Acquired hemophilia in a patient with SARS-CoV-2 infection, a case report

Acquired hemophilia (AH) is a potentially life-threatening hemorrhagic disorder. We report the second confirmed case of COVID-19-associated AH in a 45-year-old female which, unfortunately, expired as her treatment failed. She presented to the emergency department with abnormal bleeding and spontaneous hemoptysis about ten days after a removal surgery of her epiglottis tumor. Aggregation tests, such as partial thromboplastin time (PTT), are recommended in patients with COVID-19 infection that have bleeding episodes.Copyright © 2022 The Author(s);Published by Society of Diabetic Nephropathy Prevention.

Swallowing Dysfunction and its Impact on Patients Undergoing Oncological Treatment

Loco-regional control rates and tumour response have increased as a result of advancements in Head and Neck Cancer (HNC) therapy. [...]mortality is still high despite advancements in treatment and diagnostic methods. Keywords: Covid-19 pandemic * Nigeria situation * Global perspective Introduction Loco-regional control rates and tumour response have increased as a result of advancements in Head and Neck Cancer (HNC) therapy. [...]mortality is still high despite advancements in treatment and diagnostic methods. [...]we may divide the variables that predict dysphagia into three categories: treatment-related, patient-related, and tumour-related. [...]for specific procedures such as arytenoid cartilage and base of the tongue resections, dysphagia may be precisely anticipated. According to Taberna, anatomical reasons and the food consistency of dysphagia are related.

Sonographic Phenotyping of the Upper Airway in OSA With Backscattered Imaging Analysis by Machine Learning

Introduction: Anatomic assessment of the upper airway remains important in directing and monitoring of care for patients with obstructive sleep apnea (OSA). Nasopharyngoscopy is routine in clinical practice, but it can be invasive and potentially less attractive in the post-COVID-19 care setting. It also only allows subjective assessment. Ultrasound imaging of the upper airway with backscattered imaging analyzed via machine learning algorithm is investigated as a potential alternative. Method(s): Sixty-three subjects (14 female) with a mean age of 39.4 (12.6) years, body mass index (BMI) of 26.4 (4.6) kg/m2, and apnea-hypopnea index (AHI) of 19.0 (16.1) were consented from Stanford sleep surgery (July 2020 to May 2021). A standardized ultrasound protocol was used to image the soft palate, oropharynx, tongue base, and epiglottis. Via ultrasound device cleared by US Food and Drug Administation, backscattered ultrasound imaging (BUI) of the upper airway was performed and analyzed with machinelearning algorithms. Combined with B-mode measurements of airway muscular cross-sections, a logistic regression model was built to correlate with OSA severity. Result(s): The BUI of subjects with mild OSA was different from moderate-severe (AHI>=15) OSA at the soft palate (P=.0007). The axial-to-lateral ratio of upper airway length was reduced in the lower soft palate of the moderate-severe group (P=.0207). The logistic regression model with BUI, axial-to-lateral ratio at the soft palate, and BMI showed an area under the receiver-operating characteristic curve of 0.84 (95% CI, 0.726-0.920) in moderate-severe OSA. Conclusion(s): A noninvasive yet replicable technique to visualize and phenotype the upper airway is critical in the management of patients with sleep-disordered breathing. Sonographic BUI combined with B-mode airway measurements analyzed by machine learning show promise in characterizing the upper airway in patients with moderate-severe OSA.

Epiglottic Abscess in a Healthy but Unvaccinated Patient With COVID: Predilection for the Upper Airway?

Introduction: With new SARS-CoV-2 variants emerging such as Delta and Omicron, it is important to reevaluate patterns of presentation and affected patient characteristics. SARS-CoV-2 infection may be shifting from a primary insult of the lower airway to one primarily affecting the upper airway. Method(s): This is a report of a novel case of SARS-CoV-2 infection causing an epiglottic abscess during the peak of the Omicron wave. A literature review showed no previous reports of this specific entity. Result(s): An otherwise healthy, unvaccinated 25-year-old man presented with 3 days of throat pain and mild cough. He had no subjective or objective fevers, malaise, voice changes, or difficulty breathing. White blood cell count was normal. A computed tomography neck with intravenous (IV) contrast revealed edema and gas formation of the epiglottis with a small developing abscess. Flexible fiber-optic laryngoscopy showed an edematous epiglottis with prolapse posteriorly to the pharyngeal wall and mild arytenoid edema without involvement of the vocal folds. He was intubated in the operating room, and incision and drainage of the epiglottic abscess was performed. He was given steroids and broad-spectrum IV antibiotics and extubated without difficulty on postoperative day 2. Intraoperative cultures unfortunately did not speciate to guide antibiotic therapy. He continued to improve clinically and was discharged home on postoperative day 3 with a course of amoxicillin/clavulanate. Conclusion(s): This case highlights a unique presentation of COVID in a young, unvaccinated patient that was successfully managed with operative drainage. He was without any medical comorbidities or immunodeficiency. It is possible that current COVID variants have a predilection for the upper airway as evidenced by this case.

A HARD PILL TO SWALLOW

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Epiglottitis is an inflammation of the epiglottis which can be life-threatening in the absence of prompt intervention. Although primarily a pediatric condition, streptococcus pneumonia has been identified as a common pathogen in adults. SARS-CoV 2 has been known to affect a multitude of systems including the upper respiratory tract, but rarely the epiglottis. CASE PRESENTATION: A 66-year-old female with a past history of hypertension, and hypothyroidism presented with acute onset pharyngodynia and dysphagia with a feeling of throat closing up due to swelling and difficulty speaking. She had a recent COVID-19 diagnosis and was doing well except for mild fatigue. Upon presentation, she was hemodynamically stable. Physical exam revealed posterior pharyngeal edema without any exudate, mildly edematous uvula, and no stridor. Laboratory data was pristine except for elevated inflammatory markers. Rapid streptococcal test and MRSA swab were negative. Sputum culture showed usual respiratory flora and blood cultures were negative. A neck CT showed diffuse edema without any evidence of abscess. Laryngoscopy performed by the ENT surgeon revealed diffuse edema including epiglottitis. Emergent intubation revealed supra and epiglottis edema sparing the vocal cords. The patient was given Decadron and Benadryl to help with the edema along with clindamycin and subsequently transferred to ICU for further care. She was treated with Ceftriaxone for 7 days due to a chest X-ray finding of pneumonia. As for COVID 19 treatment, she received a course of Remdesivir and Decadron. Decadron was given at an increased interval to reduce edema around the epiglottis. Her ICU course was complicated with hypotension requiring intermittent vasopressor support, and acute kidney injury from ischemic acute tubular necrosis which slowly improved. Repeat CT chest showed bibasilar consolidations with peripheral ground-glass opacities. In view of hospital-acquired pneumonia, she was started on Ertapenem. Her clinical condition improved and she was successfully extubated. She was shifted to the floors from where she was discharged without any further complications. DISCUSSION: There are only two other reported cases of COVID 19 epiglottitis. The patient's advanced age and obesity were non-modifiable risk factors, but the COVID-19 infection played a role. The virus can lead to excessive upregulation of the host inflammatory response through repeat epithelial and endothelial damage leading to a cytokine storm, which may be responsible for this presentation. A great level of attention is to be maintained while attending to these patients given the multitude of systems that can be affected. CONCLUSIONS: COVID-19 is a potential cause of life-threatening acute epiglottitis. Early suspicion and direct visualization of the epiglottis is the key to success for early management. Reference #1: Emberey J, Velala SS, Marshall B, et al. Acute Epiglottitis Due to COVID-19 Infection. Eur J Case Rep Intern Med. 2021;8(3):002280. Published 2021 Mar 3. doi:10.12890/2021_002280 Reference #2: Smith C, Mobarakai O, Sahra S, Twito J, Mobarakai N. Case report: Epiglottitis in the setting of COVID-19. IDCases. 2021;24:e01116. doi: 10.1016/j.idcr.2021.e01116. Epub 2021 Apr 7. PMID: 33842206;PMCID: PMC8025537. DISCLOSURES: No relevant relationships by Arunava Saha

A Case of Adult Epiglottitis in a Patient With Uncontrolled Diabetes and Occupational Risks.

Epiglottitis is inflammation of the epiglottis with or without the involvement of supraglottic structures including the hypopharynx. Timely diagnosis is crucial as the treatment of epiglottitis is tailored to the degree of airway obstruction. Most patients improve with conservative measures, while some require an emergent airway intervention. We report a case of a 39-year-old Caucasian male with a history of uncontrolled diabetes mellitus and smoking who presented to the emergency department (ED) with a sore throat, dry cough, odynophagia, and difficulty swallowing. He was afebrile, tachycardic, tachypneic, hypertensive, and saturating at 99% on room air. His physical examination was remarkable for drooling, muffled voice, pharyngeal swelling, and erythema. Laboratory tests were significant for leukocytosis, hyperglycemia, and hemoglobin A1c (HbA1c) of 14.3% with a negative infectious workup. Lateral neck X-ray and emergent direct fiberoptic laryngoscopy revealed findings of epiglottitis with airway patency. The patient did not require intubation and was started on intravenous dexamethasone, vancomycin, ampicillin-sulbactam, and humidified air with suctioning of secretions and quickly recovered. In addition to known risk factors for developing epiglottitis such as uncontrolled diabetes and smoking, our patient was exposed to metal shavings at his new job, an occupational hazard that might have contributed to his clinical presentation. Our case highlights the importance of a prompt diagnosis and risk factor identification in the management of epiglottitis in adults.

SARS COV-2 AS A RISK FOR ANGIOEDEMA

CASE: This is a 41-year-old man who was admitted to the medical floor with mild COVID-19 symptoms without hypoxia. He had End Stage Renal Disease (ESRD) on Hemodialysis (HD), failed renal transplant, Hypertension and Schizophrenia. Patient had no relevant family history. Medications included Aspirin, Atorvastatin, Nifedipine, Benztropine, and Haloperidol. Patient had allergy to shellfish products. He tested positive a week prior to admission with mild cough no fever or hypoxia. As symptoms worsened, he presented to emergency department and was admitted because of his immunocompromised status. The night of admission, he developed wheezing and stridor, swelling of face and lips, and altered mental status. It was difficult to pass endotracheal tube due to swollen airways. Vital signs were stable except for a low oxygen saturation. Physical examination significant for stridor and swelling of the face and lips. Laboratory values were not significant. We reviewed and none of them was newly started or associated with risks of angioedema. He had no history of previous similar episodes. Patient was given anti-histamines and steroids with slight improvement. Flexible laryngoscopy was performed showing swollen epiglottis and aryepiglottic folds. He ended up getting a tracheostomy as he was regarded as a high risk to be liberated from intubation. IMPACT/DISCUSSION: Few other cases of COVID-associated angioedema have been reported in the literature, majority of the cases explained were in African American patients. The features of angioedema reported like the traditional angioedema, swelling of the face, lips and airways. This angioedema developed within 7 days of detection of COVID-19 in our case and >10 days in the previously reported cases. Angioedema develops due to increased levels of Bradykinin (BK) and its metabolites due to increased expression or decreased degradation. Angiotensin Converting Enzyme (ACE) with other enzymes prevent angioedema by degradation of BK and its metabolites . African Americans, have genetic susceptibility which leads to lower levels of other enzymes involved in the Bradykinin metabolism, thus ACE blockade put them at a higher risk of angioedema. The association of COVID-19 with ACE2 and its subsequent disruption of ACE activity is thought to be the reason behind the development of angioedema. Most of the published articles are either observational or sporadic case reports. More thorough study might help identify further mechanisms and if there is a direct true causal relationship between COVID-19 infection and angioedema or if it is the result of a “second hit,” as it was called by authors of another case that involved a Caucasian male with hypertension who has been using Lisinopril for years with no previously reported complaint. CONCLUSION: SARS CoV-2 should be suspected as cause for angioedema. Further studies needed to establish modalities for diagnosis, management and prevention in high-risk patients.

A Rare Cause of Angioedema - A Novel Case Report

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is well described as an etiology to severe acute respiratory distress syndrome (ARDS). However, rare immunologic and allergic manifestations may also occur from this infection. We report a novel case of angioedema occurring in the setting of COVID-19 infection in a fully vaccinated patient. Case Report: A 61-yearold COVID-19 vaccinated female with hypertension presented to the emergency department with tongue and lip swelling, odynophagia, dysphonia, and difficulty breathing. She denied personal or family history of allergies, anaphylaxis, or angioedema. Her home medications included Aspirin, methadone, Seroquel, and Klonopin, with no recent changes reported. Physical exam was notable for significant lip and tongue edema, audible dysphonia, and bilateral end-inspiratory wheezing. She was hypoxemic and placed on nasal cannula. Laboratory findings revealed lymphopenia, elevated inflammatory proteins, including C-reactive protein (57), Lactate dehydrogenase (LDH) (238), and D-dimer (11.52). Functional C1 esterase inhibitor levels (>91) were normal. Nasal PCR swab returned positive for SARS-CoV-2. Ear, nose, and throat specialist was consulted given concern for angioedema, and flexible nasolaryngoscopy was performed revealing uvular, epiglottic, and bilateral arytenoid edema concerning for impending airway compromise. The patient was initiated on intravenous methylprednisolone, epinephrine, antihistamines, tranexamic acid and admitted to the medical intensive care unit (ICU). She was monitored closely in the ICU with subsequent improvement of the angioedema and resolution of the hypoxemia. She was discharged with an oral steroid regimen and scheduled for a follow-up appointment with an allergist. Discussion: There exists only a handful of case reports describing angioedema in patients with COVID-19 infection. In those reports, patients also had normal C1 esterase inhibitor levels and no personal or family history of inherited angioedema. Interestingly, our patient was vaccinated six months prior to her presentation. The association between SARS-CoV-2 and angiotensinconverting enzyme 2 (ACE-2), the primary receptor for viral entry into the epithelial cells of the lungs, could be a potential explanation for the occurrence of angioedema. ACE-2 plays a pivotal role in inhibiting a potent ligand of bradykinin receptor 1, Arginine bradykinin. It has been postulated that SARS-CoV-2 downregulation of ACE-2 leads to elevated angiotensin II levels and subsequent activation of the bradykinin pathway. Excessive bradykinin production generates high levels of nitric oxide and prostaglandins, resulting in vasodilation, increased vascular permeability, and angioedema. This case highlights the importance of recognizing atypical and rare presentations of COVID-19 infection, especially angioedema, given its sudden onset and life-threatening complications.

Primary Vocal Cord Aspergillosis

Fungal infection of vocal cord in immunocompetent host is rare and may be missed as the lesion may mimic granulomatous disease, carcinoma, leukoplakia etc. Here we present a case of a healthy male patient. A 77 years old male patient presented to ENT specialist with complaints of hoarseness of voice for last 3 months. The patient was a non-smoker, not immunocompromised or taking immunosuppressive drugs. He was prone to seasonal bouts of cough & cold with sneezing. Video laryngoscopy showed inflamed tonsils and congested vallecula & epiglottis. Both vocal cords showed proliferative mass, white keratotic patch in anterior & middle third portion with restricted movement. Tissue samples from both vocal cords was sent for histopathology (HP). Slide examination revealed necrotic exudate containing broad based aseptate fungal hyphae and a provisional diagnosis of vocal cord fungal infection favoring Mucor mycosis was made. Patient was started on Itraconazole 100 mg twice daily along with treatment for patient's allergic condition. The slides and tissue sample obtained by direct laryngoscopy were sent to a different lab for reconfirmation. Further HP examination showed necrotic exudate and fibrin deposits with abundant fungal spores & hyphae. Grocott methenamine silver (GMS) stain & Periodic acid-Schiff (PAS) staining showed fungal spores and branching septate fungal hyphae confirming a diagnosis of vocal cord aspergillosis. His routine blood tests, serology, ECG reports were normal. RTPCR (Reverse Transcriptase Polymerase Chain Reaction) for SARS-CoV-2 was negative. After final diagnosis, patient was referred to pulmonologist to exclude pulmonary aspergillosis. Medication was changed to Voriconazole 200 mg twice daily along with antileukotrienes & antihistamines for his seasonal allergies. Patient was asked to follow up with CT chest to exclude pulmonary aspergillosis. The CT chest did not show any chest pathology. His voice was normal and other physical examinations were within normal limit. He was prescribed Voriconazole 200 mg twice daily for 3 months along with antihistamines, antileukotrienes, proton pump inhibitors & cough syrup. He was advised to come for follow up with liver function test after 4 weeks. Primary fungal infection of vocal cords is rare. Fungal infection is common in immunocompromised host but to detect such cases in healthy immunocompetent patient requires high level of suspicion and usually oral antifungal therapy for 3-4 weeks results in complete resolution of symptoms & lesion as per the current literature. (Figure Presented).