Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

Early infection risk in patients with systemic lupus erythematosus treated with rituximab or belimumab from the British Isles Lupus Assessment Group Biologics Register (BILAG-BR): a prospective longitudinal study

Background: Patients with systemic lupus erythematosus (SLE) are at an increased risk of infection relative to the general population. We aimed to describe the frequency and risk factors for serious infections in patients with moderate-to-severe SLE treated with rituximab, belimumab, and standard of care therapies in a large national observational cohort. Method(s): The British Isles Lupus Assessment Group Biologics Register (BILAG-BR) is a UK-based prospective register of patients with SLE. Patients were recruited by their treating physician as part of their scheduled care from 64 centres across the UK by use of a standardised case report form. Inclusion criteria for the BILAG-BR included age older than 5 years, ability to provide informed consent, a diagnosis of SLE, and starting a new biological therapy within the last 12 months or a new standard of care drug within the last month. The primary outcome for this study was the rate of serious infections within the first 12 months of therapy. Serious infections were defined as those requiring intravenous antibiotic treatment, hospital admission, or resulting in morbidity or death. Infection and mortality data were collected from study centres and further mortality data were collected from the UK Office for National Statistics. The relationship between serious infection and drug type was analysed using a multiple-failure Cox proportional hazards model. Finding(s): Between July 1, 2010, and Feb 23, 2021, 1383 individuals were recruited to the BILAG-BR. 335 patients were excluded from this analysis. The remaining 1048 participants contributed 1002.7 person-years of follow-up and included 746 (71%) participants on rituximab, 119 (11%) participants on belimumab, and 183 (17%) participants on standard of care. The median age of the cohort was 39 years (IQR 30-50), 942 (90%) of 1048 patients were women and 106 (10%) were men. Of the patients with available ethnicity data, 514 (56%) of 911 were White, 169 (19%) were Asian, 161 (18%) were Black, and 67 (7%) were of multiple-mixed or other ethnic backgrounds. 118 serious infections occurred in 76 individuals during the 12-month study period, which included 92 serious infections in 58 individuals on rituximab, eight serious infections in five individuals receiving belimumab, and 18 serious infections in 13 individuals on standard of care. The overall crude incidence rate of serious infection was 117.7 (95% CI 98.3-141.0) per 1000 person-years. Compared with standard of care, the serious infection risk was similar in the rituximab (adjusted hazard ratio [HR] 1.68 [0.60-4.68]) and belimumab groups (1.01 [0.21-4.80]). Across the whole cohort in multivariate analysis, serious infection risk was associated with prednisolone dose (>10 mg;2.38 [95%CI 1.47-3.84]), hypogammaglobulinaemia (<6 g/L;2.16 [1.38-3.37]), and multimorbidity (1.45 [1.17-1.80]). Additional concomitant immunosuppressive use appeared to be associated with a reduced risk (0.60 [0.41-0.90]). We found no significant safety signals regarding atypical infections. Six infection-related deaths occurred at a median of 121 days (IQR 60-151) days from cohort entry. Interpretation(s): In patients with moderate-to-severe SLE, rituximab, belimumab, and standard immunosuppressive therapy have similar serious infection risks. Key risk factors for serious infections included multimorbidity, hypogammaglobulinaemia, and increased glucocorticoid doses. When considering the risk of serious infection, we propose that immunosupppressives, rituximab, and belimumab should be prioritised as mainstay therapies to optimise SLE management and support proactive minimisation of glucocorticoid use. Funding(s): None.Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Prevalence of adverse drug reactions associated with emergency department visits and risk factors for hospitalization

Objective: Adverse drug reactions increase morbidity and mortality, prolong hospital stay and increase healthcare costs. The primary objective of this study was to determine the prevalence of emergency department visits for adverse drug reactions and to describe their characteristics. The secondary objective was to determine the predictor variables of hospitalization for adverse drug reactions associated with emergency department visits. Method(s): Observational and retrospective study of adverse drug reactions registered in an emergency department, carried out from November 15th to December 15th, 2021. The demographic and clinical characteristics of the patients, the drugs involved and the adverse drug reactions were described. Logistic regression was performed to identify factors related to hospitalization for adverse drug reactions. Result(s): 10,799 patients visited the emergency department and 216 (2%) patients with adverse drug reactions were included. The mean age was 70 +/- 17.5 (18-98) years and 47.7% of the patients were male. A total of 54.6% of patients required hospitalization and 1.6% died from adverse drug reactions. The total number of drugs involved was 315 with 149 different drugs. The pharmacological group corresponding to the nervous system constituted the most representative group (n = 81). High-risk medications, such as antithrombotic agents (n = 53), were the subgroup of medications that caused the most emergency department visits and hospitalization. Acenocumarol (n = 20) was the main drug involved. Gastrointestinal (n = 62) disorders were the most common. Diarrhea (n = 16) was the most frequent adverse drug reaction, while gastrointestinal bleeding (n = 13) caused the highest number of hospitalizations. Charlson comorbidity index behaved as an independent risk factor for hospitalization (aOR 3.24, 95% CI: 1.47-7.13, p = 0.003, in Charlson comorbidity index 4-6;and aOR 20.07, 95% CI: 6.87-58.64, p = 0.000, in Charlson comorbidity index >= 10). Conclusion(s): The prevalence of emergency department visits for adverse drug reactions continues to be a non-negligible health problem. High-risk drugs such as antithrombotic agents were the main therapeutic subgroup involved. Charlson comorbidity index was an independent factor in hospitalization, while gastrointestinal bleeding was the adverse drug reaction with the highest number of hospital admissions.Copyright © 2022 Sociedad Espanola de Farmacia Hospitalaria (S.E.F.H)

A rare complication of esophagoplasty in a COVID-19 reconvalescent.

Esophagoplasty in patients with esophageal cancer remains an extremely high-risk operation. This is due not only to the invasiveness of the operation, but also to the need for adequate blood supply to the gastric tube moved to the posterior mediastinum. The course of a new coronavirus infection is characterized by a high risk of thrombotic and thromboembolic complications, including after surgical interventions. The aim is to present a clinical observation of the development of a lethal complication of esophagoplasty - gastric graft necrosis in a convalescent patient with a new coronavirus infection COVID-19.Copyright © 2022 GEOTAR Media. All rights reserved.

A rare complication of esophagoplasty in a COVID-19 reconvalescent.

Esophagoplasty in patients with esophageal cancer remains an extremely high-risk operation. This is due not only to the invasiveness of the operation, but also to the need for adequate blood supply to the gastric tube moved to the posterior mediastinum. The course of a new coronavirus infection is characterized by a high risk of thrombotic and thromboembolic complications, including after surgical interventions. The aim is to present a clinical observation of the development of a lethal complication of esophagoplasty - gastric graft necrosis in a convalescent patient with a new coronavirus infection COVID-19.Copyright © 2022 GEOTAR Media. All rights reserved.

The effect of Interleukin-6 (IL-6) on malignancy in COVID-19 patients in Dr. Moewardi General Hospital Surakarta

Background: Interleukin-6 (IL-6) is a cytokine with multifaceted effects playing a remarkable role in the initiation of the immune response. IL-6 also represents one of the main signals in communication between cancer cells and their non-malignant neighbors within the tumor niche. IL-6 also participates in the development of a premetastatic niche and in the adjustment of the metabolism in terminal-stage patients suffering from a malignant disease. IL-6 is a fundamental factor of the cytokine storm in patients with severe COVID-19, where it is responsible for the fatal outcome of the disease. This study aims to determine the effect of IL-6 in patients associated with cancer and COVID-19 infection. Method(s): Case control studies were conducted in Moewardi hospital, Surakarta, Central Java, from February to June 2022. Samples were taken from medical records. All patients with cancer and COVID-19 infection were included. Incomplete data is excluded. Therapy was categorized as hormonal therapy, chemotherapy, and evaluation. Mann Whitney was performed to investigate the average difference. The P-value of <0.05 is significant. Result(s): We included 130 patients with cancer and SARS-CoV-2 infection, and 23 patients for the control. We included the total sample of 153. The median age was 50 +/- 13 years. The most frequent kind of cancer was breast cancer (n=59, 38.6%) followed by gastrointestinal cancer (n=25, 16.3%), non hodgkin lymphoma (n=21, 13.7%) and other cancers such as hematological malignancy, thyroid cancer, squamous cell carcinoma, and parotid cancer (n=23,15%). A total of 95 patients received active treatment, with hormonal therapy (n = 8, 0.08%) and chemotherapy (n = 87, 91.57%) of them. The median of IL-6 was 6.80 +/- 23.66. There are significant differences of the IL-6 between COVID-19 patients with cancer compared with the control (p=0.001). Conclusion(s): The high level of IL-6 in a patient's body are influenced by cancer progression and serious viral infections such as COVID-19. Interleukin-6 may be responsible for the failure of therapy and, eventually, fatal complications in patients with cancer and COVID-19. Legal entity responsible for the study: The author. Funding(s): Has not received any funding. Disclosure: The author has declared no conflicts of interest. Copyright © 2022

Severe Pulmonary Hemorrhage in a 3 Weeks Old Neonate with Covid-19 Infection

Aims To describe a case of 3 weeks old neonate presenting with severe pulmonary hemorrhage due to COVID-19 infection and its outcome. Methods We report an interesting case of pulmonary hemorrhage presenting at a young age of 3 weeks, in a previously healthy neonate who was infected with COVID-19 virus;Literature review and investigation results are included. This is a 3-week-old female, a product of full-term pregnancy and an uneventful perinatal course. She was admitted from the emergency department initially as a case of late neonatal sepsis, where a full septic workup was done. Her presenting complaints were low-grade fever and a blocked nose for one day. She was hemodynamically stable in the emergency department except for tachycardia secondary to fever, which improved once the fever was controlled. Her initial blood workup, including blood gas and CSF study, was reassuring (table 1a). Her COVID PCR was positive with a CT value of 17.77. She was treated with IV antibiotics and supportive management. Later that day, the patient developed cardiopulmonary arrest, CPR was initiated, and the patient was intubated. The patient was found to have pulmonary hemorrhage as evident by the fresh blood coming out of the endotracheal tube and the chest X-Ray findings of ground-glass opacities and dense consolidation (figure 1). After initial brief stabilization, the patient started deteriorating requiring escalation of respiratory support to HFOV. The patient continued to deteriorate and developed bilateral pneumothorax requiring bilateral chest tube insertion. After chest tube insertion, there was a mild transient improvement in oxygenation. The patient was put on the maximum ventilatory settings, but she kept having frequent desaturation, requiring frequent manual bag to tube ventilation. Later, she started developing progressive hypotension, that required support with maximum doses of inotropes. Her urine output started decreasing, for which frusemide were started with no response. Blood investigations showed severe DIC picture (table 1b and 1c). She was empirically covered with Meropenem and Vancomycin along with Remdesivir and Dexamethasone for COVID 19 pneumonia. Eventually, the child developed progressive desaturation, hypotension, and poor perfusion. Shortly after that, she developed cardiac arrest and was declared dead. Results The clinical picture of COVID 19 infection is more indistinct in children than in adults, with the most common symptoms being fever, cough, dyspnea, and malaise. In the few published cases of COVID-19 in the neonate, the presentation was that of late neonatal sepsis;interestingly, the lung involvement was not described as frequently as in older age groups. Pulmonary hemorrhage has been reported in adults but rarely in children. Some reports in adults suggested that patients with COVID infection had an increased inflammatory state that led to the development of vasculitis and pulmonary hemorrhage. Up to our knowledge, this is the youngest age at which a patient with COVID-19 infection developed pulmonary hemorrhage with no other underlying cause of it. Conclusion While many of the cases of COVID infection in children are mild, fatal complications like pulmonary hemorrhage can be present. Adding new challenges to the management of this viral infection.

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

SESSION TITLE: Obstructive Lung Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Individual cases of pneumothorax, pneumomediastinum and subcutaneous emphysema have been reported in asthma attacks, but rarely coincide. Pathophysiology is secondary to obstruction in the minor airways leading to air-trapping and barotrauma of distal airways with subsequent alveolar rupture. This case illustrates a case of asthma exacerbation with a synchronous triad of rare complications. CASE PRESENTATION: 65-year-old female with a history of breast cancer, asthma and hypertension presented with shortness of breath, wheezing, and productive cough since four days ago. Vital signs were remarkable for tachypnea and saturation of 91%. Physical examination revealed respiratory distress, and auscultation disclosed diffuse inspiratory and expiratory wheezing. Limited bedside ultrasound showed B-lines compatible for pulmonary edema. Arterial blood gases were compatible with respiratory acidosis and hypoxemia. Laboratories showed leukocytosis, hypotonic hyponatremia, normal brain natriuretic peptide, and negative COVID-19 PCR test. Chest Xray (CXR) demonstrated changes concerning for pneumonia with superimposed pleural effusion. The patient was admitted with the impression of asthma exacerbation versus community acquired pneumonia. Initially, the patient was placed in bi-level positive airway pressure to aid in respiratory discomfort, broad spectrum antibiotic regimen, and diuresis therapy. On follow up, she was found hypoxic with periorbital edema, dyspnea, and subcutaneous emphysema in neck, upper extremities, and thorax for which emergent intubation was performed. CXR and Thoracic CT confirmed pneumomediastinum, large right sided pneumothorax and a moderate left sided pneumothorax requiring tube thoracostomy. At the Intensive Care Unit, treatment included combination therapies with levalbuterol, ipratropium, terbutaline, theophylline, budesonide, IV steroids and magnesium without appropriate response. Mechanical ventilator was set to protective lung parameters to avoid worsening barotrauma. Subsequently, she was paralyzed for 48 hours to aid in synchrony and allow adequate pulmonary gas exchange. Nonetheless, severe bronchoconstriction was persistent along with depressed neurological status. Two months later, the patient passed away. DISCUSSION: We believe our patient developed barotrauma secondary to a cough attack combined with positive airway pressure. Similarities in presentation such as dyspnea, tachycardia, and hypoxia may prove difficult in differentiation. Although each of these pathologies separately can generally be self-limiting depending on size and hemodynamic compromise, the combination can be mortal and clinical suspicion is important in fast diagnosis and treatment. CONCLUSIONS: Our case demonstrates the importance of suspicion of barotrauma in patients with asthma attacks not responding adequately to therapy or developing worsening hypoxia which can be detrimental. Reference #1: Franco, A. I., Arponen, S., Hermoso, F., & García, M. J. (2019). Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack. The Indian journal of radiology & imaging, 29(1), 77–80. https://doi.org/10.4103/ijri.IJRI_340_18 Reference #2: Zeynep Karakaya, Şerafettin Demir, Sönmez Serkan Sagay, Olcay Karakaya, Serife Özdinç, "Bilateral Spontaneous Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema: Rare and Fatal Complications of Asthma", Case Reports in Emergency Medicine, vol. 2012, Article ID 242579, 3 pages, 2012.https://doi.org/10.1155/2012/242579 Reference #3: Subcutaneous Emphysema in Acute Asthma: A Cause for Concern? Patrick D Mitchell, Thomas J King, Donal B O'Shea Respiratory Care Aug 2015, 60 (8) e141-e143;DOI: 10.4187/respcare.03750 DISCLOSURES: No relevant relationships by Juan Adams-Chahin No relevant relationships by Gretchen Marrero No relevant relationships by natalia Mestres No relevant relationships by Are is Morales Malavé No relevant relationships by Carlos Sifre No relevant relationships by Paloma Velasco No relevant relationships by Mark Vergara-Gomez

COVID-19 CARDIAC TAMPONADE WITH CARDIOGENIC SHOCK IN A PREVIOUSLY VACCINATED YOUNG ADULT: A CASE REPORT

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Previous case reports have shown a number of cardiac complications associated with, and attributed to COVID-19 infection including acute myocardial injury and infarction, dysrhythmias, acute heart failure, pericarditis, and venous thromboembolic events, among others. Up until this point, these cases have all been documented in unvaccinated individuals 1. CASE PRESENTATION: Here we report a unique case of a 40-year-old previously vaccinated woman who presented with generalized weakness, chest pain, dyspnea, and vomiting. She was found to be septic and positive for COVID-19. Transthoracic echocardiogram showed a small pericardial effusion on admission and the patient was diagnosed with acute myopericarditis secondary to COVID-19. Within the first 24 hours following admission, the patient's condition rapidly deteriorated and she developed worsening pericardial effusion, with subsequent cardiac tamponade, and cardiogenic shock. Following attempted pericardiocentesis and surgical drainage, cardiac function did not improve and she expired soon after. DISCUSSION: Despite most of the clinical attention being focused on the effects of SARS-CoV-2 on the respiratory system and the pneumonia it causes, there have been more reported complications involving other organ systems, particularly the heart and kidneys. Studies have shown three main categories of cardiac involvement and complications related to COVID-19: myocardial injury, acute heart failure, and arrhythmia. Focusing on myocardial injuries, there have been some reports attempting to elucidate the frequency of myo- and pericarditis as complications of COVID-19. Yet still to this date, little is known about pericarditis as a COVID-19 complication. Of the case reports published thus far regarding COVID-19 pericarditis, the majority of them do not exhibit cardiac tamponade. In one systematic review published in September, 2021, a total of 33 studies including 32 case reports and one case series were included and pericardial effusion and cardiac tamponade were reported in 76% and 35% of the cases, respectively 2. To our knowledge, our case is the first of its kind, illustrating cardiac tamponade in a fully vaccinated individual. Although, there have been no clear mechanisms explaining the pathogenesis of cardiac involvement in patients suffering from COVID-19, multiple possibilities have been hypothesized. Similar to other cardiotoxic viruses, an inflammatory response is likely triggered resulting in pericarditis and pericardial effusion 3. When left unabated, cardiac tamponade can occur. CONCLUSIONS: Our case documents a reminder of the critical nature of SARS-CoV-2, even in vaccinated patients. To our knowledge, this is the first reported case of cardiac tamponade in a previously vaccinated individual. This case highlights the importance of quick diagnosis and treatment in patients suffering from potential lethal complications of COVID-19. Reference #1: Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-1507 Reference #2: Diaz-Arocutipa C, Saucedo-Chinchay J, Imazio M. Pericarditis in patients with COVID-19: a systematic review. J Cardiovasc Med (Hagerstown). 2021 Sep 1;22(9):693-700 Reference #3: Inciardi RM, Lupi L, Zaccone G, et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):819–24 DISCLOSURES: no disclosure on file for Thomas Bumbalo;no disclosure on file for Thaddeus Golden;No relevant relationships by Omar Kandah

CARDIAC TAMPONADE SECONDARY TO COVID-19 INFECTION

SESSION TITLE: Infections In and Around the Heart Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Due to the novelty of COVID-19 virus, complications of this severe respiratory infection are continually emerging. The inflammatory response to the virus carries a high mortality rate and can lead to a variety of cardiothoracic complications such as acute coronary syndrome, thromboembolism, and heart failure [1]. Here, we present a case of a young female who suffered cardiac tamponade (CT) from a pericardial effusion (PEEF) attributed to COVID-19 infection, which has only been described a handful of times in the literature. CASE PRESENTATION: A 33-year-old female with a history of Down syndrome and morbid obesity presented with worsening dyspnea and fever for one week. Her initial oxygen saturation was 50% on room air, and bilevel noninvasive ventilatory support was initiated. Her viral PCR was positive for COVID-19. A computed tomography angiogram of the chest revealed small bilateral pulmonary emboli, diffuse ground-glass consolidations, and small bilateral pleural effusions. Her respiratory status continued to decompensate and she was placed on mechanical ventilation. She became hypotensive requiring vasopressor support. The following morning, an echocardiogram (TTE) revealed an ejection fraction of 40-45% and a new PEEF with early right ventricular diastolic collapse consistent with CT physiology. She underwent emergent pericardiocentesis, and 220 mL of bloody fluid was drained. PEEF studies revealed a glucose level of 186 mg/dL, LDH of 1380 U/L, and protein of 3.0 g/dL. Total nucleated count was 16,545/uL with 68% neutrophils. Gram stain showed a few white blood cells without organisms, and final bacterial, fungal, and acid-fast cultures were negative. A pericardial drain was left in place, but the procedure was complicated by a pneumothorax and a chest tube was placed. A follow-up TTE the next day revealed improvement of the PEEF without signs of CT. A repeat chest x-ray showed resolution of the pneumothorax. Unfortunately, the patient’s oxygenation and hemodynamic status continued to worsen. She eventually suffered cardiac arrest with pulseless electrical activity and succumbed to her illness. DISCUSSION: New knowledge regarding complications of COVID-19 infection is continually emerging. According to a February 2022 systematic review, only 30 cases of severe PEEFs with CT secondary to COVID-19 have been recorded. The mechanism by which PEEFs form is unclear. It is proposed that the entry of the virus into inflammatory cells causes a release of cytokines such as TNF-alpha, IL-1, IL-6, and IL-8. This resulting cytokine storm allows rapid inflammation and infiltration of fluid into the pericardial sac [1]. CONCLUSIONS: In a decompensated patient with COVID-19, a stat TTE should be obtained to rule out PEEF. Physicians must be cognizant of this uncommon yet highly fatal complication in unstable COVID-19 patients, as cardiac tamponade is a potentially reversible cause of cardiac arrest. Reference #1: Kermani-Alghoraishi, M., Pouramini, A., Kafi, F., & Khosravi, A. (2022). Coronavirus Disease 2019 (COVID-19) and Severe Pericardial Effusion: From Pathogenesis to Management: A Case Report Based Systematic Review. Current problems in cardiology, 47(2), 100933. https://doi.org/10.1016/j.cpcardiol.2021.100933 DISCLOSURES: No relevant relationships by Amanda Cecchini No relevant relationships by Arthur Cecchini No relevant relationships by Kevin Cornwell No relevant relationships by Krupa Solanki

Does Frequency of in-Person Clinic Evaluation Impact Central Line-Associated Bloodstream Infections in Pediatric Home Parenteral Nutrition Patients

Background: Home parenteral nutrition (HPN) is the primary treatment for patients with pediatric intestinal failure. It is a complex, life-sustaining therapy requiring a central venous catheter (CVC), and carries high morbidity. Central line-associated bloodstream infection (CLABSI) is a common and potentially fatal complication of HPN. Patients on HPN require a skilled multi-disciplinary team- including physicians, nurses, dietitians and pharmacists-to prevent HPN related complications, provide safe and individualized nutrition support that is evaluated on a regular basis in the ambulatory setting. In-person visits in the clinic setting allow for HPN patients to be evaluated by all disciplines, and full assessment of weight and general condition, fluid status and laboratory values. Importantly, clinic evaluations also allow for close examination of central venous catheter (CVC), discussion with caregivers to identify potential infection risks, and opportunities for education to prevent infections and other complications. Program standard of care is bimonthly clinic and laboratory evaluation, more frequently if clinically indicated. The COVID-19 crisis required transition of many of these evaluations from in-person to telemedicine, which has created new challenges in caring for high-risk pediatric HPN patients and prevention of CLABSI. Multi-disciplinary telemedicine visits including nursing, dietitians and physicians were substituted for in-person evaluations at first exclusively at onset of pandemic, then to every other visit as COVID rates improved and vaccinations became more available. Method(s): HPN clinic encounters from 2019-present were reviewed in a large pediatric HPN program and compared to CLABSI rates. Attention was paid to in-person versus telemedicine evaluations in the setting of COVID-19 pandemic. CLABSI rate was defined as # of ambulatory infections/1000 catheter days, as defined by National Healthcare Safety Network (NHSN) guidelines. Result(s): Despite decreased frequency of in-person clinic evaluation, ambulatory CLABSI rates did not increase during this time. In fact, median CLABSI rate from 2020 to present decreased from 0.81/1000 catheter days to 0.5/1000 catheter days. In 2020, there was a mild trend toward increased CLABSI rate in patients who had higher percentage of telemedicine versus in-person encounters;however, this was not statistically significant. This trend was not observed in 2021. Conclusion(s): Pediatric patients receiving HPN are high-risk and require evaluation by a multidisciplinary team at regular intervals to maintain safety. COVID-19 pandemic interrupted ability to see these complex patients for in-person evaluation with regular frequency;therefore multidisciplinary telemedicine visits were substituted. While in-person evaluation remains the gold standard for management of patients on HPN, intermittent use of multi-disciplinary telemedicine encounters can be utilized to safely care for pediatric HPN patients, without resultant (Figure Presented).

AN OBSERVATION STUDY TO FIND ASSOCIATION OF INFLAMMATORY BIOMARKERS WITH SEVERITY OF DISEASE AMONG COVID-19 PATIENT ATTENDING A TERTIARY CARE HOSPITAL OF MUMBAI, INDIA

Introduction: Covid – 19 caused by SARS-CoV2 was declared a global pandemic on March 11, 2020 by World Health Organization. Complexity of Covid – 19 diseases is centered on its unpredictable clinical course that can rapidly develop, causing severe and fatal complications. The current study was aimed to investigate association between levels of biomarkers with Covid– 19 disease severity to identify patients at risk of fatal complications. Materials and Method’s: A Retrospective cross-sectional Hospital based study was undertaken by Department of Medicine at K.J. Somaiya Medical College, Mumbai, India. Adult patients of more than 18 year of age who were admitted with laboratory confirmed diagnosis of Covid – 19 during the period of June and July 2020 were included in the study. Gold-standard diagnosis of Covid – 19 is achieved through molecular identification of SARS-CoV-2 using nucleic acid amplification tests such as the reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) or viral gene sequencing. A total of 500 patients were included, irrespective of age, gender, ethnicity or duration of symptoms of underlying illness. The study was approved by research and ethics regulatory committee of the institution. Data was collected by reviewing the records and of the selected patients. Data was summarized by using descriptive statistics. P value of < 0.05 was considered to be statistically significant. Results: A total of 500 patients were included in the study. The age of these patients ranged from 18 to 61 years with a mean of 37.8 (18.2) years. There was a male preponderance with a male to female ratio of 2.6. Out of 500 patients that we have included in our study, 10 patients had isolated raised D –Dimer. It showed a weak association with severe lung involvement. During the study period, a total of 87 death were observed among the patients included in the study, hence a death rate of 17.4% was observed by the researchers. Conclusion: Severity of lung involvement, Assessment of levels of various biomarkers helps in immediate categorization of patients into risk groups.

BILATERAL PNEUMOTHORACES AS A COMPLICATION OF COVID-19

CASE: A 40-year-old man with no significant past medical history presented with acute hypoxemic, hypercarbic respiratory failure and was diagnosed with COVID-19 pneumonia. He reported that he was unvaccinated against SARSCoV-2. Over the course of two months, he required high-flow nasal cannula, continuous then nocturnal BIPAP for respiratory support and completed appropriate courses of dexamethasone, remdesivir, and baricitinib. He also completed a course of levofloxacin due to concern for superimposed bacterial pneumonia. After finishing the course of dexamethasone, the patient was initiated on a prolonged prednisone taper. His course was complicated by the development of fibroproliferative acute respiratory distress syndrome two months after his initial diagnosis of COVID- 19 requiring continuous followed by nocturnal BIPAP to maintain adequate oxygenation. Subsequently, he developed recurrent bilateral, spontaneous pneumothoraces, which required the insertion of multiple chest tubes due to ongoing air leaks and continued recurrence on removal. IMPACT/DISCUSSION: Acute respiratory distress syndrome (ARDS) leads to diffuse alveolar damage in the lung and is increasingly being seen as a complication of COVID-19. These patients frequently require steroids along with positive pressure ventilation to maintain adequate oxygenation. Pneumothorax is a common and sometimes fatal complication of positive pressure ventilation in patients with acute respiratory distress syndrome, with some studies quoting an incidence as high as 48%. On the other hand, development of spontaneous pneumothorax in patients with COVID-19 pneumonia is much more rare, with studies showing an incidence of approximately 1% and usually upon the initiation of invasive mechanical ventilation, with collapse due to barotrauma in the setting of cystic and fibrotic changes in the lung parenchyma. However, there are no current case reports citing pneumothoraces as late complications of COVID-19 ARDS, as occurred in our patient two months into his hospitalization, and related solely to BiPAP use in a patient who never previously underwent endotracheal intubation or ventilation. Additionally, since corticosteroids delay wound healing, it is critical to recognize the possibility of developing spontaneous, recurrent pneumothoraces in patients with COVID-19 on prolonged steroid tapers who are initiating any form of positive pressure ventilation, including non-invasive ventilation such as BIPAP. CONCLUSION: Pneumothoraces are rare complications of COVID-19 pneumonia, and are most commonly seen in males who undergo endotracheal intubation. Corticosteroids delay wound healing, and prolonged steroid tapers increase the risk of recurrent pneumothoraces once one develops. Clinicians must be wary of this rare, late complication of patients with COVID-19 ARDS and prolonged steroid exposure and should be extra judicious with the use of positive pressure ventilation.

DELAYED PRESENTATION OF MYOCARDIAL INFARCTION IN THE SETTING OF A GLOBAL PANDEMIC

CASE: A 52-yo male with hypertension and former smoker was transferred from outside hospital with dyspnea and hemoptysis. He had presented with chest pain and abnormal ECG to an urgent care 2 days earlier but declined to visit the emergency room in fear of the pandemic. This time, he had respiratory distress requiring intubation and transfer to a higher level of care. He developed cardiogenic shock and profound refractory hypoxia. ECG showed sinus tachycardia, Q waves V1-V3. Chest X-ray had right-side pulmonary edema. An urgent transthoracic echocardiogram (TTE) revealed evidence of papillary muscle rupture (PMR) and LVEF of 65%. An emergent coronary angiogram showed multivessel disease, and a simultaneous transesophageal echocardiogram confirmed torrential mitral regurgitation and PMR. An intra-aortic balloon pump was placed. Patient then underwent urgent CABG/valve replacement and was discharged 10 days later. At 4-month follow-up patient was asymptomatic in clinic. IMPACT/DISCUSSION: Here we present a case of Non-ST-segment elevation myocardial infarction (NSTEMI) whose presentation was delayed due to fear on contracting COVID-19, resulting in papillary muscle rupture (PMR). Acute mitral regurgitation (MR) due to PMR is a life-threatening mechanical complication occurring in 3/1000 patients with myocardial infarction (MI) per year. Prepandemic studies showed that mechanical complications had decreased their incidence over time given the numerous advances in reperfusion therapies. The mortality of such complications remained elevated in numerous studies (4-fold higher than patients without mechanical complications), especially for patients presenting with late-STEMI. Mechanical complications are significantly less common in patients with NSTEMI, such as our patient. The COVID-19 pandemic marked a surge in delayed presentations of MI, resulting in rising incidence of complications worldwide. Certain studies have demonstrated that the pandemic itself is an independent risk factor for delayed presentations of acute coronary syndrome. Echocardiogram remains the diagnostic modality of choice with sensitivity of 65-85% to detect complications from MI, however high clinical suspicion is key to prompt early use of this imaging modality. Our case illustrates that awareness of delayed presentations amongst clinicians may grant early diagnosis and good outcomes. CONCLUSION: Mechanical complications with catastrophic presentations had decreased after the reperfusion treatment era, however the advent of the COVID-19 pandemic has raised concerns for an increasing incidence of delayed presentations of acute coronary events resulting in lethal complications. High clinical suspicion is paramount in diagnosis and outcomes associated to patients suffering from papillary muscle rupture as well as other mechanical complications of MI.

FORTUNATELY, NOT A TTP (THROMBOTIC THROMBOCYTOPENIC PURPURA). A CASE OF COVID INFECTION WITH EXTREME THROMBOCYTOPENIA (PLATELETS 5K/UL) AND SEVERE DEFICIENCY OF ADAMTS 13 (<2 %) WITHOUT TTP SYMPTOMS AND WITHOUT NEED FOR PLASMAPHERESIS

CASE: 54-year-old female presented with 1 week of generalized weakness, headache, congestion, cough with dark- colored phlegm, and several days of decreased smell and taste. She was unvaccinated and had positive sick contacts. Patient tested positive for Covid and found to have severe thrombocytopenia with platelets of 5K/uL, very rare schistocytes on smear, and no other notable abnormalities. She received platelet transfusion and was treated for presumed immune thrombocytopenia with IVIG and dexamethasone. The patient had no petechiae, bleeding, or other symptoms concerning for secondary TMA, notably TTP. The platelet count was 93 K/uL by day 5 and she was discharged home. Later that day her ADAMTS13 test resulted at <2% and the ADAMTS13 antibody was elevated. The patient was asked to return to the hospital for monitoring of TTP symptoms. She reported improvement in her weakness. Her thrombocytopenia and oxygen saturation remained normal. Bilateral lower extremity ultrasound showed no lower extremity VTE. On the day of discharge, 10 days after her original thrombocytopenia identified, she had a platelet count of 373 K/uL and repeated ADAMTS13 of 14.8%. IMPACT/DISCUSSION: ADAMTS13 is known as von Willebrand factor (VWF) protease as it cleaves prothrombotic and highly adhesive to platelets ultra-large multimers of VWF into smaller multimers, thus modulating VWF activity and regulating the adhesive function. A severe deficiency of ADAMTS13 characterizes TTP, a rare but potentially fatal disorder associated with thrombosis due to accumulation of prothrombotic ultra-large VWF multimers. There are literature reports of TTP and TTP-like syndromes in Covid-19. It is speculated that in COVID-19, the excess of VWF released in response to endothelial activation likely exhausts the available reserves of ADAMTS13, which may then propagate formation of microthrombi in different organs. We report an extreme thrombocytopenia, marked decrease of ADAMTS 13 and elevated ADAMTS13 antibodies, which would be confirmative evidence of TTP should our patient have clinical features of it. Our patient did not have fever, neurologic abnormalities, renal dysfunction, or active hemolysis. She was followed in outpatient clinic after the discharge. The platelet count recovered and ADAMTS 13 trended up without need for plasmapheresis. Our case is a good example of a fortunate outcome without any complications despite threatening presenting criteria. CONCLUSION: Covid-19 associated endothelial stimulation and damage could mimic a life-threatening disorder without expected fatal complications. On the other hand, it can ultimately lead to the most severe form of thrombotic microangiopathy, TTP, for which the mortality rate is close to 90%. It is hard to know which outcome to expect in different circumstances. Therefore, it is crucial for physicians to promptly recognize clinical picture of TTP as treatment is lifesaving.

Under Pressure: Spontaneous Pneumomediastinum with Resultant Cardiac Tamponade Influencing the Decision to Initiate Extra-Corporeal Membrane Oxygenation

IntroductionWe present a case of a rare but serious adverse consequence of Acute Respiratory Distress Syndrome (ARDS) secondary to COVID-19 infection: spontaneous pneumomediastinum and pneumopericardium resulting in cardiac tamponade. Case descriptionA 35 year old unvaccinated female with a history of degenerative disc disease, Sjogren's disease, and mild persistent asthma presented with COVID-19 pneumonia. On admission, she required near-maximum heated high flow oxygen, yet desaturated with minimal movement. Three days later, she noted sharp chest pain with worsening oxygenation. Chest radiograph revealed diffuse subcutaneous air with concern for bilateral pneumothoraces, and follow up CT revealed pneumomediastinum, pneumopericardium, and extensive subcutaneous emphysema. She was subsequently intubated. She ultimately developed signs of obstructive shock, and an emergent chest CT demonstrated tamponade physiology on the heart from the mediastinal air. Bedside echocardiogram was unable to be performed due to air surrounding the heart. At this time, her Murray score was 3.8, and discussions began regarding transfer to a referral center for Extracorporeal Membrane Oxygenation (ECMO). Given her tenuous hemodynamics and the prospect of transfer in a low-pressure aircraft, a mediastinotomy tube was placed with a large air leak, tidaling of the tube, and improvement in hemodynamics. On arrival at the ECMO center (Saint Joseph Hospital), her tamponade physiology had improved, but she was requiring progressively higher ventilator pressures due to her severe ARDS. Her extensive pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema would likely only be worsened by higher positive end-expiratory pressures. Due to this complex physiology, she was deemed a VVECMO candidate and was cannulated the day after transfer. Following cannulation, her pneumomediastinum and pneumoperitoneum improved, and eventually her mediastinotomy tube no longer demonstrated an air leak or tidaling. As such, it was removed and her hemodynamics remained stable with no evidence of recurrent tamponade. DiscussionThis presented a unique case in which the choice for VVECMO was influenced not only by severity of ARDS, but also by the complicating factor of positive pressure ventilation causing worsening tamponade physiology due to spontaneous tension pneumomediastinum. Additionally, this case adds to the reports of spontaneous pneumomediastinum in COVID-19 infection, as our patient had no history of trauma or barotrauma before this occurred. On literature review, we have only found one other case report in which a tension pneumomediastinum in COVID-19 required bedside mediastinotomy. Physicians should be aware of this potentially fatal complication and expedite referral to an ECMO center.

Bilateral Facial Weakness as Initial Presentation of Post COVID-19 Vaccination related Guillain Barré Syndrome

Objective: The COVID-19 vaccination has been shown to be effective at protecting against severe COVID-19 related symptoms and death. However, many people have reported side effects after receiving the vaccination. Majority of them are mild, nonspecific, and go away within a few days. A few of the side effects are serious. It is important for neurologists to be aware of fatal side effects for appropriate cares. We present an unusual presentation of Guillain-Barré syndrome (GBS) post COVID-19 vaccine, bilateral facial nerve paralysis preceded by significant weakness in the lower extremities. Background: NA Design/Methods: NA Results: A 66-year-old male presented with right facial weakness which later progressed to bilateral facial paresis with difficulty in swallowing. Sixteen days prior, he received the Johnson & Johnson COVID-19 vaccine. The patient also reported development of myalgia and highgrade fever two days after the vaccination. The brain MRI was negative for acute changes and subsequently, the patient developed bilateral lower extremity weakness. The lumbar MRI revealed evidence of diffuse enhancement and mild thickening of all the nerve roots of the cauda equina. A lumbar puncture was performed, and CSF analysis showed albuminocytologic dissociation. He was diagnosed with GBS, and responded to IV immunoglobuin infusions. Conclusions: GBS is a rare neurological disorder in which the immune system attacks nerves and can result in progressive muscle weakness, numbness, and pain. Adenovirus vector is listed as a rare side effect of COVID-19 vaccine. We highlight the importance of recognizing GBS as a potential side effect of the COVID-19 vaccination.

End-Stage Kidney Disease is Underreported in Death Certificates

Background: End-stage kidney disease (ESKD) impacts more than 785,000 Americans and often occurs with multiple comorbid conditions, especially cardiovascular diseases, which are the most common cause of death (COD) in ESKD. Many complications directly arise from ESKD, but its deadly impact can be overlooked. At our institution, the death certificate is completed by clinicians and a majority by clinical house staff. We reviewed the death certificates of ESKD autopsies to understand the clinicians' perspectives on the range of CODs in this clinical setting. Design: We searched our database for autopsies of adult ESKD patients (2012-2021) that had accessible death certificates. COVID-positive cases were excluded. We evaluated the COD section of death certificates and correlated them with autopsy findings. The frequency of autopsy findings directly identifying CODs or resulting in amendments of death certificates was also noted. Results: Of 68 autopsy reports, the majority of CODs reported in death certificates were related to sepsis/infection (30%), and cardiovascular diseases (26%). There was no documentation of ESKD in the majority (78%,53/68) of death certificates. Of these 53 cases, 89% had COD either due to fatal complications of ESKD (98%) or increased mortality of another comorbid condition due to the underlying ESKD. The remaining 11% had COD unrelated to ESKD. Among the fatal complications of ESKD, cardiovascular complications were the most commonly noted (72%) followed by sepsis (20%). Autopsy findings were used to identify the COD on death certificates in only 6% of cases. No amendments were made on any of these death certificates. Conclusions: ESRD is often not mentioned in death certificates, which underestimates its mortality burden. The death certificate is a source for mortality statistics and used by government for public health policy and allocation of research funding. Hence, accurate accounting of death certificates is essential for this complex and silent disease.