Follow-up 24-Urine Studies during and Post-Covid-19 Pandemic

INTRODUCTION AND OBJECTIVE: In New York State, March 16, 2020 marked the end of any in-restaurant dining due to the COVID- 19 pandemic. The general population was forced to do more cooking at home and less dining out. Dietary modifications like this are considered first line therapy for calcium stone formers due to an effort to reduce dietary sodium intake which is known to affect lithogenic risk factors including hypernatriuria and hypercalciuria. This study aims to see if dietary changes made during the pandemic changed the risk of stone disease as evidenced in 24-hour urine studies and if these changes ceased after the end of widespread shutdowns. METHOD(S): All patients with nephrolithiasis seen for an outpatient visit from April 1, 2020-December 31, 2020 were queried and included if they had a 24-hour urine study pre-COVID (before March 16, 2020) and during-COVID (March 16, 2020-December 31, 2020);a post- COVID study was included if available (January 1, 2021- October 31, 2022). Values were compared using paired, 2-tailed t-tests. RESULT(S): 93 patients (54 males, 39 females, mean age 60.1) were studied pre-COVID, during-COVID, and post-COVID time periods with 24-hour urine studies. Stone analysis revealed calcium oxalate (61%), calcium phosphate (15%), uric acid (15%), other (9%). The 24-hour urine revealed a significant reduction in urinary sodium (uNa) and urinary calcium (uCa) in these patients. uNa levels decreased from 166.15+/-7.5 mEq/L pre-COVID to 149.09+/-7.6 mEq/L during- COVID (p=0.015) and maintained improved at 138.55+/-6.83 mEq/L post-COVID era (p=0.0035). uCa levels decreased from 214.18+/-13.05 mEq/L pre-COVID to 191.48+/-13.03 mEq/L during- COVID levels (p=0.010) and remained improved at 185.33+/-12.61 mEq/L post-COVID (p=0.012). There were no significant differences in 24-hour urine total volume, magnesium, or citrate levels. CONCLUSION(S): During the COVID-19 lockdown, dietary choices limited to home cooked meals allowed patients to better identify their food choices. This study demonstrates that known urinary risk factors for lithogenesis, such as urinary sodium and calcium, improved during the lockdown and these improvements were maintained even after restrictions in restaurants were lifted. Moving forward, it will be imperative to monitor patient's 24-hour urine to ensure these dietary modifications are continued in the postpandemic era and to see if these improved urinary parameters will impact stone formation in these patients.

CALCIUM OXALATE DEPOSITION IN PULMONARY ASPERGILLOSIS

SESSION TITLE: Infectious Complications with Obstructions and Connections SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: Invasive pulmonary fungal infections are a challenge for diagnosis. One of the most common types is Invasive pulmonary aspergillosis. It occurs usually among immunocompromised patients [1], so an early diagnosis is warranted for potential better outcome. Evidence of calcium oxalate can be an early diagnostic tool for such an infection. The presence of calcium oxalate crystals can be detected within 24 hours under polarized light in the microbiology labs. We present this case to highlight the potential importance of pulmonary oxalosis in diagnosing pulmonary aspergillosis. CASE PRESENTATION: A 62-year-old-woman with limited breast cancer was admitted to the hospital seven days after her last cycle of docetaxel and cyclophosphamide with COVID-19 pneumonia and hypoxemic respiratory failure. She was not neutropenic. She received a full course of dexamethasone and remdesivir. Sputum cultures subsequently grew Klebsiella aerogenes for which she was treated with antibiotics but failed to significantly improve over four weeks. Repeat chest computed tomography (CT) showed progressive multifocal airspace opacities with new areas of cavitation. Patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy. Transbronchial biopsy specimen from the right upper lobe showed bronchial mucosa and lung parenchyma with calcium oxalate crystals and no organisms. Biopsy specimen from the right middle lobe showed fungal organisms consistent with Aspergillus invading bronchial mucosa and lung parenchyma. Several days later, serum beta-D-glucan returned within normal limits, serum galactomannan was significantly elevated, and BAL culture grew Aspergillus niger. Patient improved with antifungal therapy. DISCUSSION: Fungal pneumonia has high morbidity and mortality. It is essential to start antifungal therapy as soon as possible. Pulmonary oxalosis or calcium oxalate has been seen among Aspergillus Fumigatus and Aspergillus Niger [2-3]. It is a combination of oxalic acid which is produced by Aspergillus spp. and calcium from blood supply of an invaded tissue. Further progression of lesions can be due to calcium oxalate toxicity itself [4-5]. In our case, clinical suspicion for pulmonary aspergillosis was high and we were able to document fungal invasion of lung parenchyma on one of the lung specimens. Though fungal culture is very sensitive and specific, it can take several days to result. Tissue staining for crystals can be performed quickly and provide more timely information when deciding about starting anti-fungal therapy. CONCLUSIONS: Pulmonary oxalosis, calcium oxalate deposition, can be seen in aspergillus infection and should be considered as an early diagnostic tool for invasive pulmonary aspergillosis. Reference #1: Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011;20(121): 156–174, doi: 10.1183/09059180.00001011 Reference #2: U. Pabuccuoglu, Aspects of oxalosis associated with aspergillosis in pathology specimens, Pathol. Res. Pract. 201 (2005) 363–368 Reference #3: Osholowu OS, Kak V, Singh H. Pulmonary oxalosis in pulmonary aspergillosis syndrome. Adv Respir Med. 2020;88(2):153-156. doi: 10.5603/ARM.2020.0090. PMID: 32383468. DISCLOSURES: No relevant relationships by Mohammed Alsaggaf No relevant relationships by Daniel Baram No relevant relationships by Ivana Milojevic

Histopathological Features of Fungal Infections in Sinonasal, Oral and Orbital Sites Associated with COVID-19 Patients

Background: The COVID- 19 infections are associated with wide range of bacterial and fungal co-infections. They may be associated with various comorbidities. Definite diagnosis requires demonstration of fungi in tissue sections or in culture. Yield of organism in culture is suboptimal. Hence histopathology plays critical role in establishing the diagnosis and provide evidence of tissue invasion. Objective(s): To study the histopathological features of fungal infections in sino nasal, oral and orbital area associated with COVID-19 patients. Material(s) and Method(s): One hundred twenty cases of fungal infections involving sinonasal, oral and orbital area in laboratory confirmed COVID-19 positive patients between June-September 2021 were taken for study. Clinical data was recorded, histopathological examination was done along with periodic acid Schiff stain and culture report was obtained. Result(s): The study included 92(76.6%) males and 28(23.3%) females with age ranging from 13 to 78 years. The tissues included debridement, biopsy and excision specimen. Acute inflammation was seen in 8(6.66%) cases, chronic inflammation in 112(93.33%), granulomas in 25, thrombosis in 14, necrosis in 104, angioinvasion in 13, perineuritis in 10 and bone invasion in 18 cases. Mixed fungal infection was seen in 11cases. Conclusion(s): Histopathology remains the mainstay in diagnosis of invasive fungal infections especially when culture is negative. Copyright © 2022 Ubiquity Press. All rights reserved.

Prompt Diagnosis and Intervention of Oxalate Nephropathy to Salvage Kidney Function

Hyperoxaluria can be primary due to defective glyoxylate metabolism leading to hepatic oxalate overproduction or secondary due to increased intestinal oxalate absorption. Oxalate nephropathy is the deposition of calcium oxalate crystals leading to tubular injury, interstitial fibrosis, and AKI or CKD. This describes three cases of renal oxalosis. First is a 60 year old male with stroke, hypertension, diabetes who presented with AKI of 4.5 mg/dL from 1.6 that rose to 11 mg/dL. Serologies for glomerulonephritis and paraproteinemia were negative. Biopsy showed tubular oxalate crystal deposition with tubular injury and interstitial nephritis. His renal failure required dialysis. Second is a 58 year old female with gastric bypass surgery who presented for edema and AKI from 1.3 to 3.6 mg/dL. Serologies were also negative. Biopsy showed interstitial nephritis with tubular calcium oxalate deposition. She was started on prednisone 60 mg. Creatinine stabilized to 2.2 mg/dL, not requiring dialysis. Third is a 82 year old male with obesity and sarcoma of the scalp treated with pembrolizumab who presented with dyspnea, edema and an AKI from 1 to 8.6 mg/dL. Urine sediment was bland with negative serologies. Differential included AIN due to pembrolizumab. Patient was started on high dose prednisone and biopsy showed interstitial nephritis and calcium oxalate crystal deposition. Patient endorsed taking frequent vitamin C as prophylaxis for Covid. Creatinine stabilized to 2.9 mg/dL not on dialysis. Classic etiologies of hyperoxaluria include dietary oxalate from ascorbic acid and fat malabsorption from gastric bypass surgery. Treatment includes increased fluid intake, oral calcium supplements and low oxalate diet. Oxalate nephropathy remains an under recognized cause of kidney failure, as such, early biopsy and intervention are necessary. (Figure Presented)

VITAMIN C NEPHROTOXICITY IN A COVID-19 PATIENT: A CASE REPORT

BACKGROUND AND AIMS: During the time of the COVID-19 pandemic, multiple treatment options have been investigated, even though their efficacy and secondary effects remain insufficiently known. We report the case of a vitamin C induced oxalate nephropathy in a COVID-19 patient with preexisting chronic kidney disease (CKD) resulting in irreversible acute renal failure. Vitamin C, also known as ascorbic acid, has been used as an anti-inflammatory therapy for COVID-19, but review of the literature shows similar cases of acute kidney injury (AKI), raising concern. METHOD: We report the case of a 73-year-old Caucasian woman admitted for hyperthermia and digestive disorders. She had recently started a first-line chemotherapy for multiple myeloma with partial response. She also displayed preexisting stage 4 CKD (eGFR 18.50 mL/min/1.73 m2 using CKD-EPI) of unknown aetiology. She was tested positive for SARS-CoV2 by nasopharyngeal swab and soon transferred to the intensive care unit. She received intravenous corticosteroids using dexamethasone 6 g/24 h for 10 days and a piperacillin + tazobactam probabilistic antibiotherapy. She also received high doses (15 g/24 h) of vitamin C for three consecutive days. No monoclonal antibodies were prescribed due to a previous vaccination with a positive serology upon admission. Although the patient recovered from respiratory tract infection, her kidney function progressively deteriorated with serum creatinine levels rising up to 8.06 g/dL, leading to her admission in our nephrology department. The patient was initially treated with high doses of diuretics for anasarca and an abdominal CT excluded urinary tract obstruction with normal kidney size and aspect. Urinary analysis showed protein to creatinine (p/c) ratio of 1348 g/g, and presence of urinary light chains. Her monoclonal spike was measured at 2.3 g/L and her kappa/lambda fraction was 1.74. Intermittent haemodialysis was initiated, and a kidney biopsy was performed. RESULTS: Histology revealed hundreds of intratubular calcium oxalate crystals, with severe and diffuse acute tubular necrosis and interstitial edema. There was no amyloidosis, no sign of active glomerular disease and no interstitial fibrosis. Immunofluorescence (IgA, IgG, IgM, C1Q, C3, kappa and lambda) was negative. We concluded to oxalate nephropathy. After a 2-month follow-up, the patient remains dialysis dependent. Vitamin C is a precursor of oxalate and has been shown to cause secondary oxaluria, particularly with high-dose regimens in patients with altered renal function. Given the histological findings evocative of acute oxalate nephropathy, the accountability of high doses of vitamin C should be considered. No other cause of hyperoxaluria was identified in our patient beside broad spectrum antibiotic use, which could decrease intestinal bacterial oxalate degradation. In particular, there was no malabsorption The limitation of our report is the unknown cause of preexisting CKD;therefore, we cannot rule out preexisting hyperoxaluria. Also, no dosage of serum vitamin C and oxalate levels were performed during follow-up. Finally, our patient had other possible causes AKI, such as recent SARS-CoV2 infection, or linked to multiple myeloma, but these were considered unlikely given the proper haematological response to treatment and non-evocative biopsy. The rationale for vitamin C use in COVID-19 is based on in vitro studies showing its antioxidant, anti-inflammatory, anticoagulant and immune modulatory properties. There lack large clinical studies, and the literature shows conflicting results. Multiple cases of acute oxalate nephropathy were described. CONCLUSION: Vitamin C is an anti-inflammatory treatment used in COVID-19 that can lead to secondary hyperoxaluria with significant and irreversible AKI. Due to the severity of AKI in patients with preexisting CKD, we believe renal function should be considered before using high doses of vitamin C. Larger controlled trials are needed both to establish the clinical benefit of vitamin C and further describe its potential ephrotoxicity.

Why Omicron Variant of SARS-CoV-2 is Less Fatal?

The article published by Nie et al. addressed one of the two key questions regarding the Omicron variant of SARS-CoV-2, while the underpinning for the less deadly nature of the variant remains unexplained. The proteins of the Omicron variant have numerous mutations, notably several substitutions of other amino acids by lysine residues. Glycine and valine attract calcium and enhance the formation of stressful, insoluble, and stiff calcium oxalate. Lysine residues in proteins build up chloride via ionic bonds which solubilizes insoluble and rigid divalent salts. The aforementioned mutations have weakened the lethalness of the Omicron variant perhaps via a biochemical mechanism. Despite net gain in favorable mutations versus deleterious mutations, the overall valine plus glycine content is still high in the proteins of Omicron variant of SARS-CoV-2, which remains a public health concern.

Comparative pharmacognostic and chromatographic assessment of COVID-ORGANICS (CVO) herbal product and Artemisia annua L

Many claims from herbal medicines have been developed to manage COVID-19. Tests for identity and purity are important parameters in the quality assurance of herbal medicines. The aim of this study is to confirm the presence of Artemisia annua as a component of COVID-ORGANICS, an acclaimed herbal product for the management of COVID-19 in comparism with A. annua cultivated at NIPRD, Abuja, Nigeria. Pharmacognostic and physicochemical investigations, thin layer and high-performance Liquid chromatography of Covid-Organics along with A. annua were carried out using standard procedures. Similar microscopic features viz T-shaped, glandular, unicellular and uniseriate trichomes, wavy epidermal cells with anomocytic stomata and prismatic calcium oxalate crystals characteristic of A. annua were observed. Moisture, total ash and sulphated ash contents ranged from 8.5 ± 0.0 to 10.4 ± 0.2%w/w;7.8 ± 0.5 to 12.1 ± 0.1%w/w and 9.7 ± 0.3 to 15.9 ± 0.4%w/w, respectively while water and alcohol soluble extractive values ranged from 20.6 ± 0.5 to 33.7 ± 0.7%w/w;and 23.4 ± 0.6 to 38.2 ± 0.6%w/w respectively. TLC and HPLC profiles showed artemisinin in evaluated samples. The findings confirm that Covid-Organics contain A. annua. The domestication of A. annua in Nigeria along with studies carried out has shown the capacity and technical know-how to develop a phytomedicine from A. annua for management of COVID-19 associated symptoms. This is possible with the provision of the enabling environment in order to provide medicines’ security. Relevant policies are therefore needed to prioritise the development of the sector.