A comparative study of serum Zn, Cu, Mg, Mn, Cr, and Fe levels and their association with the vulnerability of Iraqi COVID-19 patients.

BACKGROUND: For the immune system to protect the body from infectious diseases such as COVID-19, it needs the ideal amount of vital trace elements. Trace element levels, especially, zinc (Zn), copper (Cu), magnesium (Mg), manganese (Mn), chromium (Cr), and iron (Fe) levels, may affect how sensitive an individual is to COVID-19 and other viruses. The current study evaluated the level of those trace elements during stays in the isolation center and investigated their association with vulnerability to COVID-19. METHODS: A total of 120 individuals, 49 males and 71 females aged between 20 and 60 years, were included in this study. Forty individuals infected with COVID-19, 40 individuals who had recovered from it, and 40 healthy individuals, were all evaluated and studied. By using a flame atomic absorption spectrophotometer, levels of Zn, Cu, and Mg were assessed for all samples, whereas levels of Mn, and Cr were determined by a flameless atomic absorption spectrophotometer. RESULTS: The infected individuals had significantly lower levels of Zn, Mg, Mn, Cr, and Fe than recovered individuals and healthy control individuals (P < 0.0001). On the other hand, the total number of infected patients was found to have much higher levels of Cu than those in the recovered group and the control group. For the recovered and healthy control groups, no significant differences were observed in the levels of trace elements (P > 0.05), except for Zn (P < 0.01). Also, the findings indicated no association of trace elements with age and BMI (P > 0.05). CONCLUSION: These results show that an imbalance in the levels of essential trace elements could be associated with increasing the risk of COVID-19 infection. However, additional thorough research of greater scope is required considering the severity of the infection.

Changes of atmospheric metal(loid) deposition from 2017 to 2021 at Mount Emei under China's air pollution control strategy

Acid deposition and particulate matter (PM) pollution have declined considerably in China. Although metal(loid) and acid deposition and PM have many common sources, the changes of metal(loid) deposition in China in the recent decade have not been well explored by using long-term monitoring. Therefore, we analyzed the dry and wet deposition of eleven metal(loid)s (including Al, As, Ba, Cd, Cu, Cr, Fe, Mn, Pb, Sr, and Zn) from 2017 to 2021 at Mount Emei, which is adjacent to the most economic-developed region in western China (Sichuan Basin (SCB)). Anthropogenic emissions contributed to over 80% of the annual wet deposition fluxes of metal(loid)s and acids (SO4 2-, NO3 -, and NH4 +) at Mount Emei, and the major source regions were the SCB, the Yunnan-Guizhou Plateau, and Gansu Province. Metal(loid) and acid deposition had similar seasonal variations with higher wet deposition fluxes in summer but higher wet deposition concentrations and dry fluxes in winter. The seasonal variations were partially associated with higher precipitation but lower pH in summer (968 mm and 5.52, respectively) than in winter (47 mm and 4.73, respectively). From 2017 to 2021, metal(loid) deposition did not decline as substantially as acid deposition (5.6%-30.4%). Both the annual total deposition fluxes and concentrations of Cr, Cu, Sr, Ba, and Pb were even higher in 2020-2021 than in 2017-2018. The inter-annual and seasonal changes implied the responses of metal(loid) deposition to anthropogenic emission changes were buffered (e.g., transformation, dilution, and degradation) by precipitation rates, acidity, natural emissions, and chemical reactions in the atmosphere, among others.Copyright © 2023 Elsevier Ltd

Green synthesis of silicon dioxide nanoparticles and L arginine@silicon dioxide nano- composites using cellulose of Zizyphus Spina-Christi along with biological evaluation

The recent research focused on the green synthesis of silicon dioxide nanoparticles, SiO2@Cellulose of Zizyphus Spina-Christi nanocomposites, and L-Arginine@SiO2@Cellulose of Zizyphus Spina-Christi nanocomposites using cellulose of Zizyphus Spina-Christi as a new green polymeric surfactant. The structures of nanoparticles and nanocomposites were characterized by different spectroscopy and microscopy techniques. Nanoparticles and nanocomposites were utilized to determine the concentration of chromium, cadmium, and lead in COVID-19 patients using double-vortex-ultrasonic assisted surfactant enhanced dispersive liquid-liquid microextraction. Mean recoveries of chromium, cadmium, and lead were obtained in the range of 86-98% with relative standard deviations below 4%. The advantages of the proposed method are green and novel polymer surfactant with low detection limit. Finally, antibacterial activities were investigated. The maximum inhibition zone of L-Arginine@SiO2@Cellulose of Zizyphus Spina-Christi nanocomposites was obtained for StaphylococcusAureus (21.9..0.4 mm). L-Arginine@SiO2@Cellulose of Zizyphus Spina-Christi nanocomposites have low cytotoxicity against MCF-7 cancer cells. These results indicated the potential ability of L-Arginine@SiO2@Cellulose of Zizyphus Spina-Christi nanocomposites in the determination of metal concentrations in biological samples along with good antibacterial properties and cytotoxic properties.

Family History of Alport Syndrome with Spectrum of Chronic Kidney Disease, Dialysis and Transplantation

Introduction: Alport syndrome should be considered in the differential diagnosis of patients with persistent microhematuria. Electron microscopic examination of renal tissue remains the most widely available and applied means for diagnosing AS. The presence of diffuse thickening and multilamellation of the GBM predicts a progressive nephropathy, regardless of family history. Unfortunately, ultrastructural information alone does not establish the mode of transmission in a particular family. Method(s): 18 years-old male patient was followed in the clinic due to persistent microscopic haematuria and proteinuria. Family history is significant for one brother in his early 20s, who started to have the presentation early in life and his initial biopsy showed thin basement membrane disease. The brother subsequently progressed to renal failure and a repeat biopsy confirmed the presence of Alport syndrome. Another brother had end-stage renal disease and underwent renal transplantation. The patient status was revised, and genetic studies confirmed the presence of an autosomal recessive type of Alport syndrome involving collagen for A3 chain COL4A3. His kidney function remained stable initially with an estimated GFR of approximately 90 mL/min/1.73 m2. The most recent eGFR is around 70 ml/min/1.73 m2. His proteinuria disappeared once Losartan 25 mg was added to Ramipril 5 mg. His blood pressure has been on target. Creatinine increased to 147 micromol/L and he was diagnosed as having acute kidney injury on chronic renal disease which was obvious post covid infection, then back to baseline. Current proteinuria 3 g/g Cr on Angiotensin receptor blockers. BP 110/70, all other systemic examination is unremarkable. No hearing or visual abnormalities. Result(s): The initial renal manifestations in early childhood include asymptomatic-persistent microscopic hematuria and rarely gross hematuria. At the onset, the serum creatinine and blood pressure are normal. Over time, proteinuria, hypertension, and progressive renal insufficiency develop. ESRD usually occurs between the ages of 16 and 35 years and rarely can occur between 45 and 60 years. Renal biopsy findings of thinning and multilaminar splitting of the glomerular capillary basement membrane seen on electron microscopic examination are pathognomonic. In 2013, an expert panel issued guidelines recommending genetic testing as the gold standard for the diagnosis of Alport syndrome. Currently, a skin biopsy using commercially available monoclonal antibody against the type IV collagen alpha-5 chain (COL4A5). If the protein is clearly absent in a suspected male, a diagnosis of Alport syndrome can be made without further testing. Conclusion(s): Males with X-linked AS due to a deletion mutation of the alpha 5 chain of type IV collagen usually progress to ESRD by the second or third decade of life. Likewise, patients with autosomal recessive AS due to mutations affecting alpha 3 or 4 chains of type IV collagen tend to progress to ESRD by age 30. Autosomal-dominant AS with heterozygous mutations of COL4A3 or COL4A4 usually has a slower progression of CKD. Treatment is blood pressure control with RAAS inhibitors where clinically appropriate. Cyclosporine may be helpful in some patients with stage I and II CKD with significant proteinuria. Caution using calcineurin inhibitors is indicated in all patients with more advanced CKD stages due to potential nephrotoxicity. No conflict of interestCopyright © 2023

Positive Matrix Factorization as Source Apportionment of Paddy Soil Heavy Metals in Black Shale Areas in Western Zhejiang Province, China

The source apportionment of pollutants is the key to preventing and controlling the pollution caused by heavy metals in soils. The aim of this study was to investigate the main sources of heavy metals in the soils of black shale areas in western Zhejiang, China. Based on geostatistical spatial analysis, this research employed positive matrix factorization (PMF) for the source apportionment of heavy metals in paddy soil. The results showed that contaminated arable soils were concentrated in the western and southern study areas. At least five major sources of heavy metals were screened in this study: natural sources (39.66%), traffic emissions (32.85%), industrial emissions (9.23%), agricultural activities (9.17%), and mining (9.10%). To be specific, Cd was mainly from mining;As originated from agricultural inputs such as fertilizers and pesticides;and Hg, as an industrial pollutant, was transported by atmospheric deposition in the study area. The accumulation of Pb, Zn, and Cu was mainly influenced by natural sources and anthropogenic sources, i.e., traffic emissions, while that of Cr and Ni was controlled by natural sources.

Predicting COVID-19 Pandemic Endpoint in Some Sub-Saharan African and European Countries

In this study, a novel modified SIR model is presented with two control measures to predict the endpoint of COVID-19, in top three sub-Saharan African countries (South Africa, Ethiopia, and Kenya) including Ghana and top four European countries (France, Germany, UK, and Italy). The reproduction number's sensitivity indices with regard to the model parameters were explicitly derived and then numerically evaluated. Numerical simulations of the suggested optimal control schemes in general showed a continuous result of decline at different anticipated extinction timelines. Another interesting observation was that in the simulation of sub-Saharan African dynamics, it was observed that the use of personal protective equipment was more effective than the use of vaccination, whereas in Europe, the use of vaccination was more effective than personal protective equipment. From the simulations, the conclusion is that COVID-19 will end before the 3rd year in Ghana, before the 6th year in Kenya, and before the 9th year in both Ethiopia and South Africa. © 2023 Saviour Worlanyo Akuamoah et al.

Sindrome De Embolia Gordurosa Na Doenca Falciforme: Serie De Casos

Introducao: A Sindrome de embolia gordurosa e uma complicacao rara da doenca falciforme, descrita principalmente na doenca nao homozigotica. Resulta de extensa necrose da medula ossea (MO), durante crise vasoclusiva (CVO), com liberacao de embolos de gordura na circulacao e disfuncao organica multipla. Os criterios diagnosticos sao envolvimento de multiplos/unico orgao histologicamente comprovado por embolia gordurosa e/ou medular necrotica ou desenvolvimento de insuficiencia respiratoria aguda (IRpA) e manifestacoes neurologicas ou falencia de multiplos orgaos com evidencia de necrose medular (laboratorial ou histologica). Objetivos: Descrever caracteristicas clinicas, laboratoriais e de tratamento de 5 pacientes com sindrome de embolia gordurosa atendidos no HCFMUSP entre 10/2021 e 07/2022. Resultados: Os 5 casos eram HbSS (4 mulheres),1 em uso de hidroxiureia (HU), 2 sem HU por hepatotoxicidade e em programa transfusional, 1 interrompeu o tratamento e 1 nunca havia usado. Mediana de idade no evento: 34 (22-52) anos. Fatores desencadeantes provaveis em 3 pacientes: infeccoes por Influenza, Covid19 e S.aureus Oxacilina resistente. A admissao, todos apresentavam dor generalizada e dessaturacao;4 apresentavam confusao mental e rebaixamento do nivel de consciencia com TC de cranio normal;3 com consolidacao pulmonar sendo iniciado antibiotico. Medianas e ranges de exames a admissao: Hb 5,7 (3,6-7,2)g/dL;leucometria 30900 (8620-51600)/mm3, 2 com desvio ate mielocitos, 2 ate metamielocitos e 1 ate bastoes;eritroblastos 38,5 (2,5-53,8) EOC/100 leucocitos;plaquetas 208 (46-507) mil/mm3;DHL 1296 (502->6000)mg/dL;Cr 1,59 (0,94-3,72)mg/dL;BI/BD 2,32 (2,09-4,84)/3,4 (2,57-12,8)mg/dL;TGO 101 (44-289)mg/dL;TGP 19 (18-29)mg/dL;GGT 185 (118-423)mg/dL;FA 369 (142-1060)mg/dL. Durante a internacao, todos evoluiram com reacao leucoeritroblastica (desvio ate mielocitos/promielocitos), aumento de DHL, TGO, TGP, GGT, FA, BI, BD (predominio de BD) e lesao renal aguda, 3 evoluiram com plaquetopenia e 2 com reticulocitopenia. Todos receberam concentrado de hemacias nas primeiras 24h e durante a internacao (mediana 13;range 2-19), 2 iniciaram hemodialise e 2 foram intubados e receberam drogas vasoativas (DVA). Nenhum desenvolveu CIVD. A biopsia de MO de 1 paciente mostrou tecido hematopoietico difusamente necrotico de padrao isquemico. A mediana de internacao foi 11 dias (range 2-22). 1 paciente faleceu em 48h, 1 foi extubado e teve DVA suspensa apos 17 dias, 4 pacientes receberam alta com Hb proxima ao basal e leucometria, plaquetas e funcao renal normais. Discussao: A sindrome de embolia gordurosa e caracterizada por IRpA e manifestacoes neurologicas, podendo haver comprometimento das funcoes renal e hepatica alem de reacao leucoeritroblastica ou pancitopenia, quadro apresentado por nossos pacientes embora nossos casos destoem da literatura quanto ao genotipo, onde apenas 15% sao HbSS. Suspeitar do diagnostico e fundamental para o desfecho dos casos. Na suspeita, a instituicao rapida de terapia transfusional, para reduzir HbS, e determinante para a sobrevida. Uma revisao sistematica descreveu mortalidade de 29, 61 e 91% para quem recebeu troca, reposicao ou nenhuma transfusao, respectivamente. Conclusao: A falta de suspeita diagnostica dificulta o reconhecimento da sindrome, determinando taxas altas de mortalidade. Familiaridade com o quadro clinico e inicio imediato de terapia transfusional tem se mostrado os unicos indicadores de sobrevida. Copyright © 2022

Industrial Wastewater Discharge and Compliance Investigation for Environmentally Resilient Rwanda

While Rwanda is aiming at environmental pollution resilience and green growth, some industries are still discharging untreated effluent into the environment. This study gives a general overview of the compliance level of industrial effluent discharge in Rwanda and the linked negative environmental impacts. It comprises qualitative and quantitative analyses of data obtained from wastewater samples collected from five selected industries in Rwanda. The selected industries had previously been audited and monitored by the Rwanda Environment Management Authority (REMA), due to complains from neighboring residents. The study found that the effluent discharge from wastewater treatment plants (WWTP) for all concerned industries failed to comply with (i) oil and grease (O&G) national and international tolerable parameter limits or the (ii) fecal coliforms national standard. In addition, a compliance level of 66.7% was observed for key water quality monitoring parameters (pH, dissolved oxygen (DO), biochemical oxygen demand (BOD), chemical oxygen demand (COD), total suspended solids (TSS), and heavy metals (i.e., lead (Pb), cadmium (Cd), and chromium (Cr)). Following these study findings, one industry was closed by the REMA for deliberately discharging untreated effluent into an adjacent river. This study recommends the adoption of the best available technology for effluent treatment, installation or renovation of existing WWTPs, and the relocation to industrial zones of industries adjacent to fragile environments.

Accidental prolonged aerosol exposure to 1.5% glycine solution via inhalation

Background: Glycine is an endogenous, non-essential, simple amino acid produced in the human body. A 1.5% solution is commonly used for irrigation in gynecologic and urologic procedures as it is a sterile, clear, non-irritating liquid. It is neutral, mildly acidic and nonpyrogenic, and as it is produced by the human body it does not cause allergic reactions. If an excessive amount is absorbed during a procedure it can result in electrolyte abnormalities, such as hyponatremia or hypocalcemia. It can also result in transient vision disturbances, changes in heart rate, hypotension, hyperammonemia, or encephalopathy. Glycine has been used as a diluent in certain inhaled therapies for COVID-19 infections, such as epoprostenol. We describe a case where a 1.5% glycine solution was inadvertently used for humidified oxygen via high flow nasal cannula as opposed to distilled water. Case report: The patient was a 70-year-old male who was admitted to the hospital for hypoxia related to a COVID-19 infection with O2 saturations in the 70-80% range. He was placed on high flow nasal cannula to improve his oxygen levels. During his inpatient stay it was discovered that a 3-L bag of 1.5% glycine solution had been connected to the high flow nasal cannula instead of distilled water. This ran from Friday evening to the following Monday morning before the error was discovered. There was only 100mL of the glycine solution remaining in the bag when it was found. The patient continued to do well and had no new complaints during his stay. The case was called to the regional poison center which recommended monitoring electrolytes, watching for any possible respiratory symptoms and continuing supportive care. Initial lab work on admission showed a chemistry panel of Na 146, K 3.6, Cl 102, CO2 25.3, BUN 9, Cr 0.70, Glucose 106, Ca 9.3. Repeat lab work immediately after the mistake was found showed: Na 137, K 4.8 Cl 100, CO2 28, BUN 15, Cr 0.70, Glucose 129, Ca 9.0. On recommendations from poison control, electrolytes were monitored with repeat lab work 10 h after discontinuation of the glycine solution, showing: Na 135, K 4.3, Cl 97, CO2 26.8, Glucose 175, Ca 9.2. The patient did not develop any new complaints, had no reported altered mental status, epistaxis, nasal irritation or other symptoms related to the inhalation. He was eventually discharged home on oxygen for his persistent hypoxia related to his COVID-19 lung infection. Discussion(s): This case demonstrates that prolonged continuous inhalational exposure to a 1.5% glycine irrigation solution does not result in any mucosal irritation, metabolic or systemic toxic reactions, even though its pH is reportedly between 4.5 and 6.5. Thus, glycine solutions up to this concentration appear to be safely tolerated for its increasing use as an excipient for aerosolized medications. Conclusion(s): We describe a case where 1.5% glycine solution was inadvertently used in place of distilled water for humidified oxygen via high flow nasal cannula for approximately 3 days in a patient being treated for COVID-19 related pneumonia with no notable adverse effects.

ACUTE KIDNEY INJURY AS A PREDICTOR OF MORTALITY IN PATIENTS WITH COVID-19

SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Multiple mechanisms may cause acute kidney injury (AKI) after mechanical ventilation. Cross-talk between the lung and kidney precipitates other complications such as fluid overload, electrolyte derangements and pro-inflammatory cytokine production. In this study, we compared hospital mortality rates in unvaccinated COVID-19 patients with respiratory failure (requiring mechanical ventilation) who developed oliguric AKI. METHODS: Using an observational database, we analyzed 3183 unvaccinated hospitalized COVID-19 PCR-positive patients at Methodist Health System (Dallas, TX) from March 2020 to December 2020. The primary endpoint was all-cause in-hospital mortality in patients with respiratory failure requiring mechanical ventilation who developed AKI (as defined by the kidney disease improving global outcomes (KDIGO) guidelines). We also counted the rate of kidney replacement therapy and degree of kidney recovery among the survivors who developed AKI. Chi-square (X2), Fischer’s exact test, and odds ratio tests were used to analyze observed variables. RESULTS: Of the 3183 COVID-19 patients, 351 (11%) developed respiratory failure requiring invasive mechanical ventilation. Of those, 313 (89%) had previously normal kidney function (no documented CKD). Of the 313 intubated patients, 186 (59.4%) developed AKI and 127 (40.5%) patients did not. Thirty-five (18.9%) of the patients who developed AKI survived hospital admission, while 54 (42.5%) patients without AKI survived (OR = 3.306, 95% CI = 1.98-5.51, P<0.001). Ischemic acute tubular necrosis from septic shock was the most common cause of AKI. Hyperkalemia and metabolic acidosis were the most common indication for kidney replacement therapy, and continuous kidney replacement therapy was the most common modality used. The mean age for the AKI vs no AKI groups were 63.5 (SD 14.5) vs 62 (SD 14.49) years old. Mean BMI was comparable between both groups 32 (SD 9.7) vs 32 (SD 9.64), while the BUN level 26 (SD 26.75) vs 19 (SD 9.9) mg/dl and Cr 1.15 (SD 1.59) vs 0.08 (SD 0.27) mg/dl were higher in the AKI group. In the AKI group, kidney replacement therapy was prescribed in 73(39.2%) patients, of which only 33 (17.7%) recovered meaningful kidney function. CONCLUSIONS: As the world emerged from the COVID-19 pandemic, there are innumerable lessons still to be learned. In our study, we demonstrated that AKI in COVID-19 patients with respiratory failure is associated with a higher incidence of mortality compared to patients without AKI. CLINICAL IMPLICATIONS: The risk of new SARS-CoV-2 variants and the possibility of future pandemics makes the recognition of high-risk medical complications of COVID-19 crucial to improve outcomes in acutely ill patients. A true multi-disciplinary team and an incredible amount of resources is required to identify and treat such patients. This study reminds us that kidney replacement therapy is only a means of supportive treatment rather than a cure to COVID-19-related kidney pathology. DISCLOSURES: No relevant relationships by Victor Canela No relevant relationships by Manavjot Sidhu No relevant relationships by Lucas Wang

A CASE OF MICROSCOPIC POLYANGIITIS (MPA) FOLLOWING SARS-COV-2 INFECTION

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: ANCA-associated vasculitis (AAV) is a systemic disease that causes inflammation of small vessels in various organs, such as the lungs, kidneys, and nervous system. We report a case of AAV following SARS-CoV-2 infection. CASE PRESENTATION: A 64-year-old female from Albania with no known medical history, presented with intermittent low-grade hemoptysis and fever for 1 week prior to admission. She had chills, myalgias, fatigue, and poor appetite 6 weeks prior. On arrival, she was febrile (101F), and hypoxic (Spo2 92% on 3L O2). Labs were significant for anemia [Hb 6.8 g/dl], acute kidney injury (AKI) [Cr 2.5 mg/dl]. She was found to be Positive for Sars-CoV-2 by PCR. Chest X-Ray showed patchy bilateral airspace opacities with peripheral and lower lobe predominance, concerning for atypical pneumonia (Fig 1). Urinalysis was significant for proteinuria (2+) and hematuria (2+). CT (Computed Tomography) thorax showed extensive bilateral airspace disease (dense consolidations and ground-glass opacities) favoring multifocal infection and mediastinal lymphadenopathy(Fig 2). Due to the chronicity of her symptoms and atypical imaging for viral pneumonia, other diagnoses were explored including bacterial superinfection, Tuberculosis, and autoimmune disease. Sputum studies were negative for infections including Acid Fast Bacilli. Workup revealed elevated Antimyeloperoxidase antibodies (MPO) and positive COVID-19 Ig G. She was started on methylprednisolone 1g for AAV. Renal biopsy revealed pauci-immune glomerulonephritis with features of cellular crescent consistent with microscopic polyangiitis (Fig 3). Follow-up CT chest showed improved airspace abnormalities and mediastinal lymphadenopathy. After induction therapy with Rituximab was initiated, she continued to recover and was discharged home. DISCUSSION: The pathogenesis of AAV is believed to be an aberrant pathogenic autoimmune response that follows an initial insult which can include infections. SARS-CoV-2 has been associated with the emergence of autoimmune diseases in susceptible patients(1). The proposed mechanism is linked to elevated levels of circulating neutrophil extracellular traps (NETs) observed in covid infection. These NETS are covered with proteins including neutrophilic enzymes which can activate complement pathways causing tissue destruction and vasculitis. The diagnosis of new-onset AAV can be challenging in COVID-19 patients as symptoms and clinical manifestations of both diseases can overlap. AAV should be considered strongly in patients who are currently infected or have been infected with SARS-CoV-2 and present with atypical or non-resolving pneumonia and other organ involvement such as AKI to avoid permanent organ damage. CONCLUSIONS: The presence of non-resolving or atypical pneumonia and AKI in a patient with SARS-CoV-2 should prompt evaluation of immunological markers to assess or rule out AAV for early diagnosis and treatment. Reference #1: Caso F, Costa L, Ruscitti P, Navarini L, Del Puente A, Giacomelli R, Scarpa R. Could Sars-coronavirus-2 trigger autoimmune and/or autoinflammatory mechanisms in genetically predisposed subjects? Autoimmun Rev. 2020;19(5):102524. doi: 10.1016/j.autrev.2020.102524 DISCLOSURES: No relevant relationships by Tarik Al-Bermani No relevant relationships by Anant Jain No relevant relationships by Ian Kaplan No relevant relationships by Alina Kifayat No relevant relationships by Lisa Paul

IDIOPATHIC MULTICENTRIC CASTLEMAN DISEASE (IMCD) AS A MANIFESTATION OF POST-COVID-19 INFLAMMATORY SYNDROME

SESSION TITLE: Pulmonary Manifestations of Infections SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: Post-acute COVID-19 inflammatory syndrome is defined as persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms of original infection (1). These can manifest in various ways, but pulmonary, cardiac, and renal complications are the most common (1), with IL-6 thought to be an important mediator (2). We report what we believe to be the first case of Idiopathic Multicentric Castleman's Disease (iMCD) as a manifestation of post-acute COVID-19 inflammatory syndrome. CASE PRESENTATION: A 36-year old male with history of hypertension and childhood asthma (not on current therapy), and recently resolved COVID-19 from 4 weeks prior, is admitted to the hospital with progressive shortness of breath, cough, fevers and significant fatigue. Prior COVID-19 symptoms included fevers, cough, and shortness of breath, which improved after 2 weeks without treatment. Symptoms returned 2 weeks later and worsened. On admission, he was tachycardic to 108 with temp of 37.8C, and otherwise stable vitals. Pertinent labs included WBC 17 (neutrophil predominant), Hgb 11.6, Cr 2.52, Na 126 and albumin 2.7 (normal baselines). SARS-CoV2 PCR was negative. CT chest with PE protocol showed no PE but moderate bilateral pleural effusions and extensive mediastinal lymphadenopathy. 1.2L clear fluid (transudative with lymphocyte predominance) was removed via thoracentesis. Microbiology, flow cytometry and cytology were unremarkable. Renal and mediastinal lymph node biopsies were taken. Lymph node sampling was non-diagnostic x2, but renal biopsy showed acute microangiopathy without thrombi, concerning for acute glomerulonephritis. Serologic vasculitis and CTD workup were entirely negative. He was treated with a course of prednisone and improved, however as outpatient, had recurrence of all these issues. Repeat thoracentesis x3 was unrevealing. He was again admitted and had an excisional inguinal node biopsy, showing findings consistent with hyaline vascular Castleman Disease. Further heme/onc evaluation and discussion showed diagnosis meeting criteria for iMCD. DISCUSSION: Multicentric Castleman's Disease is most often associated with HHV-8 infection in the setting of HIV. If HHV-8 is negative, the disease is termed idiopathic (iMCD). In these cases, disease is mediated predominantly by IL-6, but the direct cause is unknown, though existing theories include non-specific viral infections, malignancy and autoimmune diseases (3). Our patient had no evidence of malignancy or autoimmune phenomena. Thus COVID-19 illness was the most plausible explanation, especially given known IL-6 activity in COVID-19 inflammatory syndromes. CONCLUSIONS: Post-acute COVID-19 inflammatory syndromes are extensive and can affect any organ system. iMCD is another possible manifestation, and must be diagnosed with excisional lymph node biopsy. High index of suspicion should be maintained to make this diagnosis. Reference #1: Nalbandian, Ani et al. "Post-acute COVID-19 syndrome." Nature medicine vol. 27,4 (2021): 601-615. Reference #2: Phetsouphanh, Chansavath et al. "Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-CoV-2 infection.” Nature immunology vol. 23,2 (2022): 210-216. Reference #3: Dispenzieri, Angela, and David C Fajgenbaum. "Overview of Castleman disease." Blood vol. 135,16 (2020): 1353-1364. DISCLOSURES: No relevant relationships by Kyle Halligan No relevant relationships by Chris Yan

FOOL'S MOLD: UNUSUAL SEQUELAE OF COVID-19 INFECTION IN A YOUNG PATIENT

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: COVID-19 Associated Pulmonary Aspergillosis (CAPA) is a subset of invasive pulmonary aspergillosis occurring in patients actively infected with or recovering from COVID-19. It has mostly been described in immunocompromised or severely ill patients requiring invasive mechanical ventilation[1-6]. The authors report a case of CAPA infection in an ambulatory and immunocompetent patient with prior lung resection. CASE PRESENTATION: A 20-year-old male presented to a Comprehensive Cancer Center for fever and hemoptysis. He carried a diagnosis of metastatic germ cell tumor to his lungs, status post left upper-lobe wedge resection. He had completed bleomycin, etoposide, and cisplatin (BEP) chemotherapy one year earlier. He was recently diagnosed with COVID-19 one month prior to admission and treated as an outpatient with monoclonal antibodies. He reported ongoing cough productive of clear sputum since his diagnosis, which had worsened over the previous two days and was now blood-tinged. He had been afebrile for weeks before noting new fevers over the same period. Physical examination was notable for fever to 38.6°C and lungs clear to auscultation. His labs were significant for a WBC of 14.5 K/mcl (82.5% neutrophils), Cr 2.1 mg/dL (baseline 1.5 mg/dL), and normal platelets and coagulation studies. Serum Aspergillus galactomannan was normal. Repeat SARS-CoV-2 PCR was negative. Chest x-ray was unchanged. V/Q scan showed no evidence of pulmonary embolism. Non-contrast CT chest performed on hospital day #4 revealed a partial opacification and increased wall thickness of patient's largest left upper lobe surgical cavitation (see Image 1). A bronchoscopy was performed day #6, with bronchoalveolar lavage (BAL) galactomannan >5.56 (normal <0.5)7;fungal culture was significant for septate hyphae. He was started on voriconazole with improvement in his symptoms and discharged day #9. DISCUSSION: Immunocompromised patients with prolonged neutropenia, solid-organ or stem cell transplants, and patients with advanced AIDS are at highest risk of contracting PA[8-9]. ARDS secondary to viral pneumonia is also a common precipitant in immunocompetent patients[1-6,10,11]. The exact mechanism of this association remains unknown, but it is postulated to occur due to multiple factors, including host immune dysregulation[1,2], widespread exposure to corticosteroids[1,2], concomitant lung disease[1], and viral-induced lymphopenia[2]. We report a case of an immunocompetent patient with prior lung resection recovering from COVID-19 who experienced a secondary worsening of symptoms ultimately found to have CAPA to further highlight the link between these conditions. CONCLUSIONS: While many of CAPA case reports describe patients with typical risk profiles for CAPA, this case suggests that clinicians should consider structural lung disease alone in an otherwise immunocompetent, ambulatory individual to be a potential risk factor. Reference #1: See Image 2 for full list of references. DISCLOSURES: No relevant relationships by Raphael Rabinowitz No relevant relationships by Matthew Velez

THE CAT IS OUT OF THE BAG: PASTEURELLA BACTEREMIA AND PNEUMONIA CAUSING SEPTIC SHOCK IN AN IMMUNOCOMPETENT PATIENT

SESSION TITLE: Atypical Cases of Sepsis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pasteurella multocida is a Gram-negative coccobacillus that causes infections after animal bites or scratches. It typically manifests as cellulitis but severe infections are possible though rare. We present a case of an immunocompetent man with COVID-19 who developed septic shock due to P. multocida bacteremia and pneumonia with no evidence of wound infection. CASE PRESENTATION: A 59-year-old Hispanic man with a history of anxiety and HLD presented with 10 days of nausea, vomiting, chills, and nonproductive cough. He was initially afebrile, on room air but tachycardic. His physical exam was unremarkable. Labs revealed WBC 10x10*3/uL, procal 3.3 ng/mL, negative lactic acid, and positive COVID-19. CT chest showed a right upper lobe consolidation with bilateral patchy infiltrates. He was admitted for sepsis secondary to COVID and superimposed bacterial pneumonia. Ceftriaxone, azithromycin, remdesivir, and dexamethasone were started. Overnight, the patient desaturated to low 80s and required HFNC FiO2 65%. In the morning, FiO2 increased to 80%. ICU was called and upon their assessment, the patient was febrile, tachycardic, tachypneic, hypotensive, and saturating 87-88% on HFNC FiO2 70%. Labs showed WBC 3.1 with left shift, Cr 1.7 mg/dL, lactic acid 5 mmol/L, and procalcitonin >100. He was intubated given persistent hypoxia and increased work of breathing. Antibiotics were broadened to vancomycin, pip/tazo, and azithromycin. The patient acutely decompensated after intubation, requiring multiple high-dose pressor support. Prelim blood cultures grew Gram-negative bacteria so antibiotics were broadened to meropenem. TTE was negative for endocarditis. Pressors were eventually weaned and the patient was extubated. Blood cultures grew P. multocida in 4/4 bottles so meropenem was narrowed to penicillin. His family reported that he was living at a friend's house with cats around but was unaware of any bites or scratches and he had no history of splenectomy. No portal of entry was noted upon careful skin examination. The patient continued to improve clinically with procal that rapidly downtrended. He was eventually discharged home. DISCUSSION: The mortality for severe P. multocida presentations is about 25-30%. Severe cases are generally reported in elderly, immunocompromised, or young immunosuppressed patients. We report what is to our knowledge, the first case of a severe P. multocida infection in an immunocompetent middle-aged man in the background of a COVID-19 infection. It is unclear the degree of COVID contribution and if his bacteremia preceded the pneumonia. His morbidity was primarily driven by the P. multocida bacteremia and pneumonia given the localized right upper lobe consolidation, elevated procal that rapidly decreased with antibiotics, and quick improvement and extubation. CONCLUSIONS: P. multocida infection should be considered in any patient with septic shock and exposure to animals. Reference #1: Blain H, George M, Jeandel C. Exposure to domestic cats or dogs: risk factor for Pasteurella multocida pneumonia in older people? Journal of the American Geriatrics Society. 1998;46(10):1329-1330. Reference #2: Tseng HK, Su SC, Liu CP, Lee CM. Pasteurella multocida bacteremia due to non-bite animal exposure in cirrhotic patients: report of two cases. Journal of microbiology, immunology, and infection= Wei mian yu gan ran za zhi. 2001;34(4):293-296. Reference #3: Kofteridis DP, Christofaki M, Mantadakis E, et al. Bacteremic community-acquired pneumonia due to Pasteurella multocida. International Journal of Infectious Diseases. 2009;13(3):e81-e83. doi:10.1016/j.ijid.2008.06.023 DISCLOSURES: No relevant relationships by Joanne Lin No relevant relationships by Harjeet Singh No relevant relationships by Jose Vempilly No relevant relationships by Joshua Wilkinson

PLASMAPHERESIS FOR HYPERTRIGLYCERIDEMIA-INDUCED PANCREATITIS

SESSION TITLE: Critical Renal and Endocrine Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: About 7% of acute pancreatitis (AP) cases are caused by hypertriglyceridemia (HTG). In such cases bowel rest, IV fluids, symptomatic therapy, and triglyceride (TG) lowering interventions are initiated. Plasmapheresis is one of the treatment options, but it has specific indications. We present a case of severe hypertriglyceridemia-induced pancreatitis that required plasmapheresis. CASE PRESENTATION: A 30 y/o man with type 2 diabetes, hyperlipidemia, multiple previous admissions for HTG-AP, presented with severe abdominal pain, nausea, and vomiting x 1 day. On admission, he was tachycardic, hypotensive, afebrile, SpO2 > 96% on RA. Labs: Glu 491 mg/dL, TG > 1000 mg/dL, Cholesterol 509 mg/dL, Lipase 987 U/L, Cr/BUN 2.4 mg/dL /20 mg/dL, VBG pH 7.25/PCO2 36.2 mmHg/PO2 19.4 mmHg/Ca 0.8/lactate 5.6;WBC 13.07 K/cm;COVID PCR positive. CXR: diffuse patchy opacities. CTAP with contrast was deferred because of AKI. He was admitted to the ICU and started on insulin drip with no improvement over 24hrs. He was still acidotic, Ca persistently low, TG still >1000, and kidney function worsened. Plasmapheresis was initiated. After one session his TG lowered to 700. He was restarted on insulin drip and in the next 24hr TG decreased to < 500 and metabolic acidosis resolved. Once AKI resolved, CT abdomen/pelvis with contrast confirmed acute pancreatitis, with focal hypodensities within the uncinate process and the proximal body, concerning infarcts as well as large phlegmon surrounding the pancreas, but no evidence of necrotizing or hemorrhagic pancreatitis. His hospital course was complicated with sepsis and DVT, which resolved with therapy. He was discharged home with TG lowering agents, Apixaban, and his previous T2DM regimen. DISCUSSION: Plasmapheresis is indicated in patients with severe HTG (>1000- 2000 mg/dl), severe HTG-AP, and when standard treatment options are inadequate. It lowers the lipid levels and removes proinflammatory markers and cytokines stopping further inflammation and damage to the pancreas and other organs faster compared to conservative therapy. Most patients need only one session which lowers TG level by 50-80%, as seen in our patient. CONCLUSIONS: Plasmapheresis should be considered in cases of HTGP with worrisome features such as lactic acidosis, hypocalcemia, worsening inflammation, and multi organ failure. Reference #1: Rajat Garg, Tarun Rustagi, "Management of Hypertriglyceridemia Induced Acute Pancreatitis", BioMed Research International, vol. 2018, Article ID 4721357, 12 pages, 2018. https://doi.org/10.1155/2018/4721357 Reference #2: Pothoulakis I, Paragomi P, Tuft M, Lahooti A, Archibugi L, Capurso G, Papachristou GI. Association of Serum Triglyceride Levels with Severity in Acute Pancreatitis: Results from an International, Multicenter Cohort Study. Digestion. 2021;102(5):809-813. doi: 10.1159/000512682. Epub 2021 Jan 21. PMID: 33477149. Reference #3: Gavva C, Sarode R, Agrawal D, Burner J. Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach. Transfus Apher Sci. 2016 Feb;54(1):99-102. doi: 10.1016/j.transci.2016.02.001. Epub 2016 Feb 20. PMID: 26947356. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Vaishali Geedigunta No relevant relationships by Zinobia Khan No relevant relationships by Jelena Stojsavljevic

SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PATIENT WITH COVID-19 AND HERPES SIMPLEX VIRUS (HSV): A CASE REPORT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic Lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome caused by severe, dysregulated hypercytokinemia. This can be associated with genetic defects or immunologic triggers such as infection, malignancy or autoimmune disorder. The clinical picture consists of multi-organ failure including fever, hepatosplenomegaly, cytopenia,hypertriglyceridemia, hemophagocytosis, high ferritin and IL-2 levels, neurological and liver dysfunction. We present a case of a patient with HLH in the setting of Herpes Simplex Virus (HSV) and SARS-CoV-2 co-infection. CASE PRESENTATION: A 39-year-old male presented to the ER with dyspnea and was found to have COVID-19 pneumonia. He had worsening hypoxemia and was admitted to ICU. He rapidly developed multi-system organ failure (MSOF)including severe hepatitis with AST 13,950 U/L and ALT 10,000 U/L, pancytopenia (Hb 12.9 g/dL, WBC 1.7 K/uL, platelet 15,000 K/uL), acute kidney injury (Cr 6.61 mg/dL), and severe ARDS requiring mechanical ventilation. Abdominal ultrasonography showed splenomegaly. Blood HSV1 DNA PCR was positive with liver biopsy revealing viral inclusions consistent with HSV hepatitis. He had elevated ferritin > 100,000 ug/L and LDH > 2500 U/L. Bone marrow biopsy demonstrated hemophagocytosis and trilineage hematopoiesis. He met 6 of 8 diagnostic criteria for HLH per the HLH-2004 protocol. He received dexamethasone. Risks and benefits of HLH-specific therapy were considered in the setting of liver dysfunction and the decision was made to withhold etoposide and administer anakinra. He died of refractory septic shock and disseminated intravascular coagulopathy. DISCUSSION: Diagnosis of HLH can be challenging due to its rarity and the clinical picture may be initially attributed to sepsis in the presence of infection, as in our patient who had COVID-19 infection and HSV hepatitis. However, a ferritin level >10,000 ng/mL is 90% sensitive and 96 % specific for HLH, with very minimal overlap with sepsis, infections, and liver failure. Additionally, infection is a known trigger of HLH. Despite high mortality without therapy, survival can be significantly increased with HLH-specific therapy, such as etoposide. Treatment with etoposide in the setting of severe liver disease can raise concern because it is metabolized by the liver but it is an essential component of optimal therapy and can be considered in patients with hepatic dysfunction with dose reduction. CONCLUSIONS: Our case highlights the importance of maintaining a high index of suspicion for HLH in critically ill patients with MSOF and liver failure, despite an apparent infectious etiology. This may allow timely diagnosis, early referral to a specialist center and consideration of HLH-specific therapy such as etoposide despite liver dysfunction, to prevent high morbidity and mortality in this potentially fatal disease. Reference #1: Filipovich AH. Hemophagocytic lymphohistiocytosis (HLH) and related disorders. Hematology Am Soc Hematol Educ Program 2009;:127. DISCLOSURES: No relevant relationships by Abdul Khan No relevant relationships by Nehan Sher No relevant relationships by yuttiwat vorakunthada

A CASE OF SARS-COV-2 ASSOCIATED WITH QUADRUPLE BACTERIAL COINFECTION

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: SARS-CoV-2 has been associated with co-infecting pathogens, such as bacteria, viruses, and fungi. Little has been reported about community acquired atypical bacterial co-infections with SARS-CoV-2. We present a case of a patient with recent COVID-19 pneumonia and diagnosis of Legionella and Mycoplasma pneumonia, in addition of E. coli and C. perfringens bacteremia, that emphasizes SARS-CoV-2 impact in human immunity and the need to consider community acquired infections. CASE PRESENTATION: A 64-year-old male with history of hypertension, alcohol use disorder, iron deficiency anemia, and recent COVID-19 pneumonia presented to the ED with shortness of breath, dark urine, and increased confusion. The patient was admitted to the hospital a week prior with COVID-19 pneumonia and acute kidney injury. He received dexamethasone, remdesivir, and IV fluids. After 8 days, he was discharged home. Upon evaluation, he was afebrile and normotensive, but tachycardic, 129/min, on 4 L of nasal cannula sating 100%. On exam, the patient was oriented only to person and had decreased breath sounds bilaterally. Labs revealed an elevated WBC, 15.3 K/mcL, with left shift, low Hgb, 7.8 g/dL, with low MCV, 61 fL, increased BUN/Cr, 56 mg/dL and 2.8 mg/dL, and an abnormal hepatic panel, AST 121 U/L, ALT 45 U/L, alkaline phosphatase 153 U/L. Ammonia, GGT, CPK and lactic acid were within normal range;but the D-dimer and procalcitonin were elevated, 4618 ng/mL and 25.12 ng/mL, respectively. A urinalysis showed gross pyuria, positive leukocyte esterase and mild proteinuria. CT head showed no acute abnormalities, but the chest X-Ray revealed a hazy opacity in the left mid and lower lung, followed by a CT chest that demonstrated peripheral and lower lobe ground glass opacities and a CT abdomen that showed right sided perinephric and periureteral stranding. Given increased risk for thromboembolism, a VQ scan was done being negative for pulmonary embolism. The patient was admitted with acute metabolic encephalopathy, acute kidney injury, transaminitis, pyelonephritis and concern for hospital acquired pneumonia. Vancomycin, cefepime and metronidazole were ordered. HIV screen was negative. COVID-19 PCR, Legionella urine antigen and Mycoplasma IgG and IgM serologies were positive. Blood cultures grew E. coli and C. perfringens. Infectious Disease and Gastroenterology were consulted. The patient was started on azithromycin and a colonoscopy was done showing only diverticulosis. After an extended hospital course, the patient was cleared for discharge, without oxygen needs, to a nursing home with appropriate follow up. DISCUSSION: Co-infection with bacteria causing atypical pneumonia and bacteremia should be considered in patients with recent or current SARS-CoV-2. CONCLUSIONS: Prompt identification of co-existing pathogens can promote a safe and evidence-based approach to the treatment of patients with SARS-CoV-2. Reference #1: Alhuofie S. (2021). An Elderly COVID-19 Patient with Community-Acquired Legionella and Mycoplasma Coinfections: A Rare Case Report. Healthcare (Basel, Switzerland), 9(11), 1598. https://doi.org/10.3390/healthcare9111598 Reference #2: Hoque, M. N., Akter, S., Mishu, I. D., Islam, M. R., Rahman, M. S., Akhter, M., Islam, I., Hasan, M. M., Rahaman, M. M., Sultana, M., Islam, T., & Hossain, M. A. (2021). Microbial co-infections in COVID-19: Associated microbiota and underlying mechanisms of pathogenesis. Microbial pathogenesis, 156, 104941. https://doi.org/10.1016/j.micpath.2021.104941 Reference #3: Zhu, X., Ge, Y., Wu, T., Zhao, K., Chen, Y., Wu, B., Zhu, F., Zhu, B., & Cui, L. (2020). Co-infection with respiratory pathogens among COVID-2019 cases. Virus research, 285, 198005. https://doi.org/10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Albert Chang No relevant relationships by Eric Chang No relevant relationships by KOMAL KAUR No relevant relationships by Katiria Pintor Jime ez

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION: A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam: faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs: CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 1:40, dsDNA 1:640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR: opacification of the left lung up to midfield. CT chest: moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon: negative. Thoracentesis: 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura: necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity: pan-sensitive M. tuberculosis. Sputum: negative for TB. She was discharged on RIPE treatment for reactivation of TB. DISCUSSION: The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high. CONCLUSIONS: Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1: Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus: case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2):563-568. Reference #2: Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3: Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8):1211-7. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic

Bio-monitoring of atmospheric heavy metal pollution of major emergency events using moss bags:a case study in Xichang

In order to trace and monitor the atmospheric heavy metal pollution in Xichang City, an investigation activity was carried out with a sort of moss (Taxiphyllum taxirameum) (packed in moss bags) as a biological indicator for monitoring heavy metal pollution. The investigation was conducted from the period from April 2019 to April 2020, during which two grave emergency events occurred during spring monitoring period from January 15 to April 15, 2020, i.e., COVID-19 and "3.30"severe forest fire in Xichang, which inevitably affected the atmospheric quality. Based on the concentration analysis of 12 kinds of heavy metal, including Al, Cr, Fe, Cu, Ni, Pb, Mn, Hg, Zn, V, As and Ba contained in the moss and the local meteorological data, comparing those informative data before and after the time when the emergency events toke place, the paper made an analysis on the impacts of two enormous emergency events on the air pollution of heavy metal in Xichang. The results showed that total amount of enrichment of above-mentioned 12 heavy metals in spring (January 15 to April 15, 2020) is (12.85 +or- 1.57) mg/g, which was significantly higher than in the other three seasons (p < 0.01), but no significant discrepancies about the total enrichment amount in the other three seasons (p > 0.05). Primarily because of COVID-19 pandemic, the level of motor vehicles emissions cut down, and the decrease of the tourism in the related areas perhaps causing the decline of pollution of Pb. In addition, the decrease of unbalanced emission of pollutants led to a noted increase of atmospheric oxidation in urban area, thus boosting the formation of secondary particulate matter, and the particulate matter from surrounding industrial sources was transported into the urban area;as a result, remarkable increases of Hg concentration of moss within the moss bags were detected downwind the industrial area located in the urban fringe. Consequently, the investigation showed that the moss-bag method is an effective biological tool for monitoring air heavy metal pollution, which could reflect the impacts of major pollution events on air quality.

Parameters that affect the outcome in ICU patients with critical COVID -19 infection

Introduction: COVID -19 pandemic continues to affect millions worldwide, while the critical form of the disease requires ICU hospitalization to manage not only respiratory failure but multiple organ dysfunctions as well. Objectives: Our retrospective observational study aimed to test the hypothesis that there is a difference in mean values of indexes pointing to organ dysfunction on ICU admission day, like BUN over Creatinine ratio, BUN over Albumin ratio, and PaCO2 over HCO3 ratio among patients with confirmed critical COVID -19 infection who died and patients who survived ICU. Methods: During late 2020 to 2021, 69 patients indicated with the diagnosis of critical COVID -19 disease admitted to ICU. The patients were separated into two groups. Group A involved all patients who survived ICU and group B all patients who died in ICU. We looked for statistically significant differences between the medians values of two groups according to BUN/Cr, BUN/Alb, PaCO2/HCO3 ratios on the ICU admission day, performing unpaired t-test or Mann-Whitney Test according to equal S.D.s assumption. Results: (Table) Conclusions: According to our data, there was a strong statistically significant difference detected between the two groups according to BUN/Alb and PaCO2/HCO3, while the BUN/Cr ratio had no statistically significant difference. Our data suggest that prerenal disorder took place early and was already present on ICU admission day, although not statistically greater in group B. However, a renal disorder associated with albumin levels was greater in group B, and acute type II respiratory failure was by far greater in patients that died in the ICU, pointing that oxygenation disorder was not the only impact of COVID -19 infection on the ICU admission day.