Advantages of Total Bilirubin for Predicting Malignant Obstructive Jaundice, A Combination of the Pandemic Era and Limited Resources Settings

BACKGROUND: Hepatopancreatobiliary (HPB) cancer incidence and mortality are increasing worldwide. An initial diagnostic predictor is needed for recommending further diagnostic modalities, referral, and curative or palliative decisions. There were no studies conducted in area with limited accessibility setting of the COVID-19 pandemic, coupled with limited human resources and facilities. AIM: We aimed to investigate the advantages of total bilirubin for predicting malignant obstructive jaundice, a combination of the pandemic era and limited resources settings. METHOD(S): Data from all cholestasis jaundice patients at M. Djamil Hospital in Pandemic COVID-19 period from July 2020 to May 2022 were retrospectively collected. The data included demographics, bilirubin fraction results, and final diagnosis. Bivariate analysis for obtain demographic risk factor, and Receiver Operating Characteristics (ROC) analysis for getting bilirubin value. RESULT(S): Of a total 132 patients included, 35.6% were malignant obstructive jaundice, and Pancreatic adeno ca was the most malignant etiology (34.4%). Bivariate analysis showed a significant correlation between age and malignant etiology (p = 0,024). Direct and total Bilirubin reach the same level of Area Under Curve (AUC). Total bilirubin at the cutoff point level of 10.7 mg/dl had the most optimal results on all elements of ROC output, AUC 0.88, sensitivity 76.6%, specificity 90.1%, +LR 8.14, and-LR 0.26. CONCLUSION(S): The bilirubin fraction is a good initial indicator for differentiating benign and malignant etiology (AUC 0.8-0.9) in pandemic era and resource-limited areas to improve diagnostic effectiveness and reduce referral duration.Copyright © 2023 Avit Suchitra, M. Iqbal Rivai, Juni Mitra, Irwan Abdul Rachman, Rini Suswita, Rizqy Tansa.

Direct bilirubin and the neutrophil-to-monocyte ratio timely predict intensive care unit admission in patients with severe acute respiratory syndrome coronavirus-2 infection (COVID-19)

Objective: Intensive care units (ICUs) collapsed under the global wave of coronavirus disease 2019 (COVID-19). Thus, we designed a clinical decision-making model that can help predict at hospital admission what patients with COVID-19 are at higher risk of requiring critical care. Method(s): This was a cross-sectional study in 119 patients that met hospitalization criteria for COVID-19 including less than 30 breaths per minute, peripheral oxygen saturation < 93%, and/or >= 50% lung involvement on imaging. Depending on the need for critical care, patients were retrospectively assigned to ICU and non-ICU groups. Demographic, clinical, and laboratory parameters were collected at admission and analyzed by classification and regression tree (CRT). Result(s): Forty-five patients were admitted to ICU and 80% of them were men older than 57.13 +/- 12.80 years on average. The leading comorbidity in ICU patients was hypertension. The CRT revealed that direct bilirubin (DB) > 0.315 mg/dl together with the neutrophil-to-monocyte ratio (NMR) > 15.90 predicted up to correctly in 92% of the patients the requirement of intensive care management, with sensitivity of 93.2%. Preexisting comorbidities did not influence on the tree growing. Conclusion(s): At hospital admission, DB and NMR can help identify nine in 10 patients with COVID-19 at higher risk of ICU admission.Copyright © 2022 Sociedad Medica del Hospital General de Mexico.

Liver biomarkers for prognosis in COVID-19

The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).Mortality attributable to COVID-19 remains considerably high, with case fatality rates as high as 8-11%. Early medical intervention in patients who are seriously and critically ill with COVID-19 reduces fatal outcomes. Thus, there is an urgent need to identify biomarkers that could help clinicians determine which patients with SARS-CoV-2 infection are at a higher risk of developing the most adverse outcomes, which include intensive care unit (ICU) admission, invasive ventilation, and death. In COVID-19 patients experiencing the most severe form of the disease, tests of liver function are frequently abnormal and liver enzymes are found to be elevated. For this reason, we examine the most promising liver biomarkers for COVID-19 prognosis in an effort to help clinicians predict the risk of ARDS, ICU admission, and death at hospital admission. In patients meeting hospitalization criteria for COVID-19, serum albumin < 36 g/L is an independent risk factor for ICU admission, with an AUC of 0.989, whereas lactate dehydrogenase (LDH) values > 365 U/L accurately predict death with an AUC of 0.943.The clinical scores COVID-GRAM and SOFA that include measures of liver function such as albumin, LDH, and total bilirubin are also good predictors of pneumonia development, ICU admission, and death, with AUC values ranging from 0.88 to 0.978.Thus, serum albumin and LDH, together with clinical risk scores such as COVID-GRAM and SOFA, are the most accurate biomarkers in the prognosis of COVID-19.Copyright © 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

Anti-SARS-CoV-2 antibodies important in diagnostics of acute hepatitis in children

The most common causes of acute hepatitis in children are hepatitis A and autoimmune hepatitis. Hepatitis in the course of Wilson's disease is sporadically registered in adolescents. An increase of activity of aminotransferases both in the course of multisystem inflammatory syndrome in children (MIS-C) and in the course of COVID-19 has been observed. Hepatitis is common in children with MIS-C and is associated with a more severe presentation and persistent elevation of liver function tests. To date, no cases of acute hepatitis in children due to COVID-19 have been reported. We present 2 cases of acute hepatitis in children where the only cause seems to be a previous asymptomatic SARS-CoV-2 infection.Copyright © 2023 Termedia Publishing House Ltd.. All rights reserved.

Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8degreeF. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 x 2.9 x 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gramnegative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion(s): Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior. (Figure Presented).

Syphilis: "The Great Imitator" Presenting as Acute Hepatitis

Introduction: Syphilis is a multi-systemic disease caused by spirochete Treponema pallidum. Very rarely, it can affect the liver and cause hepatitis. Since most cases of hepatitis are caused by viral illnesses, syphilitic hepatitis can be missed. Here, we present a case of syphilitic hepatitis in a 35-year-old male. Case Description/Methods: Patient was a 35-year-old male who presented to the hospital for jaundice and mild intermittent right upper quadrant abdominal pain. His medical history was only significant for alcohol abuse. His last drink was 4 weeks ago. He was sexually active with men. On exam, hepatomegaly, mild tenderness in the right upper quadrant, jaundice, and fine macular rash on both hands and feet were noted. Lab tests revealed an ALT of 965 U/L, AST of 404 U/L, ALP of 1056 U/L, total bilirubin of 9.5 mg/dL, direct bilirubin of 6.5 mg/dL, INR of 0.96, and albumin of 2.0 g/dL. Right upper quadrant ultrasound showed an enlarged liver but was negative for gallstones and hepatic vein thrombosis. MRI of the abdomen showed periportal edema consistent with hepatitis without any gallstones, masses, or common bile duct dilation. HIV viral load and Hepatitis C viral RNA were undetectable. Hepatitis A & B serologies were indicative of prior immunization. Hepatitis E serology and SARS-CoV-2 PCR were negative. Ferritin level was 177 ng/mL. Alpha-1-antitrypsin levels and ceruloplasmin levels were normal. Anti-Smooth muscle antibody titers were slightly elevated at 1:80 (Normal < 1:20). Anti-Mitochondrial antibody levels were also slightly elevated at 47.9 units (Normal < 25 units). RPR titer was 1:32 and fluorescent treponemal antibody test was reactive which confirmed the diagnosis of syphilis. Liver biopsy was then performed which showed presence of mixed inflammatory cells without any granulomas which is consistent with other cases of syphilitic hepatitis. Immunohistochemical stain was negative for treponemes. Patient was treated with penicillin and did have Jarisch-Herxheimer reaction. ALT, AST, ALP, and total bilirubin down trended after treatment. Repeat tests drawn exactly 1 month post treatment showed normal levels of ALT, AST, ALP, and total bilirubin (Figure). Discussion(s): Liver damage can occur in syphilis and can easily be missed because of the non-specific nature of presenting symptoms. In our patient, the fine macular rash on both hands and feet along with history of sexual activity with men prompted us to test for syphilis which ultimately led to diagnosis and treatment in a timely manner. (Figure Presented).

Efficacy of N-acetyl Cysteine in Severe COVID-19 Patients: A Randomized Controlled Phase III Clinical Trial

Background: Today, various drugs have been investigated as the primary or complementary treatment for coronavirus disease 2019 (COVID-19). N-acetylcysteine (NAC) has been used as a mucolytic in pulmonary diseases. This drug apparently contributes to the retrieval of the intracellular antioxidant system. Objective(s): This study aimed to determine the efficacy of NAC in severe COVID-19 patients admitted to the intensive care unit (ICU). Method(s): This single-blinded randomized controlled phase III clinical trial included 40 patients with confirmed COVID-19 (based on polymerase chain reaction) admitted to the Shahid Mohammadi Hospital's ICU, Bandar Abbas, Iran, in 2020. All cases had severe COVID-19. They were allocated randomly to two equal groups. Patients in the control group received standard drug therapy based on the treatment protocol of the national COVID-19 committee, while those in the NAC group received a single dose of intravenous NAC (300 mg/kg) upon admission to the ICU in addition to standard drug treatment. Clinical status and laboratory tests were done on admission to the ICU and then 14 days later or at discharge without knowing the patient grouping. Result(s): The two groups were comparable regarding age, gender, and other baseline laboratory and clinical parameters. At the final evaluation, respiratory rate (21.25 +/- 4.67 vs. 27.37 +/- 6.99 /min) and D-dimer (186.37 +/- 410.23 vs. 1339.04 +/- 2183.87 ng/mL) were significantly lower in the NAC group (P = 0.004 and P = 0.030, respectively). Also, a lower percentage of patients in the NAC group had lactate dehydrogenase (LDH) <= 245 U/L (0% vs. 25%, P = 0.047). Although the length of ward and ICU stay was shorter in the NAC group than in controls, the difference was statistically insignificant (P = 0.598 and P = 0.629, respectively). Mortality, on the other hand, was 75% in the control group and 50% in the NAC group, with no statistically significant difference (P = 0.102). Concerning the change in the study parameters, only the decrease in diastolic blood pressure (DBP) was significantly higher with NAC (P = 0.042). The intubation and mechanical ventilation rates were higher, while oxygen with mask and nasal oxygen rates were lower with NAC, but the difference was statistically insignificant. Conclusion(s): Based on the current research, NAC is related to a significant decrease in RR, D-dimer, and DBP in severe COVID-19. Also, LDH was significantly lower in the NAC group than in the controls. More research with larger sample sizes is needed to validate the current study results.Copyright © 2023, Author(s).

The relationship of serum copper and zinc levels with oxidative stress markers and other laboratory parameters in COVID-19 patients Serum copper and zinc levels with coronavirus disease 2019

Aim: Serum Copper (Cu) and Zinc (Zn) levels can be associated with novel coronavirus disease 2019 (COVID-19). However, the correlation of serum Cu and Zn levels with biochemistry, hormones, and coagulation parameters has not been fully revealed. This study aims to determine serum Cu and Zn levels and their relationships with other laboratory parameters in the acute phase of COVID-19. Material(s) and Method(s): This retrospective observational study was conducted with patients who were diagnosed with COVID-19 in a tertiary hospital. The study was continued with the remaining 116 people: 53 healthy and 63 SARS-CoV-2-positives seriously ill. All laboratory data were retrospectively scanned from patient files at the hospital information system. Result(s): It was found that serum Cu, G6PD and TAS levels decreased, Zn TOS and OSI levels increased when COVID-19 patients were compared with healthy individuals. There is a positive correlation between serum Cu level and AST in COVID-19 patients, and a negative correlation between total bilirubin and LDH. There is a negative correlation between serum Zn levels and direct bilirubin, CRP, and procalcitonin. Discussion(s): Many studies have been reported showing that both Cu and Zn have antiviral effects against COVID-19. Although our data support these studies, it has been revealed that serum Cu and Zn levels were correlated with AST, direct/total bilirubin, LDH, CRP, and prolactin.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Influencing factors and clinical significance of liver function damage in patients diagnosed with COVID-19.

Objective: To invetigate the influencing factors and clinical significance of liver function damage (LFD) in patients diagnosed with Corona Virus Disease 2019 (COVID-19). Method(s): The retrospective case-control study was conducted. The clinicopathological data of 51 patients with COVID-19 who were admitted to the Sino-French New City Branch of Tongji Hospital Affiliated to Huazhong University of Science and Technology by the 5th group assisting team from the First Hospital of Jilin University from February 9th to 27th in 2020 were collected. There were 27 males and 24 females, aged from 36 to 86 years, with an average age of 68 years. The treatment modality was according to the diagnostic and therapeutic guideline for COVID-19 (Trial 6th edition) issued by National Health Commission. Observation indicators: (1) clinical data of patients;(2) analysis of liver function index and treatment of LFD;(3) analysis of influencing factors for LFD. Measurement data with normal distribution were represented as Mean+/-SD, and measurement data with skewed distribution were described as M (range). Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. The Logistic regression method was used for univariate analysis. Result(s): (1) Clinical data of patients: of the 51 patients, 21 were classified as ordinary type of COVID-19, 19 as severe type and 11 as critical type. In terms of medical history, 31 patients suffered from more than or equal to one kind of chronic disease, 20 had no history of chronic disease. Thirteen patients had the drinking history and 38 had no drinking history. Seven patients were hepatitis positive and 44 were hepatitis negative. Five patients had septic shock at admission, 5 had systemic inflammatory response syndrome (SIRS), and 41 had neither shock nor SIRS. The body mass index (BMI), time from onset to admission, temperature, heart rate, respiratory rate of the 51 patients were (24+/-3)kg/m2, (13+/-5)days, 36.5 (range, 36.0-38.1 ), 82 times/minutes (range, 50-133 times/minutes), 20 times/minutes (range, 12-40 times/minutes). The white blood cell count, level of creatinine, and level of b-type natriuretic peptide within 24 hours after admission were 6.3x109/L [range, (2.2-21.7)x109/L], 75 mumol/L (range, 44-342 mumol/L), 214 ng/L (range, 5-32 407 ng/L). (2) Analysis of liver function index and treatment of LFD: the level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), direct bilirubin (DBil), indirect bilirubin (IBil), activated partial thromboplastin time (APTT) and prothrombin time (PT) were 31 U/L (range, 7-421 U/L), 29 U/L (range, 15-783 U/L), 36 U/L (range, 13-936 U/L), 76 U/L (range, 41-321 U/L), 4.9 mumol/L (range, 2.6-14.3 mumol/L), 5.8 mumol/L (range, 2.6-23.9 mumol/L), 37.2 s (range, 30.9-77.1 s), 13.9 s (range, 12.5-26.7 s), respectively. The percentages of cases with abnormal ALT, AST, GGT, ALP, DBil, IBil, APTT and PT were 47.1%(24/51), 47.1%(24/51), 35.3%(18/51), 13.7%(7/51), 7.8%(4/51), 2.0%(1/51), 21.6%(11/51), and 19.6%(10/51), respectively. Of the 51 patients, LFD was detected in 10 patients classified as ordinary type, in 9 patients as severe type, and in 10 as critical type, respectively. In the 51 patients, 1 of 22 patients with normal liver function developed respiratory failure and received mechanical ventilation within 24 hours after admission, while 9 of 29 patients with abnormal liver function developed respiratory failure and received mechanical ventilation, showing a significant difference between the two groups (chi2=5.57, P<0.05). (3) Analysis of influencing factors for LFD. Results of univariate analysis showed that clinical classification of COVID-19 as critical type was a related factor for LFD of patients (odds ratio=10.000, 95% confidence interval: 1.050-95.231, P<0.05). Conclusion(s): COVID-19 patients with LFD are more susceptible to develop respiratory failure. The clinical classification of COVID-19 as critic l type is a related factor for LFD of patients.Copyright © 2020 by the Chinese Medical Association.

Hematological and hepatic alterations as predictors of mortality in patients hospitalized by SARS-COV-2

Introduction: SARS-COV-2 infection has generated high mortality. Symptomatology manifests in the respiratory, gastrointestinal tract and others, such as the hematopoietic system. Altered cell counts have been observed, such as lymphopenia standing out within hematological disorders. The cytokine storm together with the use of hepatotoxic drugs prolongs the inflammatory process and increases liver damage. Objective(s): To assess hematological and hepatic alterations in patients hospitalized for SARS-COV-2 who survived. Method(s): Cross-sectional study was conducted, including patients > 18 years, with positive test for SARS-COV-2. Serial measurements of hematological and hepatic parameters were carried out during the period of hospitalization. Those who did not require hospitalization were excluded. Result(s): Patients who died were older (62.71+/-13.52 vs 54.34+/-12.43, p=<0.001), required invasive mechanical ventilation (94.6% vs 86 78.9%, p=0.009) with peak pressure (29.27+/-5.26 vs 26.17+/-5.13, p=0.002) and showing decrease in Kirby index (128.39+/-49.14 vs 153.07+/-49.01, p=0.004) unlike those who survived. There was higher mortality in patients with lymphopenia (0.7 [0.45-1.15] vs 1 [0.7-1.5], p=<0.001), anemia (11.38+/-2.54 vs 12.38+/-2.48, p 0.018) and borderline ranges for platelets (265 vs 329, p=0.003) respectively. Regarding the liver profile, those patients who died had lower total proteins (5.38+/-0.81 vs 5.86+/-0.69, p <0.001), albumin (2.41 +/- 0.50 vs 2.83+/-0.49, p <0.001) and direct bilirubin (0.16 [0.1-0.25] vs 0.14 [0.1 - 0.23], p 0.006). Conclusion(s): Hematological and liver alterations are markers of higher mortality in patients with COVID-19 as an expression of multiorgan disease.

The importance of LDH/Albumin, LDH/Lymphocyte, and LDH/Platelet ratios in the evaluation of COVID-19 B.1.1.7 variant

Objectives: The aim is to investigate the usefulness of lactate dehydrogenase (LDH)/Albumin, LDH/Lymphocyte and LDH/Platelet ratios on the prognosis of coronavirus disease (COVID-19) Alpha (B.1.1.7) variant pneumonia. Method(s): A total of 113 patients who were diagnosed with COVID-19 pneumonia and 60 healthy control group were included in this study. The cases were divided into 2 as classic COVID-19 group, and COVID-19 B.1.1.7 variant group. Complete blood count (CBC) and biochemical parameters of the patients were analyzed retrospectively. Patients with COVID-19 B.1.1.7 variant group were also grouped according to the length of stay in the hospital and the days of hospitalization. Result(s): LDH/Albumin, LDH/Platelet, and LDH/Lymphocyte ratios were found to be higher in COVID-19 B.1.1.7 variant group when compared to the control group (p<0.001). The ferritin, neutrophils/lymphocyte (NLR) ratio, procalcitonin (PCT) and LDH/Albumin had the highest area under the curve (AUC) values in the COVID-19 B.1.1.7 variant group (0.950, 0.802, 0.759, and 0.742, respectively). Albumin, Lymphocytes and hemoglobin values were significantly higher in the COVID-19 B.1.1.7 variant group than in the classic COVID-19 group (p<0.05). Conclusion(s): LDH/Albumin and LDH/Lymphocyte ratios may be useful for clinicians in predicting the risk of progression to pneumonia in COVID-19 B.1.1.7 variant patients. Copyright © 2022 the author(s), published by De Gruyter.

COVID-19 AS A PROBABLE CAUSE OF PANCREATIC INJURY

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Up to 17% of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been shown to develop pancreatic lesions (1). We present 2 cases of coronavirus disease 2019 (COVID-19) patients that presented with pancreatic lesions. CASE PRESENTATION: Case1 A 47-year-old lady with a history of type 2 diabetes mellitus present to the emergency department (ED) with complaints of flu-like symptoms for ten days. She tested positive for COVID-19 by rapid PCR. Computed tomography (CT) scan without contrast on admission shows an incidental finding of a pancreatic mass (see Figure 1). Abdominal CT with contrast shows a large, multiloculated cystic mass in the pancreatic tail (see Figure 2). Laboratory examination depicted lipase: 27 U/L, CA19-9: 72 U/mL, CEA: 6.5 ng/mL, CA125: 24 U/mL, erythrocyte sedimentation rate (ESR):2 mm/h, Total Bilirubin: 0.6 mg/dl, Direct Bilirubin: 0.1 mg/dl. Following treatment, the patient recovered fully and is discharged from the hospital 10 days later with home oxygen therapy. Case2 An 81-year old Caucasian lady presented to the outpatient clinic with complaints of fecal incontinence. She tested positive for COVID-19, four months before her visit. CT scan of the abdomen with oral contrast revealed multiple hypodense masses on the pancreas measuring 0.3cm in diameter (see Figure 3). Laboratory tests reveal CA19-9: 57 U/mL, CA125: 8 U/mL, CEA: 1.9 ng/mL, erythrocyte sedimentation rate (ESR):11 mm/h, C-reactive protein: 0.7 mg/L, Total Bilirubin: 1.5 mg/dl, Direct Bilirubin: 1.3 mg/dl. Following outpatient treatment and follow-up, the patient's symptoms were relieved. DISCUSSION: Pancreatic lesions in COVID-19 patients can be caused directly by the cytopathic effects of the viral infection, or indirectly by systemic responses to inflammation or respiratory failure. Several studies have shown that ACE2 is the functional receptor used by SARS-CoV-2 to gain access to target cells (2) and ACE-2 receptors are expressed in significant amounts in the pancreas (3). In the first case, an incidental finding of a multi-cystic pancreatic mass on admission was reported. There was no pancreatic ductal dilation on the CT scan, which may indicate a direct injury caused by cytopathic effects of the virus rather than inflammation resulting in exocrine secretions forming cysts. In the second case, multiple masses on the pancreas were found after recovering from COVID-19. These lesions could be remnants of a previous pancreatic injury during the acute phase of the infection. CONCLUSIONS: COVID-19 infection may trigger pancreatic injury in some patients. Reference #1: Yong, Shin Jie. Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments. Infectious diseases. 2021 Oct;53(10): 737–754. Reference #2: Ma C, Cong Y, Zhang H. COVID-19, and the Digestive System. Vol. 115, American Journal of Gastroenterology. Wolters Kluwer Health;2020. p. 1003–6. Reference #3: Liu F, Long X, Zhang B, Zhang W, Chen X, Zhang Z. ACE2 Expression in Pancreatic Damage After SAERS-CoV-2 Infection. Gastroenterology. 2020 Aug 1;18(9): 2128 – 2130.e2. DISCLOSURES: No relevant relationships by Ailine Canete Cruz No relevant relationships by Claudia Ramirez No relevant relationships by Joseph Varon No relevant relationships by Mohamed Ziad

Medical Rehabilitation of Elderly and Senior Patients with COVID-19-Associated Pneumonia

The aim of the study was to evaluate the effectiveness of including remaxol in the medical rehabilitation of elderly and senior patients with COVID-19-associated pneumonia and changes in liver enzyme activity. Material and methods: 116 patients (56 men and 60 women) were examined. All patients underwent a complex of medical rehabilitation on an outpatient basis on the 10–12th day after discharge from the hospital and in the presence of 2 negative results of PCR tests for SARS-CoV-2, which included, in addition to the recommended measures (drug therapy and exercise therapy), vacuum labile massage according to the author's methodology and a course of hepatoprotective drugs. Depending on the latter, the patients were divided into two groups: I — the main group (n=60) — received remaxol in the drug treatment regimen: 400 ml, intravenously, drip, in a course of 10 days, II – comparison (n=56) — ademetionine: 400 ml, intravenously, drip, in 0.9% saline, in a course 10 days. Before rehabilitation and at its end, the following tests were carried out: Stange and Genchi tests;quality of life was assessed using the SF-36 questionnaire. Laboratory studies included determination of the following indicators levels: ALT, AST, their ratio, alkaline phosphatase, GGT, total and direct bilirubin, LDH, albumin and total protein levels. Results. The inclusion of hepatoprotectors in the medical rehabilitation of the patients of this group contributes to a decrease in cytolytic and cholestatic syndromes, which is more pronounced in patients who received remaxol: (a decrease in AST by 1.5 times (from 35.4±1.4 to 23.5±l), and ALT — by 1.8 times (from 38.7±1.3 to 21.5±0.4 IU/l), as well as normalization of bilirubin metabolism: a decrease of total bilirubin by 2.1 times (from 32.1± 0.6 to 14.8±0.9 µmol/l) and of direct — by 2.5 times (from 7.1±0.6 to 2.8±0.1 µmol/l). A pronounced increase in resistance to hypoxia was noted during the therapy with the drug (according to Stange and Genche), which contributed to an improvement in psychophysiological indicators of patients’ quality of life (according to the SF-36 questionnaire). The obtained results, along with the safety of the drug, allow us to recommend its use in patients with this pathology.

Leptospirosis: A Consideration When Acute Liver Failure Accompanies Acute Kidney Injury (AKI)

A 48 y.o. male maintenance worker in a rat-infested building with history of tobacco and marijuana smoking, atrial fibrillation on no medications was admitted in July 2021 for fever, headache and body aches for 5 days and new onset of hemoptysis. Initial labs notable for BUN 36 mg/dl, Cr 1.4 mg/dl urine protein 100 mg/dl RBCs 5-10/hpf, platelets 46,000. total bilirubin 3.8 mg/dl direct bilirubin 3.0 SARS-CoV-PCR negative and CXR revealed patchy bilateral infiltrates. He was intubated on day 2 and had ventricular fibrillation and cardiac arrest on day 3 with rapid return of purposeful movement. He had worsening anemia and thrombocytopenia, positive ANA and dsDNA, leading to use of steroids and plasmapheresis on Day 6 when peak bun/cr was 91/3.1 with urine protein/cr ratio 0.7, urine microscopy 2 rbc/hpf, urine Na 20 meq/l, urine osm 775 mosm/kg and cpk 400 U/l. These tests were negative or normal: Anti-GBM, ANCA, repeat ANA, repeat dsDNA, C3, C4, HIV, RF, hepatitis C RNA, cryoglobulins, ASO titer, ADAMTS13, Pneumocystis PCR, Sputum AFB, blood, AFB and fungal cultures, viral and fungal testing, hanta virus antibodies. Leptospira antibodies IgM by Dot Blot were positive and Leptospirosis diagnosis confirmed by NYC Department of Health (DOH) after obtaining confirmatory microscopic agglutination testing from the CDC. Urine and blood Leptospira DNA PCR not detected. He remained intubated with FiO2 requirement at 100% prior to his death on hospital day 16. Initially pulmonary renal syndrome considered but he was later found to have pre-renal azotemia. The elevated bilirubin led to testing for leptospirosis, his final diagnosis. In September 2021 the NYC DOH reported 14 cases of leptospirosis (increased from 5 cases in 2020), 13 of which had acute renal and hepatic failure, with 2 having severe lung involvement (1). This case is the only one in this group who died. The leptospirosis case fatality rate for severe diffuse alveolar hemorrhage exceeds 50%. Early appropriate antibiotic treatment prior to lab confirmation has been recommended by the CDC and may decrease severity of disease.

LEPTOSPIROSIS IN THE CITY: A CASE REPORT

CASE: A 58 year-old undomiciled man with no medical history presented with three days of anorexia, malaise, abdominal pain, and decreased urination. Exam was notable for scleral icterus. Lab-work revealed sodium 133 mEq/L, BUN 132mg/dL, creatinine 8.82 mg/dL, platelet 64 K/uL, total bilirubin 6.4 mg/dL, direct bilirubin 5 mg/dL. Lab-work two years prior was normal. HCV antibody was reactive, urinalysis revealed microscopic hematuria, and cocaine was detected on toxicology. Abdominopelvic CT, MRCP and renal sonogram were non-pathologic. On hospital day 5 his creatinine downtrended but total bilirubin continued to rise to a peak of 11.2 mg/dL and a leukocytosis without fever developed (peak 21.2 K/uL). Ceftriaxone was started empirically and a workup of blood cultures, viral serologies, ANA, alpha-1 antitrypsin, complement, cryoglobulin, ceruloplasmin level, microsomal, smooth muscle and antimitochondrial antibodies was normal. Review of his history suggested exposure to rodents as he slept close to a dumpster. Pending Leptospirosis serology, the antibiotics were adjusted to doxycycline. At discharge, the WBC and platelet counts normalized while the bilirubin and creatinine downtrended. IgM serology for leptospira later resulted positive. IMPACT/DISCUSSION: Leptospirosis is a worldwide zoonotic disease commonly associated with moist environments, poor housing and inadequate sanitation. Rodents are important reservoirs, shedding spirochetes through urine. Human infection results from exposure to animal urine, contaminated soil or water, or infected animal tissue. Portals of entry include cuts, mucous membranes or conjunctivae. Person-toperson transmission is rare. The incubation period is 5-14 days and illness severity ranges from subclinical to life-threatening. Disease manifestations include jaundice with acute kidney failure (Weil's disease), rash, conjunctival suffusion, hyponatremia, thrombocytopenia, microscopic hematuria, myocarditis, pulmonary hemorrhage, and meningitis. A biphasic illness, the acute febrile bacteremic phase can last 2-9 days followed by a period of apparent improvement. An “immune” phase then follows characterized by development of complications, as in our patient. During this phase, leptospires are absent from blood but may appear in the urine. While human cases of leptospirosis are rarely reported in the US outside of Puerto Rico and Hawaii (in the absence of travel), there was a significant rise reported to the NYC DOH in 2021. A potential explanation is an increase in housing insecurity and disruptions to waste management as a consequence of the COVID-19 pandemic. CONCLUSION: Leptospirosis is an important consideration in at-risk populations who may unknowingly be exposed due to living conditions. Our case of unexpected Weil's disease in an urban setting underscores the importance of a thorough social history as well as timely recognition of uncommon infections as possible reversible causes of multi- organ failure in the context of a changing world climate.

Factors Associated with Intensive Care Unit Admission and Mortality in COVID-19 Infection during May-August 2020 Period

Objective: COVID-19 infection causes severe pneumonia and multi-organ failure in adults, increases morbidity and mortality. Our study aimed to determine the factors affecting intensive care unit admission and mortality in hospitalized COVID-19 patients. Methods: The demographic, clinical, and laboratory data of hospitalized patients due to COVID-19 between May 1, 2020 and August 1, 2020 were evaluated retrospectively. Patients who were admitted to the intensive care unit or died during follow-up were included in the study group, and patients who were followed in the inpatient settings and sur-vived consisted the control group. The data obtained at the time of hospitalization were evaluated statistically. Results: A total of 473 patients were included in the study. The median age of the patients was 53 years (40-68 years), and 269 (56.9%) were male. During the follow-up, 93(19.7%) patients were admitted to the intensive care unit (ICU). Of the 468 patients for whom follow-up data were available, 62(13.2%) patients died. Patients with older age and comorbid diseases had higher ICU admission and mortality rates (p<0.001 and p<0.001). ICU admission rate was higher in patients with cough (p=0.002), myalgia (p=0.016), and dyspnea (p<0.001) during hospital admission. At the same time, dyspnea was more common in patients who died (p<0.001), and myalgia was more common in surviving patients (p=0.020). Laboratory values associated with both ICU admission and mortality were glucose (p<0.001, p<0.001), AST (p<0.001, p<0.001), serum creatinine (p<0.001, p<0.001), direct bilirubin (p<0.001, p=0.009), albumin (p<0.001, p<0.001), CRP (C-reactive protein) (p<0.001, p<0.001), procalcitonin (p<0.001, p<0.001), leukocyte count (p<0.001, p<0.001), lymphocyte count (p<0.001, p<0.001), neutrophil count (p=0.007, p<0.001), hemoglobin (p<0.001, p<0.001), troponin (p<0.001, p<0.001), D-dimer (p<0.001, p<0.001), ferritin (p<0.001, p<0.001), prothrombin time (p<0.001, p<0.001) and INR (international normalized ratio) (p<0.001, p<0.001) levels. Conclusions: Determining the parameters that define high-risk COVID-19 infected patients in the early period can contribute to reduce ICU admissions and mortality by improving patient management and resource utilization in hospitals.

Hematological features and risk factors of hospitalized COVID-19 patients: A retrospective analysis

Background: Coronavirus disease 2019 (COVID-19) became pandemic in 2020 and recently, mutated coronaviruses have emerged in many countries. The aim of this study was to identify the clinical characteristics and risk factors for critical illness in hospitalized COVID-19 patients in Zhengzhou for clinical prevention and management. Materials and methods: A total of 70 patients hospitalized with COVID-19 were enrolled between 21 January and 29 February 2020, in Zhengzhou, China. Clinical characteristics, hematological findings, neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), and inflammatory index on admission were obtained from medical records, COVID-19 patients with different outcomes were compared. Results: The median age was 55 years. Forty-three (61.0%) patients were classified as having severe or critical cases. Eighteen (25.7%) patients died in hospital and the remaining 52 were discharged. Patients who died tend to be old with expectoration and chronic obstructive pulmonary disease. Compared to survivor, non-survivor had significantly higher numbers of leucocytes and neutrophils, NLR, aspartate aminotransferase (AST), γ-glutamyl transpeptidase, total bilirubin, direct bilirubin, lactate dehydrogenase (LDH), prothrombin time, D-dimer, C-reactive protein, and decreased platelets, lymphocytes, uric acid, and albumin (ALB). Logistic regression analysis identified leucocytes, platelets, PLR, NLR, AST, and ALB as independent predictive factors for poor outcomes. The area under curve of the combination of leucocytes, PLR, NLR, and AST was 0.87, with a sensitivity of 0.83 and specificity of 0.81. Conclusion: Our results identified risk factors among COVID-19 patients for in-hospital mortality. Leucocytes, PLR, NLR, and AST could have important reference value for predicting prognosis, especially in low-resource countries.

Unilateral Massive Pleural Effusion as Manifestation of Severe Hyperthyroidism

Introduction: Non-cardiogenic pleural involvement in hyperthyroidism is rare, with unilateral involvement being rarer still. We present the case of a patient with Graves’ disease (GD) with thyroid storm criteria who presented right pleural effusion compatible with exudate. Case Description: A 40-year-old female patient, with a history of hyperthyroidism for 3 years without treatment for severe rash to thiamazole on two occasions. She was admitted to the emergency room of a private clinic due to dyspnea that progressed to respiratory failure, a massive right pleural effusion was found for which they performed evacuatory thoracentesis, prescribed lugol, bisoprolol and dexamethasone, and she was transferred to our hospital with a total of 45 points on the Burch-Wartofsky’s scale, had respiratory failure and jaundice. The analysis showed: Hemogram: Leukocytes 9700, Hemoglobin: 10.8 g/dl;CRP: 0.43 mg/dl;Glucose 157 mg/dl;Creatinine: 0.29 mg/dl, TSH: < 0.004 uIU/ml, Free T4: > 7.77 ng/ml;Free T3: > 16 pg/ml, Anti-thyroperoxidase: > 1000 IU/ml;Total bilirubins: 5.52 mg/dL;Direct bilirubin: 3.79 mg/dL. COVID infection was ruled out, the analysis of the pleural fluid was compatible with exudate, an echocardiogram showed LVEF: 60% and mild pulmonary hypertension. Thyroid ultrasound revealed diffuse hypervascularized goiter;thyroid scintigraphy showed diffuse hyper-uptake goiter. Dexamethasone with lithium carbonate was indicated with gradual improvement in thyroid function tests and cholestatic pattern. Once compensated she received 20mCi of 131I. She was discharged with an improvement in her symptoms. Her X-ray and her control chest ultrasound did not show the presence of pleural effusion. Discussion: GD is a pathology that presents with a variety of symptoms and signs due to its multisystemic involvement, which can become life-threatening, such as a thyroid storm, if it is not treated properly and in a timely manner. The fact of presenting unilateral massive pleural effusion is a rare presentation of hyperthyroidism reported in other cases.

A case of direct hyperbilirubinemia in the setting of multisystem inflammatory syndrome in children with incidental gallbladder agenesis

Case Report In April 2020, cases of multisystem inflammatory syndrome in children(MIS-C) were reported from the UK as clinical presentations similar to incomplete Kawasaki and toxic shock syndrome in the setting of COVID-19. MIS-C is a rare but significant complication of COVID-19. We present the case of direct hyperbilirubinemia associated with MIS-C with incidentally discovered gallbladder agenesis. Case presentation A 16-year-old male presented with fever, epigastric pain, jaundice, and rash. He tested positive for SARS-CoV-2 one month prior, improved clinically, but developed fever one day before presentation. Physical exam revealed a diffuse maculopapular rash, jaundice, and right upper quadrant tenderness. Vitally stable. Work up for MIS-C revealed positive SARS-CoV-2, lymphopenia, ESR 23 mm/hr, fibrinogen 552 mg/dl, CRP 8.94 mg/ dL. Troponin, BNP, and coagulation profile were normal. Echo and CXR were unremarkable. CMP showed ALT 242 IU/L, AST 145 IU/L, total bilirubin of 5.7 mg/dL with direct bilirubin of 3.9 mg/dL, GGT 178 IU/L, consistent with obstructive jaundice. Workup for autoimmune hepatitis and viral hepatitis was negative. US right upper quadrant was done to rule out an obstructive pathology, which was normal except that it showed an absent gallbladder. MRCP and HIDA scan also showed no obstructive pathology and confirmed gallbladder agenesis. With no clear reason for direct hyperbilirubinemia, treatment for mild MIS-C was initiated with IV dexamethasone. Repeat blood work after 24 hours showed down trending bilirubin levels and stable liver enzymes, patient was discharged shortly afterwards. At one month follow up, liver enzymes and bilirubin normalized. Discussion Presentations of MIS-C vary with the most common being persistent fever along with gastrointestinal, respiratory, neurological, skin, and/or cardiac involvement. Acute hepatitis with elevated liver enzymes is a well-documented lab finding but direct hyperbilirubinemia is rare. Another interesting finding in our case was gallbladder agenesis, which is a rare congenital anomaly (incidence 10-65 per 100,000). Conclusion We highlight in our case report that cholestatic jaundice, despite being a very rare manifestation of MIS-C, can still occur. A multidisciplinary approach should be taken when treating such patients including GI, cardiology, rheumatology, and infectious disease.

Development and validation of a clinical risk score to predict the critical illness in hospitalized patients with COVID-19

The Covid-19 pandemic has obligated healthcare systems to triage patients efficiently in order to utilize resources in the proper manner. Robust, validated clinical prediction tools are lacking that identify patients with coronavirus disease 2019 who are at the highest risk of mortality. A cohort of 661 positive COVID patients admitted to the Loyola hospital from 3/11/2020 to 10/12/2020 was used to validate previously published results with the composite outcome of 'critically ill', defined as invasive ventilation, ICU admission, or in-hospital death. Epidemiological, clinical, laboratory, and imaging variables ascertained at hospital admission were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score. Accuracy of the score was measured by the area under the receiver operating characteristic curve (AUC). Fifty-two (52) percent of our cohort had critical illness compared to 8% in the Liang paper (the first predictor model which was developed in China). Our population was older, had significantly higher abnormal chest x-ray, dyspnea, and number of comorbidities compared to their population. In addition, our population had higher values for NLR and LDH and lower direct bilirubin. Using the model coefficients presenting in Liang et al, the AUC was only 0.68 (95% CI: 0.64, 0.72), considerably lower than .88 presented in their publication. LASSO variable selection identified 8 variables (HR, SBP, fever, SpO2<90, LDH, ferritin, D dimer, CRP on admission) for a multivariable model. In the multivariable model: SpO2 <90, fever at admission, and increasing LDH were found to be statistically associated with our outcome. We finally added baseline predictors of age, sex, race, and number of comorbidities to the LASSO predictors which resulted in an AUC of 0.75 (95% CI: 0.71, 0.78). In our study, we found that three predictors (SpO2 <90, fever, and increasing LDH on admission) were selected by the LASSO analysis to construct a predictive nomogram. The application of our model would help clinicians make a prompt decision to optimize patient stratification management. However, this quantitative tool needs to be validated by further large-scale prospective studies.