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Background: The COVID-19 outbreak in 2019 has presented in the form of pneumonia of unknown etiology in Wuhan. The complete clinical profile including the prevalence of different clinical symptoms of COVID-19 infection among Indian patients who develop a severe disease is largely unknown. This study is aimed to provide a detailed clinical characterization of the cohort of patients who visited our institute with signs and symptoms of COVID-19. Material(s) and Method(s): This was for inpatient hospital (inpatient) based prospective cohort study involving 520 COVID-19 patients admitted to the hospital. The adverse outcome included death and mechanical ventilation. Result(s): Total 520 participants enrolled in the study, (6.9%) participants died, (8.3%) participants required ICU and (5.5%) participants required mechanical ventilation. only signs and symptoms suggestive of severe respiratory system involvement or widespread infection were associated with adverse outcomes, T presence of dyspnoea, cyanosis and hypoxia. The most common chronic disease among patients with adverse outcomes were diabetes, hypertension and pre-existing respiratory disease, personal habit both smoking, and alcoholism was also associated with adverse clinical outcome. Conclusion(s): The adverse clinical outcome among COVID-19 patients is determined by several factors including advanced age, multi-morbidities, and the presence of severe respiratory symptoms.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.
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Background: Many aspects of the severe acute respiratory syndrome coronavirus 2 (SARSCoV2) pandemic in 2019 have been unclear, especially in newborns, and reports of neonatal diseases are usually associated with perinatal infection. Objective(s): The purpose of this study was to evaluate clinical and para-clinical manifestations in newborns that contracted the infection after birth. Method(s): This observational research was conducted from October 2020 to March 2022 to examine postnatal SARSCoV2 infection in infants admitted to the NICU or neonatal ward at the Children's Medical Center in Tehran, Iran. Inclusion in the study was open to neonates who had positive RT-PCR results postnatally. Result(s): In total, 55 newborns were confirmed to have postnatal SARSCOV2. Fever was the most frequently observed symptom, with 35 (61%). Necrotizing enterocolitis was seen in 18% of neonates, and 30% of them were preterm. Neutropenia was seen in 34% of cases, with five cases having severe neutropenia. All neonates had a normal platelet count. Twenty percent of patients showed C-reactive protein higher than 6 mg/L. Two newborns had co-existing bacterial urinary tract infections. Our neonates didn't require antiviral, anticoagulant, or corticosteroid medications, and they recovered while receiving only supportive care. Everyone in the group of newborns was discharged without complications, and there were no deaths. Conclusion(s): The high rate of fever, high C-reactive protein, and neutropenia in SARSCoV2 neonates suggests that more observational research is needed to compare these symptoms to bacterial sepsis to avoid the overuse of antibiotics in these patients.Copyright © 2023, Author(s).
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Introduction: The incidence of arterial thrombosis among critically ill patients with COVID-19 is 4.4%, acute aortic obstruction alone having a mortality rate of 31%. We present a review of the literature regarding isolated abdominal aortic thrombosis (IAAT) in the setting of COVID-19 infection, as well as a case presentation. Method(s): A literature review was performed using Pubmed with the keywords, aorta, aortic, thrombus, and Covid-19. Within these articles, the scope was narrowed to articles that related to IAAT in the setting of Covid-19 infection. Result(s): Our literature review found 9 articles detailing a total of 11 cases of IAAT in the setting of COVID-19 infection. IAAT had a mortality 22% (2 out of 9 patients). Approximately, 55% (6 out of 11) of the patients were treated with surgery and 27% (3 out of 11) received anticoagulation. 73%, (8 out of 11) of the patients in our literature review presented with symptoms of acute limb ischemia. Ages ranged from neonate to 85 years old, though 82% (9 out of 11) were over the age of 50. Conclusion(s): Our literature review suggests that IAAT is a serious complication of COVID-19 infection. IAAT is more common in males and people over the age of 50, which aligns with the 52 year- old male patient who presented to our clinic with lower extremity claudication and bilateral 1st & 5th toe cyanosis after COVID-19 infection. To prevent devastating limb ischemia, we emphasize early evaluation of claudication symptoms in patients with COVID-19 or recent COVID-19 infection.
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The clinical evaluation of the patient with COVID-19 allows better care, application of safety criteria and preventive measures. The disease progresses from mild to severe and critical. In this work, is evaluated in patients with COVID-19 clinical format to identify moderate to severe stages of the disease. Following a cohort of male and female patients over 18 years of age admitted to the Infectology Service of the General Hospital of Mexico. Each patient is studied using the"COVID-19 Infectology"clinical format and in the first 24 hours of admission, a real-time RT-PCR molecular test is performed for SARS-CoV-2 infection. 65 patients classified as severe COVID-19 were studied, the RT-PCR was positive in 60 patients and negative in 5, clinical data did not differ from the positive ones and the 5 negative were considered false negative cases of the molecular test. There were no differences between positives and negatives with Fisher's test, and no difference in age, comorbidities, or prognostic evaluation with Student's t test. The conclusion is that the clinical format"COVID-19 Infectology"allows to recognize the cases and identify those that are in a severe evolution.Copyright /© 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.
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Introduction: TBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case Presentation: A 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient's irreversible neurological status. The patient was disconnected from ECMO and expired. Discussion(s): Though we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.Copyright © 2023 Elsevier Inc.
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Introduction: Extrapulmonary manifestations of COVID-19 must not be neglected during the pandemic. Subacute thyroiditis is one of the possible complications people encounter during post-COVID-19 days. Thyroid scintigraphy and radioiodine uptake test help discriminate hyperthyroidism from destructive thyrotoxicosis. Finding a more precise way to diagnose subacute thyroiditis can help in the early detection and treatment of thyroid-related disorders. Method(s): In this cross-sectional study, we evaluated 69 cases of COVID-19. Patients were divided into moderate and severe groups based on their clinical conditions. A thyroid scintigraphy scan was performed on the discharge day. Imaging was done 15-20 minutes after intravenous administration of 3-5 mCi of [99mTc]TcO4-. Scan findings were compared between moderate and severe groups and other participants' demographic and clinical features. Result(s): In 69 patients, according to thyroid scintigraphy, 25 (36%) cases were reported as thyroiditis, and the rest were normal. There was no significant difference between the normal and subacute thyroiditis groups based on age, gender, past medical history, the severity of COVID-19, laboratory values and clinical signs and symptoms. Patients with subacute thyroiditis experienced palpitation and sore throat significantly higher than the normal group (P=0.002 and P=0.009, respectively). Conclusion(s): We conclude that patients admitted due to acute COVID-19 infection experiencing palpitation and sore throat can develop subacute thyroiditis more than others. Whereas the severity of the disease and laboratory testing were not diagnostic in subacute thyroiditis, thyroid scintigraphy may help in early detection.Copyright © 2023 The Authors.
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A right atrial myxoma extending to the inferior vena cava with associated right-to-left shunting leading to systemic desaturation is an exceedingly rare clinical entity. The number of cases reported in the literature to date is not more than five. This case study presents a 45-year-old female who was referred to our center with symptoms of breathlessness, easy fatigability, generalized weakness, and central cyanosis. On routine blood investigation, polycythemia was detected. On preoperative 2D-transthoracic echocardiography, the diagnosis of right atrial mass was confirmed but the reason for cyanosis was not revealed. A tumor thrombus in a branch of the right lower pulmonary artery with a small locoregional pulmonary infarct along with right atrial myxoma was reported in computed tomography angiography of the heart and great vessels. On-table transesophageal echocardiography showed patent foramen ovale (PFO) with right-to-left shunting because of raised right atrial pressure and dynamic obstruction of the tricuspid valve by the mass. The myxoma was resected completely via right atrial approach along with primary closure of PFO. Postoperative period was uneventful, and the patient was discharged on day seven. At three-month follow-up, the patient was doing well.
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Arterial thrombosis encountered during sars-cov2 infections is a rare complication with a poor prognosis compared to venous ones. They generally occur in severe and critical clinical forms of covid19 [1,2]. The physiopathology of arterial thrombosis, even if not completely understood highlights hypercoagulability and excessive inflammation as risk factors with a major role of the endothelial lesions in their occurrence. The presence of cardiovascular risk factors in patients infected with covid19 is also discussed as a predisposing factor for arterial thrombosis [2,3]. We report the case of a North African male patient hospitalized for acute respiratory distress syndrome (ARDS) secondary to covid19 pneumonia, complicated by the occurrence of multiple arterial thrombosis of the aorto-iliac axis with the rare finding of two free floating thrombus in the aorta and the right common iliac artery. Clinically, the patient had developed acute bilateral lower limb ischemia and multi-organ failure and the evolution was dramatic with rapid worsening of the patient…s health and eventually his death. Thromboembolic complications are frequent during covid19 infection but the aortic localization is very rare. Its diagnosis is difficult and it has a poor prognosis. Our objective through this case report is to increase knowledge about arterial thromboembolic events while discussing their link to the sars-cov2 viral infection. © 2022
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COVID-19 is a severe respiratory disease with a spectrum of clinical presentations and complications. Warm autoimmune hemolytic anemia (WAIHA) is increasingly recognized in patients with COVID-19 either while infected or shortly after infection. We report a 36-year-old male with clinical and laboratory findings consistent with WAIHA. His medical history was significant for COVID-19 infection three months before presentation. He was initially resistant to steroids but had substantial improvement following initiation of rituximab, with complete recovery thereafter. Therefore, serial assessment of complete blood cell count parameters and hemolysis markers post-COVID-19 infections is warranted for early detection and prompt treatment.
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BACKGROUND AND AIM: The COVID-19 pandemic both highlighted the importance of identifying respiratory distress and limited in-person training to develop such skills. Respiratory distress caused by infections represents significant pediatric morbidity and mortality in low- and middle-income countries. The aim of this study is to conduct a needs assessment on trainees' attitudes about the identification and management of pediatric respiratory distress. METHOD(S): A needs assessment was conducted with medical students and residents at the University of Gondar Hospital, Ethiopia. Topics included comfort with identifying and managing pediatric respiratory distress and preferred teaching methods. The means for each teaching method were calculated. RESULT(S): Seventeen trainees were surveyed, including medical students (n=3) and residents (n=14). Trainees were very or somewhat uncomfortable with identifying nasal flaring (29%) and cyanosis (24%). Trainees were very or somewhat uncomfortable with the concepts of emergency triage assessment and treatment for children in respiratory distress (29%) and with applying bubble continuous positive airway pressure (35%). Almost all trainees (92%) indicated a need for training on the identification and management of pediatric respiratory distress. Trainees ranked practical skills as the preferred teaching method, followed by hands-on simulation, videos, and written tests. Based on the needs assessment, a video curriculum was developed to address identified gaps in pediatric respiratory distress education. CONCLUSION(S): There is a need for curricula about pediatric respiratory distress for trainees in global health settings. We have developed an instructional video curriculum to be piloted in Ethiopia in 2022. Research is needed to evaluate the curriculum's pedagogic outcomes.
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BACKGROUND AND AIM: Air leak syndrome is an uncommon complication for viral infections in pediatric patients and has been associated with pneumothoraces, empyemas, necrotizing pneumonias, barotrauma, and other underlying lung diseases. We present a case series of three patients with Coronavirus infections that developed severe air leak syndrome, two of which were placed on venovenous-extracorporeal membrane oxygenation (VV-ECMO). METHOD(S): Patient 1 (Pt1) is a 6-month-old male with a history of prematurity presenting with fever, cough, and respiratory failure with severe air leak syndrome requiring VV-ECMO support with SARS-CoV2. Patient 2 (Pt2) is a previously healthy 19-month-old female presenting with fever, cough, and respiratory failure with multiple pneumatoceles and pneumothoraces in the setting of coronavirus-OC43 requiring VV-ECMO support. Patient 3 (Pt3) is a previously healthy 25-day-old infant presenting with shock, cyanosis, apnea, multiple pneumothoraces and pneumatoceles, and subsequent respiratory failure with SARS-CoV2. RESULT(S): Pt1 and Pt2 developed multiple pneumothoraces with tension physiology and severe hypoxemia from necrotizing pneumonia with severe air leak, requiring multiple chest tubes, JET ventilation, and ultimately VV-ECMO support (see Figure 1). Pt3 developed multiple loculated pneumothoraces that necessitated surgically-placed chest tubes for decompression and JET ventilation for a 3+ week course. CONCLUSION(S): These cases highlight severe air leak syndromes as an infrequent and life-threatening complication correlated with Coronavirus infections. Viral illnesses such as SARS-CoV2 and Corona-OC43 and their associated multiorgan system disease have more recently impacted a larger number of pediatric patients and must be further evaluated to better understand underlying etiologies and compare management strategies. (Figure Presented).
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Background. Since the beginning of the pandemic and its passage through the different affected continents, there have been differences in the presentation depending in part on the characteristics of each population, so it is important to know how it behaves in the local population. Methods. Clinical-epidemiological study in adults hospitalized for suspected COVID-19 at the General Hospital 71 of the City of Veracruz, Mexico, from April to December 2020. Demographic and clinical characteristics are studied, as well as a comparative and stratified analysis was performed by intubation and death. Results. 1212 patients are included, 53% are men, average age 49 years. 20.5% reported sudden onset of symptoms;the most frequent: fever (79.8%), headache (75.2%), cough (71%), myalgia (62%), arthralgia (58%) and dyspnea (46.3%). Comorbidities were reported in 54.7%, the most frequent: Hypertension (29.2%), Diabetes (29.1%) and obesity (13.9%). Regarding the outcomes, 120 (9.9%) required intubation and 300 (25%) died. Men requiring intubation were significantly older than women [62.5 vs 37.5%;p = 0.027]. The mean age of the intubated patients was higher compared to that of the non-intubated [60.5 vs 44.8 years;p = 0.001]. The male gender had a risk association for intubation. The group aged 60 years or older compared to those aged 59 years or younger had a higher risk of intubation. Clinical variables that had a risk association with intubation were: dyspnea, chest pain and prostration. Among comorbidities, hypertension and diabetes had a risk association with intubation. Female gender and headache had a protective association for intubation. In addition, odynophagia, rhinorrhea, and abdominal pain showed a protective association for intubation. There was no difference in terms of gender by death. The mean age of the patients who died was significantly older [64.5 vs 43.8 years;p = 0.001]. The clinical variables that had a risk association with death were: dyspnea, chest pain, polypnea, cyanosis and prostration. The protective variables were: rhinorrhea, odynophagia, headache and conjunctivitis Conclusion. By studying a population affected by COVID, its own characteristics and inherent risks can be known to help take local diagnosis and treatment strategies that ensure a better outcome for those affected.
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Background: There are different studies on severity and mortality indices, such as the neutrophil/lymphocyte ratio (NLI), which has been relevant as a biomarker for mortality. However, indices where hemostatic factors are present, such as the FVIII/DD and FvW/ DD ratio, have not been established for mortality in the Mexican population. Aim(s): To determine whether the factor VIII and D-dimer (FVIII/DD) and the von Willebrand factor (VWF/DD) indices can be useful as markers of poor prognosis and mortality and to identify patients with a poor prognosis in cases of COVID-19 hospitalized from the National Institute of Respiratory Diseases. Method(s): A prospective, longitudinal study was carried out in which patients were admitted in the first 24 hours of hospitalization with a diagnosis of SARS-CoV- 2 infection with a test confirmed by PCR;In a period from March to November 2020, laboratory data were recorded to generate the FVIII/DD and FvW/DD indices, including clinical, epidemiological data and discharge status. Result(s): Data from 249 hospitalized patients with severe COVID-19 were analyzed. The clinical and laboratory characteristics are described in Table 1. The FVIIIDD24H and FVWDD24H indices were constructed by dividing each FVIII data by its corresponding DD data. and in the same way it was done with the VWF. The medians of these indices were then compared between the presence or absence of cyanosis, ventilatory status, and mortality. A value >115 was established as the cut-off point for the DD/FVIII and DD/FvW index to predict mortality, which are shown in Figure 1. Conclusion(s): Low FVIIIDD24H and FVWDD24H levels on admission were associated with cianosis, severe COVID-19 and mortality. Likewise, it was shown that the cut-off point < or equal to 115 is a prognostic factor for mortality in this cohort of patients hospitalized for covid-19. (Table Presented).
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BACKGROUND: The rapid worldwide spread of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) or COVID-19 pandemic from its epicenter;Wuhan was first reported in December 2019. Egypt reported its first COVID-19 case on February 14, 2020. Thereafter, Egypt scaled-up preventive measures, with a partial lockdown starting on March 25. Several therapeutic agents along with convalescent plasma transfusion (CPT) are under investigation and data from CPTs have been receiving a lot of attention, after Emergency approvals from the Food and Drug Administration suggesting that it may provide a clinical effect in the treatment of SARS-COV-2. IMPORTANCE: Early and effective treatment of COVID-19 is vital for control of SARS-CoV-2 infection. METHODS: Designs: An interventional, single-arm, and non-randomized clinical trial conducted in Egypt from April 15 to July 21, 2020. Settings: This was a multi-center study conducted in three hospitals in Egypt. Participants: A total of 94 COVID-19 laboratory-confirmed patients using quantitative real-time polymerase chain reaction were enrolled in the study. Intervention: All patients were administered with two plasma units (each unit is 200 cc). The volume of donated plasma was 800 cc. Main Outcome and measures: Primary measure was the degree of clinical improvement among the COVID-19 patients who received CPT within 7 days. RESULTS: A total of 94 patients were enrolled who received CPT either within 7 days or after 7 days of hospitalization. 82 were severely ill and 12 were critically ill. The average age remained 58 years (±standard deviation 15.1 years). Male were 69% and 49% patients got cured while 51% died with case fatality rate 51%. Seventy-five percent deaths were above 45 years of age. The symptoms were dyspnea (55%), fever (52%), cough (46%), and loss of taste and smell (21%), and cyanosis (15%). The most common co-morbidities among the <40 years remained diabetes mellitus (21%) and asthma (14%). Among 40–60 years hypertension (56%), diabetes mellitus (39%) and among >60 years age group hypertension (57%), and chronic heart disease (24%) were reported. CPT within 7 days remained significant as compared with the CPT after 7 days with the number of days to cure (p=0.007) and ICU stay (p = 0.008) among severely ill cured cases. CONCLUSIONS: Among patients with COVID-19 and severe or critical illness, the use of CPT along with routine standard therapy resulted in a statistically significant improvement when administered within seven days of hospital admission. However, plasma transfusion, irrespective of days to transfusion may not help treat critically ill patients. The overall mean time to cure in severely ill patients was 15 days if CPT provided within 7 days with 65% cure rate. TRIAL REGISTRATION: Clinical Intervention identifier: MOHP_COVID-19_Ver1.1 registered April 2020.
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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: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal
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SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Methemoglobinemia is an increase in methemoglobin (mHb) level characterized by functional anemia and tissue hypoxia. It can be caused by congenital enzymes deficiencies, but it is usually acquired. Dapsone, an oxidizing agent, is a medication commonly associated with acquired methemoglobinemia (1). We describe the diagnosis and management of a COVID-19 patient with acquired methemoglobinemia due to Dapsone. CASE PRESENTATION: 84-year-old female with history of MPO-ANCA vasculitis with renal involvement, CKD4 and anemia of chronic disease presented with shortness of breath, lethargy and weakness. Initially, the patient was saturating (SpO2) 80% on room air and was placed on 4L nasal cannula (NC) with improvement to 92%. CT of the chest showed b/l GGOs consistent with atypical pneumonia and patient tested positive for COVID-19. About 4 months prior, she had received 2 doses of Rituximab and on high steroid therapy that was tapered to 5mg of prednisone daily. She has been on Trimethoprim/Sulfamethoxazole for PJP prophylaxis, but due to hyperkalemia the medication was stopped. After confirming no G6PD deficiency, she was started on Dapsone 100mg daily. During hospitalization, she was given dexamethasone 6 mg daily and Dapsone was continued. On hospital stay day 6, a rapid response was called after oxygen dropped to 78% while walking on 6L NC. She was placed on high flow NC 100% and SpO2 went up to 90%. An arterial blood gas (ABG) was then obtained showing pO2 of 334, oxyhemoglobin (oxyHb) of 83 and mHb of 17.4. The SpO2-PaO2 gap and elevated mHb lead to the diagnosis of Dapsone-induced methemoglobinemia. Dapsone was discontinued. Patient received a one-time dose of 1mg/kg IV of methylene blue. One hour later her dyspnea had improved and was on 3L NC. Repeat ABG showed improvement of oxyHb (98) and decreased mHb (2.2). DISCUSSION: Physiologically, mHb is less than 1% of total Hb (1) and occurs when the iron in the porphyrin group of heme is oxidized from ferrous to the ferric form (2). Ferric heme binds oxygen irreversibly causing a left shift of the oxygen-hemoglobin dissociation curve. Clinical presentation tends to correlate with mHb levels, and it varies from being asymptomatic to fatigue, dyspnea, confusion, seizure, cyanosis resistant to oxygen therapy (mHb > 15%) and death. Methylene blue is safe and can be consider when mHb level is greater than 10 to 20% (2). Methylene blue was administer to our patient given the presence of COVID (leaving patient more susceptible to medication-induced methemoglobinemia (3)) and chronic anemia which made her less likely to tolerate state of reduced oxygen delivery. CONCLUSIONS: The diagnosis of methemoglobinemia is a rare cause of hypoxemia that is often overlooked. In patients with risk factors (COVID, medication exposure) a high index of suspicion is needed when interpreting an ABG (SpO2-PaO2 gap) for correct diagnosis and appropriate treatment. Reference #1: Toker, Ibrahim, et al. "Methemoglobinemia Caused by Dapsone Overdose: Which Treatment Is Best?” Turkish Journal of Emergency Medicine, vol. 15, no. 4, Dec. 2015, pp. 182–184, 10.1016/j.tjem.2014.09.002. Accessed 31 Aug. 2020. Reference #2: Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothorac Vasc Anesth. 2014 Aug;28(4):1043-7. doi: 10.1053/j.jvca.2013.02.005. Epub 2013 Aug 13. PMID: 23953868. Reference #3: Naymagon, Leonard, et al. "The Emergence of Methemoglobinemia amidst the COVID -19 Pandemic.” American Journal of Hematology, vol. 95, no. 8, 3 June 2020, 10.1002/ajh.25868. Accessed 3 Mar. 2021. DISCLOSURES: No relevant relationships by Mileydis Alonso No relevant relationships by Samantha Gillenwater No relevant relationships by Christine Girard No relevant relationships by Sikandar Khan No relevant relationships by Jose Rivera No relevant relationships by Frederick Ross
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SESSION TITLE: Occupational and Environmental Lung Disease Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Chlorine gas is a pulmonary irritant with pungent odor that damages the respiratory tract. Chlorine gas exposure occurs in industrial or household exposures,Chlorine gas has two forms either a liquid or gas, toxicity of chlorine gas depends on the dose and duration of exposure. Chlorine gas used in manufacturing products like paper, insecticides, Chlorine is used to treat bottled and swiming pool water. CASE PRESENTATION: A 37 Y.O Male, no PMH presents with progressive dyspnea for three days worse with activity,decreases with rest, denied cough fever or chest pain he is vaccinated for COVID,no smoking history. The patient worked at a chlorine gas factory in the Dominican Republic for 15 years. Exam: Vitals: BP 124/72 mmHg. HR 100 BPM. RR 21 BPM. SpO2 84%. General: acute distress. Heart: normal S1, S2. RRR. Lung: wheeze bilaterally. Abdomen: Soft. Musculoskeletal: no pitting edema. he was placed on 6 LPM NC saturation improved to 90%. CBC and Chemistry were unremarkable, he was started on steroid, breathing treatment with antibiotics. ABG showed hypoxemia. he was placed on Venturi mask and his saturation improved to 95%.CTA was negative for PE. EKG, troponin were unremarkable. A proBNP normal. The antibiotics were discontinued because of a negative workup. A TTE study was normal. HRCT scan of the chest, showed atelectasis and infiltrates of lower lobes. No interstitial fibrosis.A PFT showed obstructive airway disease. He was discharged on oral and inhaled steroids.Hi new onset obstructive airway could be due to chlorine gas exposure. DISCUSSION: Chlorine gas causes cellular injury through oxidative damage but further damage results from activation and recruitment of inflammatory cells with subsequent release of oxidants and proteolytic enzymes. Humans can detect chlorine gas odor at a concentration between 0.1-0.3 ppm. At 1-3 ppm,it causes irritation of oral,eye mucosal membranes. At 30-40 ppm causes cough, chest pain, and SOB. At 40-60 ppm, toxic pneumonitis and pulmonary edema and can be fatal at 430 ppm concentration or higher within thirty minutes. Chronic exposure to chlorine gas lead to chest pain, cough, sore throat, hemoptysis, recurrent asthma. Physical exam findings include tachypnea cyanosis, wheezing, intercostal retractions, decreased breath sounds. Pulmonary function tests may reveal obstructive lung function disease. Chronic exposure to a low level was found to be associated with an increased risk of asthma in swimmers. CONCLUSIONS: Chlorine exposure results in direct chemical toxicity to the airways with acute airways obstruction or airways hyperreactivity, presentation varies from acute overwhelming intoxication with acute lung injury and or death, occupational exposure increase the likelihood of chronic bronchitis or isolated wheezing attacks. Treatment for chlorine exposure is largely supportive. Reference #1: 1- Center of disease control and prevention website/emergency preparedness and response/ https://emergency.cdc.gov/agent/chlorine/basics/facts.asp Reference #2: 2- C- Morim A, Guldner GT. Chlorine Gas Toxicity. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537213/. Reference #3: A- Gummin DD, Mowry JB, Beuhler MC, et al. 2020 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021;59(12):1282-1501. doi:10.1080/15563650.2021.1989785 DISCLOSURES: No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib no disclosure on file for Matthew Yotsuya;
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SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman
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Aim and background: Alcohol intoxication can complicate detection and timely management of poisoning. Case report: A 52-year-old male was found unconscious at home following heavy alcohol drinking. He presented in emergency department in the gasping state, with hypoglycemia and un-recordable BP. He had tension pneumothorax which was managed accordingly and put into mechanical ventilation, resuscitated with fluids and dextrose. However, in view of persistent hemodynamic instability needing triple inotropes, refractory hypoxemia with cyanosis on a mechanical ventilator and dark brown colored blood co-oximetry was done which showed severe methemoglobinemia. Patient was treated with intravenous methylene blue which led to a dramatic recovery. The inciting event came out to be the ingestion of paintthinner liquid under the influence of alcohol. Conclusion: We report a case of severe methemoglobinemia due to paint-thinner ingestion. High index of suspicion and timely management with methylene blue can save patients of severe methemoglobinemia.