Fulminant varicella infection complicated by disseminated intravascular coagulation following influenza-A case report

Objectives: Varicella is common infectious disease mainly in childhood, usually is a mild, self-limited illness and complications are usually rare. The incubation period for this disease is generally 14- 16 days but may vary from 7 to 21 days. Varicella in the adults with comorbidities or immunosuppressed children may be severe and prolonged with complications. Method(s): A case report of a 6-year-old girl hospitalized for new-onset manifestations of disseminated vesicular exanthema, the manifestations of which occurred mainly on the chest, back, capillitium, oral cavity, and genital area. The child was suffering from abdominal, knee and lumbosacral pain at that time. The patient's history revealed that 10 days prior to the cutaneous manifestations, she had influenza with bronchopneumonia requiring oxygen therapy, steroids and antibiotics. Result(s): The condition progressed within 48 h, complicated by the development of multi-organ failure, coagulopathy with the development of disseminated intravascular coagulopathy over the course of antiviral, antibiotic and antifungal therapy. Laboratory parameters included high elevation of C-reactive protein, il-6, leukocytosis, neutrophilia and highly elevated liver enzymes. Varicella infection was confirmed by detection of herpes zoster virus - polymerase chain reaction (PCR) from vesicles. The patient received intravenous immunoglobulin therapy at a dose of 2 g/L and fresh frozen plasma, thrombocyte concentrate. The girl was intubated with analogization. Laboratory parameters subsequently revealed high anti CoV-2 positivity, high CoV-2 IgG positivity and negative CoV-2 IgM. The patient's condition did not preclude the course of multisystem inflammatory syndrome in children (MIS-C) corticosteroids were added to the treatment at a dose of 1 mg/kg weight. Patient's condition stabilized after 1 month. Discussion(s): Our case report presents an example of fulminant complicated life-threatening course of varicella. Even in common respiratory infections, we must think about the risk and consequences of coinfections and post-infectious complications such as in our case especially influenza and COVID-19.

Rescuing orphan drugs

Philip Kranz and colleagues argue that drug regulators should not automatically assume orphan drugs are clinically "superior” for patients, in the absence of robust evidence of their clinical benefits (doi:10.1136/bmj-2022-072796).1 The US offers new evidence that not all drugs benefiting from orphan status are actually for rare diseases (doi:10.1136/bmj-2022-073242).2 A study looking at FDA approved cancer treatments over the past 20 years found that most approvals for cancer indications were designated as orphans. "Are we still getting what we thought we were paying for?” asks Joseph Ross (doi:10.1136/bmj.p928).3 Evidence matters and can take many decades of endeavour to gather, as is the case for a new vaccine to prevent respiratory syncytial virus bronchiolitis in infants (doi:10.1136/bmj.p1023).4 The RSV virus kills very young children, mostly in low to middle income countries, and a pandemic related surge in incidence resulted in many hospital admissions. FDA approval, clinical trial evidence, efficacy, epidemiology, and price for non-orphan and ultra-rare, rare, and common orphan cancer drug indications: cross sectional analysis.

Oxygen markers for predicting COVID-19 - related pneumonia mortality

Introduction: the value of oxygen as a prognostic maker of mortality due to COVID-19 pneumonia has not been evaluated at the Hospital General Docente "Dr. Agostinho Neto". Background: to identify the values of oxygenation markers for prognosing mortality caused by COVID-19 pneumonia at the Hospital General Docente "Dr. Agostinho Neto" de Guantanamo, Cuba, throughout period 2020-2021. Method: a cohort of 276 patients with COVID-19 pneumonia was studied. Peripheral oxygen saturation (SpO2), arterial oxygen saturation (SaO2), the difference between the oxygen concentration in the alveoli and arterial system (DA-aO2), arterial oxygen pressure ratio (PaO2) and inspired oxygen fraction (FiO2) [PaO2/FiO2] were studied. The association between variables and deceased discharge was determined using the Chi-square technique and the Odds Ratio (OR) calculation. Results: the variable with the highest positive predictive value was SpO2 (87.3%) with a value lower than 90 mmHg at admission. The highest negative predictive value was recorded for the DA-aO2 variable (95.6%), less than 20 mmHg at 48 hours after admission. Attributable risk was higher for PaO2/FiO2 ratio, less than 300 mmHg (0.59), at admission (0.52). Attributable risk percent was higher for the variable DA-aO2 20 mmHg at admission (95.8%) and at 48 hours after admission (95.3%). Conclusions: abnormal DA-aO2, PaO2/FiO2 ratio, SaO2 and SpO2, at admission and 48 hours after admission, are predictive markers of mortality in patients with COVID-19.

Challenges of Treating Covid 19 in Patients with Chronic Renal Failure under Limited Conditions

Introduction: Relevant clinical studies indicate a significantly poorer outcome in patients with advanced renal failure during Covid 19 probably due to significantly slower clearance of proinflammatory cytokines produced during infection but also in the presence of significantly higher cardiovascular comorbidity in these patients. Method(s): We present the characteristics of patients with chronic renal failure (CRF) who were treated for Covid 19 bronchopneumonia at the Temporary Covid 19 hospital "Stark Arena" Belgrade,during 2020/2021. In this period we have treated about 5200 patients with Covid 19 bronchopneumonia under limited conditions. Result(s): We analyzed a records of 466 patients with a history of CRF: 261 male (56.01%) and 67 female 67(43.99%), mean age 75 +/- 11.14 years (40-88 years), 297 of them (63.73%) suffered from high blood pressure, 154 patients (33,05%) suffered from diabetes mellitus and 114 patients (24,46%) had both diseases.The mean value of sO2 at admission was 92+/-4,45%, CRP 87+/-99.7mg/l, Interleukin-6 61+/-33.4 pg/ml, hemoglobin (Hgb)126+/-14.22g/l, urea 12+/-7,53 mmol /l, creatinine 137.43+/-121.22micromol/l, glomerul filtration rate (GFR) 47.44ml/min/1.73m2. Patients were treated according to the current protocol where 305 out of than (65,45%) also received an interleukin-6 receptor blocker (Tocilizumab 8-16 mg/kg). A total of 452 patients (96.99%) after successful treatment of bronchopneumonia were discharged for home treatment with average creatinine values of 116+/-31.32micromol/l and GFR 56.13ml/min/1.73m2,while 14 patients (3,01%) due to the worsening of their general condition, were transferred to a higher - level health institution, from where they were further discharged without necessity for chronic dialysis treatment. There were no lethal outcomes. Parameters on admission: [Formula presented] Parameters at discharge: [Formula presented] Conclusion(s): Advanced renal failure is a significant risk factor for adverse clinical outcome during Covid 19. In our group majority of patients were with moderate CRF who had a successful end-therapeutic outcome, but a significant percentage of them required the use of Tocilizumab (without adverse effects). The verified improvement of GFR at discharge is most likely a consequence of the remediation of factors (inflammation, dehydration, nephrotoxicity of drugs etc.) which led to worsening of preexistent CRF. Regardless of the existing degree, all patients with renal failure require serious monitoring during Covid 19. No conflict of interestCopyright © 2023

Role of 'Radiological Phenotypes' in Diagnosis, Treatment and Assessment of Covid-19 Pneumonia: Multicentric study of 6000 cases in tertiary care setting in India

Methods: multicentric observational study, included 6000 COVID-19 RT PCR Positive cases with lung involvement on HRCT thorax at entry point & categorised as Radiological presentation phenotypes as severity assessmentmild, moderate, severe as per lung segment involvement (mild<7, moderate 8-15 and severe 16-25), Evolving and Evolved phenotype- with or without GGOs, consolidations, and crazy paving with or without spreading edges, Anatomical phenotype-Unilateral or bilateral as per lung lobe segment or lobe involvement, Clinicalradiological-pathological phenotypes-five types as classical GGOs, consolidations, Bronchopneumonia, Necrotizing pneumonia and cavitating. Response to treatment phenotypes-easy to treat and difficult to treat as per interventions required & response to treatment. Radiological outcome phenotypes as Resolving, Persistent and Progressive as per lung reticular and fibrosing lesions as with or without honeycombing and or tractional bronchiectasis. Statistical analysis by Chi test and students t test and ANOVA. Observations and analysis:In 6000 radiological assessment of covid-19 pneumonia, significant association was documented in Evolving and Evolved pneumonia phenotypes (p<0.000026), Unilateral and Bilateral pneumonia anatomical phenotypes (p<0.00001), Clinical-radiological-pathological phenotypes (p<0.00001), Easy to treat and Difficult to treat pneumonia phenotypes (p<0.00001), Radiological final outcome phenotypes-Persistent, Progressive & Resolving phenotype (p<0.00001) conclusion: Radiological phenotypes will guide in assessing severity, predicting response to therapy and final outcome in covid-19 pneumonia.

Evaluation of the frequency, follow-up, and treatment of patients with multisystem inflammatory syndrome related to COVID-19

Aim: Aim of this study is evaluate the clinical features, laboratory values, treatment and follow-up of in children with COVID-19-associated multisystem inflammatory syndrome (MIS-C) disease. Materials and Methods: In this study, patients aged between 2 months and 17 years, who applied to the Inonu University Faculty of Medicine, Department of Pediatrics between March 2020, and February 2021 due to MIS-C related to COVID-19 disease, were reviewed retrospectively. Demographic data, clinical features, laboratory values, treatment and follow-up data of the patients were evaluated. Results: Forty-nine patients diagnosed with MIS-C between March 2020 and February 2021 were included in the study. Thirty-one (72.7%) patients were male and 18 (27.3%) were female. The most common indications for admission were fever (100%), abdominal pain (51.6%), vomiting (42.9%), cough (38.8%), diarrhea (28.8%), shortness of breath, rash, conjunctivitis, and convulsion. Levels of CRP (93.9%), D-dimer (85.7%), fibrinogen (73.4%), interleukin 6 (IL6) (73.4%), procalcitonin (71.4%), NT-proBNP (63.2%) remained at high levels in respective number of patients. The (32.6%) patients were followed up in the intensive care unit. These patients had cardiogenic shock (26.5%), severe pneumonia (18.3%), and acute gastroenteritis (14.3%). It was determined that the mean age of the patients followed up for cardiogenic shock was 12.5 years and relatively higher (p < 0.05). One patient died during follow-up. Conclusion: Although the manifestations of MIS- C due to COVID -19 are seen relatively rarely in children, it constitutes a serious problem and they mostly require hospitalization in intensive care unit, simultaneously involves many organ systems, and leads a serious course with higher risk of mortality. Another problem in these patients is higher rates of cardiac involvement. For this reason, it is important to take necessary precautions to protect children against COVID 19 and its associated MIS-C, and to include them in vaccination programs.

Role of CT scan thorax in nCovid19—a case-based review

BackgroundMost of the morbidity and mortality in nCovid19 is due to pneumonia which can be reduced by early diagnosis and treatment. Chest CT scan plays an important role in the early diagnosis and management of respiratory complications due to nCovid19. Clinicians should be aware about the indications for the CT scan of the thorax, timing of investigation, and limitations of CT.Main body of abstractChest CT scan is indicated in patients with moderate to severe respiratory symptoms and pretest probability of nCovid19 infection, when RT-PCR test results are negative, and in patients for whom an RT-PCR test is not performed or not readily available. When a rapid antigen test is negative and an RT-PCR test report takes time, CT can be used in seriously ill patients to decide whether it is COVID or not. For patients who are dependent on oxygen even after 2 weeks, CT may help to show the extent of lung involvement and predict long-term prognosis. CT may be done to exclude nCovid19 pneumonia. For patients with high risk for nCovid19 who require an immediate diagnosis to rule out lung involvement, CT can be done. A normal CT excludes nCovid19 pneumonia. CT scan is required in confirmed cases of nCovid19 pneumonia when complications are suspected clinically. These include pulmonary thromboembolism, pneumothorax, mediastinal/surgical emphysema, bacterial pneumonia, and unexplained deterioration with new shadows in chest X-ray. CT pulmonary angiogram is indicated when pulmonary embolism is suspected, and in other cases, plain CT should be done. In pre-operative cases where emergency surgery is required, nCovid19 disease is suspected clinically, and RT-PCR report awaited or not available, CT thorax can be done.ConclusionCT scan is useful for early diagnosis of lung involvement, detection complications, triaging of cases, risk stratification, and preoperative evaluation in select cases. CT scan should be done only when there is a definite indication so to reduce radiation hazards and to reduce health care expenditure. Normal CT excludes nCovid19 lung involvement, but the patient may have upper respiratory involvement which may progress later to involve lungs.

Characterization and antibiogram study of pneumonia causing bacteria isolated from blood culture of children in northern Bangladesh

Children are usually affected by pneumonia, which is a common ailment caused by Pathogenic Streptococcus pneumoniae. This study's objective was to isolate and identify S. pneumoniae, which was recovered from blood samples of suspected paediatric pneumonia patients using conventional techniques, such as antibiotic sensitivity profiles and molecular approaches. In this study, forty (40) samples from three major hospitals in the Dinajpur region of Bangladesh were collected and assessed using various bacteriological, biochemical, antibiotic susceptibility test, and molecular techniques. 37.5% of the 40 samples tested positive for pneumonia, and 15 isolates were discovered. In terms of age, pneumonia was more common in children aged 3-5 years (50%) than in those aged 6 to 8 (33.33%), 9 to 11 (25%) and 12 to 15 (20%). According to the results of the current study, the study area had no statistically significant impact (P > 0.05), while age and socioeconomic status had a significant impact on the prevalence of pneumonia in patients with pneumonia (P 0.05). The age group for which pneumonia was most prevalent (at 50%) was that for children between the ages of 3-5. Poor socioeconomic status was associated with the highest prevalence of pneumonia (54.54%). By sequencing the 16S rRNA gene, S. pneumoniae was identified as S. pneumoniae NBRC102642. In the antibiotic investigation, S. pneumoniae was found to be extremely resistant to ciprofloxacin, amikacin, vancomycin, and cefexime, but responsive to erythromycin and azithromycin, as well as neomycin, kanamycin, streptomycin, and bacitracin. S. pneumoniae causes serious complications in paediatric patients, and this scenario requires prevention through vaccination and the development of new, efficient antibiotic therapies for pneumonia. If specific laboratory features of paediatric patients with pneumonia are understood, sepsis will be easier to detect early, treat, and reduce mortality.

The effect of oral corticosteroid treatment on clinical course, hospitalization and mortality in COVID-19 patients

Introduction: It has been reported that short-term and lowdose intravenous corticosteroids prevent the progression of the disease and reduce mortality during the hyperinflammation period caused by the virus in COVID-19 disease. The aim of our study is to evaluate the clinical course, hospital readmission and mortality rates of patients with mild to moderate COVID- 19 pneumonia, who do not need oxygen and for whom we started outpatient corticosteroid treatment. Materials and Methods: Patients over the age of 18 who applied to our hospital with the diagnosis of mild-to-moderate COVID-19 pneumonia and were treated with outpatient oral systemic corticosteroid were included in the study. Inclusion criteria were pneumonia finding consistent with mild to moderate COVID-19 involvement in lung computerized tomography, seven days or more from symptom onset, and oxygen saturation of 93 and above. The patients were given dexamethasone 8 milligrams (mg) methylprednisolone 32 mg, methylprednisolone 40 mg as oral systemic corticosteroid. Results: The mean age of the patients was 49.2 +or- 12, and 60% of them were male. The median steroid duration was 6.76 +or- 2.35 days. Due to ongoing symptoms, 56% of the patients were admitted to the hospital again, 12% were hospitalized due to clinical and laboratory deterioration, the intensive care hospitalization rate was 3% and the mortality rate was 2% (2/100). Conclusion: As a result, the effectiveness of oral corticosteroids on mortality and morbidity has not been demonstrated in mild to moderate COVID-19 pneumonia. Well-designed randomized controlled studies are needed on this subject.

A Case Series Demonstrating the Difficulties in Diagnosing COVID-19 Associated Pulmonary Aspergillus.

Many bacterial, viral, and fungal co-infections have been reported with COVID-19-associated acute respiratory distress syndrome (ARDS). Invasive Aspergillosis has been described with COVID-19 ARDS. However, it continues to evade diagnosis in critically ill patients admitted to the intensive care unit (ICU). The difficulty is discerning an actual infection from colonization. Unfortunately, a timely diagnosis is crucial since COVID-19-associated pulmonary Aspergillus (CAPA) has high morbidity and mortality. We present three ICU cases of CAPA to illustrate the difficulty in diagnosing and treating the disease. We hope to bring awareness and improve patient outcomes of CAPA.

Herpesviridae lung reactivation and infection in patients with severe Covid-19 or influenza virus pneumonia: a comparative study

Background. Lung reactivations of Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) have been reported in Covid-19 patients. Whether or not those viral reactivations are more frequent than in other patients is not known. Methods. Retrospective monocentric cohort study of 145 patients with severe Covid-19 pneumonia requiring invasive mechanical ventilation and who were tested for HSV and CMV in bronchoalveolar lavage performed during fiberoptic bronchoscopy for ventilator-associated pneumonia suspicion. Rates of HSV and CMV lung reactivations, and HSV bronchopneumonitis were assessed and compared with an historical cohort of 89 patients with severe influenza pneumonia requiring invasive mechanical ventilation. Results. Among the 145 Covid-19 patients included, 50% and 42 % had HSV and CMV lung reactivations, respectively;whereas among the 89 influenza patients, 63% and 28% had CMV lung reactivations, respectively. Cumulative incidence of HSV lung reactivation (taking into account extubation and death as competing events) was higher in influenza than in Covid-19 patients (p = 0.03, see figure 1), whereas the rate of HSV bronchopneumonitis was similar in both groups (31% and 25%, respectively). Cumulative incidence of CMV lung reactivation (taking into account extubation and death as competing events) was similar in Covid-19 and influenza patients (p=0.07). Outcomes of patients with HSV or CMV lung reactivations were similar to that of patients without, whatever the underlying conditions, i.e., in Covid-19 patients, in influenza patients, or when all patients were grouped. Estimated cumulative incidence of herpes simplex virus (HSV) lung reactivation, extubation or death in Covid-19 and influenza patients, taking into account only the first event that occurred. p values for differences between Covid-19 and influenza patients were 0.03 for HSV reactivation, 0.53 for death and 0.87 for extubation. Conclusion. HSV andCMVlung reactivations are frequent in Covid-19 patients, but not more frequent than in patients with influenza-associated severe pneumonia, despite a higher severity of illness at intensive care unit (ICU) admission of the latter and a longer duration of mechanical ventilation of the former. Although no impact on outcome of HSV and CMV lung reactivations was detected, the effect of antiviral treatment against these Herpesviridae remains to be determined in these patients. (Figure Presented).

Clinical/biochemical characteristics and related outcomes in people with new-onset diabetes and COVID-19: experience from a single centre

Aims: It is known that there is a bidirectional relationship between diabetes mellitus (DM) and coronavirus disease (COVID-19). It has been described that those patients infected with SARS-CoV-2 could develop severe metabolic decompensation of pre-existing or new-onset DM, although diabetogenic effect of SARS-CoV-2 has still not been well consolidated. In fact, the coexistence of SARS-CoV-2 infection and new-onset DM is an infrequent situation. Method(s): We describe the clinical and analytical characteristics of 19 patients admitted to a Spanish tertiary hospital - all 19 having COVID-19 infection and new-onset DM. Result(s): 12/19 patients (63.2%) were female;the mean age at diagnosis of DM was 54 (39-65) years. The most frequent ethnic group was Caucasian (n=9), followed by Latin-American (n=7);7/19 (36.8%) previously met criteria for prediabetes due to altered basal glycaemia or HbA1c. The mean BMI at diagnosis was 32.26kg/m2 (27.62-35.18kg/m2). Eighteen of 19 patients (94.7%) showed bilateral bronchopneumonia. The mean blood glucose of the first blood was 17.5mmol/L (11.1-21.1mmol/L), and the mean HbA1c was 88mmol/mol (60-115mmol/mol). C-peptide was requested in eight patients and it was within normal range in 87.5% (n=7) and below the inferior threshold in one case. Autoantibodies were requested in 26.3% (five patients), being negative in 4/5 (80%) and positive in 1/5 (20%). Regarding the type of diabetes diagnosed, 18 were type 2 DM and only one case was diagnosed with type 1 DM. Seventeen had simple hyperglycaemia and two suffered a diabetic ketoacidosis. The mean HbA1c at 8.0 months (5.0-12.0 months) follow-up was 42mmol/mol (40-49mmol/mol). Conclusion(s): The majority of those described had type 2 DM that appears to have been unmasked by the COVID-19 infection, since they had high HbA1c and several risk factors for diabetes development, such as obesity and prediabetes. Most of them had their pancreatic reserve preserved, and this may suggest insulin resistance as the aetiology rather than direct beta-cell damage. A good evolution of diabetes after hospital discharge was observed in the patients followed up at our centre. Copyright © 2022 John Wiley & Sons. Copyright © 2022 John Wiley & Sons, Ltd.

Guillain-Barre Syndrome with Lethal Outcome Following COVID-19 Vaccination-Case Report Supported by Autopsy Examination

Objective: After the outbreak of the global pandemic caused by SARS-CoV-2 infection at the end of the year 2019, it took one year to start vaccinatioagainst this infection with products from various manufacturers. As of November 2021, more than 8 billion vaccine doses against COVID-19 havbeen administered, which is essentially linked to a spike in adverse events reports following these vaccinations, including a number of neurologicaadverse events. Case Report: We report a case of a 71-year-old patient with lethal fulminant onset of Guillain-Barre syndrome after the second dose of mRNA vaccintozinameran. This is, to our best knowledge, the first case report of this adverse event supported by autopsy and histological examination. Thpatient presented with progressive ascending weakness and paresthesia, with typical cytoalbuminologic dissociation in cerebrospinal fluid ansevere motoric and sensitive axonal-demyelinating polyneuropathy on electromyography. The patient's history and complex diagnostic workup dinot reveal any other possible causative factors. The patient did not respond to the treatment with intravenous immunoglobulins and died 10 daylater due to aspiration bronchopneumonia as a complication of respiratory muscles paralysis. Conclusion(s): Most of the reported adverse reactions following COVID-19 vaccination include mild or moderate events noticed in the post-vaccination periodhowever, reports of possible lethal outcomes are no exception. Still, the overall incidence of GBS after vaccination does not significantly exceed itincidence in the general population. Each such report should be carefully examined by a team of specialists to prevent overestimation of lethaadverse events linked to vaccinations, especially in fatalities that happen in the post-vaccination period. Copyright © 2022 Mosna et al.

Delayed Surgical Management of Acute Type A Aortic Dissection in a Patient with Recent COVID-19 Infection and Post-COVID-19 Bronchopneumonia-Case Report and Review of Literature.

Ever since it was first described in 1760, acute type A aortic dissection has created difficulties in its management. The recent COVID-19 pandemic revealed that extrapulmonary manifestations of this condition may occur, and recent reports suggested that aortic dissection may be amongst them since it shares a common physiopathology, that is, hyper-inflammatory syndrome. Cardiac surgery with cardiopulmonary bypass in the setting of COVID-19-positive patients carries a high risk of postoperative respiratory failure. While the vast majority accept that management of type A aortic dissection requires urgent surgery and central aortic therapy, there are some reports that advocate for delaying surgery. In this situation, the risk of aortic rupture must be balanced with the possible benefits of delaying urgent surgery. We present a case of acute type A dissection with COVID-19-associated bronchopneumonia successfully managed after delaying surgery for 6 days.

HERPES SIMPLEX VIRUS PNEUMONITIS IN A CRITICALLY ILL PATIENT WITH SARS-COV-2

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Herpes simplex type 1 (HSV-1) related respiratory tract infections have been described in critically ill or immunocompromised patients. We present a case of HSV-1 pneumonia in a mechanically ventilated and immunocompromised patient in the setting of SARS CoV-2 infection. CASE PRESENTATION: A 54-year-old female on Rituximab for Rheumatoid arthritis presented with shortness of breath and cough. She was afebrile, tachypneic and hypoxic. She was discharged 1 week prior after a 3 weeklong treatment for COVID-19 pneumonia. CT Angiogram showed extensive bilateral patchy consolidations with ground-glass infiltrates and subsegmental pulmonary emboli. Patient was initiated on heparin and broad-spectrum IV antibiotics with steroids for presumed ARDS with superimposed bacterial pneumonia. Her respiratory failure worsened requiring invasive mechanical ventilation. Failing oxygenation despite aggressive therapy prompted further workup that showed a normal echo and negative blood cultures. Sputum was negative for Pneumocystis pneumonia and Tuberculosis. Cytology from tracheal aspirate showed bronchial cells with inclusions and multinucleations consistent with HSV-associated cytopathic changes. A positive serum HSV-1 IgG and serum quantitative PCR of HSV-1 DNA solidified the diagnosis. Ganciclovir therapy was initiated to cover for HSV and Cytomegalovirus (CMV), however, a serum CMV PCR was negative. Within a day, her clinical course took a downward spiral. CT chest was repeated which showed worsening airspace disease. Despite ganciclovir therapy, the severity of lung disease led to eventual failure of oxygenation and patient demise. DISCUSSION: Prolonged mechanical ventilation due to ARDS is a risk factor for HSV bronchopneumonia in patients with COVID-19 and has shown an increased mortality 1,2. Diagnosis can be achieved by viral culture or observing cytopathic effects of HSV on cells in tracheobronchial aspirates, bronchoalveolar lavage, or biopsy3. In critically ill patients early treatment has been shown to prolong the ICU time to death and improved oxygenation4. It is important to test for co-infections as about 65% of HSV pneumonia cases are associated with pathogens like CMV and Pneumocystis5. CONCLUSIONS: Worsening respiratory disease in mechanically ventilated COVID-19 patients despite antibiotic therapy for suspected superimposed bacterial infection warrants a workup for secondary viral infections like HSV. Increased mortality is seen if not promptly treated. Reference #1: 1. Meyer A, Buetti N, Houhou-Fidouh N, et al. HSV-1 reactivation is associated with an increased risk of mortality and pneumonia in critically ill COVID-19 patients. Critical Care. 2021/12/06 2021;25(1):417. doi:10.1186/s13054-021-03843-8 Reference #2: Le Balc'h P, Pinceaux K, Pronier C, Seguin P, Tadié J-M, Reizine F. Herpes simplex virus and cytomegalovirus reactivations among severe COVID-19 patients. Critical Care. 2020/08/28 2020;24(1):530. doi:10.1186/s13054-020-03252-3 Reference #3: Shah JN, Chemaly RF. Herpes Simplex Virus Pneumonia in Patients with Hematologic Malignancies. Pulmonary Involvement in Patients with Hematological Malignancies. 2010:301-311. doi:10.1007/978-3-642-15742-4_24 DISCLOSURES: No relevant relationships by Andrew Cox No relevant relationships by Syeda Hassan No relevant relationships by Maria Khan No relevant relationships by Malik Muhammad Uzair Khan No relevant relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Ifrah Naeem No relevant relationships by Laura Walters

PULMONARY ASPERGILLOSIS POST-TOCILIZUMAB TREATMENT IN A PATIENT WITH COVID-19 PNEUMONIA

SESSION TITLE: Global Pulmonary Cases SESSION TYPE: Global Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: COVID 19 is associated with hyper- inflammation with levels of IL 6 correlating with the severity of COVID 19. IL6 causes increased vascular permeability and endothelial dysfunction and plays a major role in the development of ARDS.[1] Tocilizumab is a monoclonal antibody against the IL6 receptor which is being used for COVID pneumonia. Large randomized controlled trials including REMAP-CAP and RECOVERY reported a mortality benefit of tocilizumab in certain patients [3]. Aspergillus is a mold that causes variety of pulmonary infections depending on host's immune status. In immunocompromised hosts, it causes invasive pulmonary aspergillosis [2]. Symptoms initially are similar to bronchopneumonia: cough with sputum, dyspnea, fever not responsive to antibiotics. With disease progression, patients experience pleuritic chest pain and hemoptysis. CASE PRESENTATION: 69 y/o female came to ER with complaint of dyspnea and cough. PMH significant for Diabetes. She had a recent admission for COVID 3 weeks ago during which she received tocilizumab. This time, her vitals were HR- 96 RR- 24 Temp- 99.6 BP- 124/72, Sat- 88% on 2L NC. Labs WBC 31.1 D dimer- 2.17 ABG PO2- 61. CT pulmonary angiogram was consistent with left mid lung zone cavitary mass with an air-fluid level measuring 5 x 8 cm in transverse and AP dimension. Patient was started on broad-spectrum antibiotics (vancomycin, cefepime, metronidazole). Sputum cultures, Beta glucan assay, AFB and fungal immunodiffusion panel was ordered. Beta D Glucan assay came positive. Fungal immunodiffusion panel was negative. Bronchoscopy was done and AFB, aspergillus antigen and cultures were collected. BAL aspergillus antigen came positive and KOH fungal culture grew Aspergillus Fumigatus. Voriconazole was started. She was discharged on voriconazole for 12 weeks, ceftriaxone and clindamycin for 6 weeks for antibacterial coverage with plan to repeat CT chest in 3 weeks. DISCUSSION: We use tocilizumab for COVID 19 patients requiring invasive or non invasive mechanical ventilation and CRP ≥7.5 and exclude patients with ANC <2000, platelet <50,000 and history of serious bacterial, fungal or viral infection. This patient did not have any exclusion criteria but developed invasive fungal infection 3-4 weeks later. Due to worsening hypoxia and high D dimer, initial consideration was pulmonary embolism for which CT angiogram was done and a cavitary lesion was found. Differentials were bacterial abscess, tuberculosis or fungal infection. BAL played a crucial role in diagnosing aspergillosis. CONCLUSIONS: In patients presenting with worsening respiratory symptoms post tocilizumab administration we must keep a low index of suspicion for superimposed opportunistic infections including aspergillosis. Appropriate workup including CT chest, sputum or bronchoalveolar lavage for cultures (bacterial, fungal), Beta D Glucan and fungal panel is essential for diagnosis. Reference #1: Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia Ivan O Rosas;Norbert Bräu;Michael Waters;et al. New England Journal of Medicine, v384 n16 (20210422): 1503-1516 Reference #2: Pulmonary aspergillosis: a clinical review M. Kousha, R. Tadi, A.O. Soubani European Respiratory Review 2011 20: 156-174;DOI: 10.1183/09059180.00001011 Reference #3: Interleukin-6 Inhibitors. Available at: https://www.covid19treatmentguidelines.nih.gov. DISCLOSURES: No relevant relationships by Shaylika Chauhan No relevant relationships by Vipul Gidwani

Outbreak of respiratory syncytial virus subtype ON1 among children during COVID-19 pandemic in Southern Taiwan.

BACKGROUND: The regional respiratory syncytial virus (RSV) outbreak in southern Taiwan in late 2020 followed the surge of RSV cases in the national surveillance data and displayed distinct clinical features. This study investigated RSV epidemiology in the most recent five years and compared the clinical manifestations of this outbreak with non-outbreak period. METHODS: Medical records of RSV-infected children at the National Cheng Kung University Hospital from January 2016 to December 2020 were retrospectively retrieved from hospital-based electronic medical database. Cases of RSV infection were identified by RSV antigen positive and/or RSV isolated from respiratory specimens. The demographic, clinical presentations, and laboratory data were recorded. The RSV isolates in 2020 was sequenced for phylogenetic analysis. RESULTS: Overall, 442 RSV-infected cases were retrieved and 42.1% (186 cases) clustered in late 2020. The 2020 outbreak started in September, peaked in November, and lasted for 3 months. 2020 RSV-infected children were older (2.3 ± 2.2 years vs. 1.0 ± 1.0 years), more likely to be diagnosed with bronchopneumonia (57.5% vs. 31.6%), but also had a lower hospitalization rate, shorter hospital stay, less oxygen use, and less respiratory distress than those in 2016-2019 (all p value < 0.05). The RSV isolates in 2020 belonged to RSV-A subtype ON1 but were phylogenetically distinct from the ON1 strains prevalent in Taiwan previously. CONCLUSION: The 2020 RSV outbreak was led by the novel RSV-A subtype ON1 variant with clinical manifestations distinct from previous years. Continuous surveillance of new emerging variants of respiratory viruses in the post-pandemic era is warranted.

CHANGES IN THE CONTENT AND FEATURES OF LOCALIZATION OF ANGIOTENSIN-CONVERTING ENZYME-2 (ACE2) IN ACUTE EXPERIMENTAL BRONCHOPNEUMONIA

Coronavirus (SARS-CoV-2) enters the cell by binding to a transmembrane glycoprotein, angiotensin-converting en-zyme-2 (ACE2), which is expressed on the surface of the bronchial and alveolar epithelium. In this regard, the aim of this study was to determine changes in the content and characteristics of tissue localization of ACE2 in the model of acute bronchopulmonary inflammation. The latter was modeled by endotracheal injection of a foreign body (Capron thread) and a solution of lipopolysaccharide (LPS;50 μl at a dose of 12.5 mg/kg) against the background of systemic administration of LPS for two days before surgery (250 mg/ kg). ACE2 localization and quantity were evaluated by im-munohistochemical and western blot assays with the use of a specific monoclonal antibody. The experiment reproduced acute exudative-hemorrhagic bronchopneumonia with the development of diffuse progressive pulmonary fibrosis with lethality in 36% of animals. Acute exudative inflammation was accompanied by complete inhibition of ACE2 expression in bronchial epitheliocytes and its significant decrease in alveolocytes type II. With the development of the proliferative stage of bronchopneumonia, the level of ACE2 was restored, subsequently remaining without significant changes. The obtained experimental data suggest the existence of a relationship between the features of quantitative changes in the ACE2 level in the bronchopulmonary epithelium and the undulating course of the inflammatory process during SARS-CoV-2 infection. © 2022, Bogomoletz Institute of Physiology, National Academy of Sciences of Ukraine. All rights reserved.

Neonatal RSV positive bronchiolitis with fulminant viral septic shock

AimsMain purpose of presenting this clinical case is that RSV BRONCHIOLITIS can present with lobar pneumonia,Fulminant viral septic shock with DIC,pulmonory haemorrhage and asystole. Viral VS Bacterial sepsis- clinically difficult to differentiate.Methods1 month old girl,unwell for 2 days with cough,decrease oral intake, seen by GP in the morning and diagnosed as BRONCHIOLITIS,same day evening presented to the hospital with apnoea in the car arrived at PAU within 3 mins of apnoea.O/E-no HR or breathing,bleeding from nose and mouth,pale looking,mottled, CRT 5 sec.CPR started and connected to monitor showed asystole.Immediate cardiac arrest call was activated.Intubated, cannula inserted, 2 doses of adrenaline given IV,Bolus of normal saline 10mls/kg thrice,partial septic screening done and covered with triple antibiotics amoxycillin,gentamycin and cefotaxime.After 10 mins of resuscitation baby responded. Given vitamin K and transfused with O negative blood and FFP.Blood gas showed mixed metabolic and respiratory acidosis and hence connected to ventilator started on morphine,maintenance fluids,ionotropes,morphine infusion and transferred to tertiary centre. In tertiary centre admitted for 11 days,extubated to CPAP on day 5, weaned to high flow on day 6, RA on day 9. Ionotropes for 1 day,acylovir, vitamin k for 9 and 6 days respectively.Neuroprotective measures followed.ResultsNPA for RSV positive, covid 19 PCR negative, blood c/s,CSF c/s and CSF PCR for bacteria and viruses negative, X ray chest consolidation upper lobes bilateral,CT Angiogram subsegmental consolidation and possible intraparenchymal haemorrhage. Initial Echo pulmonory hypertension and repeat Echo normal.MRI Brain -hypersensitivity in posterior putamina. Deranged coagulation profile.APTT more than 180, PT 16.2, INR 1.4ConclusionRSV positive bronchiolitis with all complications can mimic bacterial sepsis and its clinically difficult to differentiate between viral and bacterial septic shock.As this baby’s blood C/S was negative only positive thing was RSV in NPA, We have to consider this case as RSV BRONCHIOLITIS with fulminant septic shock with pneumonia, DIC, Pulmonory Haemorrhage leading to Asystole.Management of bacterial and viral Septic shock is pretty much the same except in certain cases we may have to use antivirals drugs when indicated.