A Thorn in his Side

History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.

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.

Herpes Gastritis: A Rare Cause of Gastric Outlet Obstruction

Introduction: Gastrointestinal tract involvement from herpes simplex virus is commonly associated with esophagitis. However, herpes simplex infection of the stomach is very rare with only a handful of cases being reported in immunocompromised patients. We present a case of herpes gastritis causing gastric outlet obstruction in an otherwise healthy, immunocompetent individual. Case Description/Methods: A 37-year-old male with a recent past medical history of COVID-19 infection, presented to the hospital with intractable nausea, vomiting, bloating, and early satiety for two days. Upon evaluation, CBC and CMP were remarkable for a WBC of 12.5 k/mm3 and ALT and AST of 124 U/L and 129 U/L, respectively. Lipase was 373 U/L. A CT abdomen/pelvis w/contrast showed circumferential wall thickening with edematous changes in the antrum consistent with localized inflammatory response. There was suspicion for gastric lymphoma and patient was admitted for further workup. An EGD was performed which showed exudative esophagitis and antral wall edema with luminal narrowing of gastric antrum. Endoscopic ultrasound (EUS) showed a 2.5 x 3 cm antral wall lesion worrisome for linitis plastica. Esophageal biopsies showed focal cytologic changes consistent with herpes esophagitis. The FNA of the gastric antral wall showed multinucleation of the basal cell layer with classic ground glass nuclei, consistent with herpes infection. No dysplasia or malignancy was seen. Both HSV1 and HSV2 IgG were elevated. HSV IgM was normal. A HSV PCR was ordered but never resulted. Patient was started on Valacyclovir 1 g PO BID for 10 days. He underwent a follow-up EGD 3 months later which showed complete resolution of the gastric antral changes (Figure). Discussion(s): Herpes gastritis is extremely rare. Literature review has revealed only 3 case reports of herpes gastritis;and all involved immunocompromised patients. To the best of our knowledge, this is the first case of herpes gastritis in an immunocompetent patient. Our patient presented with symptoms of gastric outlet obstruction which was caused by local inflammation from herpes simplex. It is unclear if having a COVID 19 infection altered patient's immunity and lead to herpes gastritis. This may need further investigation. No established guideline exists for treatment duration. Our patient received 10-day course of Valacyclovir, and his symptoms improved. Furthermore, patient had complete resolution of the herpes infection on follow-up EGD, indicating adequate treatment response.

A Controversy: Warfarin Failure in Covid-19 with Supratherapeutic Inr

Background COVID-19 has been previously associated with thromboembolism. We present a unique case of a patient who was compliant with warfarin and yet developed breakthrough Deep Venous Thrombosis after recently being diagnosed with COVID-19. Case A 49-year-old female with past medical history of rheumatic fever complicated with mitral stenosis and treated with mechanical mitral valve replacement in 2003, presented with right-sided leg swelling, warmth, and pain for the past 1 week. She tested positive for COVID-19 almost 2 weeks ago but was not hospitalized or treated due to minimal symptoms. She had been on warfarin for the last 19 years due to underlying mechanical valve with an INR (international normalized ratio) goal of 2.5-3.5. On examination, the right calf was swollen and tender to palpation. Homan sign was positive. INR was elevated to 9.88 (a month ago it was within the therapeutic range of 2.5-3.5). The rest of the lab work up including fibrinogen levels, PT, aPTT, CBC, and CMP was unremarkable. A lower extremity venous duplex was performed that came back remarkable for acute right popliteal DVT. Decision-making Warfarin was held considering elevated risk of bleeding. INR was repeated daily and once it was below 2.5, therapeutic dose of enoxaparin 1mg/kg twice daily was started for 3 months. Due to limited anticoagulation options, a shared decision was made to place the patient back on warfarin, since she was out of the window of COVID-19 infection. She was not a candidate for DOAC's considering her mechanical valvular heart disease history and patient did not want to consider invasive interventions as well. Conclusion Our case study is the first ever reporting warfarin failure with supratherapeutic INR due to COVID-19 infection. It also raises concerns if warfarin is safe to use in COVID-19 patients, which might need further research studies to have clear answers. In patients with mechanical heart valves and supratherapeutic INR who present with concerns of warfarin failure, treatment options are limited. Recommended management is holding warfarin to achieve therapeutic INR levels, switch to enoxaparin temporarily, and eventually placement of IVC filter.Copyright © 2023 American College of Cardiology Foundation

Mineralizing angiopathy: an underrecognized clinicoradiologic entity

Case Report: Initial History/Presentation: A term vaccinated 7-month-old male with a history of eczema presents with two hours of right-sided hemiplegia and hemidystonia. Parents deny loss of consciousness, altered mental status, or facial symptoms. He has no known history of recent or remote head trauma. Patient may have had COVID two months prior when he had upper respiratory symptoms, with his mother testing COVID+ at that time. Of note, he received a Moderna COVID vaccination one day prior to onset of symptoms. Physical Exam: Pertinent exam findings include CN II-XII intact, right-sided upper and lower extremity strength 3/5, sensation intact, and truncal ataxia while seated. Physical exam is otherwise unremarkable. Diagnostic Evaluation: Initial lab work revealed leukocytosis (20.9), but otherwise a reassuring CMP, triglycerides, HDL, and LDL. PTT was elevated, but normal on recheck. Protein C antigen and activity were low, but deemed non-concerning by hematology. All other hypercoagulable labs were normal. On imaging, CT Brain showed linear calcifications in bilateral basal ganglia suggestive of mineralizing angiopathy. HisCTA head/neckwas negative.MRI Brain revealed an acute infarct of the body/tail of the left caudate nucleus, posterior limb of internal capsule, and posterior putamen. Clinical Course/Follow-up: Our patient was started on Aspirin 4 mg/kg daily. Throughout the course of his 3-day inpatient stay, he had mild improvement of right-sided strength and function, and continued improvement upon follow-up with his pediatrician. Given the short interval between receiving his COVID vaccination and onset of symptoms, his case was reported to the Vaccine Adverse Event Reporting System. Conclusion(s): From a radiological perspective, mineralizing angiopathy is an uncommon but familiar finding seen in up to 5% of all neonatal head ultrasounds and increasing to nearly 20% in preterm infants. It is most commonly associated with infection, hypoxia, and chromosomal abnormalities but is usually of minimal clinical significance. However, there are numerous reports of basal ganglia and thalamic strokes following minor head trauma in children with mineralizing angiopathy. For radiologists, this association is important to recognize and relay to the primary team so targeted history and MRI, if indicated, may be obtained to expedite definitive diagnosis and initiation of treatment to preserve precious brain tissue. Without a history of head trauma, in this case, stroke provocation is unclear, and other infectious or inflammatory disorders could appear similarly if they induced vasospasm or blood pressure lability. A short-interval timeframe between COVID vaccine administration and symptom onset is likely incidental, but research to exclude or illicit any link may be of benefit. Findings of mineralizing angiopathy on CT in the appropriate clinical setting should prompt further evaluation with emergent MRI to determine the presence of basal ganglia or thalamic stroke. Copyright © 2023 Southern Society for Clinical Investigation.

A Folk Remedy for a Bellyache

Introduction: This case describes a curious cutaneous finding with a unique etiology from a cultural remedy. Case Description: A 19-month-old female was brought in by ambulance for an acutely progressive abdominal rash. Three days prior to presentation, she had a febrile seizure. The next day, she continued to have low grade temperatures and developed a faint red rash on the abdomen. On the day of presentation, the mother found a dark violaceous rash on the abdomen and called 911. The patient's presenting vital signs were unremarkable except for tachycardia to 133 and lower blood pressure for age of 86/67. She was tired and irritable. She had a large welldemarcated dusky and dark plaque with central denudation over the whole abdomen and right lateral back [Figures]. She was exquisitely tender to light palpation and guarding her abdomen. The remainder of her exam was unremarkable. Given the extent of her skin injuries, differential included intra-abdominal injury, intra-abdominal hemorrhage, burn or bruise from accidental and non-accidental cause, allergic dermatitis and disseminated intravascular coagulation in the setting of sepsis. Laboratory evaluation revealed mildly low hemoglobin for age at 10.5 g/dl with low MCV 74.2fL and a leukocytosis with WBC of 18.41 x10-3 πl with neutrophil predominance. Coagulation factors were normal. CMP revealed mild acidosis with CO2 of 17 mmol/L. Imaging studies included normal: CT head and CT abdomen with mild subcutaneous edema in the anterior abdomen near the umbilicus. Additional infectious studies were negative including nasal SARS-CoV-2 PCR, blood culture and urine culture. After the work-up, findings were consistent with a second-degree burn confirmed by Dermatology and Plastic Surgery. Suspected Child Abuse and Neglect team conducted additional social history with maternal grandmother because she is the caretaker when parents are at work, given parental denial of witnessing or causing the burn. Grandmother had limited English proficiency, so history was taken using a Medical Spanish interpreter. Grandmother explained that one day prior to presentation, she used an Oaxacan folk remedy to alleviate abdominal pain in which green tomato pulp was applied like a salve. Final diagnosis was second degree burn from phytophotodermatitis. Patient's skin improved with daily dressing changes and application of silver sulfadiazine, and she was discharged home to parents. Discussion: The use of tomato salve is a unique etiology of phytophotodermatitis that has not been well-characterized. Typical vegetation that causes burn injuries include figs, lemons and common wildflowers. Tomatillos or green tomatoes contain plant psoralens that can induce a strong phototoxic reaction to ultraviolet A radiation exposure after cutaneous contact. Conclusion: We present this case to highlight the importance of conducting thorough social history in the family's preferred language and to share a unique folk practice that can present as a severe burn and mimic child abuse.

MANAGEMENT OF METHAMPHETAMINE INDUCED PNEUMONITIS

CASE: A 35-year-old female with history of pulmonary coccidiomycosis s/p treatment 15 years ago, ex-smoker who quit 8 years ago, unvaccinated for COVID-19 presented with two weeks of progressively worsening shortness of breath, fever, chills, generalized body aches, sore throat with hoarseness of voice, nonproductive cough, wheezing and midsternal chest pain. Denied sick contacts, recent travel, allergies or bird contact. On presentation, vitals were significant for hypoxia with SpO2 84% requiring 2L of nasal canula, sinus tachycardia to 109, tachypneic in 30s. Physical exam showed stridor and bilateral diffuse expiratory wheezing. Stridor improved with racemic epinephrine and dexamethasone 10mg IV. CBC, CMP, Procalcitonin, BNP, COVID-19 and Respiratory PCR were negative, while coccidioidomycosis antibody was positive. UDS was positive for methamphetamine. Chest X-ray showed features of atypical pneumonitis. CT Chest showed similar findings and was negative for pulmonary embolism. She was managed symptomatically with albuterol inhaler. Respiratory symptoms improved during hospitalization without any further interventions. IMPACT/DISCUSSION: Methamphetamine can cause toxic lung parenchyma injury irrespective of frequency of use. With recent increase in use of methamphetamine, paucity of literature and unclear mechanism in lung injury, it is important for physicians to be aware of methamphetamine associated lung injury as a differential diagnosis of acute/subacute respiratory distress with the risk factors of illicit drug use in the era of COVID pandemic. According to National Survey on Drug Use and Health (NSDUH) in 2018, 1.6 million people (age > 26 years) used methamphetamine in one year which is 0.5% more than 2016-2017. Crystalline methamphetamine is a widely used inhaled stimulant with few reported cases of acute respiratory distress syndrome, eosinophilic pneumonia, pneumonitis, and diffuse alveolar hemorrhage. Even though the mechanism of injury is unclear in human beings, toxicity was studied in animals. Chronic methamphetamine use causes thickened alveolar walls and reduced alveolar sacs by oxidative stress and by increased free radical formation. Patients often present with non-specific symptoms including cough, shortness of breath, sore throat or chest pain. The temporal relation of symptomatology with methamphetamine use and exclusion of infectious and other pulmonary etiology based on labs and radiological findings are crucial in establishing the diagnosis. Early diagnosis, symptomatic treatment and cessation of substance use are core management. CONCLUSION: We discussed a case of methamphetamine-induced pneumonitis, who presented with upper and lower respiratory symptoms that resolved dramatically with the early diagnosis and supportive care. We recommend considering methamphetamine-induced lung injury as a differential diagnosis in patients with risk factors of illicit drug use, especially in the era of the COVID-19 pandemic for early diagnosis and appropriate management.

A CASE OF POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME AFTER MRNA COVID-19 VACCINE

CASE: Ms.X is a 31-year-old female with an unremarkable medical history who presented to the general medicine clinic with palpitations that started 3 days after taking her second dose of Pfizer Covid vaccine. The palpitations ocurred exclusively when standing, with no associated chest pain, dizziness, or presyncope. History is negative for tobacco smoking, drug or alcohol use, and consumption of energy or caffeinated beverages. The physical examination was notable for moist mucous membranes and normal volume examination. Orthostatic vitals were remarkable for an increase in HR by 30 beats with minimal change in BP. EKG showed a normal sinus rhythm, and lab workup inclusive of a CBC, CMP, and TSH was unremarkable. As such, the patient was referred for tilt-table testing. Within 8 minutes of upright tilting, HR was137 from a baseline of 77, and BP was 144/108 from 125/71. A looprecorder was inserted which revealed presence of patient triggered episodes of sinus tachycardia upon standing. The patient was started on propranolol 10 mg every 4-6 hours while awake with almost complete resolution of palpitations. IMPACT/DISCUSSION: The incidence of POTS is 0.2-1% in developed countries, with a 5:1 female-male ratio. It presents with orthostatic symptoms like light-headedness, presyncope, and palpitations. It can occasionally present with non-orthostatic symptoms like nausea, bloating, and diarrhea. The pathophysiology is not well-understood but is postulated to be due to an autoimmune disorder, abnormally increased sympathetic activity, and/or sympathetic denervation leading to central hypovolemia and reflex tachycardia. It is a diagnosis of exclusion, but table-tilt test is used to help confirm it. The onset is typically precipitated by immunological stressors like viral infections, vaccination, and pregnancy. Recently, several case reports have been published describing POTS following infection with COVID-19 infection. This was described as long-COVID postural tachycardia syndrome by the American Autonomic Society. However, the association of POTS with COVID-19 vaccine is unclear. Only one case report was published describing the development of POTS after COVID-19 mRNA vaccine. Information relating to this remain limited, and approach to diagnosis and treatment is variable. Our understanding of this condition in relation to vaccination is mostly extrapolated from previously published reports describing it in relation to HPV vaccine. As more people continue to take the vaccine, physicians should be alert to the diagnosis. CONCLUSION: POTS is a frequently underdiagnosed or misdiagnosed disorder. It is characterized by an increase in HR by 30 within 10 minutes of standing . In rare instances, it has been described as a postvaccination adverse immune phenomena, and more recently related to mRNA COVID-19 vaccination. Increased recognition, diagnosis, and reporting will contribute to better understanding and treatment.

MYSTERIOUSLY PUFFY EXTREMITIES: AN UNINTENDED CONSEQUENCE OF IV DRUG ABUSE

CASE: A previously healthy, 27-year-old Caucasian male presented with erythema and edema in his extremities. He endorsed multiple years of injecting heroin into numerous areas from his chest to his toes, including both upper extremities. The patient was seen six months ago at local urgent care for swelling of both of his dorsal feet and a small abscess with surrounding cellulitis of the right hand. He was given a dose of Ceftriaxone and a 2-week course of Augmentin, which he completed with moderate improvement. A month prior to his presentation, he reported that this swelling started asymmetrically;it started in his legs, then in his right arm, and then in his left arm. He denied any discharge from any site on his skin. He last injected heroin the morning of his admission. He denied fever, shortness of breath, pleuritic chest pain, orthopnea, dyspnea on exertion, and any urinary symptoms. On presentation, he was afebrile and saturated 98% on room air. His extremities were warm, normal capillary refill, and distal pulses were strong and symmetric. There were also pitting edema in the right hand with associated volar erythema, pitting edema in the right foot, and left-hand edema with a punctate area around the mid-arch with associated tenderness to palpation without overlying redness, crepitus, or fluctuance. Blood cell count revealed mild leukocytosis to 12.0. CMP was unremarkable. While the infectious disease team was consulted for further evaluation, he was started on cefazolin 1g for 10 days. The urine drug screen was positive for benzodiazepines, THC, cocaine, and opiates. HIV negative, Covid negative, and blood cultures showed no growth. Histoplasma/ Blastomyces urine antigens were negative. Urinalysis without evidence of proteinuria, and transaminases were within the normal limit. Ultrasound showed occlusive cephalic vein thrombosis in the right upper extremities. Cefazolin was discontinued. Based on the presentation, the history, and the evaluation, it was concluded to be Puffy Hand Syndrome. IMPACT/DISCUSSION: Puffy hand syndrome is a form of lymphedema caused via the sclerosing nature of intravenously administered drugs, which our patient extensively utilized. Described by Abeles in 1965 as seen in New York prisoners, it affects between 7 to 16% of intravenous drug users. Its pathology is suspected to be caused due to a combination of lymphatic and venous insufficiency. Differential diagnosis of this syndrome involves identification of infection alongside cardiac or renal insufficiency, and edematous scleroderma. Treatment is mostly symptomatic. Patients are advised to stop IV drug use. Long-term use of low-stretch bandages and compression may be useful in decreasing the puffiness of the extremities. CONCLUSION: With the quality of care for drug addicts being a critical area of interest, this case displays a common drug abuse complication clinicians raise awareness for. This observation presents an opportunity to identify a possible drug abuser and intervene accordingly.

A case of direct hyperbilirubinemia in the setting of multisystem inflammatory syndrome in children with incidental gallbladder agenesis

Case Report In April 2020, cases of multisystem inflammatory syndrome in children(MIS-C) were reported from the UK as clinical presentations similar to incomplete Kawasaki and toxic shock syndrome in the setting of COVID-19. MIS-C is a rare but significant complication of COVID-19. We present the case of direct hyperbilirubinemia associated with MIS-C with incidentally discovered gallbladder agenesis. Case presentation A 16-year-old male presented with fever, epigastric pain, jaundice, and rash. He tested positive for SARS-CoV-2 one month prior, improved clinically, but developed fever one day before presentation. Physical exam revealed a diffuse maculopapular rash, jaundice, and right upper quadrant tenderness. Vitally stable. Work up for MIS-C revealed positive SARS-CoV-2, lymphopenia, ESR 23 mm/hr, fibrinogen 552 mg/dl, CRP 8.94 mg/ dL. Troponin, BNP, and coagulation profile were normal. Echo and CXR were unremarkable. CMP showed ALT 242 IU/L, AST 145 IU/L, total bilirubin of 5.7 mg/dL with direct bilirubin of 3.9 mg/dL, GGT 178 IU/L, consistent with obstructive jaundice. Workup for autoimmune hepatitis and viral hepatitis was negative. US right upper quadrant was done to rule out an obstructive pathology, which was normal except that it showed an absent gallbladder. MRCP and HIDA scan also showed no obstructive pathology and confirmed gallbladder agenesis. With no clear reason for direct hyperbilirubinemia, treatment for mild MIS-C was initiated with IV dexamethasone. Repeat blood work after 24 hours showed down trending bilirubin levels and stable liver enzymes, patient was discharged shortly afterwards. At one month follow up, liver enzymes and bilirubin normalized. Discussion Presentations of MIS-C vary with the most common being persistent fever along with gastrointestinal, respiratory, neurological, skin, and/or cardiac involvement. Acute hepatitis with elevated liver enzymes is a well-documented lab finding but direct hyperbilirubinemia is rare. Another interesting finding in our case was gallbladder agenesis, which is a rare congenital anomaly (incidence 10-65 per 100,000). Conclusion We highlight in our case report that cholestatic jaundice, despite being a very rare manifestation of MIS-C, can still occur. A multidisciplinary approach should be taken when treating such patients including GI, cardiology, rheumatology, and infectious disease.

Hematologic abnormalities and venous thromboprophylaxis in MIS-C: Data from a multi-disciplinary working group at a pediatric tertiary care hospital

Background: On May 15, 2020 the World Health Organization published the preliminary case definition of multisystem inflammatory syndrome (MIS-C) in children and adolescents, a new clinical entity in the evolving COVID-19 pandemic. COVID-19 associated coagulopathy, with prominent elevations in d-dimers was widely reported in adults;in contrast to the sepsis-related disseminated intravascular coagulation (DIC), adult patients demonstrated hypercoagulability, not bleeding, with approximately 25% having overt venous thromboembolism (VTE)., There are limited data regarding coagulopathy and hypercoagulability in pediatric patients with acute COVID-19 or MIS-C to guide treating physicians in optimal management including VTE prevention strategies. We report the hematologic findings, VTE prophylaxis strategy, and thrombotic outcomes in a cohort of patients at a single pediatric center. Objectives: NA. Methods: At Children's Wisconsin we rapidly convened a multi-disciplinary MIS-C working group to create guidelines for evaluation and treatment of suspected/confirmed MIS-C patients. A MIS-C panel, including CBC, CMP, DIC panel, ESR, CRP , ferritin, troponin I, pro BNP, and COVID PCR was obtained for all patients presenting to the ER with fever for ≥4 days plus any of the following: GI symptoms, rash, bilateral non-purulent conjunctivitis, cough, headache , and/or irritability. Specialty-specific treatment guidelines, including modifications of an existing VTE prophylaxis guideline, were established (Table 1). As a quality improvement measure, we performed electronic query of the use of the MIS-C panel including evaluating laboratory trends, and outcomes of cases receiving specific therapeutics, including anticoagulation. We present data regarding hematologic findings and outcomes of VTE prophylaxis in this cohort. Results: As of October 20, 2020, a total of 56 patients had an MIS-C panel obtained in the ER, of whom 12 (21.4%) met full criteria for MIS-C (Table 2). Of these, mild CBC abnormalities predominated as did mild coagulopathy, elevated fibrinogen levels, and d-dimers (on average 5.5 × upper limit of normal) (Table 2). Three (25%) patients met criteria for VTE prophylaxis with enoxaparin which was continued during hospitalization in 1 patient, and for 2 weeks following hospital discharge in the remaining 2. There were no reported thromboses in any patients, including those who did not meet criteria for thromboprophylaxis. Enoxaparin was well tolerated, and no patients had bleeding events despite having mild coagulopathy. Conclusions: We report an approach to evaluation of MIS-C, the hematologic abnormalities, and successful use of a VTE prophylaxis strategy in children. Given the drastic increase in COVID-19 cases in Wisconsin and the US as of October 2020, and limited large-scale pediatric studies to guide patient care, we recognize the importance of our own institutional surveillance and the need for collaboration amongst pediatric providers to gather data on outcomes of such patients. (Table Presented).

Atrial fibrillation is associated with poor clinical trajectory of COVID-19

Background: Atrial fibrillation (AF) has been described as a common cardiovascular manifestation in patients suffering from coronavirus disease 2019 (COVID-19) and is discussed to be a potential risk factor for a poor clinical course. AF is also already known to be associated with increased risk for all cause death. Purpose: In the present study we sought to investigate the impact of AF on the clinical trajectory of patients suffering from COVID-19. Methods:We included all patients hospitalized due to COVID-19 in 2020 in our Hospital. A poor clinical trajectory was defined as transfer to intensive care unit (ICU), intermediate care unit (IMC) or death from any cause. Initial ECGs were analyzed in consensus by two experienced readers. First, we compared patients with poor clinical trajectory vs. good clinical course. Secondly, the study population was categorized into two groups with or without AF on admission. A subgroup analysis was performed to differentiate between new onset AF and patients with known history of AF. To compensate for confounders (age, BMI, known cardiomyopathy (CMP), known coronary artery disease (CAD), chronic airway disease, renal insufficiency, diabetes, arterial hypertension and sex), a full clinically validated multiple logistic regression model with poor clinical trajectory as dependent target variable was performed. Results: From our enrolled 666 patients in 2020 (58% male, average age: 66 (IQR:58-80)) 223 patients (33.5%) experienced a poor clinical course. 179 (27%) patients were transferred to IMC/ICU and 86 (13%) patients died. All in all, patients with poor clinical trajectory were more frequently male (70% vs. 52%;P<0.001), older (71±14 vs. 64±20;P<0.001) and had significantly more co-morbidities such as CAD, CMP, hypertension and diabetes in comparison to patients with a good clinical course. 96 (14.4%) had AF on admission. Among these 37.5% had new-onset AF, which showed similar baseline characteristics as patients without AF. Indeed, patients with COVID-19 and new onset AF were more likely to die (25% vs 12%;P=0.038), or be in need for ICU/IMC (25% vs. 62%;P<0.001) and therefore experienced a poor clinical trajectory more frequently (75% vs. 31%;P<0.001) with a confounder adjusted OR of 5.89. In the subgroup analysis of all patients with AF on admission. Patients with new onset of AF had significantly more underlying CMP, Diabetes and chronic airways disease. While mortality was not higher in patients with new onset of AF, IMC/ICU transfers (62% vs 24%;P<0.001) and as a result poor clinical trajectory (75% vs 40%;P=0.001) was significantly increased in comparison to patients with known AF. Conclusion: In patients suffering from COVID-19, new onset of AF on admission was associated with a poor clinical course and higher in-hospital mortality.