Rapid exchange of a percutaneous gastrostomy tube during an early episode of COVID-19

We retrospectively report a case of rapid exchange of a percutaneous radiologic gastrostomy tube (balloon-occluded type catheter) via off-label use of a pigtail catheter for nutrition supply during a very early episode of coronavirus disease 2019 (COVID-19) in an outpatient clinic. This case demonstrates that minimally invasive percutaneous procedures might be provided safely and effectively under appropriate precautions for preventing COVID-19 transmission during the pandemic.Copyright © 2023, Society of Gastrointestinal Intervention.

Spontaneous Gastro-pancreatic Fistula: A Rare Complication of Acute Pancreatitis

Introduction: Although Gastrointestinal fistula is a well-recognized complication of acute pancreatitis, it has been rarely reported. Here we present a rare case of spontaneous gastro-pancreatic fistula following acute pancreatitis. Case Description/Methods: 42 y/o female with PMH of SLE with a recent prolonged hospitalization for acute drug-induced pancreatitis with pseudocyst came to ED with fever, abdominal pain, nausea, and vomiting. She was tachycardic, had leukocytosis, and was positive for COVID-19. CT Scan A/P showed multiple infected peripancreatic collections with communication of the left upper quadrant collection with the gastric lumen (Figure). The patient was hospitalized, Kept NPO, and started on fluids and antibiotics. IR evaluated and put 2 pigtail catheters for drainage of peripancreatic collections. The tip of the pigtail catheter in the left peripancreatic/retroperitoneal collection was in the gastric lumen. The surgery team recommended continuing with conservative treatment with parenteral nutrition, and IV antibiotics as the patient were nontoxic with no signs of free perforation, and pancreatitis would more likely erode a staple or suture line and would put the patient at further risk of free perforation if repair attempted. IR was successful in pulling the drain out of the gastric lumen on the second attempt to allow gastric perforation to heal. Antibiotics were upgraded as per the culture and sensitivity results of the drain fluid. Repeated multiple bedside leak tests and CT scans with oral contrast continue to be positive for patent gastro-pancreatic fistula. Pigtails catheter continues to drain significant necrotic collection. The patient continues to be hospitalized and is being managed conservatively with Parenteral nutrition, and IV antibiotics. Discussion(s): Fistula of the GI tract following acute pancreatitis can be caused by multiple reasons. Necrosis of the bowel may occur concomitantly with the pancreatic or peripancreatic tissue. Furthermore, enzyme-rich fluid and necrosis can lead to vascular thrombosis, which compromises the blood supply of the segmental GI tract, eventually leading to bowel necrosis. GI fistulas are more common in patients with necrotizing pancreatitis with infected pancreatic necrosis. Despite pharmacologic suppression of pancreatic exocrine secretion and advances in endoscopic and percutaneous therapeutic techniques, pancreatic fistula continues to be a source of morbidity and mortality following pancreatitis and requires multidisciplinary treatment.

Mediastinal Pigtail Catheterization for Treatment of Pneumomediastinum in a COVID-19 Patient: A Case Report

Spontaneous pneumomediastinum (SPM) is a decisive complication reported to be associated with COVID-19. Here, we present a case of SPM in a COVID-19positive patient that was not caused by any iatrogenic or known reasons. At the time of admission, the patient was COVID-positive and distressed. He was immediately subjected to hematological and radiological investigations (chest X-ray, HRCT), which confirmed pneumomediastinum. The patient was hypoxic and hypotensive even after receiving ionotropic support. Considering the patient's critical condition, a mediastinal pigtail catheterization was performed instead of a thoracotomy, and the catheter was in situ for nine days. Arterial blood gas was monitored during the hospital stay, and supplementary oxygen therapy was provided accordingly. The patient subsequently recovered and was discharged. Hence, SPM in this COVID patient was treated by pigtail catheterization, and major surgical interventions were avoided.Copyright © 2023 LookUs Scientific. All rights reserved.

Successful Treatment of Subclavian Artery Thrombosis by Catheter-Based Thrombus Aspiration and Thrombolytic Therapy: A Case Report

Clinical Information Patient Initials or Identifier Number: BP4****/22 Relevant Clinical History and Physical Exam: A 55 Y / Female C/C : Pain, numbness, cold sensation & weakness of left upper limb for 2 hours. Risk Factor : Hypertension, diabetes mellitus O/E : Pale, cold and absent of radial, ulnar, brachial pulse of left upper limb. Muscle power 3/5 left side. So2 86%, BP undetectable. Right upper limb were normal. BP 160/90 mm of hg, pules : 112 b/min, RR : 26/min. Body Temperature 37.5 C [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: CBC : WBC 7450, HB % 10.8 g/dl, ESR 20mm in 1st hour, Platelets : 262000, SARS Cov2 Antigen : Negative PT 14.3 sec, INR : 1.07 APTT : 32.4 sec. blood group: O positive Serum Creatinine : 1.1 mg/dl Plasma glucose 9.7 mmmol/l HIV Ab : Negative HBs Ag : Negative Anti-HCV : Negative Urine R/E : Normal lipid profile : Cholesterol 280mg/dl Vascular duplex ultrasound of left upper limb : A dilated echogenic thrombus had blocked the left subclaviav artery lumen. Relevant Catheterization Findings: Conventional angiography with the lowest amount of contrast agent through the right femoral artery, revealed that left subclavian artery thrombosis with total occlusion distal to Left internal mammary artery. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: A5Fr MPA catheter with side holes was negotiated through a right femoral sheath and was placed in the left subclavian artery. Initially thrombus aspiration was done with Eliminate aspiration catheter (TERUMO) with no success. Then suction was done with the MPA catheter itself with partial removal of thrombus. Then a 5Fr Pigtail catheter was placed inside the thrombus and kept in situ. For residual thrombus 250,000u of Inj. Streptokinase as a thrombolytic drug was given through the Pigtail catheter as bolus over 30 min. The maintenance dose 100,000 u per hour was given over 24 hours through the Pigtail catheter via infusion pump. After 24 hours of thrombolytic therapy, her pain was reduced, the left hand became slightly warm, and distal pulses were feebly palpable. Moreover, the skin colour returned to near normal with improvement of pallor. Bleeding was well controlled at the catheter site. Doppler sounds revealed partial improvement of arterial flow. After evaluation of partial improvement, a low dose 1000 iu per hour of heparin (UFH)was infused intravenously for 24 hours. After 48 hours, repeat angiography via the inserted catheter at the site did not reveal any atherosclerotic plaque and confirm the thrombosis-dissolution. The latter practice demonstrated a good blood flowto the left upper distal limb leaving a little thrombus in the superficial palmer arch. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Catheter-based thrombus aspiration and thrombolytic therapy is primarily reserved for patients with acute viable limb ischemia. As observed in the presented case, thrombus aspiration and thrombolytic therapy is recommended to be considered as an alternative therapeutic method for patients with arterial thrombosis due to the rapid response, shorter treatment time and lower cost, compared to common and sometimes unsuccessful therapies.Copyright © 2023

PLEOMORPHIC CARCINOMA IN THE MIDST OF COVID

SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pleomorphic carcinoma is a subtype of sarcomatoid carcinomas that represents <1 % of all primary lung neoplasms. This case highlights a recent diagnosis of a patient with pleomorphic carcinoma in the midst of COVID-19 pneumonia. CASE PRESENTATION: A 75 year old female with a 180-pack year smoking history presented to the emergency department with dyspnea and chest discomfort. Vital signs significant for oxygen saturation at 93% on room air. The patient had been admitted to the hospital 7 months prior for acute hypoxemic respiratory failure due to COVID-19 pneumonia. At that point, computed tomography (CT) of the chest showed a right lower lobe 5.5 cm juxtapleural lesion measuring fluid attenuation by Hounsfield units without intralesional enhancement. The lesion was initially thought to be secondary to the patient's COVID-19 pneumonia and was not investigated further. The patient was subsequently lost to follow up. Seven months later the patient presented with worsening shortness of breath. Chest CT revealed large right complex pleural effusion with near complete lung collapse. The patient underwent pigtail catheter placement with partial re-expansion of the lung. Pleural fluid analysis showed an exudative effusion with no malignant cells on cytology. Follow-up CT imaging showed a large mass-like area in the right mid and lower hemithorax. Video assisted thorascopic surgery (VATS) decortication and thoracotomy revealed a right lower lobe abscess and empyema. Pathology samples collected during procedure showed malignant cells of sarcamatoid features found in right lung and intraparenchymal lymph nodes. Histology and immunostaining showed a tumor composed of a component of poorly differentiated adenocarcinoma and more than 10% spindle/pleomorphic cells. Immunostaining showed the poorly differentiated adenocarcinoma component was positive for moc 31, Ber-EP4, cytokeratin AE1/AE3, CAM 5.2, lack TTF-1 and p40. The spindle/pleomorphic component was negative for cytokeratins. DISCUSSION: Pulmonary pleomorphic carcinoma (PC) is a rare, poorly differentiated non-small cell lung cancer (NSCLC) that contains at least 10% spindle and/or giant cells or a carcinoma consisting only of spindle and giant cells. PC has poor response to conventional treatments for NSCLC and subsequently poor 5 year survival. It more common in men and smokers. COVID-19 causes a variety of pulmonary radiographic manifestations, including nodules and mass-like consolidations. Superimposed bacterial infections are also common. Our case, however, highlights the importance of serial radiographic monitoring and, when indicated, tissue sampling to rule out alternative explanations for abnormal CT findings. CONCLUSIONS: Appropriate screening and careful follow up of suspicious lung lesions is vital to ensure prompt diagnosis and treatment of lung malignancy. Reference #1: WHO Classification of Tumours Editorial Board. Thoracic Tumours. In: WHO Classification of Tumours,Earke 5th ed, IARC Publications, 2021. Vol 5. Reference #2: Ito K, Oizumi S, Fukumoto S, Harada M, Ishida T, Fujita Y, Harada T, Kojima T, Yokouchi H, Nishimura M;Hokkaido Lung Cancer Clinical Study Group. Clinical characteristics of pleomorphic carcinoma of the lung. Lung Cancer. 2010 May;68(2):204-10. doi: 10.1016/j.lungcan.2009.06.002. Epub 2009 Jul 3. PMID: 19577320. Reference #3: Maneenil K, Xue Z, Liu M, Boland J, Wu F, Stoddard SM, Molina J, Yang P. Sarcomatoid Carcinoma of the Lung: The Mayo Clinic Experience in 127 Patients. Clin Lung Cancer. 2018 May;19(3):e323-e333. doi: 10.1016/j.cllc.2017.12.008. Epub 2017 Dec 21. PMID: 29454534. DISCLOSURES: No relevant relationships by Rachel Earle No relevant relationships by Samantha Gillenwater No relevant relationships by Miquel Gonzalez No relevant relationships by Sikandar Khan No relevant relationships by Christopher Lau no disclosure submitted for Jinesh Mehta;

BELZUTIFAN-INDUCED HYPERSENSITIVITY PNEUMONITIS

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Immunotherapy is now a standard of care in solid-tumor oncology following the approvals of CTLA-4 and PD-1 inhibitors. Belzutifan, a small-molecule HIF-2a inhibitor, has recently gained FDA-approval for the treatment of advanced von Hippel-Lindau (VHL) associated renal cell carcinomas. CASE PRESENTATION: A 63-year-old female presented to our hospital with a one-day history of progressive dyspnea. Medical history is significant for metastatic renal cell carcinoma with pulmonary metastasis. Family and social history were noncontributory. Her cancer diagnosis was established in 2019 and had undergone cytoreductive nephrectomy and treatment with axitinib/pembrolizumab. As she had little improvement with immunotherapy, she was enrolled in a clinical trial at Memorial Sloan Kettering. Due to further disease progression, she was transitioned to lenvatinib/everolimus, though the treatment was discontinued due to anorexia and worsening pulmonary symptoms. Further work up revealed that she had ERG, MPL, VHL gene mutations. Thus, she was started on belzutifan two weeks prior to her presentation. Initial vitals were significant for hypoxia on room air that recovered with high flow nasal cannula (40L/80%). Physical examination was remarkable for severe respiratory distress with coarse breath sounds bilaterally. Laboratory studies revealed an acute leukocytosis with a neutrophilic prominence and a chronic metabolic alkalosis. COVID, flu PCR were negative. Chest x-ray demonstrated diffuse bilateral reticulonodular opacities. CTA revealed innumerable pulmonary nodules with areas of mass-like consolidation and a loculated left-sided pleural effusion. She was covered with azithromycin/ceftriaxone along with high-dose steroids and was admitted to the stepdown unit for further management. While in stepdown, she had a left PleurX catheter placed given her large effusion which was complicated by bloody output that required one unit of blood. Despite high-dose steroids, she had persistent hypoxia. As she remained unstable, goals of care discussions were held, which ultimately led to a change in code status to comfort measures. All aggressive measures were discontinued. She was started on comfort medications and ultimately passed away. DISCUSSION: Currently, neoplasms associated with VHL mutations are managed surgically to minimize the risk of metastatic disease. Nearly 70% of all patients with VHL mutations will develop renal cell carcinomas which means most patients undergo numerous surgical procedures. HIF-2a inhibition therefore offers an effective alternative that could reduce surgical burden and offer a new approach to management of VHL-associated disease. However due to its new approval, several adverse effects have yet to be documented. CONCLUSIONS: We report the only known case of Belzutifan-induced hypersensitivity pneumonitis and hope this case will become a useful contribution to the literature. Reference #1: Jonasch E, Donskov F, Iliopoulos O, Rathmell WK, Narayan VK, Maughan BL, Oudard S, Else T, Maranchie JK, Welsh SJ, Thamake S, Park EK, Perini RF, Linehan WM, Srinivasan R;MK-6482-004 Investigators. Belzutifan for Renal Cell Carcinoma in von Hippel-Lindau Disease. N Engl J Med. 2021 Nov 25;385(22):2036-2046. doi: 10.1056/NEJMoa2103425. PMID: 34818478. DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Raj Parikh

USE OF ALTEPLASE AND DORNASE FOR LYSIS OF COVID-19-RELATED LOCULATED PLEURAL EFFUSION

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: We discuss a case of successful use of alteplase and dornase per MIST II protocol for the management of a loculated pleural effusion secondary to COVID-19 pneumonia. CASE PRESENTATION: 52 year old male was initially admitted for MRSA bacteremia and began appropriate antibiotic therapy. His chest radiograph on presentation was unremarkable. Seven days into his hospital course he tested positive for COVID-19 pneumonia, and developed increasing shortness of breath and escalating oxygen requirements. At this time he had a large loculated left sided pleural effusion on chest computed tomography. A pigtail catheter was placed with removal of 600ml of cloudy yellowish fluid. Follow-up CXR showed slight interval improvement, however a large loculated effusion remained. Pleural fluid studies was exudative, lymphocytic predominant (78%) with elevated pleural fluid lactate dehydrogenase of 786 U/L, pH 8.0, and glucose 97mg/dl. Additional pleural fluid workup was unremarkable, including negative cultures, AFB staining, and benign cytology. After other known causes of lymphocyte predominant pleural effusion were ruled out, and following review of the current medical literature, the conclusion was made that his effusion was most likely related to COVID-19. The decision was made to attempt lysis of the loculations with alteplase and dornase per MIST II protocol. This resulted in significant chest tube output (totaling 3480ml additional output over the ensuing days) as well as marked improvement in chest imaging. The protocol was continued for 3 days which the patient tolerated well overall. DISCUSSION: COVID-19 related pleural effusions occur with an incidence of about 7.3% of cases with an overall lag time of 11 days from symptom onset. Based on observational studies, these pleural effusions are unilateral in 66.8% of cases with a lymphocyte or neutrophilic predominance and significantly elevated pleural fluid to serum LDH ratio. The differential for exudative lymphocyte predominant pleural effusions with elevated LDH include malignancy, rheumatoid effusion, tuberculosis, and viral infections. The pleural studies workup was unremarkable for these conditions. The MIST-2 protocol was followed per the original study, with instillation of tPA 10mg via pigtail catheter which was clamped for 1 hour, opened to drain for 1 hour, then repeated with dornase 5mg. To the best of our knowledge, this is the first documented case of using MIST 2 protocol for a loculated pleural effusion related to COVID-19. CONCLUSIONS: COVID-19 related loculated pleural effusion is an infrequent occurrence that present as lymphocyte predominant exudative that can loculate with elevated lactate dehydrogenase. This is the first case of using alteplase and dornase for its management and we have demonstrated that it can be both a safe and effective method. Additional prospective studies are needed to further investigate this method. Reference #1: Chong WH, Saha BK, Conuel E, Chopra A. The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review. Heart Lung. 2021;50(4):481-490. doi:10.1016/j.hrtlng.2021.02.015 Reference #2: Ahmadinejad Z, Salahshour F, Dadras O, Rezaei H, SeyedAlinaghi S. Pleural Effusion as a Sign of Coronavirus Disease 2019 (COVID-19) Pneumonia: A Case Report. Infect Disord Drug Targets. 2021;21(3):468-472. doi: 10.2174/1871526520666200609125045. PMID: 32516107. Reference #3: Rahman, N, et al. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. N Engl J Med 2011;365:518-526. DOI: 10.1056/NEJMoa1012740 DISCLOSURES: No relevant relationships by Zachary Chandler No relevant relationships by James Cury No relevant relationships by Peter Staiano No relevant relationships by Daniel Weigle

TENSION PNEUMOMEDIASTINUM RESULTING IN OBSTRUCTIVE SHOCK IN COVID-19

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

SHEWANELLA SEPTIC SHOCK COMPLICATING COVID-19 SURVIVORSHIP FOLLOWING EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) RECOVERY

SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Shewanella are gram-negative bacteria that inhabit salt and brackish watery environments, rarely causing skin and soft tissue infections. We report a case of septic shock, bacteremia, and empyema due to Shewanella in a COVID-ARDS survivor who previously received ECMO. CASE PRESENTATION: A 67-year-old man with a medical history of hypertension, diabetes, recent COVID-ARDS illness complicated with STEMI, leading to a VT/VF arrest requiring 21-days of VV-ECMO support presented three weeks after discharge due to worsening oxygen needs. The patient was hypotensive, febrile, tachycardic, tachypneic, with SatO2 92% on HFNC> 50%FIO2. Labs showed leukocytosis, lactic acidosis, and acute kidney injury. Chest x-ray showed a loculated left pleural effusion. Broad spectrum antibiotics were started. Blood cultures grew Shewanella species in aerobic and anaerobic bottles. A CT of the chest is shown (Figure 1). Thoracentesis was performed with findings consistent with empyema (Table 1). The empyema was managed with pigtail catheters and TPAse-DNAse. Pleural fluid cultures had no growth. The patient improved and was discharged on 6-week course of IV ceftazidime. DISCUSSION: Shewanella is a rare cause of skin and soft tissue infections, following traumatic injuries in association with exposure to salt or brackish water. It has also been associated with pneumonia, in the setting of near drownings, in both fresh and saltwater. Individuals with underlying liver disease and immunocompromising conditions are at the highest risk of contracting the pathogen and manifesting illness. Shewanella algae and putrefaciens may manifest as deep ulcers with hemorrhagic bullae, bacteremia, endocarditis, and meningitis (1). In addition, biliary tract infections and peritonitis can occur (2). Our patient had no epidemiologic risk factors for Shewanella infection. Although nosocomial transmission is possible, we are not aware of any previous reports of such exposure in association with this infection. Given negative pleural fluid culture with positive blood culture, we hypothesize our patient's empyema is due to Shewanella given no other apparent infectious etiology. Studies have shown that approximately 40% of pleural infection are culture negative. It is possible that antibiotic therapy started before fluid collection lowered the diagnostic yield of thoracentesis. The prevalence of bloodstream infections during ECMO ranges from 3 to 18%, with coagulase-negative staphylococcus as the most frequent cause, followed by Candida spp., Pseudomonas aeruginosa, Enterobacteriaceae, Staphylococcus aureus and Enterococcus spp. (3) with no known reports of Shewanella per the ELSO registry. CONCLUSIONS: This case may confer possible healthcare-related acquirement of Shewanella. Our case adds awareness to clinicians about potential routes of inoculation, predisposing factors, and the wide clinical manifestations of Shewanellosis. Reference #1: Weiss TJ, Barranco-Trabi JJ, Brown A, Oommen TT, Mank V, Ryan C. Case Report: Shewanella Algae Pneumonia and Bacteremia in an Elderly Male Living at a Long-Term Care Facility. Am J Trop Med Hyg. 2021;106(1):60-61. Published 2021 Nov 15. doi:10.4269/ajtmh.21-0614 Reference #2: Savini V, Marrollo R, Nigro R, Fazii P. Chapter 6-Skin and Soft Tissue Infections Following Marine Injuries. In: The Microbiology of Skin, Soft Tissue, Bone and Joint Infections. Vol 2.;2017:93-103. Reference #3: S. Biffi et al. / International Journal of Antimicrobial Agents 50 (2017) 9–16 DISCLOSURES: No relevant relationships by Akram Alkrekshi No relevant relationships by Robert Kalayjian No relevant relationships by Ismini Kourouni No relevant relationships by Srinivasa Potla No relevant relationships by Zahra Zia

COVID-19-ASSOCIATED PULMONARY MUCORMYCOSIS PRESENTING AS SPONTANEOUS PNEUMOTHORAX: A RARE PRESENTATION

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Mucormycosis is an angio-invasive fungal infection with substantial morbidity and mortality. While diabetes and immune suppression remain well-known risk factors for mucormycosis, COVID-19 is now emerging as its independent predictor. CASE PRESENTATION: A 43-year-old male, with a history of hyperlipidemia and alcoholism, presented to the hospital with complaints of progressive dyspnea on exertion, productive cough, intermittent fever, anorexia, and chest pain over the course of 2 weeks. About 5 weeks prior to the current presentation, he was tested positive for COVID-19 by a polymerase chain reaction (PCR) based test and remained in quarantine at home. He was not vaccinated against COVID-19. He had no known immunosuppressive disease. On initial examination, he was ill-appearing and had a temperature of 101 F, blood pressure 138/83 mmHg, respiratory rate 22/minute, pulse 102/minute, and saturation of 91% on 2 L nasal cannula oxygen. A computerized tomography (CT) scan of the chest revealed small bilateral pneumothorax (2 cm and 5mm) along with extensive ground-glass opacifications in all lobes. In the next 24 hours, the right-sided pneumothorax progressed to tension pneumothorax requiring pigtail pleural drainage catheter placement. The drained pleural fluid had more than 100,000/uL total nucleated cells (91% neutrophils, 2% lymphocytes, and 1% eosinophils) and ultimately cultures grew Rhizopus spp. He was started on intravenous liposomal amphotericin-B infusion (5 mg/kg daily). On hospital discharge, he was switched to oral posaconazole (started with loading 300 mg delayed-release tablet twice a day, followed by 300 mg dosing of delayed-release posaconazole tablets daily) to complete the long term treatment course. DISCUSSION: Most of the reported cases of mucormycosis in COVID-19 were in patients with either diabetes or receiving steroids. This is a rare presentation of COVID-19–associated pulmonary mucormycosis (CAPM) as spontaneous pneumothorax, in the absence of known immunosuppression history. COVID-19 results in a considerable increase in cytokines, particularly interleukin-6 (IL-6), which increase free iron by increasing ferritin levels due to increased synthesis and decreased iron transport. Also, concomitant acidosis increases free iron by reducing the ability of transferrin to chelate iron and this available iron becomes a considerable resource for mucormycosis. [1] Also, Mucorales adheres to and invades endothelial cells by specific recognition of the host receptor glucose-regulator protein 78 (GRP-78). Acidosis associated with severe COVID-19 triggers GRP-78 and fungal ligand spore coating homolog (CotH) protein expression on endothelial cells, both contributing to angioinvasion, hematogenous dissemination, and tissue necrosis. [2] CONCLUSIONS: Mucormycosis can present as spontaneous pneumothorax after recent COVID-19 and clinicians should be aware of rare clinical presentation. Reference #1: Singh AK, Singh R, Joshi SR, et al. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021;15:102146. doi:10.1016/j.dsx.2021.05.019 Reference #2: Baldin C, Ibrahim AS. Molecular mechanisms of mucormycosis—The bitter and the sweet. PLOS Pathog 2017;13:e1006408. doi:10.1371/journal.ppat.1006408 DISCLOSURES: No relevant relationships by Faran Ahmad No relevant relationships by AYESHA BATOOL No relevant relationships by Zachary DePew No relevant relationships by Neil Mendoza

Acute Necrotizing Pancreatitis in COVID-19 Disease: A Case Report

Aims and objectives: Gastrointestinal symptoms like abdominal pain can be atypical presentations associated with coronavirus disease. This case report describes the presentation of acute pancreatitis in a patient with moderate COVID-19 infection. Materials and methods: Data were collected from a patient who was admitted with acute pancreatitis as sequelae of COVID-19 infection in our intensive care unit in June 2021. Case presentation: A 25-year-old female with no comorbidities presented to our emergency department with complaints of fever and dry cough for 10 days for which she had taken treatment at home. COVID RTPCR was negative and CT severity was 10/25. She also complained of abdominal pain with vomiting for 2 days. So she was admitted to our hospital on the tenth day of her illness. Laboratory analysis showed >3 times elevation of serum lipase. CT abdomen showed acute pancreatitis with gallbladder sludge. Causes of pancreatitis like gallbladder stones, alcohol, hypercalcemia, and hypertriglyceridemia were excluded by history and investigations. She was diagnosed with acute pancreatitis due to COVID-19. C-reactive protein and D dimer was highly elevated. She was admitted in ICU and was started on conservative management with IV fluids and bowel rest. Oral intake was resumed gradually as tolerated. The patient was maintaining adequate oxygen saturation on room air. Her repeat COVID RTPCR was again negative. However, her CT severity had increased to 14/25. Her total antibody SARS-CoV-2 was highly reactive. She had severe pain which was not improving despite multimodal analgesia which included opioid infusion. She had bilateral minimal pleural effusion and consolidation and required 2-4 L oxygen support. Repeat CT abdomen after a week showed acute necrotizing pancreatitis with gross pancreatic ascites and partial splenic vein thrombosis (modified CT severity index 8). On day 7 of admission, she developed a fever. Blood and urine cultures were sent and empirical antibiotic was started. Urine culture showed Klebsiella pneumoniae and antibiotic was escalated as per sensitivity pattern. Her pain scores persisted to be high despite all measures. On day 14, she developed abdominal distension. Intra-abdominal pressures were normal and repeat CT abdomen showed extensive free fluid with dilated bowel loops which was likely paralytic ileus. A CT-guided pigtail was inserted for continuous drainage of fluid. The ascitic fluid culture showed no organism. Her abdominal distension gradually reduced. We tapered the requirement of opioids day by day and she got symptomatically better. She could tolerate oral feeds better, off oxygen support, and was shifted to wards with pigtail catheter in situ. She stayed in ICU for 26 days. She was doing better in wards and was discharged home after 5 days with oral anticoagulant and other symptomatic medications and was adviced for gastroenterology follow-up after 10 days. Results: A patient was diagnosed with acute pancreatitis associated with SARS-CoV-2 and was treated accordingly. Other causes of acute pancreatitis were excluded in the patient including alcohol, biliary obstruction/gall stones, drugs, trauma, hypertriglyceridemia, hypercalcemia, and hypotension. Conclusion: This case highlights acute pancreatitis as a complication associated with COVID-19 and underlines the importance of evaluating and treating patients with COVID-19 and abdominal pain.

Tension Pneumomediastinum in COVID-19 ARDS Patient Managed with Percutaneous Ultrasound-guided Catheter Insertion: A Case Report

Introduction: Tension pneumomediastinum is a condition in which there is a trapping of air in the mediastinum with a resultant increase in the pressure causing compression of the great vessels which leads to decreased venous return and cardiovascular collapse. It is a rare and severe form of pulmonary barotrauma in ICU ventilated patients which can lead to refractory hypotension and death if not addressed at the right time. Case description: A 42-year-old man with no known comorbidities referred to our centre in view of severe COVID ARDS with refractory hypoxemia. Endotracheally intubated and put on ventilatory support. Developed shock not responding to fluid resuscitation and was started on IV vasopressor infusion. CT chest revealed tension pneumomediastinum. The patient continued to worsen clinically with hypotension and hypoxia despite low PEEP and high FiO2 ventilation. So bedside USG-guided pigtail catheter was inserted into the anterior mediastinum using a modified Seldinger technique following which there was a rapid clinical improvement. Conclusion: Tension pneumomediastinum is a rare and life-threatening cause of refractory hypotension and hypoxia in mechanically ventilated ARDS patients and bedside ultrasound-guided intervention is a feasible and quick therapeutic option. Highlights: A review of the literature showed very few case reports of tension pneumomediastinum in mechanical ventilated ARDS patients. Because ultrasound of the chest gives air artefacts and poor visualization in patients with pneumomediastinum and subcutaneous emphysema, CT-guided drainage catheters insertion is the standard of care. But in a very sick ICU patient, bedside ultrasound-guided catheter insertion could be a safe and immediate measure to save a patient's life. To our knowledge, this is the first case report of an adult ARDS patient with tension pneumomediastinum managed with bedside ultrasound-guided catheter insertion.

Clinical study of pyogenic liver abscess in patients with history of COVID 19

Objectives: SARS COVID-19 was associated with thrombosis and vascular events, also associated with liver injuries but data and study of liver pathologies in relation to COVID-19 is scarce. The aim of this study was to evaluate the incidence of pyogenic liver abscess in patients with history of COVID-19. Materials and Methods: A current retrospective observational study is done during study period of 6 months (march 2021-august 2021) duration on patients diagnosed with pyogenic liver abscess on ultrasound or computed tomography, which was conformed with pus culture sensitivity reports from fluid obtained with fine needle aspiration or during pigtail catheter insertion. History of COVID-19 and incidence of pyogenic liver abscess was evaluated according to age, gender, comorbidities, severity of covid19. Results: Total 78 patients with pyogenic liver abscess History of COVID-19 in 64 patients 27 males, 37 females Age wise distribution< 20 = 9,20-40 = 8,40-60 = 22, 60-80 = 19, >80 = 6 13 patients were diabetics, 24 patients were hypertensive. Distribution according to severity of COVID-19, asymptomatic = 23, mild illness = 11, moderate illness = 19, severe illness = 8, critical illness = 3. Conclusion: The study concluded that high incidence rate of pyogenic liver abscess in post COVID-19 infection which may require further study.

Tension Pneumothorax Following Nasogastric Tube Placement -A Case Report

Introduction: Naso-(NGT) and oro-gastric tubes play an integral role in the nutritional support of patients who are not able to meet dietary needs through independent oral consumption. Although uncommon, serious pulmonary complications may arise from this mostly blindly performed procedure (0.2-2%). We report a case of an elderly female who developed a right-sided tension pneumothorax (PTX). necessitating tube thoracostomy following NGT misplacement. Case: Our patient is a 79-year-old elderly female woman with no known past medical history who was admitted for altered mentation and hypoxemia due to COVID-19. Although her initial course was complicated by progressive respiratory failure requiring ICU admission and initiation of high-flow nasal cannula, she was quickly weaned to nasal cannula and transferred to a regular floor. Due to poor mentation and inconsistent food intake, enteral access was attempted using a weighted-tip 10 FR NGT. The patient had mild cough and discomfort during the procedure. There was no resistance during insertion. After advancement to 55 CM the patient ceased coughing and the procedure was completed. Chest X-ray (CXR) obtained as part of routine post-procedural evaluation revealed an intra-pleural NGT abutting the R hemi-diaphragm (Figure) and small PTX. Follow-up CXR revealed enlarging PTX with mediastinal shift to the left for which emergent thoracostomy utilizing a 14FR pig-tail catheter was performed. There was complete resolution of the pneumothorax with removal of the chest tube three days later. The patient was discharged home shortly after. Discussion: NGT placement is commonly performed by healthcare providers of varying degrees of expertise and experience. Risk factors associated with complications include multiple attempts, insertion at night, presence of artificial airway and altered mentation, among others. In case of trans-pulmonary placement, withdrawal of intra-pleural NGTs is associated with high risk of pneumothorax and requires close observation. To decrease the likelihood of malposition, a two-step radiograph, gradual progression technique can be deployed if fluoroscopic placement is not available. This should be strongly considered in patients at high risk for adverse events. Conclusions: Blind insertion of NGT using traditional techniques may be of limited safety and put patients at risk of complications. This is particularly true in those who are critically ill, frail or experiencing altered mentation. Institutional protocols to identify patients at high risk on whom blind placement should not be attempted are warranted. Post-withdrawal CXR to rule-out the presence of tension physiology is highly recommended.

Safe and effective administration of multiple recombinant factors on VA-ECMO via post-oxygenator pigtail during acute massive pulmonary hemorrhage

Introduction: Massive bleeding on extracorporeal membrane oxygenation (ECMO) is associated with multiple coagulation defects, including depletion of coagulation factors and development of acquired von Willebrand syndrome (AVWS). The use of recombinant factors, in particular recombinant activated factor VII (rFVIIa, Novoseven), to treat severe refractory hemorrhage in ECMO has been described. However, the use of multiple recombinant factors has been avoided in large part due to concern for circuit complications and thrombosis. Here, we describe the safe and effective administration of rFVIIa and recombinant von Willebrand factor complex (vWF/ FVIII, Humate-P) via post-oxygenator pigtail catheter on VA-ECMO for the treatment of massive pulmonary hemorrhage. Case Description: A 21-month-old (13.4 kg) girl with a recent history of COVID-19 infection presented to an outside hospital with parainfluenza bronchiolitis resulting in acute refractory hypoxemic respiratory failure (oxygenation index 58), refractory septic shock, and myocardial dysfunction. She was cannulated to VA-ECMO and subsequently diagnosed with necrotizing pneumonia from Pseudomonas and herpes simplex infections. Her course was complicated by a large left-sided pneumatocele and bronchopleural fistula requiring multiple chest tubes. She also had right mainstem bronchus obstruction from necrotic airway debris and complete right lung atelectasis. She was noted to have prolonged episodes of mucosal and cutaneous bleeding (oropharynx, chest tube insertion sites, peripheral IV insertion sites) associated with absent high molecular weight von Willebrand multimers consistent with AVWS. Tranexamic acid infusion was initiated and bivalirudin anticoagulation was discontinued. VA-ECMO flows were escalated to 140-160 ml/kg/min to maintain circuit integrity and meet high patient metabolic demand in the absence of anticoagulation. On ECMO day 26, she underwent bronchoscopy to clear necrotic debris from her airway to assist with lung recruitment. The procedure was notable for mucosal bleeding requiring topical epinephrine and rFVIIa. Post-procedure, she developed acute hemorrhage from her right mainstem bronchus, resulting in significant hemothorax (estimated 950 ml) with mediastinal shift, increased venous pressures, desaturation and decreased ECMO blood flow rate, necessitating massive transfusion of 2,050 ml (150 ml/kg) of packed red blood cells, platelets, plasma and cryoprecipitate. An airway blocker was placed in the mid-trachea to control bleeding. In addition to transfusion of appropriate blood products and continuation of tranexamic acid infusion, she was given both rFVIIa (100mcg/kg) and vWF-FVIII (70 units vWF/kg loading dose on the day of hemorrhage, followed by 40 units vWF/kg every 12 hours for 3 additional doses). Both products were administered over 10 minutes through a post-oxygenator pigtail to allow the product to circulate throughout the patient prior to entering the ECMO circuit. The circuit was closely monitored during administration and no changes to circuit integrity were noted in the subsequent hours while hemostasis was achieved. The ECMO circuit remained without thrombosis for 9 days after the bleeding event. Discussion: Balancing anticoagulation and hemostasis is a central challenge in maintaining ECMO support, especially given the prevalence of acquired coagulopathies such as AVWS. For our patient, AVWS contributed to mucosal bleeding necessitating cessation of anticoagulation and utilization of a high ECMO blood flow strategy to minimize circuit clot burden. This was further complicated by absent native lung function and minimal myocardial function, resulting in complete dependence on ECMO. An acute massive pulmonary hemorrhage was treated with multiple recombinant factors (rFVIIa and vWF/FVIII), that are often avoided on ECMO. To minimize clotting risk to the circuit and to maximize transit of these factors to our patient, we added a post-oxygenator pigtail for administration. While this approach was the result of extreme circumstances, th use of a post-oxygenator pigtail for administration of recombinant factors may represent a viable strategy for refractory hemorrhage while on ECMO.