Severe Acute Hepatitis: An Emerging Grave Illness in Children

Acute hepatitis of unknown origin in children has been recently described in the literature, and a case definition has also been proposed for this condition. The exact etiology is unknown and exclusion of infectious, metabolic, autoimmune and toxin mediated injuries is essential. Management for this condition is supportive, but some may require liver transplantation. Infection prevention and control practices are important as the etiology remains unidentified.Copyright © 2023, Indian Academy of Pediatrics.

Comparative Study of Serum Electrolytes in Covid-19 and Healthy Patients in Tertiary Care Center, Karimnagar

Introduction- Electrolyte balance of the body is maintained by renin angiotensin aldosterone system. Some previous studies suggested that COVID-19 is associated with gastrointestinal symptoms, such as diarrhea and vomiting. This may results in electrolyte disturbances in patients. Electrolytes in body like sodium (Na), potassium (K). Chloride (Cl) plays an important physiological role in maintaining acid base and water balance of cells of the body. Aims and objectives: Our study aimed to compare some electrolyte between covid 19 and non-covid patients retrospectively. Material(s) and Method(s): This retrospective study included total 57 males and 43 females in the age group of 28 to 65 years. The results were compared with 100 age and sex matched healthy controls. Estimation of serum electrolytes was done with the collected venous blood samples using the ion selective electrode technique in an electrolyte analyzer. Analysis was done using SPSS V 25 Software. Chi-square and t-test were used to see association and difference between two variable respectively. Result(s): We have found that covid 19 is associated with low levels of electrolytes like Na, K, Cl. Chloride levels in both the groups was not statistically significant. But Hyponatremia and Hypokalemia were observed in cases group with high statical Signficance. Conclusion(s): Study found that electrolytes deterioration in these patients play a critical role in patients management. Thus a monitoring of electrolyte is essential throughout their illness to manage covid patients to improve their quality of life.Copyright © 2020 Ubiquity Press. All rights reserved.

Empagliflozin-Induced Fanconi Syndrome in a Patient With COVID-19

Introduction: Fanconi syndrome is a renal tubular acidosis type 2 that also presents with phosphaturia, renal glucosuria, aminoaciduria, and tubular proteinuria. Etiologies of fanconi syndrome include wilson's disease, inborn errors of metabolism, type 1 glycogen storage disorders, multiple myeloma, heavy metal toxicity, and medications. While a variety of drugs can lead to fanconi syndrome, there are only 4 published cases due to an SGLT-2 inhibitor, all of which were associated with canagliflozin. Based on our literature review, this is the first reported case of fanconi syndrome due to empagliflozin use. Case Description: 61 year-old female with history of type II diabetes mellitus and rheumatoid arthritis. She had been taking empaglofazin-metformin 12.5 mg-1,000 mg, twice a day for 1.5 years and A1C was 7%. She had covid, and was admitted for severe fatigue and nonanion gap metabolic acidosis. Empaglofazin-metformin was held on admission. Metabolic panel showed bicarbonate 11 mmol/L, phosphate 1.2 mg/dL, magnesium 1.5 mg/dl and potassium 2.7 mmol/L. She required a lot of replacement over the course of 9 days before returning to normal electrolyte levels (table 2). Discussion(s): Urine studies (table 1) including aminoaciduria also demonstrated that patient had an underlying Fanconi Syndrome. The severe fatigue was exacerbated by Covid infection, but was multifactorial due to low levels of serum electrolytes as well. Fanconi syndrome is a rare form of renal tubular acidosis type II, historically associated with a variety of medications. Some notable drugs include aminoglycosides, cisplatin, valproic acid, tetracyclines, ifosfamide, and tenofovir, as well as heavy metal toxicity. Currently, fanconi syndrome is not a known adverse effect for SGLT 2 inhibitors as there are only 4 previously reported cases. Due to recent emerging data supporting the use of this medication class in diabetes mellitus, especially complicated by congestive heart failure and chronic kidney disease, more data is needed in order to evaluate the benefits of these medications compared to the increasingly growing body of reported complications. (Table Presented).

Serum Electrolytes and Trace Elements Disorders in Viral Diseases (Covid-19)

The Coronavirus will induce a rapid change in nephrology. Nephrology will be stronger and better if we display the same solidarity we did while we fought the virus. Malnutrition and electrolyte imbalance can make dysfunction in the immune system and impairment of the immune system causes increasing the risk of infection. Dietary management is considered a strategy to minimize the potential risk of viral infections (COVID-19). Potassium: It has shown that COVID-19 patient's loss of potassium from urine so it causes hypokalemia in these patients. Sodium: The hyponatremia that mostly due to the SIADH, up to 12% of coronavirus patients have a low sodium level. Calcium: Coronavirus membrane fusion is associated with extracellular conditions. It has been observed that cellular ion conditions involve in the entrance of the virus. Magnesium: The role of magnesium in immune function is mediated by several mechanisms including immune cell adherence, antibody-dependent cytolysis, and IgM lymphocyte binding. Zinc: Zinc is an important trace element that has critical roles in the body, proliferation and function of NK cells, macrophages, neutrophils, T and B cells, and also the production of cytokines can be controlled by zinc. Selenium: In the structure of some enzymes and as well as Vitamin E prohibits producing free radicals. Iron: Viral replication needs iron, a high level of iron may increase viral infections. Folic Acid: has an inhibitory function, it might be useful for the treatment of new coronavirus. Copper: Copper is an essential trace element in the body and the need for protecting DNA from oxidative stress.

Biochemical and Anthropometric Nutritional Assessment in Children Infected with COVID-19: A Cross-sectional Study

BACKGROUND: Severe acute respiratory syndrome has led to a pandemic of coronavirus disease 2019 (COVID-19). Malnutrition either biochemically or anthropometrically is a well-known risk factor for COVID-19 and may be the vice versa AIM: The objectives of this study were to investigate the prevalence of malnutrition in children infected with COVID-19 through evaluating the nutritional biomarkers such as serum electrolytes, serum albumin, and hemoglobin together with the anthropometric assessment. METHODS: A cross-sectional study that was conducted at El-Matria Teaching Hospital for all children admitted with confirmed COVID-19 for 6 months from February 1, 2021 to the end of July, 2021. Nutritional biochemical evaluation included serum electrolytes particularly the potassium and other nutritional biomarkers such as serum albumin and hemoglobin. Nutritional anthropometric evaluation depended on body mass index, the height/length, weight for length, and weight for height. The prevalence of malnutrition esp. hypokalemia was the main outcome. RESULTS: Hypokalemia was present in 21.8% of the study participants. Other nutritional biomarkers were found as hyponatremia, hypocalcemia, hypophosphatemia, and hypomagnesemia were detected in 49.1%, 38.2%, 21.8%, and 34.5% of the study subjects, respectively. Anthropometric malnutrition was present in most of the enrolled children with COVID-19 in the study (65.5 % [n = 36]) through which overweight and obese children occupied a greater percentage. CONCLUSION: Malnutrition either biochemically or anthropometrically could be linked to COVID-19 in children. COVID-19 could have negative outcomes on the nutritional status such as electrolytes disturbances. Both malnutrition and COVID-19 are considered synergistic associations.

HYDROXYCHLOROQUINE OVERDOSE

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Hydroxychloroquine (HCQ) is commonly prescribed for the management of connective tissue disorders such as systemic lupus erythematosus and rheumatoid arthritis. Despite its widespread use, there are limited case reports describing HCQ intoxication and management. HCQ toxicity presents predominantly with cardiovascular manifestations, including hypotension, arrhythmias, and QT interval prolongation on electrocardiogram (EKG). Other findings include visual disturbances, altered mental status, and hypokalemia. CASE PRESENTATION: We present the case of a 60-year-old female with a history of rheumatoid arthritis and depression. She presented to the emergency department (ED) after ingesting 10-15 tablets of HCQ 200 mg in a suicide attempt. In the ED, she was noted to be lethargic and tachycardic. EKG revealed sinus tachycardia with a heart rate of 127 beats per minute and prolonged QTc of 680msec. The diagnostic evaluation also revealed hypokalemia with potassium 3.7mmol/l. Initial management in the ED included administration of activated charcoal, potassium supplementation, and intravenous bicarbonate infusion. The patient was admitted to the ICU for monitoring and supportive care. Serum electrolyte panel and EKG were monitored. The patient made an uneventful recovery after 2-3 days. The QT interval normalized, and hypokalemia improved. She was subsequently discharged to an inpatient psychiatric unit. DISCUSSION: Although HQC is commonly prescribed, there is limited data describing overdose. Our case of HCQ overdose presented as changes in mental status, QT interval prolongation, and hypokalemia. Similar findings have been reported in previous case reports. Management includes early gastric decontamination with activated charcoal, potassium supplementation, and supportive care. Intravenous bicarbonate infusion has been utilized for prolonged QT intervals, and benzodiazepines have been used for agitation and sedation. CONCLUSIONS: Although rare, HCQ toxicity can be life-threatening. It is a commonly prescribed agent, and therefore the clinician should be aware of its toxicity profile and management. Reference #1: Bakhsh HT. Hydroxychloroquine Toxicity Management: A Literature Review in COVID-19 Era. J Microsc Ultrastruct. 2020;8(4):136-140. Published 2020 Dec 10. doi:10.4103/JMAU.JMAU_54_20 Reference #2: McKeever R. Chloroquine/hydroxychloroquine overdose. Vis J Emerg Med. 2020;21:100777. doi:10.1016/j.visj.2020.100777 Reference #3: Lebin JA, LeSaint KT. Brief Review of Chloroquine and Hydroxychloroquine Toxicity and Management. West J Emerg Med. 2020;21(4):760-763. Published 2020 Jun 3. doi:10.5811/westjem.2020.5.47810 DISCLOSURES: No relevant relationships by Priyaranjan Kata No relevant relationships by Wajahat Khan No relevant relationships by Pratiksha Singh

Electrolyte Imbalance and COVID-19 Severity in Hospitalized Patients

Background: Various risk factors have been proposed for severe coronavirus disease 2019 (COVID-19);nonetheless, the prognostic role of serum electrolytes has not been widely studied. Objectives: The present study aimed to identify the potential prognostic role of electrolyte imbalance in hospitalized COVID-19 patients. Methods: This retrospective study was conducted in Imam Reza Hospital, Mashhad, Iran. The medical records of all COVID-19 patients admitted to the emergency department from May to August 2020 were evaluated. Demographic data and clinical findings upon admission were collected. Disease severity, lung involvement severity on imaging, inflammatory serum biomarkers, admission to the intensive care unit, and serum levels of sodium, potassium, magnesium, calcium (corrected by serum albumin level), and phosphorus were documented. Results: Most patients (60%) were male, and the mean age of the total population was 58.87 ± 1.82 years. Severe COVID-19 was detected in most cases (94.9%) who were significantly older (P = 0.037), had hypertension (P = 0.032), ischemic heart disease (P = 0.033), and higher serum urea (P = 0.001) and serum potassium (P < 0.001). Patients with poor prognosis based on computed tomography (CT) scores had significantly higher serum urea (P = 0.002) and magnesium (P = 0.035) than patients with good prognosis, while serum calcium was significantly higher in the latter group (P = 0.007). Furthermore, there was a significant relationship between COVID-19 severity and serum potassium (P < 0.001). Conclusions: Abnormal serum electrolytes are correlated with COVID-19 severity. Moreover, serum potassium level is a predictor of severe disease.

Association of Respiratory Tract Infections causing Alterations in Lung Parenchyma and Pulmonary Vasculature with Body Electrolyte Imbalance

Aim: The assessment of serum electrolytes at the time of initial presentation of the patient with respiratory tract infection possibly causing lung parenchyma and pulmonary vasculature damage and serial monitoring during the stay could be beneficial in order to determine when and how to take remedial action when necessary. Methodology: A non-probability sampling was done on 139 subjects with suspected respiratory tract infection. For confirmation, culture, MTB PCR, COVID-19 testing was done to diagnose the nature of infection. Serum electrolytes were tested on chemical analyses Alinity instrument. Results: Most common infections found were COVID-19 and bacterial (n=59) collectively in a co-morbid state. Mycobacterium tuberculosis and fungal infections were also found in (n=8) each. Electrolytes imbalance was markedly observed in high prevalence amongst Tuberculosis and COVID-19 patients but also showed significant association with other respiratory investigated infections. Conclusion: A robust association of electrolyte imbalance was found in all cases presented with upper or lower respiratory tract infections.

DE RITIS RATIO OF COVID-19 PATIENTS ADMITTED DURING FIRST, SECOND AND THIRD WAVE

Background: To date, the 2019 novel coronavirus pneumonia (COVID-19) is the greatest public medical issue in the world. World Health Organization (WHO) declared this outbreak a “public health emergency of international concern” on January 31, 2020. Therefore, it bodes well to look for a potential biomarker that could quickly and effectively distinguish serious cases early. Of the total confirmed Covid-19 patients, the severe cases often suffer from underlying diseases such as cardiovascular disease and diabetes that can accelerate the movement of 2019 novel coronavirus (SARS-CoV-2) infection. Moreover, acute respiratory distress syndrome could lead to death in some severe Covid-19 patients, and various disorders often accompany this. Biochemical findings showed representative features of acute respiratory distress syndrome and association of multiple organs. Aim: To estimate routine biochemical parameters of patients admitted to the Covid-19 ward. Method: Clinical samples from cases of Covid-19 admitted to Adesh Medical College and Hospital, Mohri, Shahbad (M), Haryana, India, during 1st, 2nd, and 3rd waves were collected and analyzed. Result: In this study, we investigated routine biochemical investigations (RBS, LFT, RFT & Serum Electrolyte) of Covid-19 patients and calculated De Ritis ratio. It was found that biochemical parameters and De Ritis ratio were worse affected than the first and second waves. Conclusion: De Ritis ratio may be a good marker for liver abnormalities and prognosis and a hospital stay of the Covid-19 patients.

A Case of Hashimoto's Encephalopathy Presenting with Cognitive Impairment and Visual Hallucinations

Introduction: Hashimoto's encephalopathy (HE) is a rare immune–mediated complication of Hashimoto thyroiditis. It is presented as subacute onset of altered mental status with confusion, seizures and myoclonus. It is a diagnosis of exclusion and requires that all other possible causes of cognitive impairment are excluded with a response to steroid therapy and evidence of thyroid autoimmunity in a patient. Here, we present a case of HE in a patient who presented with altered mental status and visual hallucinations despite no history or symptoms of thyroid disorder. Case Description: A 77 year old male with past medical history of hypertension presented with altered mental status, lethargy, and visual hallucinations. Per patient’s wife, patient started to get somnolent and was having memory problems six weeks prior to presentation. His mental status gradually deteriorated, and he started to have visual hallucinations. He was somnolent and noted to have myoclonus and twitching on admission. Magnetic resonance imaging (MRI) of the brain with gadolinium showed chronic microvascular changes with no acute intracranial pathology or masses. Electroencephalogram (EEG) showed no signs of epileptiform activity. Infectious disease work up, including complete blood count, urinalysis, sexually transmitted diseases, and cerebrospinal fluid (CSF) analysis, was negative. Blood glucose levels, serum electrolytes, liver function tests, blood urea nitrogen, and creatinine were normal. Coronavirus disease 2019 (COVID-19) was negative. CSF analysis for autoimmune encephalopathy and Creutzfeldt-Jakob disease was negative. Thyroid function tests were normal. Thyroid peroxidase antibody (TPOAb) was negative (8.6 IU/mL [reference range (RR): < 9.0 IU/mL]) and TgAb was positive (8.2 ng/ mL [RR: < 4 IU/ mL]). With suspicion of Hashimoto's encephalopathy, he was started on intravenous Solu-Medrol 1 g for five days. He was then switched to oral prednisone 60 mg daily, which he received for ten days. His mental status improved upon day 14 of admission. On day 17 of admission, he was discharged on oral prednisone 40 mg daily with taper for five weeks. He was evaluated in the clinic few months after discharge. His mental status had improved significantly, and he was back to his baseline in about two months after discharge as per his wife. Repeat thyroid function tests, TPOAb, and TgAb were negative. Discussion: The incidence of Hashimoto’s encephalopathy (HE) is 2.1 per 100,000 individuals in the general population, and is more common in women than men. This case highlights that HE should be considered in patients with subacute presentation of neurological problems, which cannot be explained with other possible diagnosis, despite no symptoms of thyroid disease such as the patient in this case study. Therefore, HE should be evaluated for in patients with cognitive impairment for prompt diagnosis and treatment with steroid therapy in order to improve the prognosis in these patients.

Evaluation of Pattern and Impact of Electrolytes Abnormalities in Critically Ill Covid-19 Patients

OBJECTIVE: To evaluate the pattern of serum electrolytes abnormalities and their impact on ICU admitted Covid-19 patient outcomes. METHODOLOGY: This retrospective study was carried out at OMI hospital and Dr. Ziauddin Hospital, Karachi, Pakistan, between August to December 2020. Total 102 PCR positive, ICU admitted with severe Covid-19 patients as per WHO criteria were included. The patient's demographic characteristics, clinical features including co-morbidities, electrolytes reports at the time of admission, length of ICU and/or hospital stay, and outcome (expired/survived) were evaluated. RESULTS: Biochemical testing found abnormal electrolyte levels in 90.2% ICU admitted Covid-19 patients. Electrolytes abnormalities including hyponatremia 45.1%, hypermagnesemia 40.2%, hypocalcemia 31.4%, hyperchloremia23.5% and hyperphosphatemia in 20.6% patients. Out of the total, 28.4% of patients needed invasive respiratory support, and 37.3% could not survive. A higher incidence of mortality (39.1% vs. 20%) was seen in patients with electrolytes abnormalities compared to those presented with normal values. CONCLUSION: Electrolyte abnormalities were found in 90% of the ICU Admitted Covid-19 patients. The most common abnormalities found among the patients were hyponatremia, hypermagnesemia, and Hypocalcemia. The findings revealed that several electrolyte imbalances harm patients' in-hospital outcomes. Electrolyte assessment of Covid-19 patients at the time of admission would be helpful in risk stratification for adverse outcomes.

Pancarditis as the Clinical Presentation of Eosinophilic Granulomatosis with Polyangiitis: A Multimodality Approach to Diagnosis

Eosinophilic pancarditis (EP) is a rare, often unrecognized condition caused by endomyocardial infiltration of eosinophil granulocytes (referred as eosinophilic myocarditis, EM) associated with pericardial involvement. EM has a variable clinical presentation, ranging from asymptomatic cases to acute cardiogenic shock requiring mechanical circulatory support (MCS) or chronic restrictive cardiomyopathy at high risk of progression to dilated cardiomyopathy (DCM). EP is associated with high in‐hospital mortality, particularly when associated to endomyocardial thrombosis, coronary arteries vasculitis or severe left ventricular systolic dysfunction. To date, there is a lack of consensus about the optimal diagnostic algorithm and clinical management of patients with biopsy‐proven EP. The differential diagnosis includes hypersensitivity myocarditis, eosinophil granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome, parasitic infections, pregnancy‐related hypereosinophilia, malignancies, drug overdose (particularly clozapine) and Omenn syndrome (OMIM 603554). To our knowledge, we report the first case of pancarditis associated to eosinophilic granulomatosis with polyangiitis (EGPA) with negative anti‐neutrophil cytoplasmic antibodies (ANCA). Treatment with steroids and azathioprine was promptly started. Six months later, the patient developed a relapse: treatment with subcutaneous mepolizumab was added on the top of standard therapy, with prompt disease activity remission. This case highlights the role of a multimodality approach for the diagnosis of cardiac involvement associated to systemic immune disorders.