DERMATO-NEURO SYNDROME PRECIPITATED BY COVID-19 INFECTION IN THE SETTING OF SCLEROMYXEDEMA

BackgroundA black female in her 40s presented with a nonpruritic rash for 10 months consisting of bumps on the face, hands, forearms, and thighs. She had no prior treatment. Past medical history was significant for pulmonary embolism (PE) 6 years prior. She had no personal or family history of autoimmune disease. Physical exam revealed numerous smooth 2-3 mm skin-colored papules over the bilateral forearm dorsa, hands, anterior thighs, and face. Serum protein electrophoresis revealed monoclonal IgG lambda gammopathy. Skin biopsy of her left elbow showed dermal fibroplasia with mucin deposition. IgG was less than 1.5 grams/deciliter;bloodwork was otherwise stable. The diagnosis of scleromyxedema was rendered.ObjectivesThe objective of this clinical case was to evaluate a neurologic sequela of COVID-19 infection in a patient with scleromyxedema.MethodsOne month following diagnosis of scleromyxedema, our patient was diagnosed with COVID-19 five days before admission to the emergency department with altered mental status and aphasia. Rheumatology was consulted due to malignant hypertension and acute kidney injury with question of scleroderma-like renal crisis in the setting of recently diagnosed COVID-19 infection, although she had no other features of systemic sclerosis. The infectious disease team was consulted due to COVID-19-induced inflammatory reaction.ResultsThe patient's creatinine kinase and brain natriuretic peptide were elevated. Creatinine and potassium trended upwards. She developed seizures and became hemodynamically unstable with rapidly declining clinical status. She was transferred to the intensive care unit, where she developed respiratory arrest, shock, hyperkalemia, and acidemia. She received escalating doses of pressors but experienced frequent arrhythmic disturbances and developed asystole. Resuscitation efforts were unsuccessful;she expired within 24 hours of consultation.ConclusionDermato-neuro syndrome (DNS) is a potential complication of scleromyxedema associated with confusion, dysarthria, seizures, and coma. The patient's clinical presentation is consistent with DNS in the setting of scleromyxedema likely precipitated by COVID-19. Intravenous immunoglobulins are first-line treatment for scleromyxedema;however, it is associated with risk of venous thromboembolism. The patient was considered for treatment as an outpatient but deferred due to history of PE. She was reevaluated for treatment upon presentation to the hospital, but given the severity and rapidity of her condition, it was already too late. This is the second reported case of COVID-19 induced DNS in a patient with scleromyxedema. Given the severity, we recommend early initiation of treatment in patients with scleromyxedema and aggressive treatment for those contracting COVID-19.References[1] Haber R, Bachour J, El Gemayel M. Scleromyxedema treatment: a systematic review and update. Int J Dermatol. 2020;59:1191-1201.[2] Flannery MT, Humphrey D. Deep Venous Thrombosis with Pulmonary Embolism Related to IVIg Treatment: A Case Report and Literature Review. Case Rep Med. 2015;971321.[3] Lee YH, Sahu J, O'Brien MS, D'Agati VD, Jimenez SA. Scleroderma Renal Crisis-Like Acute Renal Failure Associated With Mucopolysaccharide Accumulation in Renal Vessels in a Patient With Scleromyxedema. J Clin Rheumatol. 2011;17:318-322.[4] Hoffman-Vold AM, Distler O, Bruni C, et al. Systemic sclerosis in the time of COVID-19. Lancet Rheumatol. 2022;4:e566-575.[5] Fritz M, Tinker D, Wessel AW, et al. SARS-CoV-2: A potential trigger of dermato-neuro syndrome in a patient with scleromyxedema. JAAD Case Rep. 2021;18:99-102.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Big data approach on the impact of COVID-19 lockdown on pediatric neurosurgery

Objective: COVID-19 lockdowns in 2020 limited activities of daily life. Data on the impact on healthcare systems is ambiguous. So far no data has been published for pediatric neurosurgery in Germany. We present the results of a big data approach. Method(s): We obtained anonymous data from the nationwide database of hospital statistics (German Federal Statistical Office, www. desta tis. de) in August 2022. For the age group <18 years in 2016- 2020, the following diagnoses (ICD-10 code) were analysed: Intracranial injury (S06), malignant (C71), benign (D33) and unspecified (D43) neoplasia, abuse (T74), violent attack (Y09) and, for comparison, forearm fracture (S52). The following operations (OPS code) were chosen: Operation of the central nervous system (CNS, 5-01- 05), excision of intracranial lesion (5-015), shunt insertion (5-023), shunt revision (5-024), plastic operations of the spinal cord (5-036) and, for comparison, overall number of operations (OPS-5), spondylodesis (5-836) and functional neurosurgery (5-028) at all ages. Result(s): The number of operations declined from 17.23 million in 2019 to 15.82 million in 2020 (8.2%). CNS operations declined by 5%. Shunt insertion declined by 8.1%, revision by 5.1% and spinal cord operations by 6.6%, whereas excisions of intracranial lesions increased by 1.7%. Spondylodesis and functional operations both decreased by 11.9%. The hospitalisations for intracranial neoplasia declined by 8.8% compared to previous years. The number of inpatients with intracranial injury declined by 16%. Violent attack was also documented less often (-13.2%), but child abuse increased by 3.3%. Forearm fractures declined by 5.6%. Conclusion(s): The COVID-19 lockdown in 2020 lead to reduction of operations. Neuro-oncological operations were not affected. Intracranial injury even declined by 16%, reflecting limited activities and mobility. An increase in documented child abuse by 3.3% compared to the average of previous years was observed. These results help understand the impact of pandemics and political decisions and guide future decision-making.

Covid-19 Vaccine-Induced Myositis

Background/Aims Through the COVID pandemic there have emerged reports of autoimmunity or new rheumatic diseases presenting in patients after they had COVID-19. This is thought to be caused by cross-reactivity of the COVID-19 spike protein to human antigens. Given the use of mRNA COVID-19 vaccinations which express the spike protein we might expect to see presentation of new rheumatic diseases following their use. We discuss a case where this appears to have occurred. Methods Our patient is a 24-year-old male with mixed phenotype acute leukaemia who had been treated with allogenic stem cell transplant and was currently in remission. He presented with fevers, palpitations, myalgia and bilateral arm and leg swelling. Symptoms began the day after receiving the first dose of an mRNA COVID-19 vaccination (Pfizer/BioNTech.) There were no other symptoms or recent change in medications. Physical examination revealed tender oedema in his forearms, biceps and thighs bilaterally with sparring of the hands. He had reduced power with shoulder (MRC 3/5), elbow (4), wrist (4+) and hip (4) movements. Observations revealed tachycardia and fevers up to 40C. Results Laboratory studies showed markedly elevated C-reactive protein (202), creatinine kinase (6697) and troponin (593) whilst investigations for infection were negative. An autoimmune panel was positive for anti- PM-SCL-75-Ab. An electrocardiogram showed sinus tachycardia. Echocardiogram was normal. Bilateral upper limb dopplers revealed no deep vein thrombus. An MRI of his thighs showed diffuse symmetrical oedema within the muscles, in keeping with an inflammatory myositis. A quadricep muscle biopsy showed evidence of MHC class 1 up-regulation, suggesting an inflammatory process. In addition, there were numerous macrophages evident in the endomysium. While this can be seen in graft-versus-host disease (GVHD), they would usually be found in the perimysium. After discussion between haematology, rheumatology and neurology, this was felt to be a case of vaccine induced myositis and myocarditis. Autoimmune myositis was thought to be less likely due to the relative sparing of the hands and the absence of Raynaud's phenomenon. 1 gram of intravenous methylprednisolone was then given for 3 days. The patient had a marked response with defervescence, improving laboratory markers, improved myalgia and decreased limb swelling. The patient was stepped down to a reducing regime of prednisolone and discharged. Due to relapse whilst weaning he has started on mycophenalate mofetil and rituximab and now continues to improve. Conclusion There are case reports of myositis following COVID-19 vaccination but our patient's case is complicated by the differential diagnosis of GVHD and concurrent myocarditis. Ongoing work is needed to clarify the exact link between vaccination and the presentation of a new inflammatory myositis, but it is important to recognise and start treatment early in order to preserve muscle bulk and ensure recovery.

Covid-19 Booster Vaccine Related Dermatitis: A Case Study

Case Report: A 28 year old male with a past medical history of hypothyroidism and positive ANA presented to an outpatient dermatology clinic with a diffuse pruritic rash two weeks after the administration of his first Moderna COVID booster vaccine. He denied any other accompanying symptoms such as fever or chills as well as any similar rashes to prior doses of the Moderna COVID vaccine. The rash consisted of pink erythematous minimally scaly papules, thin plaques and patches involving the left and right dorsal hands, forearms, wrists, face, neck and left shoulder. The remainder of the patient's skin including the bilateral lower extremities, the eyelids, conjunctiva and oral mucosa was clear. The patient denied any similar rashes in the past. The patient denied any allergies to medications, or food or environmental allergies. He denied any notable contact allergen exposures, including to soaps, lotions, and cosmetic products. The patient also denied any significant family history or past surgical history. The patient was on Armour Thyroid for hypothyroidism and testosterone for low levels since age eighteen. The patient was started on cetirizine 10 mg once daily for the rash with minimal improvement. Autoimmune workup for the rash was notable for an elevated anti-RNP and as the patient's past medical history included Raynaud's phenomenon and ANA positivity for ten years, the patient was diagnosed with mixed connective tissue disease (MCTD). Autoimmune conditions can often have an indolent course, where symptoms progressively develop and worsen. MCTD is an autoimmune overlap syndrome that can consist of the following three connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis. Millions of individuals across the world are receiving COVID vaccines to protect themselves and members of their community, and it is of utmost importance that we continue to investigate adverse events. Although of low incidence, these rare effects have the ability to impact large numbers of people within both healthy and immunocompromised populations. It is critical that we examine and document them in a rigorous manner, to ensure safe vaccine delivery and reassure the public about vaccine safety overall.

Supraclavicular regional anaesthesia affecting bispectral index as level of consciousness monitor (SUPRABLOC): a pilot randomised controlled trial

Background: Renewed interest in regional anaesthesia during the recent COVID-19 pandemic has inspired application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by the bispectral index (BIS). In contrast, no published study has investigated the possible sedative effects of non-neuraxial regional anaesthesia. This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of, performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Method(s): Forty participants presenting for forearm surgery were randomly allocated to two treatment groups (supraclavicular block and control). Their level of sedation was monitored with BIS prior to surgery for 60 minutes. Specific feasibility outcomes were planned and data were collected according to CONSORT 2010 recommendations. Result(s): Out of 48 patients screened, 41 (85.42%) were invited to participate. Forty patients (97.56%) consented and 100% of these completed the study. In four participants (10%), BIS electrodes needed replacement, while inadequate contact was shown in three participants (7.50%). Data collection and form completion were deemed "easy" and block success rate was 100%. Differences in mean BIS between groups were < 5 and a difference of 10% between groups in incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion(s): We propose that progression to formal RCT is feasible only with specific modifications to the study design. The decrease in BIS value from baseline should be measured per patient and a clinically significant decrease should be estimated;emergency patients should be excluded;the sample size should be 500 patients;and multiple trial sites should be used. Further consideration should be given to whether such a trial would provide clinically useful information, and would justify the risks, patient discomfort and the considerable financial cost.Copyright © 2023, Medpharm Publications. All rights reserved.

Eosinophilic fasciitis triggered by intensive exercise

A 59-year-old white female who was previously fit and well, developed gradual tightening and thickening of the skin on her forearms progressing to the abdomen, chest and lower legs associated with restricted movement. She also noticed bruise-like patches on her trunk. There were no systemic symptoms and no history of Raynaud syndrome. Since the beginning of the COVID-19 lockdown, the patient had engaged in increasing amounts of exercise compared with normal;this included yoga once weekly for 75 min, high-intensity interval training for 20 min on alternate days, running three times weekly for 45 min, lifting 2.5 kg weights for the arms every day and regular long walks. Examination showed a 'groove' sign on her forearms and a peau d'orange appearance of the skin with a woody induration and hardness on palpation. Symmetrical and circumferential involvement on the forearms and lower legs and bruise-like indurated patches on the abdomen were noted. Differential diagnoses included eosinophilic fasciitis (EF), morphoea, EF/morphoea overlap, scleroderma, scleromyxoedema and nephrogenic systemic fibrosis. Blood investigations showed an eosinophilia of 1.2 x 109 cells L-1, erythrocyte sedimentation rate of 31 mm h-1, a C-reactive protein of 20 mg L-1 and negative autoimmune and viral serology. She underwent two incisional biopsies down to fascia. The first was taken from the back, which showed an interstitial inflammatory cell infiltrate composed of lymphocytes, plasma cells and very occasional eosinophils. The subcutaneous septa were minimally thickened. The second biopsy taken from the left forearm showed striking thickening of the subcutaneous septa, with an associated inflammatory cell infiltrate, composed predominantly of lymphocytes and plasma cells. This process was deeper and more established than that seen in the biopsy from the trunk. The appearances were clearly those of a sclerosing process of the dermis and subcutis and consistent with eosinophilic fasciitis. Our diagnosis was EF with morphoea overlap and she was treated with oral methotrexate 15 mg weekly and oral prednisolone 50 mg once daily (weight 60 kg), reducing the dose by 5 mg every 2 weeks. An 80% improvement was seen in functionality within 3 months, but the skin remained tight and thickened and therefore the patient was referred for phototherapy [ultraviolet A 1 (UVA1)] as combination therapy. We present a rare case of EF, which appears to have been triggered by intensive exercise. Other causes include insect bites, radiation, infections (Mycoplasma and Borrelia) and paraneoplastic. Haematological associations have been seen, including aplastic anaemia and lymphoma. Treatment options for EF include prednisolone, UVA1/psoralen + UVA, immunosuppressive systemic agents (including ciclosporin and methotrexate), biological agents (including infliximab and rituximab) and physiotherapy.

Melanized (dematiaceous) fungal infections simulating skin cancer in African organ transplant recipients

Fungi are the most frequent skin infections in organ transplant recipients (OTRs) and usually present as superficial mycoses. Deeper infections are much less common, potentially more serious and the incidence is higher in the first few months post-transplant. We report two African OTRs with deep fungal infections caused by dematiaceous (melanized, pigmented or black) fungi, who both presented with suspected skin malignancies. A 60-year-old Nigerian man developed a painful, ulcerated, amelanotic, bleeding nodule on his right fourth toe 2 months after renal transplantation. Clinical differential diagnoses included Kaposi sarcoma (KS), amelanotic acral melanoma and subungual squamous cell carcinoma (SCC). However, histology showed pseudoepitheliomatous hyperplasia, extensive mixed inflammation, multinucleated giant cells and pigmented septate hyphae with rounded 'budding' forms. Periodic acid-Schiff, Grocott and Masson-Fontana stains were positive, and Alcian blue stain was negative, consistent with infection by a dematiaceous fungus. Fungal 18S polymerase chain reaction (PCR) was positive and culture identified Nigrograna mackinnonii. Treatment with oral itraconazole was supervised virtually during the COVID-19 pandemic. After 6 months there was minimal response and he opted for amputation of the digit. A 61-year-old Nigerian man presented 2 months after renal transplantation with a 2-cm diameter nodule on his left thigh at the site of a previous burn. This failed to respond to antibiotics. Magnetic resonance imaging was suggestive of possible malignancy, but surgery was deferred because of the COVID-19 pandemic. Two months later the lesion was 5 cm in diameter and verrucous with an 8-cm sessile, purplish plaque on his right forearm. Atypical KS, lymphoma and chronic burns-associated SCC were all considered. However, histology from both lesions was similar to the first patient. Fungal culture and 18S PCR confirmed infection with the dematiaceous fungus Alternaria alternata. At his request, the right thigh lesion was excised. The lesion on his forearm has partially responded to 8 months of ongoing oral itraconazole. In our African OTR cohort, KS is more common than deep fungal infection. However, despite this suspicion of skin malignancy, both patients had phaeohyphomycoses caused by dematiaceous fungi. Characterized by the presence of melanin in their cell walls, > 130 species of these plant pathogens and soil saprophytes are implicated in human disease, particularly in immunocompromised individuals. Although localized skin diseases (phaeohyphomycoses, chromoblastomycosis and mycetoma) are the most common manifestations, rare disseminated, central nervous system and pulmonary infections may prove fatal. Although uncommon, deep fungal infection should be considered in atypical skin lesions in OTRs;histology, tissue culture and fungal PCR are critical to confirming this diagnosis.

Remote Upper Limb group intervention post stroke increases intensity and improves wellbeing

Introduction: Increasing the intensity for upper limb rehabilitation post stroke has been emphasized in research and evidence. COVID-19 limitations with face-to-face therapy, have increased the opportunities to consider remote rehabilitation to provide the intensity needed. The aim of the group is to provide a goal based, structured exercise programme for upper limb among stroke survivors. Method(s): The Remote Upper Limb group has started to be part of the service that CST provides since 2020. The group consists of a warm-up, exercises using activity station, and functional exercises where we use items available at patients' home. The exercises are designed to address these areas: shoulder, elbow, forearm, wrist fingers, activities, and functional activities. The group also provides education session for the upper limb including pain, sensory deficits, specificity, subluxation, oedema and, learned non-use. Standardised outcome measures are taken at the beginning and the end of the group and used to measure progression and improvement. Result(s): The remote upper limb group intervention has emerged as a promising intervention to increase intensity and achieve patients' outcomes. The outcome measures have shown clinically significant improvement in patients' physical outcomes and their wellbeing. The patients report opportunities for peer support as their main benefit. Conclusion(s): The remote upper limb group is an intervention that increases patients' intensity and improves well-being in a costly effective way for both therapists and stroke survivors.

Atraumatic radial and ulnar artery thrombotic occlusion resulting in critical limb ischemia triggered by black mold infestation

Background: Atraumatic upper extremity arterial thrombosis is uncommon. We present a case of radial and ulnar artery thrombosis with critical limb ischemia, with symptoms resolving after remediation of a black mold home infestation. This case highlights the importance of identifying potential environmental exposures in uncommon clinical presentations. Case presentation: Chart review of all visits in two hospital systems. Informed consent was obtained from the patient. Result(s): A 51-year-old male noted pain and paresthesia of the left hand. Critical ischemia was found with mid-forearm occlusion of the radial and ulnar arteries;surgical care included no distal target for bypass and digital ray amputation. Workup did not reveal autoimmunity, thrombophilia, or source of embolism. Symptoms were recurrent with ongoing ischemia and tissue loss. Further evaluation identified a home water leak. Professional remediation of black mold coincided with resolution of pain, discoloration, and ulceration without return of symptoms at follow up of 22 months. Conclusion(s): Immune-mediated mechanisms can lead to clinical thrombotic events. Vascular occlusion related to COVID-19 has stimulated interest in thrombotic pathways not routinely emphasized. We postulate neutrophil extracellular traps (NETs), triggered by chronic exposure to mold, contributed to persistent digital ischemia. NETs are fibrous extensions of extracellular strings of DNA, antimicrobial peptides, and chromatin that bind pathogenic microbes and provide scaffolding for thrombi, triggering vascular occlusion. This is a novel case of upper extremity arterial occlusion leading to amputation associated with exposure to black mold. Thrombosis may be related to NETs formation and symptoms did not resolve until the environmental mediator was eradicated. Environmental exposure should be considered in otherwise healthy patients who present with atraumatic critical digital ischemia without thrombophilia, autoimmunity, illicit drug use, or vasculitis.

Acute upper limb ischemia as initial presentation of COVID-19 infection in a 49-year-old male: A case report

Background: Coronavirus disease-19 (COVID-19) is an emerging threat because of its significant damage to the lungs and its risk of thrombosis in microvascular, venous, and arterial beds. Moreover, thrombosis in patients with the COVID-19 infection may also be more extensive, leading to limb loss and death. One of the thrombotic complications reported in COVID-19 is acute limb ischemia (ALI), which is characterized with an abrupt decrease in the arterial perfusion of a limb, threatening its viability and integrity. In this report, we describe an unusual case of an unvaccinated patient who presented with acute unilateral upper extremity ischemia as the initial manifestation of COVID-19. Case presentation: A 49-year-old man, unvaccinated for COVID-19, presented to the emergency room due to worsening left hand and forearm pain of one week duration. The brachial, radial, and ulnar pulses were absent. Emergency arterial duplex scan of the left arm showed acute thrombi totally occluding the lumen of axillary artery and extending to the proximal to distal brachial, proximal to distal radial and ulnar arteries. Anticoagulant infusion in the form of heparin was immediately started was titrated accordingly depending on aPTT. Surgical embolectomy was offered but could not be immediately done within 6 hours of presentation due to positive result for SARSCoV2. Patient denied history of respiratory symptoms and was also noted to have normal lung findings. During surgical embolectomy, a significant amount of large, elongated acute thrombi were retrieved. Anticoagulation was resumed post-operatively and no signs and symptoms of compartment syndrome were noted. Patient slowly recovered his sensory and motor functions within a month from onset of ALI. Conclusion(s): Thrombotic events such as acute limb ischemia may be the initial manifestation of COVID-19 infection. In this patient, what we found particularly peculiar was that he had no respiratory symptoms despite being unvaccinated during the time that the Delta variant was the prevailing strain of coronavirus. This case underscores the fact that clinicians should have high index of suspicion of COVID-19 infection as a cause of thrombotic events, especially in patients with no or very few risk factors.

Bookshelvers' Tendinopathy in the Time of COVID: Flexor Carpi Ulnaris Tendinopathy in a Librarian

Case Diagnosis: Flexor carpi ulnaris (FCU) tendinopathy Case Description: A 55-year-old female librarian presented with pain along the volar aspect of the right ulna of many months duration. A librarian, she attributed this to change in her work during the COVID-19 pandemic, where she was suddenly extensively shelving and picking up books. Radiographs were normal. She was diagnosed with FCU tendinopathy and treated successfully with eccentric exercises and a saline anesthetic injection. Setting(s): Outpatient clinic (Middlebury, VT) Assessment/Results: Eccentric exercises and normal saline injection completely resolved the patient's symptoms at 1-month follow-up Discussion: FCU tendinopathy is rarely reported in the literature, with only 8 case reports presenting a total of 12 total cases dating back to 1951. Of these, there has been only 1 other case report of occupationally-related FCU tendinopathy, and 1 other case report of FCU tendinopathy despite normal radiographs. Furthermore, to our knowledge our study is the first to report the use of normal saline injection - which has been used for treatment of patellar and Achilles' tendinopathies - for successful treatment of FCU tendinopathy. Conclusion(s): FCU tendinopathy is an overlooked diagnosis that may be common in patients who use their forearm flexor muscles repeatedly. While most cases of FCU tendinopathy reported in the literature have calcification on xrays, we suspect many cases do not have calcification since tendinopathies are not always calcific in nature. The standard for diagnosis of FCU tendinopathy should be the physical exam, much like it is for lateral epicondylitis. Lastly, our study suggests that normal saline injections merit consideration as an alternative to corticosteroid injections for treatment of FCU tendinopathies.

Wrist and hand degloved injuries salvaged with reverse radial forearm flap in the CoVid-19 era.

Reverse radial forearm flap is a quick and reliable flap, providing a well-vascularized tissue for coverage of hand defects. It is based on the reverse flow of the radial artery and the only drawback is the proximal ligation of the vessel. Two cases with complex dorsal hand defects were referred with delay to our Hand Unit, due to the CoVid-19 pandemic restrictions. In both cases deep structures of the wrist and fingers were exposed and the wounds were infected. Surgical debridement, skin coverage and reconstruction were decided in a staged approach: The reverse radial forearm flap was first performed, and in subsequent stages, functional restoration with hamstrings tendon grafts and finger joints arthrodesis successfully followed. These two cases highlight the reliability of a traditional pedicled flap in the salvage of complex hand defects, especially when time and resources are limited due to a pandemic.

Vascular Accesses Used in the Administration of Antineoplasic Therapy in an Oncological Day Hospital

Introduction: Antineoplasic chemotherapy in intravenous infusion is one of the most common therapeutic modalities in cancer patients. The vast majority of antineoplasic drugs have an Osmolarity >900 mOsm/l, so its administration must be done through central venous routes. However, the channelling of central routes is limited to patients with difficulty in peripheral venous approach or long-term treatments. Objective(s): Describe the vascular accesses used at the University Hospital of La Ribera for the administration of antineoplastic drugs, assess the adequacy of the same and determine if the type of vascular access used varied during the COVID-19 pandemic. Methodology: A quantitative, observational and analytical cross-sectional study of the vascular accesses used in the administration of antineoplasic therapy in cancer day hospital was carried out. Data collection was carried out through direct observation and consultation of the medical history. The pre-pandemic period was executed from 20 to 21/1/2020(n=125), the pandemic sample from 8 to 12/2/21(n=121). Result(s): Although 70% of the drugs administered had the capacity for tissue aggression, the peripheral venous route was established in 69.9% of cases, the forearm being the most frequent anatomical location (n=102) and the peripheral venous catheter the most commonly used device (n=172). The expected duration of treatment was medium-term in 74.8% of patients. The use of central venous routes during the pandemic increased by 30.7%,(p=0.017), being the subcutaneous venous reservoir the one with the highest representation(RVSC 75.5 %, IPCC 24.5 %). Conclusion(s): Short peripheral venous catheter was the most used device in the administration of chemotherapy in oncology HDD of the UHLR, even administering drugs with high tissue aggression and establishing a medium duration of treatment, being this an area of improvement in the care of cancer patients. During the pandemic, the use of central routes increased in the administration of antineoplasic treatment on an outpatient basis.

Vascular Response to a Cardiac Rehabilitation Program Adapted for COVID-19

Background: Cardiac Rehabilitation (CR) is a supervised exercise and risk factor modification program for patients with cardiac conditions. Endothelial dysfunction is often present and is associated with worsening cardiac prognosis, and several studies have indicated that standard onsite CR has improved endothelial function in heart disease patients. However, during the COVID-19 pandemic, many CR programs transitioned to a virtual or hybrid model of care to increase safety of CR programs. Objective(s): The objective of this study was to determine vascular function of patients with coronary artery disease (CAD) measured before and after 4 months of outpatient CR using a virtual model of care. Method(s): Virtual CR included 1 virtual group session/week by videoconferencing and hybrid CR included 1 session/week (4 on-site and 12 virtual group sessions) for a total of 16 weeks. CAD patients (6 females, 4 males) mean age 68.1+/-7.5 years rested in a supine position to measure 1) brachial artery flow-mediated dilation (FMD), 2) microvascular function, and 3) augmentation index (AI) using ultrasound sonography (n=8) and an EndoPAT 2000 (n=9). Two patients completed virtual CR and the rest underwent hybrid CR. These measurements were obtained concurrently using an ultrasound transducer at the brachial artery proximal to a blood pressure cuff on the forearm with EndoPAT cuffs on the index fingers during 5-minute intervals of baseline, occlusion, and recovery. FMD results were analyzed using automated Cardiovascular Suite software. AI and Reactive Hyperemia Index (LnRHI) were determined using automatic analysis via the EndoPAT 2000. Anthropometrics, blood pressure, and food intake were recorded at each visit. Patients were advised to refrain from strenuous exercise, alcohol, caffeine, and highly saturated foods at least 12 hours prior to the study appointment. One tailed paired t-tests were conducted between baseline and completion. Result(s): Adherence to CR averaged 10.3+/-3.2 out of 16 sessions. FMD improved from (2.75+/-1.71% to 5.63+/-4.37%, p=0.048) while there was no improvement in AI (14.2+/-18.8 to 13.2+/-19.6, p=0.45) or LnRHI (0.56+/-0.12 to 0.52+/-0.20, p=0.24). Conclusion(s): While there was no improvement in LnRHI or AI after CR, FMD improved in CAD patients after 4 months of adapted CR. Our results indicate that while virtual and hybrid models of CR may not be sufficient for improving microvascular function and aortic stiffness in CAD, there is an improvement of endothelial function. Future studies should examine the effects of adherence, duration and exercise intensity within these alternative models of CR on aortic and microvascular improvements.

DYSPNEIC AFTER EVERY COVID-19 SHOT: SUSPECTED BNT162B2 MRNA VACCINE-RELATED, DRUG-INDUCED PULMONARY EOSINOPHILIA

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Eosinophilia is the most commonly reported adverse event following administration of the Pfizer/BioNTech vaccine, accounting for 237 of 372 events (63.7%). Eosinophilic pneumonia has been described noted in 3 of all reported cases. CASE PRESENTATION: We present the case of a 73 year-old male presented to his PCP with a 3 week history of nonproductive cough and wheezing. He completed a 2-shot series of BNT162b2 mRNA (Pfizer/BioNTech) COVID vaccine 1 week prior to symptom onset. He had no history of respiratory symptoms, smoking, sick contacts, recent travel, chemical or biological exposures. On presentation, he was afebrile, tachycardic and required 3LPM supplemental oxygen to maintain peripheral oxygen saturation (SpO2) above 94%. Laboratory findings noted leukocytosis (13,200/mL) and eosinophilia at 5% (Absolute Eosinophil Count (AEC): 580 cells/L). Respiratory viral panel, procalcitonin, ESR and D-dimer were negative. Chest CT scan was unremarkable. He was treated with azithromycin, prednisone and inhaled bronchodilators with improvement in hypoxia. 2 weeks later, he reported intermittent dyspnea during a pulmonary clinic visit. Pulmonary function testing was normal (FEV1/FVC: 76%;FVC: 3.67L (90% predicted);FEV1: 2.80L (88% predicted). IgE level was normal and eosinophilia had resolved. 6 months after initial symptom onset, the patient received his third BNT162b2 mRNA vaccine dose. 2 weeks after vaccination, he presented to the ED with severe dyspnea, wheezing and cough with yellow sputum. He also noted a new itchy, erythematous bilateral forearm rash and painless oral ulcers. On exam, he was afebrile, tachypneic with SpO2 of 93% on 4LPM supplemental oxygen and audibly wheezing with a prolonged expiratory phase. Laboratory studies noted elevated creatinine and leukocytosis (23,100/mL) with marked eosinophilia (29.5 %, AEC: 6814 cells/L). Chest CT scan revealed a 2 cm rounded ground-glass opacity in the right upper lobe. (Figure 1.) Further workup revealed a weakly positive antihistone antibody (1:4 titer). IgE, ANA, ANCA, SS-A/B, anti-CCP, and complement levels were normal. Intravenous methylprednisolone treatment was initiated with rapid improvement in dyspnea, eosinophilia and renal function. A transbronchial biopsy (Figure 2.) of the RUL lung lesion revealed organizing pneumonia with mixed inflammatory infiltrate. Bronchoalveolar lavage analysis revealed elevated WBC (432 cells/L) with neutrophilic predominance (85%). Patient was discharged home on a prednisone taper with resolution of symptoms. DISCUSSION: Subsequent allergy work up did not indicate any apparent etiology of hypereosinophilia. Testing for strongyloides, coccidiosis and aspergillosis were also negative. A final diagnosis of BNT162b2 mRNA vaccine related pulmonary eosinophilia was made. CONCLUSIONS: Additional study is warranted into eosinophilic disease associated with the BNT162b2 mRNA vaccine. Reference #1: 1. United States Department of Health and Human Services (DHHS), Public Health Service (PHS), Centers for Disease Control (CDC) / Food and Drug Administration (FDA), Vaccine Adverse Event Reporting System (VAERS) 1990 - 03/11/2022, CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/vaers.html on Mar 11, 2022 1:18:37 PM DISCLOSURES: No relevant relationships by Matthew Haltom No relevant relationships by Nikky Keer No relevant relationships by Thekrayat Khader No relevant relationships by Muthiah Muthiah

COVID-19-Related Neuropathy in Colombia: The Experience During the First 23 Months of Pandemic

COVID-19-related neuropathy in Colombia: The experience during the first 23 months of pandemic Introduction: The SARS-CoV-2 virus has a high neuroinvasive capacity due to the increased expression of angiotensin-converting enzyme receptor 2 (ACE-2) in neurons (1) and it is believed that the mechanism by which it can cause injury to the nervous system peripheral nervous system is immunemediated, although a direct cytotoxic effect of the virus cannot be ruled out (2). Multiple types of neuropathy associated with SARS-CoV-2 infection have been described, the most frequent being Guillain- Barré syndrome, pre-existing diabetes, compression neuropathies and drugs used to treat symptoms of COVID-19 (3). Objetives: To characterize the patients who were referred to the electromyography laboratory at the Fundacion Santa Fé de Bogotá, Colombia due to suspected COVID-19-related neuropathy Methods: Descriptive observational study, case series type. The electrodiagnostic studies carried out between January 2020 and December 2022 in the electromyography laboratory at the Fundacion Santa Fé de Bogotá, Colombia with suspected COVID- 19-related neuropathy were reviewed. Results: 94 patients were evaluated in the electromyography laboratory with suspected COVID 19-related neuropathy between January 2020 and December 2021, of which 53% (50/94) were men. The average age was 54.8 years. 32% (30/94) had severe COVID and 31% (29/94) were hospitalized in the ICU. Most of the studies were normal: 35% (33/94). of the abnormal findings, it was found in order of frequency: Symmetric motor and sensory axonal polyneuropathy in 21.2%, and of this group of patients, 55% were in the ICU, 35% had no data and 20% were hospitalized-not ICU. 18% presented compression neuropathy of the median nerve in the carpal tunnel, 6.3% asymmetric motor and sensory axonal neuropathy, 6.3% suggestive findings of cervical and/or lumbosacral root involvement, 4.2% Guillain Barré syndrome, 4.2% compression neuropathy of the peroneal nerve , 2.1% brachial plexus axonal injury, 2.1% peroneal nerve axonal injury, 2.1% radial axonal injury, 2.1% myopathic changes, 1% hypoglossal nerve axonal injury, 1% symmetric axonal and demyelinating polyneuropathy, 1% hereditary neuropathy, 1% asymmetric demyelinating neuropathy, 1% axonal injury of the sciatic nerve, 1% axonal injury of the median nerve in the forearm, 1% axonal injury of the lumbosacral plexus, 1% compression neuropathy of the ulnar nerve in the elbow and 1% axonal injury from a sensory branch of the median nerve. Conclusions: The most frequent abnormality in the study was symmetric motor and sensory axonal polyneuropathy, which can be explained by the prolonged ICU stay, which increases the risk of Critical illnes Neuropathy.

SUPraclavicular Regional Anaesthesia affecting Bispectral Index as Level Of Consciousness monitor (SUPRABLOC): a pilot randomised controlled trial

Background: Recent renewed interest in regional anaesthesia during the COVID-19 pandemic has inspired the application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by Bispectral Index (BIS). In contrast, no studies have investigated the possible sedative effects of non-neuraxial regional anaesthesia. Aim: This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Methods: Forty patients presenting for forearm surgery were randomly allocated to two treatment arms (supraclavicular block and control). Their level of sedation was quantitatively monitored before surgery for 60 minutes. Specific feasibility outcomes were planned and data collected according to CONSORT 2010 recommendations. Results: Out of 48 patients screened, 41 (85.42%) were invited to participate, 40 (97.56%) consented and 100% completed the study. Four (10.00%) BIS electrodes needed replacement, inadequate contact was shown in three patients (7.50%), data collection and form completion were deemed “easy”, and block success rate was 100%. Differences in mean BIS between groups were < 5, and a difference of 10% between groups in the incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion: We propose that progression to formal RCT is feasible with modifications. Decrease in BIS value from baseline should be measured per patient, and clinically significant decrease should be estimated (we suggest a decrease of 10 or more), exclusion of emergency patients (starved for longer, more anxious, may affect BIS), the sample size should be 500 patients and multi-site involvement implemented.

A CASE of SEVERE ANCA ASSOCIATED VASCULITIS after COVID-19 VACCINATION

Background: The world is currently rocking to and fro in the midst of the COVID-19 viral storm and vaccinations have played a pivotal role in calming this.Although COVID-19 vaccines have been thoroughly assessed and studied before being rolled out to the general population, there have been reports of post vaccination complications in limited number of subjects strongly associated with COVID-19 vaccinations[1]. Objectives: To report a case of severe ANCA associated vasculitis after COVID-19 vaccination. Methods: A case report and discussion. Results: In view of this, we report the case of a 77 year old caucasian male who developed severe ANCA associated vasculitis (AAV) after two doses of Astra-Zeneca vaccine and one booster dose of Pfzer COVID-19 booster. He presented with acute onset infammatory arthritis with mononeuritis multiplex with bilateral foot drop and left radial and ulnar nerve forearm weakness in typical asymmetrical pattern two weeks after the Pfzer vaccination. He had a raised MPO-ANCA titre of 66 IU/ml, C-reactive protein of 131mg/L and reactive thrombocytosis of 458 X 10 9/L. Nerve conduction study confrmed mononeuritis multiplex in the bilateral peroneal nerves and left radial and ulnar nerve. A total body CT had excluded malignancy and paraneoplastic associations and Gullian-Barre diagnosis was also excluded. The patient was treated with 3 days of intravenous methylprednisolone 1g daily then given intravenous Rituximab 1g, two weeks apart. He is currently undergoing rehabilitation in view of the vasculitic neuropathy from his diagnosis. Conclusion: Diagnosis of AAV is often delayed or missed by other medical specialties due to its varied presentation. AAV should be suspected in a patient with paraesthesia/weakness in keeping with mononeuritis multiplex or other peripheral neuropathy in the absence of an alternative explanation (e.g. diabetes,B12 defciency) and in particular with a wrist or foot drop.Exposure to certain drugs and substances of abuse such as cocaine, hydralazine and propylthiouracil has been implicated with AAV.While short-term side effects of COVID-19 vaccine resemble those of other vaccines, long-term side effects remain unknown[2]. Rare side effects continue to surface as millions of people receive COVID-19 vaccines around the world.

Reduction in transfer of micro-organisms between patients and staff using short-sleeved gowns and hand/arm hygiene in intensive care during the COVID-19 pandemic: A simulation-based randomised trial

Background: Current personal protective equipment (PPE) practices in UK intensive care units involve “sessional” use of long-sleeved gowns, risking nosocomial infection transmitted via gown sleeves. Data from the first wave of the COVID19 pandemic demonstrated that these changes in infection prevention and control protocols were associated with an increase in healthcare associated bloodstream infections. We therefore explored the use of a protocol using short-sleeved gowns with hand and arm hygiene to reduce this risk. Methods: ICU staff were trained in wearing short-sleeved gowns and using a specific hand and arm washing technique between patients (experimental protocol). They then underwent simulation training, performing COVID-19 intubation and proning tasks using either experimental protocol or the standard (long-sleeved) control protocol. Fluorescent powder was used to simulate microbial contamination, detected using photographs under ultraviolet light. Teams were randomised to use control or experimental PPE first. During the simulation, staff were questioned on their feelings about personal safety, comfort and patient safety. Results: Sixty-eight staff and 17 proning volunteers were studied. Experimental PPE completely prevented staff contamination during COVID-19 intubation, whereas this occurred in 30/67 staff wearing control PPE (p =.003, McNemar). Proning volunteers were contaminated by staff in 15/17 control sessions and in 1/17 with experimental PPE (p =.023 McNemar). Staff comfort was superior with experimental PPE (p<.001, Wilcoxon). Their personal safety perception was initially higher with control PPE, but changed towards neutrality during sessions (p <.001 start, 0.068 end). Their impressions of patient safety were initially similar (p =.87), but finished strongly in favour of experimental PPE (p <.001). Conclusions: Short-sleeved gowns with hand and forearm cleansing appear superior to sessional long-sleeved gowns in preventing cross-contamination between staff and patients.

ITS NOT AN ALLERGIC REACTION TO THE COVID VACCINE: HERPES ZOSTER FOLLOWING COVID MRNA VACCINE

CASE: A 72 year old male presented to the outpatient clinic with a “vaccine reaction” after he developed a left arm rash following his Moderna COVID-19 booster. He had received the Moderna vaccines in March & April with the only side effect being arm soreness. On 10/30/2021, he received his booster in his lateral left upper arm. Three days later, he reported arm soreness that progressed in intensity by day 6 and developed a rash. Patient had no prior history of shingles and had received the SHINGRIX vaccine. Medical history was remarkable for subtotal colectomy with ileostomy 2/2 to Crohn's disease, stage III CKD, hypertension, HLD, amputations of the right big toe and left metatarsal 2/2 to osteomyelitis. Home medications included daily allopurinol 100mg, amlodipine 5mg, mesalamine 1,000 mg and octreotide 200 mcg/mL injection 0.5mL SQ BID. Presenting vital signs were normal. A physical exam revealed vesicles on an erythematous base in a C5 dermatome distribution. Incidentally, there was a concentration of vesicles located at the Moderna Booster vaccine site. Rash collected in groups of vesicles on the anterior forearm. Due to delay in presentation and stage III CKD, antivirals were not prescribed. Patient was prescribed Gabapentin 300mg nightly for pain and instructed to continue OTC Tylenol. After several weeks the rash resolved and pain subsided. IMPACT/DISCUSSION: Approximately 4% of patients with a history of Varicella develop a recurrent episode later in life with people who are immunosuppressed most affected. Possible triggers of zoster (HZ) include external reexposure to the virus, acute or chronic diseases such as malignancies or infections (i.e COVID-19), medications and stress. As of 12/5/21, the Vaccine Adverse Event Report System (VAERS) reported shingles in 1200 patients after receiving Pfizer vaccine, 1201 Moderna, and 1203 in Janssen vaccine recipients. While these reports are unable to be validated, it is important for clinicians to recognize the suggested relationship. Hypotheses of why our patient developed shingles include: 1) the immune activation from the vaccine activated dormant varicella, 2) the patient being older & immunocompromised puts him at a higher risk of developing HZ in general, and 3) the vaccine triggers a transient lymphopenia similar to being infected with COVID-19 and lymphopenia causes reactivation. As we continue to reach higher percentages of individuals receiving vaccines, we likely will continue to encounter cases such as described. CONCLUSION: It is important for clinicians to be aware of HZ reaction post COVID vaccination and to have this in their differential when a patient complains of a “reaction” to the vaccine. We regret that the patient being mis-triaged as an “allergic reaction” led to the patient being evaluated outside of the possible window of acute treatment of HZ. By describing this case we hope clinicians will be more aware of this relationship and prevent delay to treatment or misdiagnosis.