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Introduction: Prior to colonoscopy, it is well understood that patients must undergo bowel cleansing. Based on the type of laxative, colonoscopy preparations fall into two categories - polymer-based formulas (PEG) and saline-based formulas (NaP). Both types of bowel preparations are deemed to be relatively safe and part of routine practice. However, we describe the rare case of an ulcerative colitis (UC) flare due to the bowel preparation formula. Case Description/Methods: A 29-year-old female with diagnosis of UC, presently in clinical and biochemical remission on oral mesalamine, contracted COVID-19 and had reactivation of UC symptoms. After being on budesonide tablets and rectal foam for two months, patient achieved clinical remission, and a surveillance colonoscopy was performed which revealed normal colon and terminal ileum except mild congestion in the cecum (Figure A). Pathology revealed unremarkable mucosa in the entire colon except for chronic active colitis in the cecum. Immediately following this colonoscopy, the patient started to experience another severe UC flare requiring hospitalization. The patient's laboratory work-up was normal except for an elevated fecal calprotectin (1710). Stool infectious work-up was negative and the patient denied any NSAID or antibiotic use. The patient underwent a repeat colonoscopy which revealed severe Mayo 3 pancolitis (Figure B) in comparison to a stable colonoscopy a few weeks prior. It was revealed that for her initial colonoscopy, she had used SUPREP bowel prep kit. On prior colonoscopies she had used MiraLAX bowel prep with no adverse effects. During hospitalization, the patient was started on biologic therapy with good effect. Discussion(s): There are no clear guidelines on appropriate bowel preparation formula for the inflammatory bowel disease (IBD) population. Sufficient literature exists to confirm that NaP can irritate the intestinal mucosal wall. Moreover, numerous animal experiments have employed dextran sodium sulfate for chemical induction of intestinal inflammation to mimic UC flares in humans [1]. Thus, it can be surmised that because SUPREP ingredients contain sodium sulfate, the potential for UC flare is higher. It is pertinent for practitioners to be aware of the possible rare adverse effects of saline-based formulas, especially when treating the IBD population.
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Introduction/Aim: Western Australia had its first wave of COVID-19 cases in March 2022. This retrospective study assessed the adherence to guidelines for prescribing COVID-19 disease modifying therapies (DMT), based on the National COVID-19 Clinical Evidence Taskforce Australian guidelines for the clinical care of people with COVID-19. Method(s): The first 100 cases admitted to the respiratory ward at Fiona Stanley Hospital (FSH) with confirmed COVID-19 were reviewed. Data was collected from the hospital Digital Medical Record to determine clinical severity on presentation and the need for DMT. Prescribing of DMT was assessed for adherence against the National guidelines and/or whether it was recommended by the infectious diseases (ID) team. Disease progression, length of stay, mortality and readmission rates were assessed within 28 days of admission. Result(s): During the audit period (11.03.2022 - 19.04.2022), the National guidelines underwent six updates. In the first 100 cases of COVID-19, the median (IQR) age was 65.11 years, the median (IQR) length of stay was 4 days and the mortality rate was 1%. There was a 7% readmission rate with 6% of patients treated with DMT having disease progression. 16% of patients were immunocompromised and 58% were partially vaccinated or unvaccinated. 63% of unvaccinated patients had severe disease. 84% of patients were recommended a DMT, of which, 63% received the correct combination of DMT. 14% of cases were recommended and not prescribed a DMT, though 71% of these cases were recommended budesonide alone. 12% were not recommended and not prescribed a DMT and 4% were not recommended, yet prescribed a DMT. Conclusion(s): Overall adherence with the National guidelines/ID advice for DMT was >80% excluding inhaled budesonide. The continually evolving nature of the National guidelines added complexity to prescribing. A dedicated medical proforma would aid with risk stratification and DMT prescribing for patients with COVID-19.
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Background: Currently, the present world is facing a new deadly challenge from a pandemic disease called COVID-19, which is caused by a coronavirus named SARS-CoV-2. To date, no drug or vaccine can treat COVID-19 completely, but some drugs have been used primarily, and they are in different stages of clinical trials. This review article discussed and compared those drugs which are running ahead in COVID-19 treatments. Method(s): We have explored PUBMED, SCOPUS, WEB OF SCIENCE, as well as press releases of WHO, NIH and FDA for articles related to COVID-19 and reviewed them. Result(s): Drugs like favipiravir, remdesivir, lopinavir/ritonavir, hydroxychloroquine, azithromycin, ivermectin, corticosteroids and interferons have been found effective to some extent, and partially approved by FDA and WHO to treat COVID-19 at different levels. However, some of these drugs have been disapproved later, although clinical trials are going on. In parallel, plasma therapy has been found fruitful to some extent too, and a number of vaccine trials are going on. Conclusion(s): This review article discussed the epidemiologic and mechanistic characteristics of SARS-CoV-2, and how drugs could act on this virus with the comparative discussion on progress and drawbacks of major drugs used till date, which might be beneficial for choosing therapies against COVID-19 in different countries.Copyright © 2022 Bentham Science Publishers.
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COVID- 19 was the most challenging public health problem worldwide for better part of 2 years (2019 - 2021). Although several of the medication have not demonstrated promising benefits in the majority of research, they are nonetheless utilized. The purpose of this study was to compare and contrast the hospital pharmaceutical care of COVID-19 patients by sex, age group, and with regards to oxygen consumption classifying and grouping them with comorbidities seen and auxiliary medication given . Hospital based retrospective observational study was conducted among 123 patients with antigen positive Reverse Transcriptase Polymerase Chain Reaction confirmed COVID- 19 infection admitted in the ICU for 24 hours prior. As the age increased the chance for ICU admission also increased. The most affected age group was above 50 years of age. The total number of patients requiring oxygen was 100% in COVID- 19 ICU patients. Some of the most common comorbidities were heart disease (18%) followed by Diabetes Mellitus (15%) and Hypertension (15 %). Only 48 % of patients received antivirals. Remdesivir which was the mainstay antiviral was given (41%). Amoxicillin and clavulanate combination (Augmentin 625 mg) was the most commonly prescribed antibiotic (27%).The antipyretic of choice was paracetamol which was given to 100% of patients. Almost all patients (78%) were given enoxaparin sodium as the anticoagulant of choice. Regardless of equivocal results, multivitamins and supplements were recommended to all patients. All prescription guidelines as given by ICMR for COVID- 19 ICU patients were followed with the exception of the extensive antimicrobial use.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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Due to the non-pharmacological interventions to control the COVID-19 pandemic increased and more severe respiratory syncytial virus (RSV) infections occurred worldwide due to the inadequate training of the immune system in small children. As viral infections are associated with the exacerbation of childhood wheezing and asthma, safe and efficient inhalation therapy in asthmatic children is essential. PARI has developed an advanced high-repeatability test set-up for pMDI with valved holding chamber (VHC) and masks to investigate therapy efficiency. The study presents the aerosol performance of budesonide (BUD) and salbutamol (SAL) pMDIs with PARI's VORTEX and masks according to USP <1602>. A standardized setup and methodology mimicking clinically relevant conditions with minimized operator variability as used in this study is key for realistic VHC testing. Tests were performed using VORTEXwith Babymask Ladybug (0-2 yrs.) or Childmask Frog (2-4 yrs.) and ageappropriate baby and child face models. Both models mimic facial geometry and tissue softness and were connected to a next generation impactor. VORTEXand pMDIs (Sutanol, GSK;Budiair, Chiesi) were mounted in an automated shake-and-fire setup and applied with a contact force of 16 N. Tests were carried out with validated HPLC analysis (n=12). Fine particle dose (FPD, <5mum) was more than doubled for VORTEXwith Babymask Ladybug (FPD=22.4%) and Childmask Frog (FPD=23.8%) compared to pMDI alone (FPD=10.9%) for BUD and increased by =30% for SAL. Throat deposition of both active substances nebulized using VORTEX+ mask was reduced to <0.3% compared to >60% for pMDIs alone. Mask size does not influence the performance of the aerosol significantly.
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Background: Severe covid-19 disease has led to many death. Some post mortem study has investigated the cause. The autopsy revealed occurrence of DVT and postmortem lung CT showed reticular infiltration, dense consolidation, while histologically showed diffuse alveolar damage. Through FOB conducted In mechanically ventilated COVID-19 patient, airway obstruction was seen due to hypersecretion and mucus plug in the bronchi. Inhaled budesonide in COVID-19 patient has showed faster recovery and the research focus in the administration of ICS is limited. Objective(s): This study aims to investigate the benefit of LABACS treatment in LONG COVID-19 patients in Pringsewu Indonesia. Method(s): The method of this research was cross sectional. Total subjects included in this study were 276 patients. 168 subjects were treated with Beclomethasone-Formoterol (61%), 49 subjects were treated with FluticasoneSalmeterol (17%), 59 subjects were treated with Budesonide-Formoterol (22%) during 3 months period. We assessed symptoms improvement, mMRC score and chest X-ray imaging. Spirometry of 34 subjects were measured. Result(s): There was a significant correlation between the incidence of lung obstruction and persistent symptom of long covid patients according to spirometry measurement (P value = 0.000). There was a significant correlation between symptoms improvement, mMRC score and chest X-ray imaging after treatment with Beclomethasoneformoterol (p-value = <0.05) Fluticasone-Salmeterol (P value = <0.05) Budesonide-Formoterol (P value = 0.002, P value = 0.007, P value = 0.049). Conclusion(s): LABACS treatment improved lung function and clinically benefit in managing obstruction due to COVID-19.
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Simple, direct, rapid, and sensitive HPLC and spectrophotometric methods were established for simultaneous estimation of a novel combination of budesonide and azelastine (BUD/AZL) in their laboratory-prepared mixture and dosage form according to the medicinally recommended ratio 1:4.28. Budesonide is an important inhalation corticosteroid that plays a vital role in the inhibition of COVID-19 replication and cytokine production. The first chromatographic method was created for the simultaneous estimation of BUD epimers in the presence of AZL with excellent efficiency in a relatively short chromatographic run (< 9 min). The separation of BUD epimers with AZL was carried out on a C18 column using acetonitrile: phosphate buffer of pH 3.5 adjusted by 0.2 M orthophosphoric acid (40:60, v/v) as a mobile phase, UV detection at 230 nm and a flow rate of regulated at 2 mL/min. Besides, three spectrophotometric methods were applied for the simultaneous determination of the provided mixture adopting zero order, first order derivative, and ratio first derivative approaches. The Zero-order spectrophotometry was used for the determination of AZL in presence of BUD, where BUD shows no absorbance at 290 nm. The first derivative amplitude at 265 nm (1D265) (zero-crossing of AZL) and the ratio of first derivative amplitudes at 270 nm (1DD270) using 10.0 µg mL-1 AZL as divisor was chosen for the simultaneous determination of BUD in the presence of AZL in the binary mixture. The proposed methods were found to be rectilinear in the concentration range of (0.4-40.0 µg mL-1) and (0.05-40.0 µg mL-1) for BUD and AZL, respectively in the HPLC method. Whereas the concentration range for AZL in the zero-order method was (1.0-35.0 µg mL-1) and for BUD in the first derivative and ratio derivative method was (6.0-20.0 µg mL-1). Validation of the suggested approaches according to the ICH criteria was performed. Furthermore, to ensure the proposed approaches' greenness, The AGREE and GAPI metrics were utilized, and the afforded results revealed an excellent greenness of the proposed approaches.
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Background: Cough is a wearisome and exasperating symptom affecting the daily life of the infected patient. Cough due to coronavirus disease 2019 (COVID-19) causes excessive morbidity in human populations globally. Apart from the morbidity associated with cough, it also enhances the transmission of this viral infection through droplets. Therefore, curbing cough is crucial to limit its spread. Patients often administer over-the-counter products and antitussive agents, which have no proven benefit. The present study was undertaken to find out if cough associated with COVID-19 and other indicative clinical outcomes is alleviated with a budesonide/formoterol fixed-dose combination (FDC) metered-dose inhaler (MDI). Materials and Methods: A prospective observational study was conducted in mild COVID-19 patients who presented with a cough score ≥8 at presentation. Patients who were initiated on ICS-LABA MDI were observed as group A and those who were not initiated on MDI were observed as Group B. Cough symptom score (at baseline and on day 3 and day 7), the incidence of hospital admission and/or death, and need for mechanical ventilation were documented. Prescribing patterns of anti-cough medications were also noted and analysed. Results: Compared to group B, a higher mean cough score reduction was noted for group A patients at day 3 and day 7 when compared to the baseline, and this was significant at P < 0.001. A significant negative correlation was also observed between mean latency of MDI initiation from the symptom onset and mean cough score reduction. Analysis of the proportion of patients prescribed medications to treat cough showed that overall, 10.78% did not require these, with a greater proportion in group A compared to group B. Conclusion: Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) COVID-19 who were treated with ICS-LABA MDI along with usual care benefitted significantly in terms of symptom reduction compared to usual care.
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Budesonide (BUD), a glucocorticoids drug, inhibits all steps in the inflammatory response. It can reduce and treat inflammation and other symptoms associated with acute lung injury such as COVID-19. Loading BUD into bilosomes could boost its therapeutic activity, and lessen its frequent administration and side effects. Different bilosomal formulations were prepared where the independent variables were lipid type (Cholesterol, Phospholipon 80H, L-alpha phosphatidylcholine, and Lipoid S45), bile salt type (Na cholate and Na deoxycholate), and drug concentration (10, 20 mg). The measured responses were: vesicle size, entrapment efficiency, and release efficiency. One optimum formulation (composed of cholesterol, Na cholate, and 10 mg of BUD) was selected and investigated for its anti-inflammatory efficacy in vivo using Wistar albino male rats. Randomly allocated rats were distributed into four groups: The first: normal control group and received intranasal saline, the second one acted as the acute lung injury model received intranasal single dose of 2 mg/kg potassium dichromate (PD). Whereas the third and fourth groups received the market product (Pulmicort® nebulising suspension 0.5 mg/ml) and the optimized formulation (0.5 mg/kg; intranasal) for 7 days after PD instillation, respectively. Results showed that the optimized formulation decreased the pro-inflammatory cytokines TNF-α, and TGF-ß contents as well as reduced PKC content in lung. These findings suggest the potentiality of BUD-loaded bilosomes for the treatment of acute lung injury with the ability of inhibiting the pro-inflammatory cytokines induced COVID-19.
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EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.
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Background: Budesonide multimatrix is prescribed to treat forms of inflammatory bowel disease (IBD) during periods of relapse, and it is licensed to treat mild-to-moderate ulcerative colitis (UC). However, during the COVID-19 pandemic, there was a rise in the use of budesonide multimatrix to treat all forms of IBD after fears that systemic corticosteroid use, such as prednisolone, could increase the risk of COVID-19 severity. Methods: This audit included records of all patients who were prescribed the budesonide multimatrix Cortiment (9 mg once a day) over a year in NHS Lothian. Patients were grouped by disease activity at the point of prescription (Partial Mayo Score (PMS) less than 5 showed milder disease and above 5 showed more severe disease) and disease phenotype. The primary endpoint was response at 8 weeks from start of treatment, grouped into full response, partial response, no response and escalation. Results: The full response rate to budesonide multimatrix was 52% among all patients, but 80% in those with PMS ≤4 and only 15% in those with a PMS ≥5. By phenotype, response rates were 41% in Crohn's disease, 50% in IBD unclassified, 56% in proctitis, 56% in left-sided colitis and 51% in pancolitis. Conclusions: Budesonide multimatrix is effective to treat mild disease but is not effective in patients who are having a moderate-to-severe flare of IBD. This medication was 80% effective if the PMS was below 5, suggesting that it is very effective in mild disease.
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The recent global outbreak of coronavirus disease-19, also known as COVID-19, has infected more than 142 million people worldwide, causing more than 3 million deaths. It has been shown that up to 40% of hospitalized COVID-19 patients may develop ARDS. Although not proven, anti-inflammatory and anti-cytokine treatments are recommended to suppress the cytokine storm that develops in the early stages of the disease.In this case report, a case of pulmonary aspergillus developed as a complication of treatment for ARDS caused by covid 19 in a 50-year-old male patient will be presented in the light of current literature. © 2022 Ondokuz Mayis Universitesi. All rights reserved.
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BACKGROUND: Air pollution may induce or reinforce nasal inflammation regardless of allergy status. There is limited direct clinical evidence informing the treatment of airborne pollution-related rhinitis. OBJECTIVE: To assess the effectiveness of intranasal budesonide in adults with self-reported rhinitis symptoms triggered/worsened by airborne pollution. METHODS: Adults in northern China with self-reported rhinitis symptoms triggered or worsened by airborne pollution were randomized to budesonide 256 µg/day or placebo for 10 days in pollution season (October 2019 to February 2020). The primary endpoint was the mean change from baseline in 24-h reflective total nasal symptom score (rTNSS) averaged over 10 days. The secondary endpoints were subject-assessed Global Impression of Change (SGIC), mean change from baseline in individual nasal symptom severity, and mean change from baseline in individual non-nasal symptoms of cough and postnasal drip severity. One-sided P < 0.0125 was considered statistically significant. RESULTS: After an interruption by COVID-19, an interim analysis showed that the study could be ended for efficacy with n = 206 participants (103/group) since the primary efficacy endpoint demonstrated significant results. The final efficacy results showed that the 10-day-averaged rTNSS change in the budesonide group was greater than with placebo (- 2.20 vs - 1.72, P = 0.0107). Budesonide also significantly improved 10-day-averaged itching/sneezing change (- 0.75 vs - 0.51, P = 0.0009). Results for SGIC and all other individual symptoms did not show significant differences between the two groups. CONCLUSIONS: Intranasal budesonide 256 µg once daily improved the total nasal symptoms and itching/sneezing over 10 days in adults with rhinitis triggered/worsened by airborne pollution.
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The goal of Asthma treatment is to achieve a controlled condition, that is, to minimize the burden of symptoms and the risk of exacerbations. Many factors hinder the achievement of this goal: non-compliance with recommendations for drug therapy, the influence of concomitant diseases, the impact of triggers, low patient adherence to prescribed treatment, violation of inhalation technique. In general, there is no significant difference in the risk of hospitalization or mortality due to COVID-19 in patients with Asthma. At the same time, studies show that non-allergic Asthma, severe Asthma, Asthma in combination with obesity, lack of adequate basic therapy can create the greatest risk of infection and severe clinical outcomes of COVID-19. Asthma can be a predictor of a prolonged intubation period in severe respiratory failure during COVID-19, especially in people younger than 65 years. GINA experts agree that during a pandemic, it is especially important that patients with Asthma continue taking basic therapy, including inhaled corticosteroids (ICS), as prescribed by the recommendations. ICS therapy in combination with long-acting β2-agonists (LABA) is the main pharmacological method of treating moderate and severe Asthma in adolescents and adults. A single inhaler regimen with the use of a combination of ICS/formoterol is associated with a lower risk of severe exacerbations compared with supportive treatment of ICS/LABA in combination with SABA on demand. Studies show that the technique of inhalation maneuver can significantly affect the success of therapy. A wide variety of DPI causes problems with the choice and use by patients. © 2022, Remedium Group Ltd. All rights reserved.
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SESSION TITLE: Challenges in Asthma SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Asthma is a chronic illness affecting 334 million people worldwide[1]. Asthma affects the respiratory gas exchange, which plays a significant role in acid-base balance. Acid-base disorders in asthma involve respiratory alkalosis, respiratory acidosis, and AG acidosis[2]. CASE PRESENTATION: A 37 years old Hispanic male with a PMH of intermittent asthma presents with progressive dyspnea for three days, worse with activity and decreases with rest. He reported no [cough, fever, rhinorrhea, chest pain]. No orthopnea. He is vaccinated for COVID ( 2 Pfizer doses), has no sickness exposure, and works as a driver. The patient is not a smoker. Physical Exam: Blood pressure 124/72 mmHg. Heart Rate 100 PPM. Temperature 97.1 F.Respiratory Rate 21BPM.SPO2 90% General appearance: acute distress with nasal flaring. Heart: Normal S1, S2. RRR. Lung: Poor air entry with diffuse wheeze bilaterally. He was placed on a 6 LPM NC. CBC and differential were unremarkable. He was started on methylprednisone, Ceftriaxone, and azithromycin. The patient was started on inhaled Salbutamol and Budesonide. Chest X-ray was unremarkable, Chemistry was unremarkable except for elevated Lactic acid 4.7, There was no concern for reduced tissue perfusion or hypoxia, with no evidence of an infectious process because both viral and bacterial causes for pneumonia were excluded, and antibiotics were stopped. A serial lactic acid level trend was 4.5/4.3/ 4.1/ 4 on the first day, while on the next day, it was 3.1/ 2.9/ 2.7/ 2.5/ 3.5, we stopped trending his lactic acid level. He improved and was discharged on an oral taper steroid and inhaled steroids with a B2 agonist. DISCUSSION: There are two types of Lactic acidosis in patients with asthma: 1- Type-A results from impaired oxygen delivery to tissues and reduced tissue perfusion in severe acute asthma may be accompanied by reduced cardiac output. 2- Type B where oxygen delivery is normal, but the cellular function is impaired due to increased norepinephrine in plasma, increasing metabolic rate and lactate production, drugs like beta-agonists increase glycogenolysis leading to an increased pyruvate concentration;pyruvate is converted to lactic acid. B2 agonist increases lipolysis and increases Acetyl CoA, this increase in Acetyl CoA inhibits the conversion of pyruvate to Acetyl CoA, increasing pyruvate which will be converted to lactic acid[2], Theophylline is a non-selective 5'-phosphodiesterase inhibitor and potentiates the activity of ß-adrenergic agents by increasing the intracellular concentration of cAMP, Glucocorticoids are also known to increase the ß-receptor's sensitivity to ß-adrenergic agonists. CONCLUSIONS: Providers are increasingly challenged by hyperlactatemia,it is not harmful but elevated Lactic acid levels and clearance rate is used for prognostication,hyperlactatemia might be misleading,and all possible causes of elevated lactic acid levels must be explored. Reference #1: 10.5334/aogh.2412 Reference #2: https://doi.org/10.3390/jcm8040563 Reference #3: Edwin B. Liem, Stephen C. Mnookin, Michael E. Mahla;Albuterol-induced Lactic Acidosis. Anesthesiology 2003;99:505–506 doi: https://doi.org/10.1097/00000542-200308000-00036 DISCLOSURES: No relevant relationships by Vasudev Malik Daliparty No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib No relevant relationships by MATTHEW YOTSUYA
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SESSION TITLE: Occupational and Environmental Lung Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We describe a case of acute progression of chronic hypersensitivity pneumonitis (HP) in an adult, previously misdiagnosed as COPD for 13 years due to severe emphysematous changes seen on imaging. He was also found to have acutely worsened disease as a result of Covid-19. CASE PRESENTATION: A 64-year-old male presented to the pulmonary clinic with dyspnea on minimal exertion. He reported respiratory complaints for 13 years, treated with 2 L/min of oxygen overnight, and budesonide-formoterol and tiotropium inhalers. These complaints were previously associated with brief occupational mold exposure and possible COPD. His respiratory distress worsened one year ago when he was hospitalized for Covid-19. On discharge, his oxygen requirement had increased to 6 L/min. CT chest showed air-trapping in the mid-zones bilaterally, mosaic attenuation, and peri-bronchial thickening. PFTs showed an FEV1 33% and FVC 55% of predicted, consistent with severe obstruction and reduction in lung volume. As the patient was a lifetime non-smoker, alternative diagnoses were pursued. Alpha-1 antitrypsin levels and immunologic testing, including scleroderma and myositis panels, were within normal limits. Positive findings included CCP IgG/IgA antibodies at 96 units and HP panel positive for pigeon serum antibodies. Prompted by this testing, the patient revealed that he had parakeets in his home for the past 15 years. He also reported significant symptom improvement on occasions that he took a course of steroids. Based on these findings, a diagnosis of chronic fibrotic hypersensitivity pneumonitis with bronchiolitis obliterans was considered. The patient's severe airflow obstruction and respiratory failure precluded surgical lung biopsy. Empiric management was initiated with 30 mg of prednisone daily with a slow taper and instruction to eliminate exposure to exotic birds. DISCUSSION: HP is commonly caused by inhalation of and sensitization to an aerosolized environmental antigen;a common subtype is bird fancier's lung due to repetitive exposure of avian antigen. Continuous antigen exposure increases the risk for development of fibrosis, which was also seen in our patient. The most commonly described radiologic findings in HP are ground-glass opacities, ill-defined centrilobular nodules, and focal areas of air trapping resulting in mosaic attenuation and fibrosis. More than 20% lymphocytosis on bronchoalveolar lavage is also a sensitive tool in detecting alveolitis. The relationship between Covid-19 and disease progression in HP is not well studied. CONCLUSIONS: Chronic hypersensitivity pneumonitis from avian antigens, or Bird fancier's lung, can present with severe emphysematous changes on CT imaging, along with obstructive pattern of PFTs. This should be an important differential, especially in patients who are non-smokers. Covid-19 causes disease progression in HP, this relationship needs to be further explored. Reference #1: Funke M., Fellrath J.-M. Hypersensitivity pneumonitis secondary to lovebirds: a new cause of bird fancier's disease. Eur. Respir. J. 2008;32:517–521. DOI: 10.1183/09031936.00108507 Reference #2: Pereira C., Gimenez A., Kuranishi L., Storrer K. Chronic hypersensitivity pneumonitis. J. Asthma Allergy. 2016;9:171–181. DOI: 10.2147/JAA.S81540 Reference #3: C.S. Glazer, C.S. Rose, D.A. Lynch Clinical and radiologic manifestations of hypersensitivity pneumonitis J. Thorac. Imag., 17 (4) (2002), pp. 261-272. DOI: 10.1097/00005382-200210000-00003 Morell F, Roger A, Reyes L, Cruz MJ, Murio C, Muñoz X Bird fancier's lung: a series of 86 patients. Medicine (Baltimore). 2008;87(2):110-130. DOI: 10.1097/MD.0b013e31816d1dda DISCLOSURES: No relevant relationships by Momina Amjad No relevant relationships by Amit Chopra No relevant relationships by Rafeh Safdar