Mitral valve chordal rupture against the background of cardiac SARS-CoV-2 infection. Cases series.

In an ever-changing information flow on coronavirus disease 2019 by the fact that the infection symptoms were mild, followed by signs (COVID-19) pandemic, we describe a case series of mitral valve chordal of probable endomyocarditis, unrecognized in time, and acute mitral rupture (MVCR) in non-comorbid middle-aged men that occurred over valve regurgitation developed against the background of physical a period of 3 to 5 weeks after Severe Acute Respiratory Syndrome provocation (exercise and cough). Two patients had previously been CoronaVirus 2 (SARS-CoV-2) infection. With significant advances diagnosed with mitral valve prolapse (myxomatous degeneration in the prevention of acute rheumatic fever, the treatment of bacterial and connective tissue disease). Two patients were successfully endocarditis and acute coronary syndrome, acute mitral regurgitation operated on in different clinics. The described cases emphasize that has become a relatively rare diagnosis. During the pandemic, there has the consequences of inflammation persistence may be more severe been a surge in the incidence of spontaneous MVCR, and new data on than the primary viral damage, which determines the importance of a the problem are accumulating. The presented case series are united comprehensive examination and long-term follow-up. To date, the differential diagnosis of patients with sudden onset of dyspnea and chest pain associated with an infectious process should include MVCR.Copyright © 2023 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved.

A Case of Post Covid-19 Endotheliitis

A 49-year-old man presented with shortness of breath and fever. He was in diabetic ketoacidosis on admission and tested positive for COVID-19 on PCR. He became bacteraemic with streptococcus pneu- moniae secondary to a super-added left lower lobe pneumonia. He developed new heart failure felt to be secondary to myocarditis, evidenced by a resolving ejection fraction throughout his admission and an unremarkable cardiac MRI. After developing confusion on the ward, a CT head and MRI brain identified a spontaneous frontal haematoma and multiple micro-haemorrhages throughout the cerebral hemi- spheres, cerebellum and the pons. Repeat MRI brain with diffusion weighted imaging identified multiple silent infarcts in the small vessel territories. Bacterial endocarditis was excluded with Cardiology input and hypoperfusion also excluded based on normotension throughout admission. The case was discussed at the Encephalitis and Neurovascular MDT meetings where MRI vessel wall imaging was reviewed and felt to represent a post-infectious endotheliitis. He was treated with intravenous methylprednisolone for 3 days and a further 5 days, due to new silent infarcts on a subsequent MRI brain, before a 10 week oral steroid taper. Multi-system complications from COVID-19 are not limited to those in the intensive care unit or with severe respiratory illness.

Cardiac Magnetic Resonance Imaging for the Diagnosis of Infective Endocarditis in the COVID-19 Era

In the COVID-19 pandemic, to minimize aerosol-generating procedures, cardiac magnetic resonance imaging (CMR) was utilized at our institution as an alternative to transesophageal echocardiography (TEE) for diagnosing infective endocarditis (IE). This retrospective study evaluated the clinical utility of CMR for detecting IE among 14 patients growing typical microorganisms on blood cultures or meeting modified Duke Criteria. Seven cases were treated for IE. In 2 cases, CMR results were notable for possible leaflet vegetations and were clinically meaningful in guiding antibiotic therapy, obtaining further imaging, and/or pursuing surgical intervention. In 2 cases, vegetations were missed on CMR but detected on TEE. In 3 cases, CMR was non-diagnostic, but patients were treated empirically. There was no difference in antibiotic duration or outcomes over 1 year. CMR demonstrated mixed results in diagnosing valvular vegetations and guiding clinical decision-making. Further prospective controlled trials of CMR Vs TEE are warranted. © 2022 Elsevier Inc.

P22-10 Prevalence and outcome of Covid-19 in patients with substance abuse disorder presented to tertiary care hospital emergency department

Background: Currently, there is few studies looking at of the risks and outcomes for COVID-19 infection in individuals with substance abuse disorder (SUD). SUD are believed to be at increased risk of covid infection and at more risk of bad outcome. Objective(s): The aim of this study is to describe the prevalence of covid-19 and outcomes in patients with SUD presented to Sultan Qaboos University Hospital Emergency Department (ED) over 1 year. Method(s): It is a retrospective study that included all patients presented to Sultan Qaboos University Hospital Emergency Department from March 20120 to March 2021 who had drug abuse screening done. Patients were included if they are they are found to be positive for SUD and had a covid-19 swab test as well. Result(s): A total of 422 patients were found but only 104 patients met the inclusion criteria 0.99% (103/104) were male and Omani. The age range was 21-62 years old. Covid was positive in 8.6% (9/104). 0.98.5% presented with respiratory symptoms. 15.3% (16/104) had history infective endocarditis and 38.4% (40/104) had psychiatric disease. 57.6% (60/104) are smoker. 67.3 (70/104) were morphine abuser while 25% (26/104) methamphetamine abusers. 72.1% (75/104) were admitted to hospital with 77.8% admission (7/9) in patients with SUD with covid infection. Mortality was 6.7% (7/104) in general, with 33.3% mortality (3/9) in covid positive SUD. 55.6% (5/9) had hepatitis B, C and E compare to 43%(95/104) of covid negative. Further analysis showed, SUD patients with hepatitis B or hepatitis E have 5.5 increased risk of getting infected with covid-19. SUD patients with covid-19 have 11.4 increased risk of death. Drug abusers who are more?> = 30 years old have 4.2 increased risk of getting at least 2 complications (acute kidney injury, rhabdomylosis, aspiration pneumonia liver cirrhosis, ect). Conclusion(s): The prevalence of covid-19 in patients with substance abuse disorder was slightly high, and patients with hepatitis having 5.5 increased risk of getting infected with covid. Covid infection in SUD patients have high morbidity and mortality. Further studies are required to determine factors that would predict a worse prognosis of covid infection in SUD patients. Copyright © 2022 Elsevier B.V.

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.

Left Ventricular Apical Thrombus after Covid-19 Infection Associated with Pediatric Stroke

INTRODUCTION: Stroke is rare in the pediatric population but is often associated with significant morbidity and mortality prompting evaluation for a wide range of pathologic processes. Neurologic manifestations of COVID-19 infection include meningoencephalitis, acute demyelinating encephalomyelitis, Guillain barre and stroke. Throughout the literature, patients seen with neurologic disease had severe COVID-19 infection and/or the multi-system inflammatory syndrome (MIS-C). Only a small proportion of patients had neurologic manifestations as the presenting feature with confusion and seizures being most common. DESCRIPTION: We report the case of a 12-year-old male who presented with left sided weakness and confused speech. This occurred following a 3-day illness with reported fever, malaise, and headache with photophobia resolved. On admission he was afebrile with a left facial droop, grade 4 power in the left hemibody and ankle clonus. Labs revealed an elevated WBC (16.4 x 103 cell/mm3) and CRP (7.3mg/dl), a negative respiratory viral panel and COVID-19 PCR test but positive COVID-19 antibody 315 s/co ratio and increased fibrinogen (523mg/dl) and d-dimers (2.69 mcg/ml). CSF had no WBCs and a negative meningitisencephalitis panel. Computed tomography of the brain was normal but an MRI brain with angiography and venography showed multiple infarcts consistent with embolic strokes. An echocardiogram revealed a mobile mass at the left ventricular apex measuring 2.5 x 1.6 cm suggestive of a large clot in the presence of normal biventricular function, and no wall motion abnormalities. Due to the risk of re-embolization with devastating neuro-cardiac effects, he underwent left ventriculotomy and clot removal with cardiopulmonary bypass and was continued on therapeutic anticoagulation. Alternative etiologies such as thrombophilia, infective endocarditis or an intracardiac tumor were ruled out. DISCUSSION: Intracardiac thrombosis has been reported in adults and children with COVID-19 but often along with pneumonia, dilated cardiomyopathy and myocardial infarction or acute MIS-C and intracardiac devices. Delayed thrombosis in the absence of MIS-C or cardiac dysfunction is not as frequently seen and brings to light the prolonged prothrombotic state post COVID infection.

Complex Outpatient Antimicrobial Therapy (COpAT) Program at a Rural Academic Medical Center: Evaluation of First 100 Patients

Background. Literature shows early intravenous (IV) to oral (PO) antimicrobial transition for infective endocarditis (IE) and bone and joint infection (BJI) is noninferior to prolonged IV antimicrobial therapy. COVID-19 pandemic peaks resulted in critical shortages of staffed hospital beds spurring innovation. Outpatient parenteral antimicrobial therapy (OPAT), a well-established program using prolonged IV antimicrobials, faces challenges such as infusion resource needs and social circumstance limitations. Complex outpatient antimicrobial therapy (COpAT) uses PO in place of IV antimicrobials. We hypothesized rapid adoption of COpAT would decrease hospital length of stay and open beds while retaining satisfactory clinical outcomes. Methods. COpAT protocols (Image 1) and guidelines by infection type and isolated organism (Image 2) were created. Hospitalized patients including persons who inject drugs (PWID) were evaluated for IV to PO antimicrobial transition by an infectious diseases (ID) physician and then followed by an ID physician-pharmacist team. Demographic, ID, and clinical outcome data for the first 100 COpAT patients between December 2020 and February 2022 were obtained by retrospective chart review. Image 1. COpAT Inpatient and Outpatient Protocols Image 2. COpAT Guidelines by Infection Type and Isolated Organism MSSA = methicillin-susceptible Staphylococcus aureus;MRSA = methicillin-resistant Staphylococcus aureus;spp. = species;TMP/SMX = trimethoprim-sulfamethoxazole;DS = double strength;SSTI = skin and soft tissue infection;CAP = community-acquired pneumonia Results. PWID accounted for 78% of COpAT patients. BJI followed by mixed infection (IE and BJI) was most prevalent (Image 3) with bacteremia in 53% of cases. Staphylococcus aureus was most frequently isolated (Image 4). Oral linezolid and fluoroquinolones, often in combination, were most commonly used. IV and PO antimicrobials were taken for a median 28 and 14 days, respectively. The COpAT program saved 1425 IV antimicrobial and 1363 hospital days. Assuming daily inpatient cost of $2050, cost avoided was $2,794,150. COpAT patients participated in ID follow-up and adhered to PO antimicrobials with low 30-day readmission rates (Image 5). Image 3. Infection Type Image 4. Isolated Organism CoNS = coagulase-negative staphylococci Image 5. Clinical Outcomes Conclusion. In a sample of 100 COpAT patients including PWID, IV to PO antimicrobial transition safely saved hospital days and mitigated critical bed shortages during pandemic peaks. A successful COpAT program requires a multidisciplinary group: close ID physician-pharmacist collaboration extending to OPAT and antimicrobial stewardship teams. With a COpAT program in place, even earlier IV to PO antimicrobial transitions should be studied.

A Case of Right Side Infective Endocarditis in Patient with Ventricular Septal Defect

A 25-years old white female was admitted to our emergency department presenting with dyspnea, fever, cough and nausea. Her medical background included a small ventricular septal defect (VSD) (congenital) with a left to right shunt, micropolicistic ovary syndrome, Sars Cov 2 infection on January 2022, history of cutaneous infection after sternal piercing in the last three years. Patient showed onset of fever, headache and nausea since 20 days and had a history of ampicillin and cephalosporin usage for 15 days for comunitary pneumonia. Upon arrival in the emergency room, physical examination revealed temperature 38degreeC, crackles on down right lung fields, regular but tachycardic rhythm, 3/6 holosystolic murmur in the third left intercostal space, also skin redness around the piercing zone. Laboratory test showed increasing of WB (white blood cells), C-reactive protein (CPR) and procalcitonin. Because of worsening of respiratory conditions, CTchest was performed, showing tree in bud sign, with pulmonary pattern suggestive of staphylococcal "emboligenous-like infectious state. According to patient's clinical history and CT results, she was referred to transthoracic echocardiogram (TTE) demonstrating the presence, on the right side of the small VSD, of a isoechoic large mass (20x 13 mm) with irregular margins attached to the right ventricular wall near the ostium of the VSD, compatible with vegetation;septal tricuspid valve leaflet involvement could not be ruled out. Methicillin-susceptible Staphylococcus aureus (MSSA) was detected six times from blood cultures;therapy with oxacillin 2 gr every 4 hours combined with daptomycin 750 mg daily was started. Cardiac MRI performed after few days, documented the infective involvement of the ventricular and atrial side of the septal leaflet with moderate tricuspid regurgitation (TR). Congenital heart disease (especially Tetralogy of Fallot, bicuspid aortic valve, aortic coarctation, ventricular septal defect) is a lifelong risk factor for infective endocarditis (IE). Size of VSD is generally not correlated with IE that is directly correlated with turbulent flow;tricuspid valve involvement is mostly seen in VSD, often complicated by pulmonary embolism. In this predisposing situation, skin infection of the piercing zone could have caused transient bacteremia which led to the formation of vegetations in the highest turbulence flow zone..

Infective endocarditis in children: state of the art

Infective endocarditis (IE) is an infection of the endocardium and/or heart valves. Although more common in adults than in children, it is important to identify and treat IE because of its significant morbidity and mortality. This review summarizes the main features involved in the IE pathogenesis and treatment to reduce and prevent IE risk. A comprehensive search of published literature using the PubMed (HTTP:// www.ncbi.nlm.nih.gov/pubmed/) database was carried out to identify all articles published in English in peer-reviewed journals. The search terms included ("Infective Endocarditis") AND ("Young" OR "Children" OR "Adolescence"). Copyright © 2022, Biolife s.a.s.. All rights reserved.

Off Label Picc as a Femoral Catheter in an Almost Noncannulated Patient

Introduction: 39-year-old patient presented with rapid progressive metastatic (lung, bone) sarcoma. He was in a life-threatening situation on peritoneal dialysis, with cardiomyopathy and ongoing infectious endocarditis. He had multiple cannulations with the introduction of dialysis catheters (jugular, axillary, femoral veins), AV fistulas on both shoulders for hemodialysis followed by calcification of these fistulas and he had tumour thrombosis of the right femoral vein. He should receive chemotherapy, but unfortunately, he tested positive for COVID-19. He developed massive bilateral covid related pneumonia. Subsequently, he fell down and broke his right arm (traumatic humerus fracture with dislocation). Method(s): According to the guidelines from GAVACELT, in covid patients, PICC is recommended as a safe and simple central venous access (CVA). This patient needed a safe CVA, because of intravenous application of antibiotics to treat the endocarditis. We were not able to use the upper part of the body to insert the line. In addition, the patient underwent kidney transplantation followed by graft explantation, because of rejection. We did not exactly know, how was the condition of the renal vessels. There was a possibility that venous stenosis would be present in the postoperative area. We decided to use the PICC 'off label', to insert from the left femoral vein, the one and only possible vein to insert a line in this patient. Result(s): We used ultrasound to guide the cannulation. Through the left femoral vein, we successfully inserted a 4Fr one-lumen tunnelled PICC line without complications. We checked the distal end of the PICC also by X-ray, to ensure the right tip position. Discussion and conclusion: We managed to cannulate this complicated patient to ensure safe CVA, despite all obstacles. We conclude, that there is no non-cannulate patient. The physician must select the correct procedure and the most suitable vein to insert the catheter.

Complex Case of Endocarditis Post-COVID Infection

A 42-year-old man presented to hospital with fever, dyspnea and fatigue. In the previous days he reported illness and cough and he had not received the vaccination for COVID-19. Moreover, he had a bicuspid aortic valve with mild insufficiency. Blood tests showed raised inflammatory markers and leukocytosis;high-sensitivity cardiac troponin T and natriuretic peptides were also elevated. Serological tests showed a recent COVID-19 infection, but the nasopharyngeal test was negative. A transesophageal echocardiogram was performed showing moderate reduction in the systolic function of the left ventricle, an aneurysm of the aortic root (52mm) and endocarditis of the aortic valve with severe insufficiency and an abscess on the mitro-aortic junction. So, he was started on empirical antibiotic therapy. For the development of multiorgan failure it was decided to replace the aortic valve, the root and the ascending aorta according to Bentall technique. The bacteriological research on blood and surgical material was negative. During rehabilitation there was a new clinical worsening with raised inflammatory markers and fever. An aortic CT angiography and a transesophageal echocardiogram were performed with evidence of a para-aortic contrast medium collection and a fistula of the prosthetic tube. The patient was then transferred to another cardiac center for a new surgery. It is important to be vigilant for the possible cardiovascular complications of COVID-19, including infective endocarditis. Early diagnosis is the corner stone for early treatment and multimodality imaging has a central role.

SPLENIC INFARCTS AS THE INITIAL MANIFESTATION OF NATIVE VALVE ENDOCARDITIS CAUSED BY STREPTOCOCCUS DYSGALACTIAE

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We describe the clinical course of a COVID-19 patient with Streptococcus Dysgalactiae (SD) infective endocarditis, managed with six weeks of antibiotics and valve replacement surgery. CASE PRESENTATION: A 50-year-old previously healthy man presented with two weeks of fever, congestion, and diarrhea, and one day of acute change in mentation. On arrival, the patient's heart rate was 130/min, respiratory rate 25/min, and temperature 103.5 F. On physical examination, he appeared lethargic. Initial labs showed a white blood count of 16 k/mm with bands and platelets of 64 k/cmm. The patient was treated empirically for severe sepsis with intravenous vancomycin and cefepime. Blood cultures grew SD. Antibiotics were narrowed to intravenous ceftriaxone. A CAT scan of the chest, abdomen, and pelvis identified multiple splenic infarcts. A transesophageal echocardiogram was performed to evaluate the potential source of the splenic emboli, and this showed mild to moderate mitral regurgitation and a large globular mobile vegetation on the anterior mitral valve. Intravenous gentamicin was added to the treatment regimen. Subsequent cultures remained negative, and he underwent bioprosthetic mitral valve replacement on hospital day 11. He received a total of 6 weeks of outpatient intravenous antibiotic therapy. DISCUSSION: SD is a normal commensal of the skin, upper airway, and gastrointestinal tract. It can cause localized and invasive infections. Major risk factors for invasive infections include malignancy, diabetes mellites, and other cardiovascular diseases. Besides a recent COVID-19 infection, our patient was healthy. The COVID-19 infection causes a hypercoagulable state, and when combined with COVID-19 related diarrhea, can lead to the translocation of the gut bacteria, and subsequent infective endocarditis (IE) [1]. SD is a rare cause of IE, but the incidence of IE in bacteremic patients is about 10% [2]. Clinicians should have a low threshold to suspect IE in cases of SD bacteremia. American Heart Association Guidelines on IE [3] state that systemic embolization occurs in 22% to 50% of cases of IE, and the highest incidence of embolism occurs when the vegetation is mobile, on the anterior mitral valve and > 10 mm, like in our case. In such patients, early cardiac surgery should be considered. SD bacteremia recurrence occurs in about 10% of patients within the first year, and patients should be informed about this risk. CONCLUSIONS: Clinicians should suspect IE in the setting of SD bacteremia. COVID-19 infection increases the chances of the development of infective endocarditis. Prolonged intravenous antibiotic therapy and prompt replacement of the involved valve is necessary. SD IE is associated with a high rate of recurrence, and clinicians should be cognizant of this risk. Reference #1: "COVID-19 INFECTION PREDISPOSING ENDOCARDITIS ….” https://www.scienceopen.com/document?vid=02f2bbbe-479d-4d11-ad60-2ceba336a4e1. Accessed 4 Apr. 2022. Reference #2: "Bacteremia caused by group G Streptococci, taiwan - PubMed.” https://pubmed.ncbi.nlm.nih.gov/18439377/. Accessed 4 Apr. 2022. Reference #3: "Clinical relevance of vegetation localization by … - Semantic Scholar.” https://www.semanticscholar.org/paper/Clinical-relevance-of-vegetation-localization-by-in-Rohmann-Erbel/0106e26e3f2102eb6dd2fd7e086210c0a44ebf45. Accessed 4 Apr. 2022. DISCLOSURES: No relevant relationships by Husam Bader No relevant relationships by Poorva Bhide No relevant relationships by Gaurav Mohan No relevant relationships by Muhammad Tayyeb No relevant relationships by Charmee Vyas No relevant relationships by Siva Naga Yarrarapu

COVID-19 Infection Concomitant With Infective Tricuspid Valve Endocarditis

The COVID-19 pandemic, together with its complications and management, has been a significant issue worldwide since March 2020. Concomitant infections in vulnerable patients with preexisting cardiovascular diseases are not uncommon. Sharing information about the diagnostic management and treatment of these comorbidities has a prominent role in unveiling some of this pandemic's challenges. We herein describe a young adult with a history of implantable cardioverter-defibrillator implantation diagnosed with COVID-19 infection and infective endocarditis. (Iranian Heart Journal 2022;23(4): 102-108). Copyright © 2022, Iranian Heart Association. All rights reserved.

ACUTE INTERSTITIAL NEPHRITIS AS A PRIMARY PRESENTATION OF CANDIDA INFECTIVE ENDOCARDITIS

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

Diagnosis and treatment of vasculitis

Primary angiitis of the central nervous system (PACNS) is an inflammatory disease affecting exclusively small and medium-sized vessels of the central nervous system. CNSvasculitis may also occur in systemic diseases like giant cell arteritis, Takayasu arteritis, granulomatosis with polyangiitis, or Behçet syndrome. The most common presenting symptoms of CNS vasculitis are multifocal symptoms associated with recurrent episodes of ischemia or hemorrhage, encephalopathy-related cognitive and affective abnormalities, and headaches. Diagnostic work up of CNS vasculitis includes MRI, CSF examination, digital subtraction angiography and brain biopsy. High-resolution, contrast-enhanced, compensated and fat-saturated MRI imaging of the cerebral vessel walls (black-blood imaging) may be of some value for the detection of CNS-vasculitis. Patients with normal CSF findings are unlikely to have CNS vasculitis. Brain biopsy should be performed in suspected PACNS. Important differential diagnoses include reversible cerebral vasoconstriction syndrome, moyamoya angiopathy and infectious vasculopathies (VZV, SarsCoV2, borreliosis, bacterial endocarditis). The adherence to diagnostic criteria and the avoidance of inappropriate therapies are essential. Treatment recommendations for CNS-vasculitis include glucocorticoids in combination with cyclophosphamide or rituximab;however, randomized clinical trials of PACNS treatment do not exist. Induction therapy is recommended for 6 to 12 months. After remission is achieved, treatment may be continued with substances as mycophenolate mofetil, methotrexate, or azathioprine. Repeated clinical, CSF- and neuroradiological monitoring is needed to determine the individual duration of maintenance therapy.

CRYPTIC PREGNANCY, SYPHILIS AND CONSTITUTIONAL SYMPTOMS IN AN IV DRUG USER DURING THE COVID-19 OUTBREAK

Background Infective endocarditis (IE) during pregnancy is rare and is associated with high maternal and fetal morbidity and mortality. We report the case of a 30-year-old patient with IE who was incidentally found to be 24 weeks pregnant during the COVID outbreak. We also reviewed the relevant literature. Case An active intravenous drug user presented with a 2-week history of constitutional symptoms (myalgias, fever) and lower back pain during the COVID outbreak. Initial investigations revealed bilateral consolidations on chest X-ray. After she tested negative for COVID-19, CT chest showed septic pulmonary emboli and grew MSSA on blood cultures. An echocardiogram revealed a large (1.6 × 1.0 cm) mass attached to the tricuspid valve suggestive of IE with severe tricuspid regurgitation. She was also incidentally found to be 24 weeks pregnant (G1P0) and positive for syphilis. Viable intrauterine pregnancy was confirmed at 25 weeks on an ultrasound. She was treated with 5-weeks course of IV flucloxacillin, however a repeat echocardiogram demonstrated an increase in vegetation size (> 3 cm). As her vegetation size had increased, a surgical opinion for IE was sought. Cardiac operation under cardiopulmonary bypass in a pregnant woman is associated with high maternal and fetal morbidity and mortality. She was managed conservatively with oral antibiotics, regular echocardiographic and obstetrics reviews and delivered a healthy baby at 37 weeks following induction of labour. Conclusions: The review of literature confirms that if IE in pregnancy is diagnosed early, an uncomplicated outcome is possible with a multidisciplinary team approach.

Special Issue: All subjects about laboratory sciences in emerging diseases. (Special Issue: All subjects about laboratory sciences in emerging diseases.)

This special issue contains 10 papers on the following topics: evaluating association between ABO blood groups and COVID 19;impact of COVID-19 on Libyan laboratory specialists;microscopic agglutination test for diagnosis of leptospirosis by using filter paper-dried serum samples;prevalence of haemoparasites among blood donors in Calabar, Nigeria;assessment of peripheral blood lymphocytosis in adults and determination of thresholds for differential diagnosis between clonal and reactive lymphocytosis;investigation of antibiotic resistance pattern in isolates from urine and blood samples of patients admitted to the Intensive Care Unit of Velayat Hospital in Qazvin, Iran;evaluation of rejection rates and reasons among specimens taken from different hospital units;quality tools to ensure patient safety and reduce the turnaround time of medical laboratories in tertiary care teaching hospitals;prevalence and antibiotic resistance pattern of Gram-positive isolates from burn patients in Velayat Burn Center in Rasht, North of Iran;and infective endocarditis caused by Staphylococcus aureus in a 6-year-old girl with no history of heart and dental problems.

DELAYED DIAGNOSIS OF HISTOPLASMOSIS IN A PATIENT WITH A PROSTHETIC AORTIC VALVE

Background: Histoplasmosis is a rare cause of infective endocarditis. Here we describe a case of disseminated histoplasmosis involving a prosthetic aortic valve (AV). Case: A 50-year-old male from Ohio, with history notable for congenital aortic valve disease status post bioprosthetic AV replacement (AVR) in 2014, presented with 6 months of flu-like illness, pancytopenia, and suspected transient ischemic attack after receiving the COVID-19 Johnson & Johnson vaccine, posing concern for post-vaccination reaction. However, COVID-19 polymerase chain reaction testing was negative. Detailed workup revealed myelodysplastic syndrome and positive urine histoplasmosis antigen. Chest computed tomographic angiography (CTA) demonstrated a 16x16 mm left lower lobe pulmonary nodule with central cavitation suspicious for pulmonary histoplasmosis. Transesophageal echocardiography (TEE) showed bulky thickening of the prosthetic leaflets with suspected vegetation causing severe prosthetic aortic stenosis. Head and neck CTA showed no mycotic aneurysms. Decision-making: He was treated with Amphotericin B and underwent redo AVR. Intraoperative findings included a very large vegetation with near-total obstruction of the aortic valve and circumferential necrotic tissue of the aortic root (Figure 1). Conclusion: Despite its rare incidence, histoplasmosis should remain on the differential for infective endocarditis in patients presenting with systemic illness and prosthetic valves. [Formula presented]

THE GREAT AORTIC VALVE DESTROYER: A CASE OF NEISSERIA GONORRHEA INFECTIVE ENDOCARDITIS

Background: With the advent of antibiotics to eradicate common sexually transmitted infections (STIs), such as those due to Neisseria gonorrhea, we do not often see their most severe complications. Disseminated gonococcal infection (DGI) occurs in 0.5-3% of all infections, with infective endocarditis (IE) being a complication in 1-2% of patients with DGI. Case: A 30-year-old male with no past medical history, presented for 2 weeks of progressively worsening midline pleuritic chest pain, fevers, chills, malaise and dyspnea. TTE on admission noted severe aortic regurgitation and mild to moderate mitral regurgitation. Follow-up TEE noted destruction of the aortic valve with evidence of para-aortic abscess and a small dissection of the aortic root. Empiric intravenous antibiotic coverage was subsequently initiated. These findings, coupled with 2 blood cultures positive for N. gonorrhea, led to the patient's transfer to our institution for surgical evaluation. Decision-making: There have been about 50 reported cases of N. gonorrhea infective endocarditis since 1949. Treatment of the offending pathogen is made difficult by the infected typically being asymptomatic, which is why the mortality rate remains at about 20%. In our case, the patient was treated empirically for chlamydial co-infection and maintained on IV ceftriaxone until 6 weeks post-operatively. Due to the patient's symptoms and degree of valvular destruction, urgent surgical aortic valve replacement (AVR) was undertaken. The 2015 European Society of Cardiology guidelines for IE management recommend either bioprosthetic or mechanical AVR. A mechanical valve was chosen based on 2020 data indicating that there may be an association between bioprosthesis and higher IE risk. Conclusion: Despite our current ability to eradicate STIs with oral antibiotics, complicated infections like IE are still seen. This is pervasive amongst the sexually active in our underserved populations, augmented by decreased healthcare contact due to the COVID-19 pandemic. Therefore, continued consideration of this diagnosis in patients like ours, as well as a multidisciplinary approach inclusive of surgical evaluation, is imperative.

LEUKOCYTOCLASTIC VASCULITIS IN MITRAL VALVE ENDOCARDITIS

Background: Vasculitis is a known, although not commonly observed, manifestation of bacterial endocarditis. It is imperative that diagnosis is made promptly and appropriately treated, as vasculitis can often be painful and uncomfortable for patients. Case: 75-year-old male is admitted to the hospital for Coronavirus Disease 2019 (COVID-19). Several weeks after recovering from his respiratory infection, patient developed a diffuse, purpuric rash that began on his forearms and gradually spread throughout his bilateral upper extremities to his hands and fingers, as well as to his shoulders and lateral chest. Skin biopsy was performed and revealed findings suggestive of leukocytoclastic vasculitis. Blood work revealed Methicillin Resistant Staph Aureus (MRSA) bacteremia, sensitive to Vancomycin. Transthoracic echocardiogram revealed native mitral valve endocarditis. Transesophageal echocardiogram was not performed due to patient's underlying comorbidities and high risk. Decision-making: Patient was diagnosed with leukocytoclastic vasculitis secondary to bacterial endocarditis. Rheumatologic workup, including antineutrophil cytoplasmic antibodies, antinuclear antibodies, serum complement levels, anti-smith antibodies and double stranded deoxyribonucleic acid, was negative. Patient was ultimately discharged on a prolonged course of Vancomycin and his diffuse rash resolved one month later. Conclusion: There are only a few case reports describing the direct association between leukocytoclastic vasculitis and infective endocarditis. It is important to consider the association of vasculitis and endocarditis in order to effectively treat because immunosuppression, particularly with steroids, is the gold standard treatment for vasculitis. Our patient experienced near complete resolution of the rash after completion of antibiotics and no other therapy was deemed necessary.