Non-Hodgkin's lymphoma complicated with human coronavirus HKU1 pneumonia: A case report and literature review.

Objective: To analyze the clinical manifestations, diagnostic methods and treatment process of the patients with non-Hodgkin's lymphoma complicated with human coronavirus(HCoV)-HKU1 pneumonia and improve the clinical medical staff's awareness of the disease, and to reduce the occurrence of clinical adverse events. Method(s): The clinical data of a patient with non-Hodgkin's lymphoma complicated with HCoV-HKU1 pneumonia with hot flashes and night sweats, dry cough and dry throat as the main clinical features who were hospitalized in the hospital in January 2021 were analyzed, and the relevant literatures were reviewed and the clinical manifestations and diagnosis of HCoV-HKU1 were analyzed. Result(s): The female patient was admitted to the hospital due to diagnosed non-Hodgkin's lymphoma for more than 2 months. The physical examination results showed Karnofsky score was 90 points;there was no palpable enlargement of systemic superfical lymph nodes;mild tenderness in the right lower abdomen, no rebound tenderness, and slightly thicker breath sounds in both lungs were found, and a few moist rales were heard in both lower lungs. The chest CT results showed diffuse exudative foci in both lungs, and the number of white blood cells in the urine analysis was 158 muL-1;next generation sequencing technique(NGS) was used the detect the bronchoalveolar lavage fluid, and HCoV-HKU1 pneumonia was diagnosed. At admission, the patient had symptoms such as dull pain in the right lower abdomen, nighttime cough, and night sweats;antiviral treatment with oseltamivir was ineffective. After treatment with Compound Sulfamethoxazole Tablets and Lianhua Qingwen Granules, the respiratory symptoms of the patient disappeared. The re-examination chest CT results showed the exudation was absorbed. Conclusion(s): The clinical symptoms of the patients with non-Hodgkin's lymphoma complicated with HCoV-HKU1 pneumonia are non-specific. When the diffuse shadow changes in the lungs are found in clinic, and the new coronavirus nucleic acid test is negative, attention should still be paid to the possibility of other HCoV infections. The NGS can efficiently screen the infectious pathogens, which is beneficial to guide the diagnosis and treatment of pulmonary infectious diseases more accurately.Copyright © 2023 Jilin University Press. All rights reserved.

First Case Mild Symptoms COVID-19 in Rural Central Java Area: Case Report of an Indonesian Patient

BACKGROUND: SARS-CoV-2 virus infection is a pandemic that began to emerge in December 2019 in various countries with high death rates of 4-9% until now. In March 2020, Indonesia found its first case where the condition of the infection kept spreading to various regions in Indonesia. Different regional conditions in Indonesia make it difficult to manage this virus infection. The capability of the regional hospitals to detect this virus infection with their facilities and infrastructure is required. CASE PRESENTATION: A 17-year-old man came to the Ajibarang Regional Hospital with complaints of coughs and colds felt for 4 days and fever for 2 days. Physical examination found a good general condition, moderate pain, the temperature of 38.8degreeC, pharyngeal hyperemia, and minimal lung crackles sound. Laboratory tests showed normal leukocytes, platelet, and hemoglobin levels. Chest radiograph was suggestive of bronchitis. The patient was hospitalized for approximately 4 days until the fever resolved and was discharged. Five days after the patient was discharged from the hospital, the results of the viral load examination using real-time polymerase chain reaction confirmed positive for Coronavirus Disease 2019 (COVID-19). CONCLUSION(S): This case showed unusual conditions of a mild clinical COVID-19 infection, laboratory results that did not support viral infections, as well as radiology examination of only bronchitis. The viral load test was found to be positive. Therefore, the diagnosis of the COVID-19 infection requires a comprehensive interpretation of complete history taking, clinical examination, laboratory, and radiology examinations for clinicians working with limited hospital facilities and infrastructures.Copyright © 2023 Edward Kurnia Setiawan Limijadi, Inge Cahya Ramadhani, Dian Tunjungsari Hartutiningtyas, Gara Samara Brajadenta.

Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

Acute urticaria with Angioedema in a patient with COVID-19 pneumonia: Favipiravir side effect or a rare cutaneous manifestation

Introduction: Coronavirus disease 2019 (COVID-19) has caused thousands of deaths since it was declared as a pandemic. Recently it continues to be one of the most followed topics in the world in terms of its course and treatment. Favipiravir is a broad-spectrum anti-viral agent that has been shown to be effective against various Coronaviruses in vitro. However, as with any drug use, side effects may develop with the use of favipravir treatment. Case Report: We reported a 55-year-old female patient with acute urticarial with angioedema whom had COVID-19 pneumonia. She had no history of allergy, atopy, previous similar episodes or family history of hereditary angioedema. There is no drug or food consumption that may be suspicious in terms of allergy described by the patient other than favipravir. Conclusion(s): As far as we know, it is the first case reported from our country. Since there is no specific examination for differential diagnosis, we cannot distinguish as a rare side effect due to favipiravir treatment or COVID-19 cutaneous manifestation. As a result, studies involving more cases of COVID-19 skin findings are needed.© Copyright 2020 by Emergency Physicians Association of Turkey.

Emergence of a genotype I lineage 1 variant avian infectious bronchitis virus in Assam, India

Background: Infectious bronchitis (IB) is an acute and highly contagious viral disease of poultry affecting chicken of all ages. The causative agent IB virus (IBV) is a Gammacoronavirus within the family Coronaviridae. Viral genetic mutations and recombination events particularly in the spike protein (S1) of IBV constantly give rise to emerging IBV variants. Vaccination is considered as the most reliable approach for IBV control, but current vaccines have been found to be ineffective due to constant emergence of new variant viruses. Objective(s): The objective of our study was to detect IBV genotypes prevalent in Assam, India. Material(s) and Method(s): Oro-pharyngeal swabs and tissue samples from unvaccinated broiler chickens showing respiratory symptoms were tested using RT-PCR targeting the N gene of IBV. The virus was isolated from infected swab/tissue samples in 9 days old specific pathogen free embryonated chicken eggs through allantoic cavity route. Phylogenetic studies were done based on the S1 gene of IBV. Results and Conclusion(s): Clinically, the birds showed gasping and tracheal rales. Necropsy revealed distended ureters. Virus was isolated and identified by curling and dwarfing of the dead embryos and further confirmed by RT-PCR. Positive PCR amplicons were sequenced and phylogenetic analysis clustered the IBV isolate from Assam with genotype I lineage 1 IBV prototype sequence belonging to Beaudette and Mass 41 strains but the isolate exhibited a relatively high degree of sequence divergence with reference strains. Our findings suggest that the IBV isolate might have emerged from recombination with the local circulating virus or vaccine strains. This will have important implications for IB prevention strategies.

An integrated approach: The use of both methylprednisolone and dexamethasone in the management of COVID-19 acute respiratory distress syndrome (ARDS) in Trinidad and Tobago

Case report Background: With the continued rise of COVID-19 hospitalizations due to variants, breakthrough infections and vaccine hesitancy, current treatment regimens must be evaluated. Corticosteroids (CS) have been shown to decrease mortality in patients who require oxygen, especially those on invasive mechanical ventilation [Pinzo et al. 2021]. Steroids also lower intubation rates and transfer to intensive care units [Ahmad et al. 2021]. Methylprednisolone (MP) and dexamethasone (DEX) have been used for the treatment of COVID-19 patients with varied data on outcomes. Having obtained the patient's consent, the case below aims to highlight the use of both MP and DEX in the management of COVID-19 ARDS. Case: A 61-year- old male with a history of prostate cancer in remission presented with fever for 2 weeks and cough and dyspnoea for 2 days. He denied any gastrointestinal or neurological symptoms. He was unvaccinated to COVID-19 and reported recent exposure. On examination his oxygen saturation was 89% on room air and on auscultation, decreased air entry and crepitations were noted bilaterally. COVID-19 infection was confirmed by a positive nasopharyngeal swab. Lab investigations revealed an elevated C-Reactive Protein (CRP) of 26 mg/L, with a normal leukocyte count and renal function. Chest radiograph showed scattered consolidations bilaterally. A diagnosis of ARDS was made and non-invasive ventilation via dual oxygen therapy was initiated. He was later admitted to the High Dependency Unit (HDU) for continuous positive airway pressure ventilation. A tapering dose of MP was administered starting with a loading dose of 1g intravenously (IV) followed by 250 mg IV daily for 3 days and then 1 mg/kg twice daily until discharged from the HDU. MP was then switched to DEX 8mg IV daily and continued until supplemental oxygen was no longer needed. Serial blood draws noted a gradual decline in the CRP value. He was subsequently discharged and followed up in an outpatient setting. Conclusion(s): Current guidelines recommend fixed dosing regimens of CS in COVID-19 ARDS. This case demonstrates the effectiveness of using tapered MP followed by DEX in the management of COVID-19 ARDS. As such CS should not be a fixed dose regimen but rather tailored to the patient's requirements with dose adjustments guided by supplemental oxygen demand and CRP values. Further research is required on CS potency and dosing in COVID-19 associated pulmonary disease.

Interstitial changes after severe SARS-CoV-2 Infection

Introduction and aim: COVID19 pandemic caused by SARS-CoV-2 is associated with high morbidity and mortality rate worldwide,producing inflammation that can lead to persistent parenchymal lesions. The aim was to analyse the medium-long term evolution of patients with severe COVID19. Method(s): Follow-up of a cohort of 97 COVID19 patients admitted to intensive care unit from March 2020 to June 2021,requiring invasive/non-invasive mechanical ventilation (IMV/NIMV) and/or high-flow nasal cannula (HFNC). They were clinically evaluated in the Interstitial Diseases consult at 4-6 weeks after discharge with spirometry (SP),CO diffusion capacity (DLCO) and thoracic ultrasound (TU);those suggestive of mild interstitial changes (IC) were evaluated at 3 months and moderate-severe ones at 6 months with HRCT,SP and DLCO. Result(s): Mean age was 61+/-15 years (61% male) and hospital stay was 26+/-17 days.93% used HFNC,57% NIMV and 31% IMV. At 4-6 week after discharge assessment showed 45% dyspnea and 33% crackles. SP was normal in 63%,with mild DLCO disorders in 36% and 77% pathological TU. The most frequent abnormality on HRCT was ground glass. After clinical-functional and ultrasound-radiological evaluation at 4-6 weeks after COVID19,37% of cases were discharged,another 2% at 3 months,22% at 6 months and 7% at 12 months. The remaining 32% are still being followed up for persistent IC(6 receiving home oxygen therapy,6 treated with steroids and 4 with antifibrotic). Conclusion(s): Most patients with severe COVID19 infection have after discharge IC with mild clinical-functional impact at 4-6 weeks,although one third have persistent changes after 12 months. Medium to long-term follow-up of postCOVID19 patients is necessary to identify those with permanent abnormalities.

Case report of an antimelanoma differentiationassociated protein 5 antibody-associated amyopathic dermatomyositis

Autoantibodies against melanoma differentiation-associated protein 5 (MDA5) associated with dermatomyositis have recently been described in Asians with rapidly progressive respiratory disease. Here we report the case of a middle-aged white woman with anti-MDA5 antibody-associated amyopathic dermatomyositis with interstitial lung disease (ILD), which is stable with minimal immune suppression. A 55-year-old woman was referred to a virtual dermatology clinic during the COVID-19 pandemic suspected of having widespread eczema involving the chest, face, arm and hands on the background of atopy. On direct questioning, she admitted to having constitutional symptoms, exertional dyspnoea, joint pain and symptoms of proximal muscle weakness. On clinical suspicion of possible connective tissue disorder, she was urgently reviewed in the hospital, where she was found to have a photodistributed rash involving cutaneous ulceration and violaceous plaques. Hand examination showed mechanic's hand mimicking hand eczema, ragged nail cuticles and acute tenosynovitis in the left index finger. Her upper and lower limb muscle power was normal and respiratory examination revealed bi-basal fine end-expiratory crepitation. Her repeated biochemical, haematological and muscle enzymes remained normal. Skin biopsy taken from photosensitive rash over the wrist showed hypergranulosis, Civatte body formation, colloid bodies and dyskeratotic keratinocytes, in keeping with severe lichenoid eruption. Superficial dermis showed patchy red-cell extravasation, perivascular chronic infiltration, dermal oedema and serum on the surface, in keeping with ulceration secondary to severe inflammatory processes. There were no eosinophils and eccrine coils were free of inflammation, raising the suspicion of a drug eruption. Her antinuclear antibody and double-stranded DNA were repeatedly negative. Myositisspecific antibody panel was performed owing to a high clinical suspicion of photosensitive dermatoses, both clinically and histologically. Histology revealed positive anti-MDA5 antibodies;repeated positive testing confirmed this. Although lung function was normal, computed tomography revealed evidence of ILD. We made a diagnosis of anti-MDA5 antibodyassociated amyopathic dermatomyositis with ILD. Her malignancy screening was negative. The patient was started on lowdose prednisolone and hydroxychloroquine 200 mg twice daily, with topical steroid applications, which resulted in remarkable clinical improvement. Anti-MDA5 associated dermatomyositis has characteristic cutaneous lesions consisting of skin ulceration and tender palmar papules, mechanic's hands, inflammatory arthritis and rapidly progressive ILD, which is frequently fatal. Although our patient had ILD, she was relatively stable on minimal immunosuppression. It is important for clinicians to have an increased awareness of this disease as it could have a highly variable clinical presentation in the white population.

Lung ultrasound for detection of pneumonic changes in patients with COVID-19 infection

This study aims to determine the suitability of lung ultrasound as an alternative to CT chest to aid in the initial management of these patients. The aim was to determine the value of lung ultrasound in the diagnosis of lung parenchymal affection in patients with COVID-19. Patients and Methods: A prospective including 150 patients was carried out in the Chest, Interventional Radiology and Clinical Pathology Departments in Bab-El-Sha'aria and Al-Hussin Hospitals, Al-Azhar University, during the period from May 2020 to September 2020. Lung ultrasound was performed in 150 patients with COVID-19 pneumonia diagnosed based on the integrated clinical, laboratory, and CT chest radiological data. Result(s): Among 150 patients, there were 86 males and 64 males, ranging in age from 30 to 75 years and a mean age of 55.8+/-12.1 years. Bilateral lung infiltrates in the CT scan were present in 146 patients (97.3%), CXR infiltrates were present in 63 patients (42%), sonographic evidence of pleuropulmonary involvement was present in 139 patients (92.7%), B lines and pleural line thickening were present in all patients with ultrasound findings (100%), subpleural consolidation associated with B lines was present only in 33 patients (23.7%) and pleural effusion was absent in all cases;crackles were only present in 53 (35.3%) patients. Conclusion(s): Because of its simplicity in interpretation, bedside availability, lack of risk of radiation and good sensitivity in the detection of lung parenchymal affection, the chest ultrasound is a useful tool in the management of patients with symptoms suspicious of COVID-19 infection and seems to be a suitable substitute for the CT chest in such circumstances.

Initial COVID-19 Severity and Long-COVID Manifestations: An Observational Analysis

OBJECTIVE: New-onset or persistent symptoms beyond after 4 weeks from COVID-19 are termed "long-COVID." Whether the initial severity of COVID-19 has a bearing on the clinicoradiological manifestations of long COVID is an area of interest. MATERIAL AND METHODS: We did an observational analysis of the long-COVID patients after categorizing them based on their course of COVID-19 illness into mild, moderate, and severe groups. The clinical and radiological profile was compared across these groups. RESULT(S): Out of 150 long-COVID patients recruited in the study, about 79% (118), 14% (22), and 7% (10) had a history of mild, moderate, and severe COVID-19, respectively. Fatigue (P = .001), breathlessness (P = .001), tachycardia (P = .002), tachypnea (P < .001), raised blood pressure (P < .001), crepitations (P = .04), hypoxia at rest (P < .001), significant desaturation in 6-minute walk test (P = .27), type 1 respiratory failure (P = .001), and type 2 respiratory failure (P = .001) were found to be significantly higher in the long-COVID patients with a history of severe COVID-19. These patients also had the highest prevalence of abnormal chest X-ray (60%) and honeycombing in computed tomography scan thorax (25%, P = .027). CONCLUSION(S): The course of long COVID bears a relationship with initial COVID-19 severity. Patients with severe COVID-19 are prone to develop more serious long-COVID manifestations.Copyright © Author(s).

A Case of Myositis in Patient with Atypical Bacterial Pneumonia

Case report - Introduction: Bacterial community-acquired atypical pneumonia is sometimes complicated by myositis or by renal parenchymal disease. They can present with myositis and present with muscle weakness, pain or swelling, and elevated muscle enzymes. We present the case of a patient with lower limb weakness and raised creatinine kinase with atypical pneumonia caused by Legionella pneumophila. Case report - Case description: A 76-year-old Caucasian man, who was previously fit and independent and walked 3 miles every day presented with a 1-week history of progressive leg weakness, and inability to mobilize. He had a fall and was on the floor for 2 hours. He had a background history of hypercholesterolemia and was on atorvastatin for 15 years. On his vital observation, he was found tachypnoeic, tachycardic, and hypoxic. He had a right upper lobe crackle but he didn't have respiratory symptoms. His muscle power in his leg was 3/5 with carpet burns on knees and elbow. Initial investigation showed raised inflammatory marker CRP 412mg/L, AKI stage 1, and CK 43400 IU/L. His CXR showed dense right upper lobe consolidation. Legionella urinary antigen was positive. Myositis myoblot, ANA, ANCA negative. COVID-19 swab negative. Treated with IV antibiotic, supplemental oxygen, and IV fluid. Transferred to ITU due to worsening of hypoxia and kidney function. Interestingly, the CK level had improved significantly within 48 hours along with clinical improvement in his symptoms. There was no role of steroid or immunosuppressant due to his significant clinical improvement. On day 7 he was off oxygen, kidney function improved, had physiotherapy, and transferred to ward and on day 10 he was ambulant and discharged home. Case report - Discussion: To date, very few case reports of myositis in a patient with atypical pneumonia have been reported. The mechanism underlying acute myositis in atypical pneumonia is still unknown. The present analysis points out that the organism underlying atypical bacterial pneumonia may occasionally invade the muscle tissue thereby inducing both myositis and secondary kidney damage. Case report - Key learning points: We should be aware of this rare complication of atypical pneumonia and the resolution of symptoms that occur with the treatment of pneumonia. This would avoid unnecessary investigation and use of steroid.

Coughing up a lung? Expectoration of obstructive fibrinous tracheal pseudomembrane

Case Report: Most common causes of shortness of breath are asthma, COPD, CHF, pulmonary embolism, diffuse lung parenchymal diseases and obesity hypoventilation syndrome. Rare conditions can be bronchiectasis, constrictive pericarditis, kyphoscoliosis, tracheomalacia, cardiomyopathies and so on. We present a rare case of tracheal stenosis presenting with repeated hospital admissions followed by intubations and resolution after spontaneous expectoration. A 52-year-old female with a history of end stage renal disease on hemodialysis, resistant hypertension, and COVID pneumonia on supplemental oxygen, presented with dyspnea associated with yellowish productive sputum for one day. She was admitted one week prior due to the same complaint associated with encephalopathy due to hypercapnia, required endotracheal intubation, got extubated four days later, was provisionally diagnosed with asthma and volume overload, and discharged home. During the admission of interest, the patient's examwas normal except severe hypertension with BP of 192/101, bilateral crackles and rhonchi. Arterial blood gasses (ABGs) again showed hypercapnia. CT thorax showed evidence of left lower lobe pulmonary infiltrate and ground-glass opacities. Due to repeated admissions for hypercapnic respiratory failure, suspicion for persistent anatomic or pathologic abnormality was high. Reexamination of CT thorax suggested subglottic stenosis and she underwent fiberoptic laryngoscopy which revealed grade 3 subglottic stenosis. On day three, she became hypoxic and unresponsive, ABGs revealed PCO2 of 150, and got intubated again. Soon after intubation, the patient had spontaneous expectoration of a large piece of firm, fleshy, blood-tinged, thick, luminal tissue. On the histologic examination, the material was found to be a plug of fibrin with small to moderate numbers of inflammatory cells embedded in the matrix. Follow-up CT neck and chest revealed resolution of previously visualized tracheal stenosis. She underwent repeat direct laryngoscopy and flexible bronchoscopy which did not show any tracheal stenosis. The patient remained hemodynamically stable and was discharged home. Tracheal stenosis is challenging to diagnose. Examples of tracheal stenosis due to pseudomembrane formation are rare in medical literature, and the expectoration of fibrin material after intubation in a person with this condition is even rarer. A similar case has been described before with an identical situation of coughing up soft tissue and comparable histopathology report. Our case highlights the importance of critical analysis for broad differentials, adding up pieces of the puzzle to explain the missing link. This patient came with recurrent episodes of dyspnea that were misdiagnosed as volume overload, pneumonia, and asthma exacerbations. CT chest findings of possible subglottic stenosis were the missing link in this case which steered further work-up and led to the final diagnosis. Copyright © 2023 Southern Society for Clinical Investigation.

A Case of Myositis in Patient with Atypical Bacterial Pneumonia

Case report - Introduction: Bacterial community-acquired atypical pneumonia is sometimes complicated by myositis or by renal parenchymal disease. They can present with myositis and present with muscle weakness, pain or swelling, and elevated muscle enzymes. We present the case of a patient with lower limb weakness and raised creatinine kinase with atypical pneumonia caused by Legionella pneumophila. Case report - Case description: A 76-year-old Caucasian man, who was previously fit and independent and walked 3 miles every day presented with a 1-week history of progressive leg weakness, and inability to mobilize. He had a fall and was on the floor for 2 hours. He had a background history of hypercholesterolemia and was on atorvastatin for 15 years. On his vital observation, he was found tachypnoeic, tachycardic, and hypoxic. He had a right upper lobe crackle but he didn't have respiratory symptoms. His muscle power in his leg was 3/5 with carpet burns on knees and elbow. Initial investigation showed raised inflammatory marker CRP 412mg/L, AKI stage 1, and CK 43400 IU/L. His CXR showed dense right upper lobe consolidation. Legionella urinary antigen was positive. Myositis myoblot, ANA, ANCA negative. COVID-19 swab negative. Treated with IV antibiotic, supplemental oxygen, and IV fluid. Transferred to ITU due to worsening of hypoxia and kidney function. Interestingly, the CK level had improved significantly within 48 hours along with clinical improvement in his symptoms. There was no role of steroid or immunosuppressant due to his significant clinical improvement. On day 7 he was off oxygen, kidney function improved, had physiotherapy, and transferred to ward and on day 10 he was ambulant and discharged home. Case report - Discussion: To date, very few case reports of myositis in a patient with atypical pneumonia have been reported. The mechanism underlying acute myositis in atypical pneumonia is still unknown. The present analysis points out that the organism underlying atypical bacterial pneumonia may occasionally invade the muscle tissue thereby inducing both myositis and secondary kidney damage. Case report - Key learning points: We should be aware of this rare complication of atypical pneumonia and the resolution of symptoms that occur with the treatment of pneumonia. This would avoid unnecessary investigation and use of steroid.

Dabbing Lung Injury Managed by Vv Ecmo

INTRODUCTION: E-cigarette or vaping-associated lung injury (EVALI) is an uncommon complication of e-cigarettes or vaping. Most cases are associated with tetrahydrocannabinol (THC) containing products. "Dabbing" refers to the process of ingesting high concentrations of THC-containing oils or waxes with butane solvents to vaporize cannabinoids for inhalation. Another distinction is the presence of impurities and unpurged butane in the vapors inhaled by the users. DESCRIPTION: A 29-year-old male presented with cough, dyspnea, and fever seven days prior to admission. He reported smoking marijuana but denied vaping. Initial chest radiograph demonstrated multifocal pneumonia. PCR for SARS-CoV-2 was negative. He required four liters of supplemental oxygen. Physical exam was remarkable for diffuse pulmonary crackles. Broad spectrum antibiotics for pneumonia were initiated. Oxygen requirements rapidly increased, prompting intubation 48 hours from presentation. Ventilator settings escalated to a positive end-expiratory pressure of 18 cm H2O with 100% FiO2. Computed tomography angiography ruled out pulmonary embolism, however showed diffuse patchy nodular and confluent opacities. Respiratory cultures grew commensal flora and blood cultures were negative. Comprehensive laboratory investigations for an infectious etiology and autoimmune vasculitis were negative. In further discussion with the patient's wife, he has been "dabbing" for the past six months. High dose intravenous steroids were initiated. The patient continued to have refractory hypoxemic and hypercapnic respiratory failure with ARDS requiring prone positioning. The patient ultimately required transition to veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patient received 12 days of VV-ECMO and was eventually liberated after 19 days of ventilator support. At discharge he was asymptomatic, at his baseline level of function, and required no supplemental oxygen. He was discharged on daily steroids with a taper and outpatient follow-up. DISCUSSION: The necessity of VV-ECMO utilization in "dabbing" associated acute lung injury represents a rare severe presentation. Dabbing is emerging as a trend among young adults and represents an under-investigated cause of severe inhalational lung injury.

A Case of Right Side Infective Endocarditis in Patient with Ventricular Septal Defect

A 25-years old white female was admitted to our emergency department presenting with dyspnea, fever, cough and nausea. Her medical background included a small ventricular septal defect (VSD) (congenital) with a left to right shunt, micropolicistic ovary syndrome, Sars Cov 2 infection on January 2022, history of cutaneous infection after sternal piercing in the last three years. Patient showed onset of fever, headache and nausea since 20 days and had a history of ampicillin and cephalosporin usage for 15 days for comunitary pneumonia. Upon arrival in the emergency room, physical examination revealed temperature 38degreeC, crackles on down right lung fields, regular but tachycardic rhythm, 3/6 holosystolic murmur in the third left intercostal space, also skin redness around the piercing zone. Laboratory test showed increasing of WB (white blood cells), C-reactive protein (CPR) and procalcitonin. Because of worsening of respiratory conditions, CTchest was performed, showing tree in bud sign, with pulmonary pattern suggestive of staphylococcal "emboligenous-like infectious state. According to patient's clinical history and CT results, she was referred to transthoracic echocardiogram (TTE) demonstrating the presence, on the right side of the small VSD, of a isoechoic large mass (20x 13 mm) with irregular margins attached to the right ventricular wall near the ostium of the VSD, compatible with vegetation;septal tricuspid valve leaflet involvement could not be ruled out. Methicillin-susceptible Staphylococcus aureus (MSSA) was detected six times from blood cultures;therapy with oxacillin 2 gr every 4 hours combined with daptomycin 750 mg daily was started. Cardiac MRI performed after few days, documented the infective involvement of the ventricular and atrial side of the septal leaflet with moderate tricuspid regurgitation (TR). Congenital heart disease (especially Tetralogy of Fallot, bicuspid aortic valve, aortic coarctation, ventricular septal defect) is a lifelong risk factor for infective endocarditis (IE). Size of VSD is generally not correlated with IE that is directly correlated with turbulent flow;tricuspid valve involvement is mostly seen in VSD, often complicated by pulmonary embolism. In this predisposing situation, skin infection of the piercing zone could have caused transient bacteremia which led to the formation of vegetations in the highest turbulence flow zone..

High-Altitude Pulmonary Edema Precipitated by Sars-Cov-2 Infection: A Case Presentation

Ladakh is a high-altitude area of India, with its altitude ranging from 2500 to 6000m, and it has been one of the famous tourist destinations for explorers, trekkers, and 6 of 24 mountaineers. Every year a large number of tourists, as well as laborers, visit Ladakh, risking their lives to highaltitude illnesses ranging from acute mountain sickness to fulminant high-altitude cerebral edema and high-altitude pulmonary edema (HAPE). HAPE is a life-threatening altitude illness that usually occurs in insufficiently acclimatized climbers in the first few days at altitudes >2500m. Apart from genetic susceptibility, mode, and rate of ascent, upper airway infections pose a risk determinant of HAPE. The hallmark of HAPE is hypoxic pulmonary vasoconstriction. Symptoms of HAPE are incapacitating fatigue, dyspnea at a minimal effort that advances to dyspnea at rest, and dry cough progressing to productive cough expectorating pinkish frothy sputum. The main modalities of treatment are immediate descent to lower altitude areas, hyperbaric oxygen therapy, and pulmonary vasodilator. For prophylaxis, slow ascent at the rate of 300m/day and acetazolamide 500mg/day 2 days before ascent is recommended. The objective of this report is to know the diagnostic and therapeutic approach of HAPE since it is confused with other pathologies presenting with respiratory failure. Little is known about viral infections as a risk factor for HAPE. Emphasis has been given to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as a risk determinant for HAPE, which is a rare case. To date, there is no study on SAR-CoV-2 as a risk determinant of HAPE. We report here a case of a 35-year-old young male, laborer from Bihar (India) with previous high-altitude experience ascending to Leh Ladakh on July 16, 2020 by flight. He got admitted to SNM Hospital Leh on July 24, 2020 with complaints of fever, body aches, and pain 2 days before ascending. After 3 days at altitude, he also developed a cough, which was initially dry but within a few days became productive with expectoration of pink frothy sputum. He also developed breathlessness on exertion, progressing to severity at rest within few days. There was no history of chest pain, orthopnea, and paroxysmal nocturnal dyspnea. General physical examination revealed Glasgow Coma Scale of 15/15, sick looking, respiratory rate of 24 breaths/min, oxygen saturation (SpO2) of 65% in room air, blood pressure of 110/70mmHg, pulse rate of 120 b/min regular, and temperature of 99.8 F. Chest examination showed bilateral coarse crackles on auscultation. The rest of the systemic examinations were unremarkable. Chest radiograph revealed bilateral patchy nonhomogenous alveolar opacities more on the right side with hilar haze. A provisional diagnosis of HAPE was made with the differential diagnosis of coronavirus disease 2019 (Covid-19) pneumonia. He was managed on the line of HAPE. The next day, his nasopharyngeal swab for Covid-19 reverse transcription-PCR (RT-PCR) test turned out to be positive, but his general condition had markedly improved maintaining a SpO2 of 93% on 2-3 L/min and RR of 18/min. Repeat chest radiograph on Day 4 was within normal. He got discharged from the hospital on Day 22 of admission after a nasopharyngeal swab for RT-PCR turned out to be negative.

Acute Pericarditis in ESRD due to COVID-19 Despite Vaccination

Introduction: - Myocarditis, cardiomyopathy, and heart failure;common cardiac manifestations of Coronavirus infectious disease (COVID-19).1-3 - Acute pericarditis is rare.4 - We report a case of a new-onset pericardial rub diagnosed as acute pericarditis due to COVID-19 in a patient with end-stage renal disease (ESRD) despite vaccination. Case Description: - A 61-year-old male with a history of chronic kidney disease stage 5 (CKD 5) approaching dialysis, status post renal transplant twice (first in 1997 and second in 2010) presented with dyspnea of a few days' duration. - Medications: amlodipine, atorvastatin, calcitriol, clonidine patch, hydralazine, sevelamer, tacrolimus, and tamsulosin. - Physical examination: 2+ pitting edema and rales over bilateral lung fields. - Laboratory tests: Blood urea nitrogen (BUN) and Creatinine (Cr) of 154/13.6, respectively. Initial COVID-19 serologies were negative. - Electrocardiogram (EKG) and echocardiogram (ECHO) at admission were unremarkable. - Received seven hemodialysis sessions that improved his symptoms. - Subsequently, he spiked a fever with a recurrence of dyspnea and pleuritic chest pain. - Auscultation: New onset pericardial rub. - Laboratory test: BUN/Cr of 54/5.3. Tested positive for COVID-19. - Repeat ECHO: Pericarditis and moderate-sized pericardial effusion with normal left ventricular systolic function and ejection fraction. - Treated with heparin-free intensive hemodialysis and colchicine. Discussion(s): - Acute pericarditis presentation;Two or more of the following symptoms: chest pain, friction rub, diffuse ST-elevations, PR depressions on EKG, and new or worsening pericardial effusion.5 - Can lead to cardiac tamponade if left untreated.6 - In ESRD, important to consider differential diagnoses of pericarditis;uremia, and fluid overload causing effusion. Due to the recent pandemic, COVID-19 must be taken into consideration irrespective of vaccination status.

Collapsing Glomerulopathy in a Patient With Recent COVID-19 and APOL-1 High-Risk Genotype

Introduction: Collapsing glomerulopathy (CG) is an aggressive subtype of focal segmental glomerulosclerosis, associated with poor renal outcomes. Risk factors for CG include HIV infection, APOL1 high-risk genotypes, and CG has also recently been reported in patients with COVID-19. We report a case of CG with acute kidney injury (AKI) in a patient with a high risk APOL1 genotype, who had renal recovery after prednisone treatment. Case Description: A 43-year-old male with no past medical history presented with fever, myalgia, hemoptysis, vomiting, and diarrhea of 2 weeks duration. Initial exam was remarkable for temperature 103 degrees Fahrenheit, SpO2 95% on room air, and inspiratory crepitations without peripheral edema. Labs were notable for serum creatinine 2.6 mg/dL (unknown baseline), peak creatine kinase 4037 U/L, and urine protein creatinine ratio 19 g/g without RBCs. Chest CT was consistent with multilobar pneumonia. SARS-CoV2 PCR was repeatedly negative but COVID-19 spike and nucleocapsid IgG were positive. Extensive serologic workup for causes of glomerulonephritis and nephrotic syndrome was negative. He was empirically treated with antibiotics for pneumonia but cultures remained negative. Bronchoscopy revealed no evidence of alveolar hemorrhage. His renal function worsened, requiring hemodialysis. Kidney biopsy revealed collapsing glomerulopathy associated with thrombotic microangiopathy, few myoglobin casts suggestive of rhabdomyolysis, and acute tubular injury. Prednisone was initiated at 1mg/kg daily and tapered over 2 months. Lisinopril was initiated for proteinuria. After 5 months, serum creatinine was 1.3 mg/dL and urine protein creatinine ratio improved to 0.6g/g. Genetic testing revealed APOL1 G1/G1 genotype. Discussion(s): In this patient, SARS-CoV2 PCR was likely negative because he presented weeks after symptom onset but the clinical course and serologic evidence of prior SARS-CoV-2 infection supports the diagnosis of COVID-19 associated CG in the setting of APOL1 high-risk G1/G1. Proposed mechanisms of COVID-19-related CG include increased cytokines, that upregulate podocyte expression of toxic APOL1 variants and AKI with tubular injury is often found. Our patient improved with steroid treatment but the treatment of COVID-19 associated CG requires further study.

Two Case Reports of Cytomegalovirus Induced Collapsing Focal Segmental Glomerulosclerosis in Immunocompetent Hosts

Introduction: Collapsing focal segmental glomerulosclerosis (cFSGS) refers to a distinct pattern of glomerulopathy characterized by a glomerular capillary collapse in a segmental global manner, podocyte proliferation, and tubulointerstitial injury. Viral infections like HIV, Parvovirus B19, and CMV seem to be prominent triggers for the development of a conventional histological pattern of FSGS. CMV-associated renal disease has been described only in transplant and immunocompromised patients. Case Description: Case 1 18-year-old female with history of asthma and HbSS disease presented with fever, nausea, vomiting, and neck pain Physical examination revealed a temperature of 102 F, icterus, negative meningeal signs, no rales, rhonchi or wheezing. Initial creatinine 0.2 mg/dL. COVID-19 PCR was negative but IgG antibodies positive. Patient developed non-oliguric AKI with fluid overload requiring hemodialysis. CMV IgM and CMV PCR were positive. She recieved antibiotic therapy and also ganciclovir. Biopsy revealed collapsing FSGS with acute tubular injury. A week after completion of ganciclovir therapy creatinine returned to baseline of 1.7 mg/dL. Case 2 40-year-old African American male with history of diabetes and asthma presented with fever, fatigue, epigastric pain and chest pain. Initial creatinine 1.2 mg/dl, hepatic function (AST 333 U/L, ALT 265 U/L, ALK 207 U/L), ferritin (13682 ng/ml), triglycerides (276 mg/dl) and proteinuria (urine protein /creatinine ratio: 2, urine albumin/creatinine:1016 mg/gm). Patient developed anuric renal failure which required hemodialysis. Biopsy revealed collapsing FSGS with diffuse podocyte effacement, moderate tubular atrophy, and interstitial fibrosis. CMV DNA antibodies were positive. Methylprednisolone and valganciclovir were started with patient creatinine trending down to 3.7 mg/dL. Three weeks following discharge, creatinine levels were 1.5 mg/dL with decreased proteinuria. Discussion(s): Collapsing FSGS in immunocompetent patients is uncommon. Reports mention benefits of ganciclovir and steroid therapy for CMV infection in immunocompromised patients. CMV infection should be considered in patients with systemic inflammatory disease and severe renal failure, as early treatment with steroids and antivirals helps preserve renal function.

THE CLOT THICKENS: THE CASE OF A YOUNG MALE WITH RECURRENT PULMONARY EMBOLISMS

SESSION TITLE: Rare Cases with Masquerading Pulmonary Symptoms SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Paget-Schroetter (PS) syndrome, also known as venous thoracic outlet syndrome, is a primary thromboembolic sequela of compression of the subclavian vein. CASE PRESENTATION: A previously healthy 24 year old male presented with shortness of breath and cough. He had recently been exposed to COVID. He denied fever, diarrhea, vomiting, leg swelling, and rashes. On physical exam he was tachycardic, had no murmurs or JVD, and was CTAB with no wheezing or rales. Labs were significant for a WBC of 17k, and troponin of 0.033. CTA of the chest showed multiple filling defects in the pulmonary arteries consistent with Pulmonary Embolism (PE). He was started on a heparin drip. All COVID testing was negative. Lower extremity venous doppler ultrasounds (US) were negative for DVT. His respiratory status improved, and he was discharged on apixaban with the diagnosis of PE provoked by possible COVID infection. He returned approximately 2 months later with exertional dyspnea and upper extremity swelling and was found to have recurrent PE despite having been compliant with his apixaban. Upper extremity venous doppler US was significant for DVT in his right subclavian vein. He was placed on warfarin. At this time his hypercoagulable workup was also negative. Symptoms persisted despite being on warfarin with outpatient monitored INR. A venogram was ordered to evaluate upper torso blood flow. The venogram was remarkable for high-grade stenosis of the right subclavian vein. This finding led to the consideration of thoracic outlet syndrome aka Paget-Schroetter (PS). DISCUSSION: PS is a rare clinical entity that results from stress placed on the endothelium of the subclavian vein as it passes between the junction of the first rib and the clavicle. It can predispose otherwise healthy patients to recurrent venous thromboembolisms that are refractory to anticoagulation. The clinical features usually include upper extremity swelling and pain which is exacerbated by repetitive or strenuous exercise. Venous collaterals can also be seen in some patients. Evaluation should include some form of upper extremity Doppler and a CT/MR venogram or venography to make the final diagnosis. Treatment may involve anticoagulation, thrombolysis, and/or surgical decompression. Best results are seen with early thrombolysis and surgical decompression. If caught early and treated appropriately, PS has a good outcome with few long-term sequela. CONCLUSIONS: Our goal was to describe a patient with an uncommon cause for recurrent venous thromboembolisms that were refractory to anticoagulation. Our patient's presentation of PS serves to describe many aspects of the disease process, evaluation, diagnosis, and management as seen in the case presentation. The patient's demographic fit the epidemiological profile age of 20s-30s with typical imaging findings and pertinent negative workup which would lead providers to this rarer diagnosis. Reference #1: Saleem T, Baril DT. Paget Schroetter Syndrome. [Updated 2022 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482416/ Reference #2: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. Reference #3: Karl A. Illig, Adam J. Doyle, A comprehensive review of Paget-Schroetter syndrome, Journal of Vascular Surgery, Volume 51, Issue 6, 2010,Pages 1538-1547,ISSN 0741-5214, https://doi.org/10.1016/j.jvs.2009.12.022. DISCLOSURES: No relevant relationships by Jonathan Marks No relevant relationships by Zachary Stachura