitor. The patient had a radial pulse on evaluation. Manual blood pressure measurement was 119/71 with a HR of 99. Arterial blood gas after ROSC showed a pH 7.0, pCO2 68, pO2 273, HCO3 16, lactic acid 19. A few hours later, the patient rapidly de-compensated and underwent resuscitation for a second time. Efforts were deemed futile and the patient expired. DISCUSSION: The physiologic description of the Lazarus phenomenon is yet to be fully elucidated. Hypotheses include auto-PEEP due to rapid manual ventilation generating increased intrathoracic pressure and decreased venous return, delayed drug effect and stunned myocardium during active chest compressions (1). Once chest compressions and positive pressure ventilation via manual bag-mask stops, sudden decrease in intrathoracic pressure allows for sudden venous return and re-perfusion of cardiac tissue, resulting in ROSC in some cases. A recent literature review cited 65 published cases over the past 30 years with the most common rhythm being asystole (2). Most cases of auto-resuscitation occurred between 5-10 minutes post stopping of chest compressions (2). Mortality of these cases were 70% post resuscitation (2). CONCLUSIONS: It is important for clinicians to be aware of the Lazarus phenomenon post resuscitative efforts and to observe patients carefully post resuscitation. Reference #1: Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. J R Soc Med. 2007;100(12):552-557. doi:10.1177/0141076807100012013 Reference #2: Gordon, L., Pasquier, M., Brugger, H. et al. Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review. Scand J Trauma Resusc Emerg Med 28, 14 (2020). https://doi.org/10.1186/s13049-019-0685-4 DISCLOSURES: No relevant relationships by Vincent Chan No relevant relationships by Mackenzie Kramer No relevant relationships by Nathaniel Rosal No relevant relationships by Laura Walters No relevant relationships by William Ward

ATYPICAL PRESENTATION OF MUCORMYCOSIS IN A NONSEVERE COVID-19 PATIENT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Coronavirus Disease 2019 (COVID-19) infection ranges from asymptomatic to severe disease as defined by WHO. Emerging fungal infections such as mucormycosis and aspergillosis have been described in critically ill patients, most notably in India, when treated with steroids due to severe COVID-19 [1]. We present a unique case of an atypical presentation of mucormycosis in a non-severe COVID-19 patient not treated with corticosteroids. CASE PRESENTATION: A 19-year-old male with type 1 diabetes mellitus presented to the emergency room for evaluation of shortness of breath, nausea and fatigue. History was significant for insulin noncompliance with home blood glucose in the 300s and a positive COVID-19 test one day prior to arrival. Initial vitals positive for tachycardia, tachypnea and hypertension while on room air. Labs showed leukocytosis 14,000 cells/uL, bicarbonate 7.2 mmol/L, anion gap 24.8, glucose 428 mg/dL, beta-hydroxybutyrate 58 mg/dL and nucleic acid amplification COVID-19 positive. Physical exam showed left eyelid and facial swelling, nasal congestion without sinus tenderness or other deformity, and kussmaul breathing pattern. CT face confirmed left periorbital cellulitis. Transfer to tertiary center for Ophthalmology evaluation was attempted but refused due to capacity. He was started on diabetic ketoacidosis treatment as well as broad spectrum antibiotics with the assistance of Infectious Disease, however COVID-19 treatments were held due to mild illness. Despite these interventions, he became stuporous and amphotericin was started. MR Brain showed findings suggestive of cavernous sinus thrombosis, acute ischemia and local mass effect. ENT then performed an endoscopic antrostomy with ethmoidectomy and biopsies were taken. Pathology resulted as invasive fungal sinusitis with 90° branching hyphae confirming mucormycosis and a lumbar drain was placed with intrathecal amphotericin started for concern of mucormycosis meningitis. The patient was ultimately transferred to a tertiary care center where he expired. DISCUSSION: Mucormycosis, an angioinvasive fungal infection affecting the immunocompromised and diabetics, is rare but deadly. The estimated prevalence in the United States is 0.16 per 10,000 hospital discharges [2] and bears a mortality rate of 46%. Recent systematic reviews report 275 cases of COVID associated mucormycosis with 233 in India [1] with 76.3% receiving corticosteroids prior to diagnosis [3], likely contributing to an immunocompromised state. Our case demonstrates that despite not receiving corticosteroids, even those with mild COVID-19 are at risk for this disease. CONCLUSIONS: Patients with diabetes, immunocompromised states, and now COVID-19, presenting with orbital symptoms warrant consideration of mucormycosis. Prompt management of the underlying condition, IV amphotericin, and possible debridement may increase survival. Reference #1: John TM, Jacob CN, Kontoyiannis DP. When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis. J Fungi (Basel). 2021 Apr 15;7(4):298. doi: 10.3390/jof7040298. PMID: 33920755;PMCID: PMC8071133. Reference #2: Kontoyiannis DP, Yang H, Song J, et al. Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study. BMC Infect Dis. 2016;16(1):730. Published 2016 Dec 1. doi:10.1186/s12879-016-2023-z Reference #3: Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021 Jul-Aug;15(4):102146. doi: 10.1016/j.dsx.2021.05.019. Epub 2021 May 21. PMID: 34192610;PMCID: PMC8137376 DISCLOSURES: No relevant relationships by james abraham No relevant relationships by christian ALMANZAR ZORRILLA No relevant relationships by Grace Johnson No relevant relationships by Thanuja Neerukonda No relevant relationships by Blake Spain No relevant re ationships by Michael Su No relevant relationships by Steven Tran No relevant relationships by Margarita Vanegas No relevant relationships by Alexandra Witt

Mitigating the Inflammatory Response in Acute Pancreatitis, a Randomized Clinical Control Trial Comparing the Effects of Lactated Ringers and Normal Saline

Introduction: Data driven management strategies for acute pancreatitis (AP) in pediatrics have been limited. Adult data suggests use of lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes. The first management guideline for pediatric patients based on a standardized definition of AP severity was published in 2018;it described the need for early aggressive fluid resuscitation, but had insufficient data to recommend a specific fluid. Objective(s): To evaluate the efficacy of LR as the intravenous fluid (IVF) during the first 48 hours of an AP episode compared with NS. Study Design: A prospective multi-site randomized controlled clinical trial, started in 2016 at Children's Hospital of The King's Daughters, (Clinical Trials.gov NCT03242473), expanded to Children's National Hospital (2017), and to Cincinnati Children's Hospital Medical Center (CCHMC) (2018). Eligible patients (<19 years) diagnosed with first episode of AP were enrolled within 6 hours of presentation and were randomized to either LR or NS. A comprehensive biochemical profile was obtained at admission, and at 24 and 48 hours from time of admission. Vital signs, SIRS status, and signs of complications of AP were monitored. Clinical decisions regarding management (e.g. discharge criteria) were determined by the primary clinical team. Recruitment was stopped in the spring of 2020 due to the SARS-CoV2 pandemic. Primary outcomes were C-Reactive Protein (CRP) values at 24 and 48 hours after admission;secondary outcomes were changes in labs, SIRS status length of stay, time to initation of feeds, and development of severe AP (SAP). Result(s): There were 76 eligible patients (38 LR, 38 NS). There was no significant differences in baseline characteristics or AP etiology for either group (Table 1). There was no significant differences in initial biochemical profile except a slightly elevated anion gap in the LR group (Table 2). There was a higher proportion of patients in the LR group (32%, 12/38) discharged before 48 hours compared to NS (13%, 5/38) (Table 3). The LR group had a significantly higher rate of discharge within the first 72 hours compared to the NS group (p=0.02) (Figure 1a and 1b). In the first 48 hours, there was no difference in the primary or most of the secondary outcomes measured (Table 3). Conclusion(s): Use of LR was associated with a faster rate of discharge in the first 72 hours and had no significant negative outcomes associated with its use. No other significant differences in overall outcomes were identified with the use of LR or NS during hospitalization for AP in this study. This reduction in length of hospitalization has significant implications for patients as well as healthcare expenditures. This data suggests that early resuscitation with LR may be beneficial to recovery, particularly in patients more likely to have mild AP, who may be able to be identified early in the hospital course. Future pediatric AP studies will be required to confirm these findings. (Table Presented).

ANOTHER COMPLICATION OF COVID-19?: A CASE OF RHINOORBITAL-CEREBRAL MUCORMYCOSIS

CASE: A 44-year-old male with past medical history of type II insulindependent diabetes mellitus (DM) and end stage liver disease (ESLD) due to alcohol use and nonalcoholic fatty liver disease (NAFLD) presented with one week of left-sided retroorbital headache and diplopia. Two weeks prior, the patient tested positive for COVID-19 and initially his severe headache was attributed to this diagnosis. On hospital presentation the patient was found to have ophthalmoplegia, ptosis and diminished sensation in the CN V1 distribution on the left. The patient was in diabetic ketoacidosis (DKA) with glucose of 686, venous blood gas of 7.32/29/15 and serum anion gap of 17. Contrasted orbital and maxillofacial CT showed complete opacification of the left sphenoid sinus and CT angiography/venography of the head were negative for venous sinus thrombosis. MRI of the brain showed left optic nerve ischemia and left frontal lobe cerebritis without abscess. Bedside nasal endoscopy with ENT showed purulent, fuzzy white debris bilaterally concerning for fungal sinusitis. He was taken urgently to the operating room and was found to have angioinvasive fungal sinusitis with cultures growing Lichthemia corymbifera, a fungus in the Mucor family. In addition to treatment with IV insulin and fluids for DKA, the patient was given amphotericin B and posaconazole;however, surgical intervention was deemed too high risk and futile in the setting of patient's comorbidities. IMPACT/DISCUSSION: Mucormycosis is a fungal infection that typically involves the sinuses, orbits and the central nervous system (CNS). Infection of the sinuses manifests with fever, sinus congestion/pain and headache, but can rapidly progress to involve the orbits, leading to vision changes, and the CNS, leading to encephalopathy. Other structures that can be involved include the cavernous sinus, leading to palsies of cranial nerves III-VI. Known risk factors for mucormycosis include DM, especially in patients with DKA, glucocorticoid treatment, immunosuppression and deferoxamine use. Urgent histopathologic diagnosis, initiation of intravenous antifungal agents (amphotericin B) and surgical intervention with ENT, ideally prior to extension beyond the sinuses, are fundamental to decreasing mortality, which is as high as 62%. There have been numerous case reports of mucormycosis in patients with COVID-19, particularly from India. Many of these patients were prescribed glucocorticoids as part of the COVID-19 treatment pathway or had underlying DM. Additional research is needed into the association between COVID-19 and invasive mucormycosis. CONCLUSION: In patients with poorly controlled DM or immunosuppression presenting with severe headache, sinus pain, and/or neurologic changes, mucormycosis must be considered, as it is a fatal entity requiring urgent surgical intervention and initiation of antifungal agents. Patients with COVID-19 infection may be at increased risk for mucormycosis, especially in those with underlying DM or on glucocorticoids.

MITIGATING THE INFLAMMATORY RESPONSE IN ACUTE PANCREATITIS;A RANDOMIZED CLINICAL CONTROL TRIAL COMPARING THE EFFECTS OF LACTATED RINGERS AND NORMAL SALINE

Introduction: Data driven management strategies for acute pancreatitis (AP) in pediatrics have been limited. Adult data suggests use of lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes. The first management guideline for pediatric patients based on a standardized definition of AP severity was published in 2018;it described the need for early aggressive fluid resuscitation, but had insufficient data to recommend a specific fluid. Objective: To evaluate the efficacy of LR as the intravenous fluid (IVF) during the first 48 hours of an AP episode compared with NS. Study Design: A prospective multisite randomized controlled clinical trial, started in 2016 at Children's Hospital of The King's Daughters, (Clinical Trials.gov NCT03242473), expanded to Children's National Hospital (2017), and to Cincinnati Children's Hospital Medical Center (CCHMC) (2018). Eligible patients (<19 years) diagnosed with first episode of AP were enrolled within 6 hours of presentation and were randomized to either LR or NS. A comprehensive biochemical profile was obtained at admission, and at 24 and 48 hours from time of admission. Vital signs, SIRS status, and signs of complications of AP were monitored. Clinical decisions regarding management (e.g. discharge criteria) were determined by the primary clinical team. Recruitment was stopped in the spring of 2020 due to the SARS-CoV2 pandemic. Primary outcomes were C-Reactive Protein (CRP) values or changes in CRP and SIRS;secondary outcomes were changes in labs, length of stay, and development of severe AP (SAP). Results: There were 76 eligible patients (38 LR, 38 NS). There was no significant differences in baseline characteristics or AP etiology for either group (Table 1). There were no significant differences in initial biochemical profiles except a slightly elevated anion gap in the LR group (Table 2). There was a higher proportion of patients in the LR group (32%, 12/38) discharged before 48 hours compared to NS (13%, 5/38) (Table 3). The LR group had a significantly higher rate of discharge within the first 72 hours compared to the NS group (p=0.02) (Figure 1). In the first 48 hours, there was no difference in the primary or most of the secondary outcomes measured (Table 3). Conclusion: Use of LR was associated with a faster rate of discharge in the first 72 hours. This reduction in length of hospitalization has significant implications for patients as well as healthcare expenditures. This data suggests that early resuscitation with LR may be beneficial to recovery, particularly in patients more likely to have mild AP, who may be able to be identified early in the hospital course. No other significant differences in overall outcomes were identified with the use of LR or NS during hospitalization for AP in this study. Future pediatric AP studies will be required to confirm these findings.(Table Presented)(Table Presented)(Table Presented) (Figure Presented)

MANAGEMENT OF DIABETIC KETOACIDOSIS ON MEDICAL FLOORS IN A CORONAVIRUS DISEASE 2019 (COVID-19) PATIENT

Case Report Introduction Patients with mild to moderate diabetic ketoacidosis (DKA) can be safely treated with subcutaneous, rapidacting insulin analogs on the medical floor or in the emergency department. Here we describe a case of COVID pneumonia with DKA, effectively treated with a subcutaneous insulin regimen with anion gap closure in 4 hours since the presentation on medical floors. Case The patient is a 64-year-old male with no medical history, has not been in follow-up with a primary care physician for the past 20 years presents to the emergency department [ED] with a 2-week history of generalized weakness and fatigue. Reports feeling very thirsty and dehydrated with increased frequency of urination. On arrival he was noted to be saturating at 88 to 89% on room air, was switched to non 2 Litres nasal cannula with improvement in saturation to 94%, sinus tachycardia at 110 beats per minute, blood pressure 110/72 mmHg. Blood glucose was noted to be at 486 mg/dL with anion gap greater than 24 mEq/L, bicarbonate less than 10 mEq/L, creatinine at 1.62 mg/dL. Arterial blood gas analysis showed pH of 7.39, partial pressure of carbon dioxide at 16, partial pressure of oxygen at 61, bicarbonate of 10 suggestive of metabolic acidosis with respiratory compensation. He received a bolus of 0.3 units/kg [21 units] of subcutaneous insulin lispro (rapid-acting). Then was switched to 0.2 units/kg [14 units] subcutaneous insulin every 2 hours, the basic metabolic panel was done every 2 hours. Anion gap was closed in 4 hours. For transition, we calculated 0.5 units/kg [35 units] which was divided into basal - insulin glargine 17 units and bolus - sliding scale insulin lispro before meals and bedtime (insulin naive patient). His anion gap remained closed thereafter. He was treated with remdesivir and dexamethasone for COVID pneumonia. He was discharged after 5 days with improvement in his respiratory status from COVID pneumonia with outpatient follow-up. Discussion Subcutaneous insulin protocols are being used with increasing frequency to treat selected patients with mild to moderate DKA. Especially during this COVID pandemic, this helps to decrease the exposure frequency of staff (health care workers especially doctors and nursing staff) to patients given insulin dosing and lab frequency of 2-4 hours (compared with hourly checks for insulin intravenous drip), decreases the use of personal protective equipment (PPE), decreases the upgrade to intensive care units (ICU) that in turn helps with effective resources management in ICU for more critical patients. This protocol has not been studied in severe DKA yet but has similar efficacy and safety in mild or moderate DKA patients when compared to IV insulin therapy.

Starvation Ketoacidosis in the Third Trimester of Pregnancy

Introduction: Starvation ketoacidosis represents one of the three metabolic acidoses caused by the accumulation of ketone bodies within the bloodstream. Outside of late pregnancy, it is a relatively rare condition. In late pregnancy, the placental production of the hormones estrogen, cortisol, and human placental lactogen combined with increased lipolysis causes greater insulin resistance and an overall catabolic state which improves nutrient availability for vital fetal growth. However, this also allows for a magnified response to fasting that results in increased ketone production and in rare cases “accelerated starvation.” In this case, we present a 25-year-old pregnant patient who presented with nausea, vomiting, and poor oral intake, who was found to be in starvation ketoacidosis. Case Description: A 25-year-old G2P1001 cis female with a previous medical history of migraines presented at 33 weeks gestation with nausea, vomiting, and poor oral intake for four days prior to admission in the setting of COVID-19 infection. Patient presented hemodynamically stable and in no acute distress. Fetal non stress test on admission was reactive. Initial lab work revealed a glucose of 95, anion gap of 21, and a bicarbonate level of 7. A beta hydroxybutyrate (BHB) level was elevated at 5.26. Arterial blood gas showed a pH of 7.2 and a PCO2 of 23, consistent with an anion gap metabolic acidosis. Urinalysis revealed 3+ ketones. Overall labs were consistent with starvation ketoacidosis and the patient was immediately resuscitated with dextrose containing intravenous fluids and an insulin drip to help shunt away from ketoacidosis. Her BHB rapidly downtrended to 1.28 within 12 hours and within 24 hours it normalized. Her metabolic acidosis continued to improve throughout her hospitalization. She was able to tolerate a regular diet prior to being discharged home. A few weeks later, she had an uncomplicated full term delivery of a healthy baby. Discussion: Starvation ketoacidosis outside of pregnancy is rare and takes at least two weeks to manifest as a mild ketoacidosis. In pregnancy, patients are in an insulin resistant state which increases with gestational age, making them prone to ketoacidosis particularly in the second and third trimesters. Ketoacidosis in pregnancy is not only harmful for the pregnant individual, but for the developing fetus as well. Ketones can cross the placental barrier, leading to neurological impairment and even fetal demise if the acidosis is not addressed quickly. Prompt treatment with IV fluids, dextrose, and insulin is imperative to prevent neurodevelopmental compromise. Patients with appropriate and timely treatment can continue on to have uncomplicated pregnancies and deliveries.

New Onset Autoimmune Diabetes Associated with Acute SARS-COV-2 Infection

Introduction: Infection with SARS-CoV-2 has been shown to cause complications affecting nearly all organ systems of the human body. Here, we outline a case of SARS-COV-2 associated with new onset of autoimmune diabetes. Case Description: A 62-year-old female with past medical history of class III obesity, primary hypothyroidism, obstructive sleep apnea, and endometrial cancer established care with a multidisciplinary bariatric team in March 2021. This team included a dietician and psychologist to promote healthful lifestyle intervention with the intent to undergo bariatric surgery in December 2021. At a follow up visit in September 2021 her HbA1c was 6.7% (normal < 5.7 %) and she was diagnosed with type 2 diabetes treated with healthful lifestyle. After lifestyle modification the patient successfully lost 40 pounds. In December 2021, she presented to the ED (Emergency Department) complaining of fatigue and neuropathy. She was found to be hyperglycemic with glucose 369 mg/dL (normal 70-100 mg/dL). β-hydroxybutyrate was 32.1 mg/dL (normal 0.20-2.81 mg/dL) and anion gap was 10 mmol/L (normal 3-13 mmol/L). She was resuscitated with fluid and referred urgently to Endocrinology. One week later, she was seen in the office by her endocrinologist for initial consultation. She was acutely complaining of anosmia and ageusia and found to be positive for acute SARS-COV-2 infection. Bloodwork revealed an increase in HbA1c to 13.9 %, fasting glucose 303 mg/dL (normal 70-100 mg/dL), normal C-peptide 1.6 ng/dL (normal 0.5-3.3 ng/dL), elevated GAD antibody 154.3 IU/mL (normal 0-5 IU/mL), elevated anti-Islet Cell antibody IgG ratio 1:64 (normal < 1: 4), elevated anti-Islet Antigen 2 antibody >120 U/mL (normal 0–7.4U/mL), and elevated anti-Zinc Transporter 8 antibody 500 U/mL (normal 0–15 U/mL). Patient was diagnosed with autoimmune diabetes associated with acute SARS-COV-2 infection and was started on basal-bolus insulin with improvement in her hyperglycemia. She did not require hospital admission or steroid treatment for SARS-COV-2 infection. Discussion: Although viral infections are associated with type I diabetes related autoimmunity in children, this case study is unique regarding its mechanism in association with SARS-CoV-2 infection. Potential mechanisms underlying onset of diabetes in patients with SARS-COV-2 infection are still under investigation. One potential mechanism involves pancreatic beta cell dysfunction with diminished insulin secretion due to a systemic inflammatory cascade. This case is unique in as the patient’s C-peptide was still detectable indicating intact beta cell function. Furthermore, the patient’s diabetes paradoxically worsened after a more healthful lifestyle and 40-pound weight loss. This patient’s case of autoimmune diabetes illustrates the need for further research into the mechanisms underlying the onset of diabetes after SARS-COV-2 infection.

A Rare Presentation of Acute Renal Failure Secondary to Rhabdomyolysis in a Patient Due to Atorvastatin Requiring Short-Term Renal Replacement Therapy.

Renal failure secondary to rhabdomyolysis due to statins is quite rare. We present a case of a 57-year-old patient who developed acute renal failure due to rhabdomyolysis secondary to atorvastatin. Interestingly, this patient had a similar presentation 27 years ago requiring dialysis only once resulting in complete resolution of symptoms. He presented to the hospital generally feeling unwell and then developed generalized body ache. He had an extremely elevated creatinine kinase level of 116,000 and it went up to 145,000. His urine dip was negative for nitrites and was positive for blood and protein. He was commenced on intravenous fluids. He also had a computerized tomographic scan of the kidneys, ureters, and bladder, which showed some fat stranding around both kidneys likely inflammatory in origin. His creatinine level continue to rise despite intravenous fluids and was acidotic on blood gases. He also tested positive for COVID-19 on day 7 of admission and eventually needed dialysis. His renal functions improved to baseline post dialysis and kidney functions returned to normal. His autoimmune screen was negative and his renal functions remained normal on a follow-up visit.

Euglycemic diabetic ketoacidosis in a patient with COVID-19 case report

Purpose of The Study Awareness of Covid-19 virus infection can precipitate decompensation of chronic diseases such as type 2 diabetes Mellitus. Euglycemic diabetic ketoacidosis (eu- DKA) has been seen in patients using sodium-glucose co-transporter 2 inhibitor (SGLT2i) and with COVID-19 infection. Methodology Authors identified the case while providing clinical care of a 61-year-old man with medical history of Diabetes Mellitus Type II using SGLT2i and hypertension presented to the Emergency Room with chief complaint of fever, chills, dry cough, watery diarrhea and general malaise 5 days prior arrival to the hospital. Summary of Results A 61-year-old man Puerto Rican male with medical history of Diabetes Mellitus Type II using sodium-glucose co-transporter 2 inhibitor (SGLT2i), and hypertension, already vaccinated against COVID-19, who presented to the Emergency Room with chief complaint of fever, chills, dry cough, watery diarrhea and general malaise 5 days prior arrival to the hospital after returning from a recent family trip to Florida. Home medications include Empagliflozin. Patient referred he had a recent travel to Florida (United States) and was in contact with a family member infected with COVID-19 infection. Physical examination was remarkable for dry oral mucosa and laboratories showed a metabolic acidosis with a high anion gap of 20 mEq/L with a marked increase in plasma b-hydroxybutyrate of 57.8 mg/dL and a central glucose <300 g/dL. Patient tested positive for COVID- 19 infection. Chest X-ray showed bilateral scattered peripheral hazy groundglass opacities. Considering mentioned findings patient placed on airborne isolation precautions and was admitted to Medical Intensive Care Unit where he was started on DKA protocol with continuous intravenous regular, D5W and aggressive hydration. Medical therapy also included Remdesivir and Dexamethasone. Patient improved after 2 days with resolved eu-DKA. Patient transferred to Internal Medicine Ward. Conclusion Eu-DKA has been seen in patients using SGLT2i and with COVID-19 infection;several cases described in literature are suggestive of a specific association between these factors. Our case also highlights the importance of early recognition and management of euglycemic DKA in patients using SGLT2i infected with COVID-19, both increase the risk of dehydration. Physicians must be aware and identify this patients earlier in outpatient setting and be more aggressive in hydration, maintaining euvolemic status to avoid admission to Intensive Care Unit.

Ethylene glycol poisoning: A diagnostic challenge in a patient with persistent seizures and a severe metabolic acidosis.

INTRODUCTION: Due to the nationwide lockdown to mitigate the spread of COVID-19 and subsequent alcohol ban in South Africa, several cases of toxic alcohol ingestion presented to our emergency unit. Many of these patients admitted to making home brews of alcohol while others simply use industrial toxic alcohols. The diagnosis of these poisonings is challenging as direct assays are not available in our setting. CASE REPORT: We present a case of presumed ethylene glycol poisoning that presented with persistent seizures and a high anion gap metabolic acidosis (HAGMA). DISCUSSION: A high index of suspicion for toxic alcohol poisoning should be maintained in patients presenting with an altered mental status, seizures and a HAGMA. Indirect markers such as clinical features and laboratory results can lead to the diagnosis when direct assays are unavailable.

Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA.

Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.