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.

Leukocytoclastic vasculitis following immunization with COVID-19 vaccine

Case report Introduction: Vaccines have been recognized as agents associated with development of different forms of vasculitis. We describe the case of a leukocytoclastic vasculitis which developed after immunization with inactivated COVID-19 vaccine. Case presentation: A 68-years old female patient presented with painful purpuric papules and plaques, and areas of necrosis, dominantly localized on her feet (Figure 1), developing 12 days after she received first dose of inactivated COVID-19 vaccine (BBIBP Cor-V). There were no other symptoms except mild fatigue and low-grade temperature of 37.3degreeC. Skin biopsy showed damaged vessel wall with perivascular, neutrophilic inflammatory infiltrate, leucocytoclasia and erythrocytes extravasation (Figure 2). Thorough work-up, including broad immunoserological and virological analysis didn't reveal any other potential trigger. Three months before vaccination the patient recovered from COVID-19 pneumonia. After the four weeks course of prednisone (initially 20 mg/day) with tapering a complete resolution of skin changes was achieved. The patient was followed for one year with no relapses. Conclusion(s): COVID-19 immunization should be considered as a potential trigger for development of cutaneous vasculitis.

Case report of an antimelanoma differentiationassociated protein 5 antibody-associated amyopathic dermatomyositis

Autoantibodies against melanoma differentiation-associated protein 5 (MDA5) associated with dermatomyositis have recently been described in Asians with rapidly progressive respiratory disease. Here we report the case of a middle-aged white woman with anti-MDA5 antibody-associated amyopathic dermatomyositis with interstitial lung disease (ILD), which is stable with minimal immune suppression. A 55-year-old woman was referred to a virtual dermatology clinic during the COVID-19 pandemic suspected of having widespread eczema involving the chest, face, arm and hands on the background of atopy. On direct questioning, she admitted to having constitutional symptoms, exertional dyspnoea, joint pain and symptoms of proximal muscle weakness. On clinical suspicion of possible connective tissue disorder, she was urgently reviewed in the hospital, where she was found to have a photodistributed rash involving cutaneous ulceration and violaceous plaques. Hand examination showed mechanic's hand mimicking hand eczema, ragged nail cuticles and acute tenosynovitis in the left index finger. Her upper and lower limb muscle power was normal and respiratory examination revealed bi-basal fine end-expiratory crepitation. Her repeated biochemical, haematological and muscle enzymes remained normal. Skin biopsy taken from photosensitive rash over the wrist showed hypergranulosis, Civatte body formation, colloid bodies and dyskeratotic keratinocytes, in keeping with severe lichenoid eruption. Superficial dermis showed patchy red-cell extravasation, perivascular chronic infiltration, dermal oedema and serum on the surface, in keeping with ulceration secondary to severe inflammatory processes. There were no eosinophils and eccrine coils were free of inflammation, raising the suspicion of a drug eruption. Her antinuclear antibody and double-stranded DNA were repeatedly negative. Myositisspecific antibody panel was performed owing to a high clinical suspicion of photosensitive dermatoses, both clinically and histologically. Histology revealed positive anti-MDA5 antibodies;repeated positive testing confirmed this. Although lung function was normal, computed tomography revealed evidence of ILD. We made a diagnosis of anti-MDA5 antibodyassociated amyopathic dermatomyositis with ILD. Her malignancy screening was negative. The patient was started on lowdose prednisolone and hydroxychloroquine 200 mg twice daily, with topical steroid applications, which resulted in remarkable clinical improvement. Anti-MDA5 associated dermatomyositis has characteristic cutaneous lesions consisting of skin ulceration and tender palmar papules, mechanic's hands, inflammatory arthritis and rapidly progressive ILD, which is frequently fatal. Although our patient had ILD, she was relatively stable on minimal immunosuppression. It is important for clinicians to have an increased awareness of this disease as it could have a highly variable clinical presentation in the white population.

Ultrasound-Guided Infiltrative Treatment Associated With Early Rehabilitation Program in Adhesive Capsulitis in "Post-Covid syndrome"...American Congress of Rehabilitation Medicine (ACRM) 99th Annual Conference, November 8-11, 2022, Chicago, Illinois

The aim of the study is to evaluate the efficacy of ultrasound-guided infiltrative treatment associated with early rehabilitation program in patients with adhesive capsulitis devoleped in Post-Covid syndrome. This is an observational study. The setting for patient assessment is ambulatory. Six consecutive patients regarded to outclinic for adhesive capsulitis in the post-covid syndrome are clinically and ultrasonographically evaluated and undergo an interventional ultrasound procedure associated with early rehabilitation treatment. Patients are treated with infiltrative hydrodistension therapy under ultrasound guidance. This technique consists in injecting a saline solution combined with corticosteroids and anesthetic that relax the capsule thanks to the increase in hydrostatic pressure (called hydrodistension) increasing the volume capacity of the shoulder. The rehabilitation treatment is undertaken immediately after the infiltrative treatment in order to improve the joint ROM. Attive shoulder range of motion (ROM), Visual Analogic Scale for Pain (VAS), Shoulder Pain and Disability Index (SPADI) and Disability of the Arm, Shoulder and Hand (DASH) are used for clinical assessment. In patients with adhesive capsulitis, before the treatment, a fairly reduced shoulder range of motion is seen with mean elevation values allowed for 55°;abduction 40 °, internal rotation allowed for 30 ° with arm abducted to 90 °, external rotation allowed for 40 ° with arm abducted to 90 °. After 2 months from the treatment we obtain an almost complete recovery of the range of motion (elevation 150 °;abduction 130 °, internal rotation allowed in for 70 ° with arm abducted to 90 °, external rotation allowed for 80 ° with arm abducted at 90 °). The VAS mean score before the treatment is 6,9, after 2 months of treatment the VAS score is 1. In patients with adhesive capsulitis developed in post-Covid Syndrome, infiltrative hydrodistension therapy associated with early rehabilitation treatment provides more successful results in terms of active ROM of the joint and reduction of pain. The author declares no conflict of interest.

Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with (pseudo) aneurysm is demonstrated in three cases: 1) massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and color Doppler (CD), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CD was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

COVID-19 associated spontaneous hemorrhagic cholecystitis

Hemorrhagic cholecystitis is a rare disorder associated with considerable morbidity and mortality. The clinical presentation of hemorrhagic cholecystitis is non-specific and imaging findings can be difficult to accurately interpret without a high level of suspicion. Most recent reports of hemorrhagic cholecystitis have been associated with concurrent therapeutic anticoagulation. Here, we report imaging findings of a case of acute, spontaneous hemorrhagic cholecystitis in a 67-year-old male patient admitted for hypoxic respiratory failure secondary to COVID-19 pneumonia. © 2022

Increased reliability of CT-imaging signs of bleeding into soft tissue in patients with COVID-19 for planning transarterial embolization.

INTRODUCTION: Spontaneous bleeding into the soft tissues of the abdominal and thoracic wall is described as complication of anticoagulant therapy. Computed tomography (CT) allows to detect the presence of extravasation of the contrast agent into a hematoma, which is indicated as a sign of ongoing bleeding. Other specific CT signs of such coagulopathic bleeding have been described earlier. AIM OF THE STUDY: To evaluate the significance of specific coagulopathic CT signs for predicting the dynamics of spontaneous bleeding into soft tissues in patients with COVID-19. MATERIALS AND METHODS: A retrospective study included 60 patients with COVID-19 with spontaneous bleeding into soft tissues and extravasation of a contrast agent on CT. In addition to extravasation, a "hematocrit effect" was detected in 43 patients on CT. Of these, 39 had extravasation in the form of a "signal flare." All patients underwent transarterial catheter angiography (TCA). To assess the prognostic value of CT signs, the results of CT and TCA compared. The absence of extravasation on the TCA more often corresponded to stopped bleeding. RESULTS: Extravasation on TCA found in 27 (45%) patients. The presence of the "hematocrit effect" or the combination of this sign with the phenomenon of a "signal flare" on CT (n = 43) led to more frequent confirmation of extravasation on TCA than in their absence (n = 17): 23.5% vs. 53.4% (p = 0.028). CONCLUSION: The presence of a fluid level and the phenomenon of a "signal flare" on CT in the structure of spontaneous hematomas of the soft tissues of the abdominal and thoracic wall in COVID-19 patients more often corresponded to ongoing bleeding on the TCA. The absence of coagulopathic CT signs more often corresponded to stopped bleeding.

Broader Epstein-Barr virus-specific T-cell receptor repertoire in patients with multiple sclerosis

Introduction: Epstein-Barr virus (EBV) infection precedes signs of multiple sclerosis (MS) pathology and cross-reactive antibodies might link EBV infection mechanistically to CNS autoimmunity. Objective(s): As an altered immune reaction against EBV antigens in T cells of MS patients has been suggested, we queried deep, peripheral blood T-cell receptor beta chain (TCRbeta) repertoires of 1395 MS patients, 887 controls, and 35 monozygotic, MS-discordant twin pairs for multimerconfirmed, viral antigen-specific TCRbeta sequences. Aim(s): Quantification of HLA-matched EBV-specific, CMV-specific, Influenza A virus-specific, and SARS-CoV-2-specific TCRbeta sequences in MS patients, controls, and COVID-19 patients. Result(s): We detected higher numbers of MHC-I restricted EBVspecific TCRbeta sequences in MS patients, and validated this with independent cohorts and sequencing methods. Genetic as well as early environmental factors could be excluded by validation in diseased siblings of monozygotic twin pairs discordant for MS. Therapeutic blockade of VLA-4-mediated T-cell extravasation amplified this observation, while interferon beta treatment and B-cell depletion did not modulate occurrence of EBV-specific T cells. EBV-specific CD8+ T cells were characterized as effectormemory cells in peripheral blood and cerebrospinal fluid of healthy controls. In MS patients, the cerebrospinal fluid also contained EBV-specific central-memory CD8+ T cells, suggesting recent priming. Conclusion(s): MS is not only preceded by EBV infection, but also associated with a broader EBV-specific TCR repertoire, which would be consistent with an ongoing anti-EBV immune reaction in MS patients.

IT'S NEXT TO THE PLEURA

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan

HEMORRHAGIC SHOCK SECONDARY TO LUMBAR ARTERY RUPTURE

SESSION TITLE: Critical Cardiovascular Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Hemorrhagic shock is a life-threatening condition in which severe blood loss results in cellular and tissue hypoxia. The bleeding can be external or internal. Internal bleeding to one of the body cavities;retroperitoneum, as well as the proximal thigh. Diagnosing nontraumatic bleeding can be challenging and needs a high index of clinical suspension. Here we present a case of hemorrhagic shock secondary to spontaneous lumbar artery rupture causing retroperitoneal bleeding. CASE PRESENTATION: Here we present a 73-year-old male patient with a history of renal cell carcinoma metastatic to the lungs and stage 3 chronic kidney disease (CKD), who presented with confusion, one day after he tested positive for covid after he had a fever and flu-like symptoms for about 4 days. On admission, he was hemodynamically stable and saturating well on ambient air. Head computed tomography (CT) scan and Chest radiograph were negative for acute insults. On the day after admission, his mental status deteriorated, developed acute hypoxic respiratory failure requiring 4 liters of oxygen per minute, tachycardia, and skin mottling over his hands and feet. Labs revealed elevated serum D-dimer. He was started on full-dose anticoagulation with Enoxaparin, and a CT angiogram of the chest was done and revealed new multifocal infiltrates consistent with COVID pneumonia but no pulmonary embolism. He was treated started on IV antibiotics, in addition to Remdesivir and hydrocortisone were started. On the fourth day of admission, he collapsed suddenly and became profoundly hypotensive. Repeat labs revealed a significant hemoglobin drop from 12 to 7.5 g/dl, and creatinine went up to 2.8 mg/dl. An emergent CT of the abdomen revealed an acute retroperitoneal hematoma with active extravasation. After adequate resuscitation and vasopressor support, an aortic angiogram was done showing lumbar artery bleeding requiring embolization, which was done, however, he remained hypotensive and went into cardiac arrest with failed resuscitation. DISCUSSION: Spontaneous lumbar artery rupture is a rare entity (1). Most of the reported cases had chronic kidney disease and were receiving anticoagulation (2,3). It can result in retroperitoneal hematoma, which can present with abdominal pain, hemodynamic instability, and nonspecific symptoms. Abdomen pelvis CT scan with contrast is needed to evaluate for the presence of retroperitoneal hematoma. In addition to resuscitation with fluid and blood products, urgent angiography is needed to confirm the bleeding site and to control it (e.g. embolization). CONCLUSIONS: Spontaneous Lumbar artery rupture should be considered in patients with chronic kidney disease and/or on anticoagulation who are in shock without obvious cause. It's a life threatening condition that needs immediate recognition. Reference #1: Kim JY, Lee SA, Hwang JJ, Park JB, Park SW, Kim YH, et al. Spontaneous lumbar artery rupture and massive retroperitoneal hematoma, successfully treated with arteriographic embolization. Pak J Med Sci. 2019;35(2):569-574. doi: https://doi.org/10.12669/pjms.35.2.639 (Literature review) Reference #2: Hwang NK, Rhee H, Kim IY, et al. Three cases of spontaneous lumbar artery rupture in hemodialysis patients. Hemodial Int 2017;21: E18-21 Reference #3: Sun, PL., Lee, YC. & Chiu, KC. Retroperitoneal hemorrhage caused by enoxaparin-induced spontaneous lumbar artery bleeding and treated by transcatheter arterial embolization: a case report. Cases Journal 2, 9375 (2009). https://doi.org/10.1186/1757-1626-2-9375 DISCLOSURES: No relevant relationships by Mohamad Al-Momani No relevant relationships by Rami Dalbah No relevant relationships by Mohammad Darweesh No relevant relationships by Ratib Mahfouz No relevant relationships by nizar obeidat No relevant relationships by Ahmad Othman

A Novel Ogremorphin Group of First-in-Class GPR68 Inhibitors Upregulate Endothelial Barrier Function and Rescue Bacterial Pathogens or Acidosis-Induced Inflammation in Lung Endothelium

Rationale: An increase in endothelial permeability resulting from the disruption of endothelial barrier and aggravated inflammatory responses are two major pathological hallmarks of various lung disorders including the current global pandemic COVID-19. Drugs that enable the preservation and restoration of endothelial function represent attractive therapeutic targets to treat endothelial dysfunction-derived cardiopulmonary diseases. A role of G protein-coupled receptors (GPCRs), especially a sub-family of proton-sensing GPCRs including GPR4 and GPR68, has been suggested in modulation of endothelial function. In this study, we analyzed the barrier protective and anti-inflammatory effects of two recently developed novel class of GPR68 inhibitors: ogremorphins OGM8345 and OGM-1.Methods: Transendothelial electrical resistance (TER) was monitored in human pulmonary arterial endothelial cells (HPAECs) to evaluate endothelial barrier function. Quantitative real time PCR and western blot analyses were performed to determine mRNA and protein expression of endothelial inflammation markers, respectively. Acidic pH (6.5) medium was used to induce acidosis, and luciferase-based Tango assay was employed to evaluate GPR68 activation. C57BL/6 mice were exposed to lipopolysaccharide (LPS from Escherichia coli) or heatkilled Staphylococcus aureus (HKSA), and vascular leak/inflammation was assessed by determining the extravasation of intravenously injected Evans blue tracer into lungs and total cells/protein count in bronchoalveolar lavage samples. Results: A robust dose-dependent increase in basal EC barrier function was observed with OGM8345 (1-5 μM) and OGM-1 (0.3-1.5 μM) evident by an 150-200% increase in TER values. Both inhibitors also effectively rescued LPS- and HKSA-induced EC hyperpermeability. RT-PCR analysis demonstrated that LPS or HKSA-induced upregulation of inflammatory cytokines/chemokines genes TNF-α, ICAM-1, VCAM-1, IL-6, IL-8, IL- 1β, and CXCL5 was significantly attenuated by OGMs. Consistently, both OGMs suppressed LPSand HKSA-induced protein expression of VCAM-1 and ICAM-1. In contrast, pharmacologic inhibition of GPR4 by NE 52-QQ57 failed to alleviate LPS or HKSA-induced EC barrier dysfunction and inflammation. Importantly, LPS, HKSA or acidosis stimulation resulted in increased GPR68 mRNA expression and GPR68 activity that was inhibited by OGMs. Intratracheal injection of LPS or HKSA in C57BL/6 mice caused vascular leak and lung inflammation that was attenuated by both OGMs as illustrated by reduced Evans blue accumulation in the lungs and significant inhibition of accumulation of inflammatory cells and protein content in bronchoalveolar lavage samples. Conclusion: These results establish a critical role of GPR68 in endothelial dysfunction and strongly suggest a therapeutic potential of GPR68-selective inhibitors in improving endothelial dysfunction caused by bacterial infections and acidosis associated with acute and chronic lung injury.

Purulent pericarditis can be near fatal

A previously healthy 27 years-old male presented with 2 weeks of substernal chest pain, progressive dyspnea, palpitations, dizziness, and(&) fever. On exam, he had tachypnea & tachycardia, was hypotensive with an elevated JVP & muffled heart sounds. Labs showed elevated WBC, CRP, lactate & high sensitive troponin. Negative for COVID-19, flu. EKG showed sinus tachycardia. CT showed large pericardial effusion with gas in the pericardial space. Echo (Figure 1) revealed large pericardial effusion with tamponade. Emergent pericardiocentesis was performed draining a liter of straw-colored thick fluid (fluid: serum LDH >3) (Figure 2). Cultures grew Strep. Anginosus & Propionibacterium acnes. Extensive infectious & immunological workup returned negative. He had initially improved on broad-spectrum antibiotics however declined clinically on day 5. Repeat CT (Figures 3 & 4) showed recurrent pericardial effusion & mediastinal abscess with trace extravasation of contrast from the esophagus to posterior mediastinum. We present a case of esophageal perforation leading to Pyopneumopericardium. Stephenson et al. reported a case series of 13 patients with esophagopericardial fistulas & pyopneumopericardium with a 100% mortality rate. Another case series showed survival rates of only 17% in 60 patients with pyopneumopericardium secondary to esophageal perforation. Erosion of esophageal ulcers, ingestion of foreign body, iatrogenic, trauma, malignancy, localized inflammation can lead to esophageal perforation. Streptococcus pneumoniae & Staphylococcus aureus are common pathogens involved. Constrictive pericarditis is a possible complication in up to 20 to 30%. Our patient underwent pericardial window & surgical debridement followed by EGD-guided gastro-jejunal tube placement. He did well after 4 weeks of IV antibiotics. Our case demonstrates that early recognition & intervention can favorably alter the course of this potentially fatal cardiac condition.

Sars-Cov-2 Infection Promotes Endothelial Dysfunction and Thrombosis in a Mouse Model of COVID-19

Coronavirus disease 2019 (COVID-19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Most infected individuals are asymptomatic or show only mild symptoms, but 20% of infected individuals become severely ill resulting in a 2-5% mortality rate for severe infections. Men, the elderly and patients with comorbidities (such as cardiovascular disease, hypertension, diabetes, and obesity) are more likely to develop severe disease. Clinical features characterizing severe COVID-19 cases include inflammation and thrombosis, but the molecular mechanisms underlying these processes remain elusive. K18 hACE2 transgenic mice express the SARSCoV-2 receptor human angiotensin-converting enzyme 2 (hACE2) under the control of the human cytokeratin 18 (K18) promoter. K18 hACE2 mice express hACE2 in airway epithelial cells and are susceptible to SARS-CoV-1 and SARS-CoV-2 infections. At the dose of 10 5 PFU/mouse, all SARS-CoV-2-infected K18 hACE2 mice rapidly lose weight and succumb to viral infection by 5-6 days post infection. Morbidity and mortality correlated with SARS-CoV-2 replication in the nasal turbinates and lungs. Notably, susceptibility was highly associated with a local and systemic cytokine/chemokine storm. SARS-CoV-2 infection in K18 hACE2 mice recapitulates many of the pathological findings observed in human patients offering a reliable animal model for the study of SARS-CoV-2 pathogenesis. Infection with a lower viral dose (10 4 and 2.5x10 3 PFU/mouse) prolongs the symptomatic phase of the infection, postponing time of death up to 16 days post infection (mortality rate at 10 4 PFU: ~40% in females, 100% in males;mortality rate at 2.5x10 3 PFU: ~30% in females, ~55% in males). At these lower viral doses, K18 hACE2 mouse males exhibited both increased susceptibility to the SARS-CoV-2 infection and more severe disease. Male mice showed increased mortality associated with an increase in weight loss and decrease in body temperature. Disease characteristics showed striking similarities with reported human COVID-19 cases, including severely reduced O 2 saturation. The pathogenesis of severe COVID-19 cases involves both virus-induced cell damage and secondary tissue damage due to a vicious cycle of dysregulated - hyperactive coagulation and inflammatory pathways that present as “a cytokine storm”, endothelial dysfunction, and “immunothrombosis”. Analysis of murine plasma analytes from infected mice revealed additional pathogenetic features resembling SARS-CoV-2 infection in humans. High circulating D-dimer levels are now considered a main predictor of poor outcome of SARS-CoV-2 infection. Notably, we also observed a progressive increase of circulating D-dimer levels in the plasma of K18 hACE2 infected mice peaking at day 7 post infection, suggestive of a hypercoagulable state. Moreover, similar to humans, the increase in soluble thrombomodulin plasma concentration and its correlation with disease severity was indicative of endothelial activation and dysfunction in K18 hACE2 infected mice. SARS-CoV-2 infection-induced changes of coagulation and endothelial activation in mice resulted in a biphasic alteration of endothelial permeability where an initial increase in vascular permeability, peaking at day 5 post infection, was followed by a sudden decrease in Evan's blue dye extravasation in the lung parenchyma and characterized by the appearance of areas of hemorrhagic infarction indicative of thrombotic events. Altogether, our results identify the K18 hACE2 transgenic mouse as an important small animal model to study the molecular mechanisms involved in the derangement of the finely tuned interaction between the immune and coagulation systems associated with severe cases of SARS-CoV-2 infections. Disclosures: Mosnier: Hematherix: Membership on an entity's Board of Directors or advisory committees;Coagulant Therapeutics: Research Funding.

Painful Blisters of Left Hand Following Extravasation of Remdesivir Infusion in COVID-19.

How to cite this article: Kumar N, Kumar A, Pradhan S, Kumar A, Singh K. Painful Blisters of Left Hand Following Extravasation of Remdesivir Infusion in COVID-19. Indian J Crit Care Med 2021;25(2):240-241.

Peripheral Inotropes in Critically Ill Children: Is It Safe?

Many children needing pediatric intensive care units care require inotropes, which are started peripherally prior to securing a central venous access. However, many hospitals in low- and middle-income countries (LMIC) may not have access to central lines and the vasoactive medications are frequently given through a peripheral venous access. Aim: The aim of our study was to describe the role of peripheral vasoactive inotropes in children. Methods: Children requiring peripheral vasoactive medications were included in this study. We retrospectively collected data at 2 time points on use and complications of peripheral vasoactive medications. Results: Eighty-four children (51 pre-COVID era and 33 COVID pandemic) received peripheral vasoactive medications. Only 3% of children (3/84) developed extravasation injury, all of whom recovered completely. Conclusions: Results from our study suggest that extravasation injury due to peripheral inotrope infusion is very low (3%) and it may be safely administered in children at a diluted concentration.