Anti-SARS-CoV-2 antibodies important in diagnostics of acute hepatitis in children

The most common causes of acute hepatitis in children are hepatitis A and autoimmune hepatitis. Hepatitis in the course of Wilson's disease is sporadically registered in adolescents. An increase of activity of aminotransferases both in the course of multisystem inflammatory syndrome in children (MIS-C) and in the course of COVID-19 has been observed. Hepatitis is common in children with MIS-C and is associated with a more severe presentation and persistent elevation of liver function tests. To date, no cases of acute hepatitis in children due to COVID-19 have been reported. We present 2 cases of acute hepatitis in children where the only cause seems to be a previous asymptomatic SARS-CoV-2 infection.Copyright © 2023 Termedia Publishing House Ltd.. All rights reserved.

A Rare Case of Congenital Choledochal Cyst (CCC) Resulting in Recurrent Acute Pancreatitis in an Otherwise Healthy Young Woman

Introduction: Congenital choledochal cyst (CCC) is a rare cystic dilatation of intrahepatic or extrahepatic biliary ducts. We present a case of a type IVb choledochal cyst presenting as recurrent acute pancreatitis in a young healthy female with initial negative screenings. Case Description/Methods: An 18-year-old-female with a history of COVID-19 presented to the emergency department with one month of persistent abdominal pain, nausea, and vomiting. She was hospitalized once prior for similar symptoms and was diagnosed with acute pancreatitis. This admission, blood work showed elevated lipase, elevated liver enzymes, mild bilirubinemia with a normal lipid panel and urine was significant for infection. She received fluids, antiemetics and was started on prophylactic antibiotics for ascending cholangitis. A right upper quadrant ultrasound ruled out cholelithiasis or acute cholecystitis, but showed dilation of the common bile duct. MRCP confirmed dilation with bulbous termination in the periampullary region diagnosed as type IVb choledochal cyst. Discussion(s): CCCs are rare in Western countries with an incidence between 1 in 100,000 to 150,000. 80% of these cysts are diagnosed in patients under the age of 10. They are difficult to diagnose due to variable clinical presentations. A study of 214 CCC patients demonstrated the most common symptom was abdominal pain, followed by jaundice and fever. When cysts are found in adults, symptoms resemble atypical acute biliary tract disease. Surgical cyst removal may be needed for patients with significant risk factors such as older age and age of symptom onset, due to increased risk of malignant transformation. Longer periods of observation have been documented to be associated with an increased chance of developing late complications, such as anastomotic stricture, biliary calculi and recurrent cholangitis. Type IVb CCCs, as seen in this case, consist of multiple extrahepatic cysts and hepaticojejunostomy is the treatment. This patient's young age and recurrent acute pancreatitis combined with her lab and imaging findings strongly suggest the diagnosis of CCC. The anatomical location of the CCC impeded flow of pancreatic enzymes through the ampulla of vater, leading to recurrent pancreatitis in an otherwise healthy young female. CCC, although very rare, should be considered in the differential of acute pancreatitis when other causes such as gallstones and heavy alcohol consumption cannot be identified, as prompt diagnosis and surgical removal is imperative.

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.

Impact of Sars-Cov2 Infecion during Pregnancy on Maternal and Neonatal Outcomes

Purpose of Study: Pregnant women are at considerable risk for SARS-CoV-2 infection with adverse maternal and neonatal outcomes. Mother-to-child-transmission can occur, in-utero, perinatally or postnatally with significant complications in the newborn. Little is known on impact of SARS-CoV-2 on newborn infants. Our objectives were to describe maternal and neonatal outcomes among those with SARS-CoV-2 infection since beginning of the pandemic. Methods Used: This was a retrospective review of data from a single center with level III NICU from April 2020 through March 2022 in Los Angeles, CA. The study included pregnant women who were screened at delivery and/or during pregnancy and tested positive with PCR test. Data of these women and their infants were reviewed from medical records. Institutional IRB approval was obtained to review the data. Summary of Results: During the study period 152 mothers were SARs-CoV-2 positive in pregnancy or at delivery. Maternal risk factors included obesity (13.2%), pre-eclampsia (15.1%) and diabetes (19.7%). Fourteen (9.2%) were symptomatic for 0-7 days prior to delivery predominantly with cough, fever and myalgia. Majority (58.7%) delivered vaginally. SARS-CoV-2 exposed infants had a median gestational age of 38.3 weeks;35 (23%) were preterm. Median birthweight was 3120 grams and 32 infants 31 (20.5%) were low birthweight. Thirty-one (20.4%) infants needed resuscitation at delivery. Common symptoms for infants included respiratory symptoms (22.4%), hyperbilirubinemia (15.1%) and hypoglycemia (7.2%). Sixty-eight infants (44.7%) required admission to NICU. Majority of the infants (130) had PCR tests at 24 hours and 48 hours if still hospitalized. Five (3.8%) were PCR+: 4 at 24 hours and 1 at 48 hours. Another 5 infants had positive PCR for SARS-CoV-2 in infancy. Conclusion(s): SARS-CoV-2 infection was present at delivery in a significant number of pregnant women with 3.8 % of their infants. Although a majority of women were asymptomatic at the time of delivery, there was significant morbidity among women with pre-eclampsia and diabetes. Newborn morbidity included prematurity, low birth weight and respiratory distress even in PCR- newborns. These data emphasize the need for screening all pregnant women for SARS-CoV-2 at delivery, and close monitoring of mother-infant dyad if infected. Vaccination of pregnant women should be encouraged.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh.

BACKGROUND: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh. METHODS: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs. RESULTS: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers. CONCLUSION: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

Liver Injury after Covid-19 Vaccination Compared to Post-Influenza Vaccines: Retrospective Cohort Study

Introduction and Objectives: Cases suggestive of immune-mediated acute hepatitis following SARS-CoV-2 vaccination have been reported. The risk of liver injury after Covid-19 vaccination is unknown. This study aimed to estimate the cumulative incidence of liver injury within 90 days after the Covid-19 vaccine, defined as the occurrence of AST and/or ALT increases at least two times the limit of normal or ALP increases at least x 2. To compare with an active comparator group (influenza vaccine). Material(s) and Method(s): Retrospective cohort study. We analyze a consecutive sample of adult patients vaccinated with Covid-19 vaccines (Sputnik, AstraZeneca/Oxford, Covishield, or Sinopharm) between January 1 and May 30, 2021, and a historical control group vaccinated with influenza between March 1 and July 30, 2019. Qualifying labs were collected as part of routine clinical care or the development of symptoms. Result(s): From a total of 29,918 subjects who received the Covid-19 vaccine in 2021 and 24,753 who received the Influenza vaccine in 2019, 130 and 148 patients, respectively, were excluded because of previously altered liver function tests or known hepatic disease. Both groups were comparable in age (73 years old (IQR 65-80), p=0.125) and gender (67% were females). In the Influenza group were more dysmetabolic and immunosuppressed patients. A total of 269 and 273 patients, respectively, presented altered liver function tests within 90 days post-vaccination. The cumulative incidence of liver injury was 4.6 per 1,000 (95% CI 3.9-5.5) for Covid-19 and 5.1 per 1,000 (95%CI 4.3-6.1) for Influenza (p=0.453). Although, two patients from the COVID group had a more severe injury, with hyperbilirubinemia, development of autoantibodies and requirement of steroids for disease control. Conclusion(s): The occurrence of events was similar in subjects vaccinated with Covid-19 compared to the control group. Acute hepatitis characteristics arising after the COVID-19 vaccine needs to be further clarified.Copyright © 2023

Major Drugs Used in COVID-19 Treatment: Molecular Mechanisms, Vali-dation and Current Progress in Trials

Background: Currently, the present world is facing a new deadly challenge from a pandemic disease called COVID-19, which is caused by a coronavirus named SARS-CoV-2. To date, no drug or vaccine can treat COVID-19 completely, but some drugs have been used primarily, and they are in different stages of clinical trials. This review article discussed and compared those drugs which are running ahead in COVID-19 treatments. Method(s): We have explored PUBMED, SCOPUS, WEB OF SCIENCE, as well as press releases of WHO, NIH and FDA for articles related to COVID-19 and reviewed them. Result(s): Drugs like favipiravir, remdesivir, lopinavir/ritonavir, hydroxychloroquine, azithromycin, ivermectin, corticosteroids and interferons have been found effective to some extent, and partially approved by FDA and WHO to treat COVID-19 at different levels. However, some of these drugs have been disapproved later, although clinical trials are going on. In parallel, plasma therapy has been found fruitful to some extent too, and a number of vaccine trials are going on. Conclusion(s): This review article discussed the epidemiologic and mechanistic characteristics of SARS-CoV-2, and how drugs could act on this virus with the comparative discussion on progress and drawbacks of major drugs used till date, which might be beneficial for choosing therapies against COVID-19 in different countries.Copyright © 2022 Bentham Science Publishers.

COVID-19-induced transaminitis and hyperbilirubinemia: Presentation and outcomes.

The risk of liver injury in patients with coronavirus disease 2019 (COVID-19) infection is quite evident. Furthermore, liver function test abnormalities are still detected in COVID-19 patients despite the development of antivirals and the availability of several types of vaccines. This editorial describes liver involvement during COVID-19 infection in patients with or without preexisting liver injury, such as chronic liver disease, to elucidate COVID-19-induced liver function abnormalities and their severity, pathophysiology, clinical manifestations, and clinical and laboratory outcomes. We also discuss the effect of vaccination against COVID-19 to better understand host factors, such as age, gender, and race, on the incidence and severity of liver dysfunction at initial presentation and during the illness. Finally, we summarize the results of relevant meta-analyses published to date and highlight the importance of adequate liver function monitoring in the current climate of the overwhelming COVID-19 pandemic.

ACUTE HEPATIC SEQUESTRATION CRISIS: AN OFTEN UNDERDIAGNOSED AND FATAL SYNDROME

SESSION TITLE: Critical Renal and Endocrine Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Sickle Cell Disease (SCD) is an autosomal recessive disease characterized by an abnormal beta-globin chain of hemoglobin (Hb) that leads to malformed sickled cells with a multitude of downstream microvascular occlusions and anemia. While splenic infarction is by far the most common gastrointestinal (GI) manifestation, vaso-occlusion may occur in the liver, leading to an acute hepatic crisis. Acute hepatic sequestration of sickled erythrocytes is an exceedingly rare manifestation. CASE PRESENTATION: A 43-year-old man with homozygous sickle cell disease complicated by End-Stage renal disease was admitted with generalized malaise, right upper quadrant (RUQ) abdominal pain, nausea and vomiting. He was febrile with a temperature of 38.1°C, hypotensive with a blood pressure of 93/61 mmHg and tachycardic with a heart rate of 120 bpm. He was lethargic and uncomfortable with diffuse abdominal tenderness without guarding. Due to concern for septic shock, blood cultures, COVID PCR and influenza were obtained, and the patient was rapidly transferred to the intensive care unit for closer monitoring. Empiric vancomycin and cefepime were started promptly. The initial hemoglobin level was 6.1mg/dL with a leukocytosis of 31.2 K/CUMM and absolute neutrophil count of 21.8 K/CUMM;total hyperbilirubinemia of 17.45 mg/dL, direct hyperbilirubinemia of 11.46mg/dL and elevated INR at 1.66. Computed tomography of the abdomen and pelvis without contrast showed a known 4 cm cystic lesion of the right hepatic lobe and atrophic kidneys. Duplex flow of the abdomen and pelvis showed no portal vein thrombosis and patent flow in the portal vein and artery. Over the course of several hours, the patient's hemoglobin dropped to 3.8mg/dL with a steep rise in LDH and total bilirubin to 632 U/L and 27.04 mg/dL, respectively consistent with hepatic sequestration crisis. Patient was transfused with two units of packed red blood cells, fluid hydration and initiation of erythrocyte exchange transfusion. Prior to receiving exchange transfusion, the patient experienced rapid clinical deterioration with subsequent pulseless electrical activity. Return of spontaneous circulation was achieved transiently however patient's family at this point opted for palliative measures and the patient passed away shortly thereafter. DISCUSSION: Complications of SCD manifest in multiple organ systems. One of the few acute manifestations, hepatic sequestration crisis, is often unfamiliar to many clinicians and left unrecognized, results in poor clinical outcomes. It is rarely encountered and treatment options with blood and, more importantly, exchange transfusion remains often underutilized. CONCLUSIONS: Acute hepatic sequestration crisis is an often-unrecognized manifestation of SCD in which delay in diagnosis and prompt treatment with exchange and blood transfusions may impart a significant risk of mortality in an already prone patient population. Reference #1: Shah R, Taborda C, Chawla S. Acute and chronic hepatobiliary manifestations of sickle cell disease: a review World J Gastrointestinal Pathophysiology 2017;8(3): 108-116 Reference #2: Norris W. Acute hepatic sequestration in sickle cell disease. J of the National Medical Association 2004;96: 1235-1239 Reference #3: Praharaj D, Anand A. Sickle Hepatopathy J of Clinical and Experimental Hepatology 2021;11: 82-96 DISCLOSURES: No relevant relationships by Karim Dirani No relevant relationships by Georgiana Marusca No relevant relationships by Aryan Shiari

UNDERSTANDING THE NEED FOR A BROAD DIFFERENTIAL DIAGNOSIS: A CASE OF PNEUMONIC TULAREMIA

SESSION TITLE: Disseminated Bacterial Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Tularemia is a rare infectious disease caused by Francisella Tularensis that typically affects the skin, eyes, lymph nodes, and lungs. There are a variety of forms of tularemia with varying rates of contagiousness and mortality. Respiratory tularemia has a high mortality rate if left untreated and presents with non-specific viral like symptoms occurring in conjunction with respiratory symptoms: cough, hemoptysis, and pleuritic chest pain. In this COVID ARDS era, it is important to evaluate a broad differential diagnosis. Therefore, the authors describe a patient presenting with flu-like respiratory symptoms whom was ultimately was diagnosed with acute respiratory distress syndrome (ARDS) due to F. Tulerensis. CASE PRESENTATION: A 44-year-old male presented with a four-day history of night sweats, shortness of breath, a productive cough which progressed to hemoptysis, and oliguria. Prior to admission, his initial symptoms were treated as chronic sinusitis with varied antibiotics. Social history including tobacco abuse and deer hunting 1 month prior to presentation. Vitals were stable except for tachycardia, hypoxia, and tachypnea. Laboratory findings were significant for AKI, lactic acidosis, mild transaminitis, hyperbilirubinemia, and leukocytosis with predominant neutrophilia. Thoracic CTA showed bilateral diffused pulmonary edema without evidence of pulmonary embolism. Due to the patient's worsening respiratory status, he was intubated for support. The patient progressed to Severe ARDS per Berlin Criteria eventually requiring pronation and continuous paralyzing. Bronchoscopy was performed with bronchial lavage. Bacterial, viral, and fungal cultures did not show growth while vasculitic work-up was negative. Empiric antibiotic treatment did not show improvement until the patient was diagnosed with F. Taularensis via serological testing with an IgM of 20 U/mL, and patient was transitioned to gentamycin. Ultimately, the patient was extubated, transitioned to oral doxycycline, and discharged home. DISCUSSION: Approximately 250 cases of tularemia are reported to CDC each year. Respiratory tularemia has a mortality rate up to 30% if not treated. For this reason, F. tularensis is a potential biological weapon and is categorized as a Group A pathogenic agent. Serological testing may be negative early in disease progression;therefore, early inflammatory markers with clinical suspicion are essential to diagnose the disease early in its course. DNA microarray has high specificity and sensitivity for rapid diagnosis of tularemia while being cost effective. After prompt diagnosis, intravenous aminoglycosides;such as gentamycin or streptomycin;must be started. CONCLUSIONS: In the above case, we illustrate the gradual onset and rapid patient deterioration when treatment is delayed;yet, there is rapid recovery once appropriate treatment is used. Reference #1: 1. Ranjbar, Reza, Payam Behzadi, and Caterina Mammina. "Respiratory tularemia: Francisella tularensis and microarray probe designing.” The open microbiology journal 10 (2016): 176. Reference #2: 2. Akhvlediani, N., I. Burjanadze, D. Baliashvili, T. Tushishvili, M. Broladze, A. Navdarashvili, S. Dolbadze et al. "Tularemia transmission to humans: a multifaceted surveillance approach.” Epidemiology & Infection 146, no. 16 (2018): 2139-2145. Reference #3: 3. Tularemia in British Columbia: A case report and review. Issue: BCMJ, vol. 52, No. 6, July August 2010 (Pages 303- 307). Megan Isaac-Renton, BSc, Muhammad Morshed, PhD, SCCM Eleni Galanis, MD, MPH, FRCPC Sunny Mak, MSc Vicente Loyola, MD, FRCPC, Linda M.N. Hoang, MD, MHSc, FRCPC DISCLOSURES: No relevant relationships by Munish Adhikari No relevant relationships by Ashma Ul Husna No relevant relationships by Yan Jiang No relevant relationships by Divya Kharel No relevant relationships by Gregory Polcha

Neonatal Acute Liver Failure in a Preterm Neonate with Gestational Alloimmune Liver Disease and Congenital Portosystemic Shunts

Introduction: Gestational alloimmune liver disease (GALD) is a leading cause of neonatal acute liver failure (NALF), a rare but important diagnosis. Congenital portosystemic shunts (CPSs) are rare vascular anomalies that leave patients at risk for developing a wide spectrum of complications and have not been previously associated with GALD. In this case, we present a newborn male with NALF secondary to GALD complicated by intrahepatic shunts. Case Description: The patient is a 30 weeks gestational age male born to a 28-year-old gravida 2 para 0 mother via urgent cesarean section for severe placental malperfusion. The pregnancy was complicated by severe intrauterine growth restriction, oligohydramnios, and maternal COVID-19 infection. The patient's initial NICU course was remarkable for respiratory distress requiring ventilatory support, hypotension requiring inotropes and stress dose steroids, and coagulopathy with bleeding requiring transfusion of multiple blood products. An abdominal ultrasound showed large congenital intrahepatic portosystemic shunts. Over the course of the hospitalization, the infant progressed to fulminant hepatic failure with associated coagulopathy, hypoalbuminemia, direct hyperbilirubinemia, and hyperammonemia. There was persistent anasarca in addition to elevated ferritin (1,922 ng/dL) and alpha-fetoprotein (97,855 ng/mL). Serial SARS-CoV-2 NAAT were negative. In consultation with the hepatologist there was high clinical suspicion for GALD, and treatment with intravenous immunoglobulin was initiated, however, no clinical or laboratory improvement was noted. Abdominal MRI showed progression of the large CPSs and enlargement of the hepatic arteries. The infant continued to deteriorate, was transitioned to comfort care, and died on day of life 82. A limited autopsy revealed a markedly edematous and jaundiced male with grossly enlarged liver with hepatocellular cholestasis, portal fibrosis, diffuse hepatobiliary iron depositions, and C5b9 positivity within hepatocytes confirming a diagnosis of GALD. Discussion: Neonatal hemochromatosis is the phenotypic result of severe liver injury leading to iron overload and extrahepatic siderosis, the mechanism of hepatic injury now recognized in GALD. Liver failure in newborns with GALD often presents with marked coagulopathy, hypoalbuminemia, and edema with and without ascites. The establishment of the diagnosis is crucial given without treatment, the prognosis is very poor. There have been no case reports of neonates with acute liver failure from CPSs or CPSs occurring with GALD. We hypothesize that the presence of CPSs worsens the clinical course of GALD through an unknown mechanism that further expedites hepatocellular damage. Furthermore, the role of SARS-CoV-2 infection and transmission in the neonatal population is still unknown. Conclusion: Neonatal acute liver failure caused by GALD is a rare but potentially fatal diagnosis. CPSs associated with GALD have not been previously documented. This case demonstrates the interplay of these disease entities likely contributing towards a more severe course of NALF and highlights the importance of early identification for guiding management. (Figure Presented).

Liver related adverse events reported after the use of COVID-19 vaccines: A descriptive study

Objectives: The present study focus on the liver-related adverse events (AEs) reported with COVID-19 vaccines in VigiBase, a database maintained by WHO for reporting adverse events. Materials and Methods: The data of liver-related adverse events following COVID-19 vaccination was acquired on a subscription basis from VigiBase. This study included all the suspected liverrelated adverse events reported in VigiBase after administering any of the three COVID-19 vaccines: Moderna, BNT162b2 Pfizer and 1222 AstraZeneca between December 15, 2020, and January 24, 2021. The MedDRA (Medical Dictionary for Regulatory Activities) and WHOART terminology- SOC (System Organ Class) and PT (Preferred Terms) were used for analysis. We extracted three SOCs - hepatobiliary disorders, gastrointestinal disorders and investigations. All the SOC were further cleaned to remove all PTs other than those related to the liver. Disproportionality analysis was reported in the form of IC025, Reporting Odds Ratio and Prevalence Odds Ratio. Results: A total of 103,954 AEs were reported for COVID-19 vaccines from 32,044 individuals, out of which only 51 (0.049%) AE from 32 patients was related to the liver. Most common liver-related AE reported were in the SOC ''investigations''- increase in alanine amino transferase (0.009%) followed by increased aspartate aminotransferase and increased bilirubin (0.006%). Based on the disproportionality analysis (IC025 values) none of them was vaccinerelated AE. Conclusion: COVID-19 vaccines are safe for liver and there was no increase in the events were associated with the use of vaccines. As these were early data of vaccine use, analysis based on recent data need to be done to ascertain it fully.

Liver function tests in recovered COVID-19 patients with acute heart failure and associated outcomes

Objectives: The objective of this study characterize abnormal liver function test after recovered coronavirus in patients with heart failure (HF) as they are commonly encountered yet poorly defined. Materials and Methods: This study is a Clinical Effectiveness of nesiritide in decompensated Heart Failure use data from SCEND-HF to characterize associations with baseline liver function tests (LFTs). each LFT was analysed as both a continuous and dichotomous variable >normal vs. abnormal;bilirubin>1.0 mg/dL;aspartate aminotransferase (AST) and alanine aminotransferase ALT>35 mmol/L. Results: Mean Logistic regression assessed the association of LFTs and 30-day all-cause mortality and HF rehospitalization, and Cox proportional hazards assessed the association with 180-day all-cause mortality among patients alive at a 30-day landmark. In SCEND-HF, 2128 (48%) had complete admission LFT data. of these, 39% had abnormal bilirubin, 22% had abnormal ALT, and 29% had abnormal AST. Patients with abnormal LFTs were younger, had lower body mass index, and lower left ventricular ejection fraction. In multivariable models, increased total bilirubin was associated with increased 30-day mortality or HF rehospitalization >hazard ratio (HR) 1.17 per 1 mg/dL increase 85% confidence interval (CI) 1.04, 1.32;P = 0.012], but not with an increase in 180-day mortality (HR 1.10, 95% CI 0.97, 1.25;P = 0.13) per 1 mg/dl increase. Compared with normal bilirubin levels, abnormal bilirubin was associated with increased 30-day mortality or HF rehospitalization (HR 1.24, 95% CI 1.00, 1.54;P = 0.048) and 180-day mortality (HR 1.32, 95% CI 1.08, 1.62;P = 0.007). We found no association with AST or ALT and outcomes. Conclusion: More than 40% of patients Hospitalized with acute HF had abnormal LFTS.After multivariable regulation, only High bilirubin was independently related with worse clinical outcomes and may represent an important prognostic variable.

AN EVALUATION OF ADVERSE DRUG REACTIONS WITH REMDESIVIR IN PATIENTS OF COVID-19

Objectives: The aim of the study was to evaluate the adverse drug reactions (ADR) following Remdesivir therapy in patients of COVID-19. Methods: All patients more than 18 years of age of any gender, diagnosed with COVID-19 infection receiving remdesivir therapy and fulfilling the selection criteria were included in the study after informed consent. They were monitored for ADRs till end of treatment and analyzed for characteristics of the ADRs: Causality, severity, and preventability. Results: Out of 80 patients (mean age of 49.27±16.22 years) enrolled, 51 (63.75%) developed 84 ADRs. Most common ADRs included increased aspartate transaminases, (20.23%), increased bilirubin (19.04%), increased alanine transaminases (13.09%), increased creatinine (11.90%), and increased blood urea (9.52%). Causality assessment using WHO-UMC scale showed, 85.71% possible, 13.09% probable, and 1% certain causal association of the ADRs with remdesivir. A total 75% ADRs were mild in severity and 45% patients recovered from the event at the end of treatment. Conclusion: Hepatic and Renal dysfunctions are observed with remdesivir in COVID-19 patients. Intensive monitoring of ADRs with newer drugs with EUA such as remdesivir is warranted to ensure safer use in patients.

High rates of neonatal polycythemia and hyperbilirubinemia during the first phase of COVID-19 pandemic in Italy: a single-center experience.

In our third-level Neonatal Unit in Northern Italy, we recorded a high rate of neonatal hyperbilirubinemia requiring phototherapy in March-November 2020, during the first phase of COVID-19 pandemic, compared to the previous year (198/1348, 14.2%, vs 141/1432, 9.8%, p = 0.0004). Supposing it could be the result of neonatal polycythemia, we evaluated capillary hematocrit (Hct) and the rate of hyperbilirubinemia in all newborns ≥36 weeks gestational age born in December 2020. Out of 73 neonates, 37 had Hct ≥65% (50.7%). However, as capillary blood samples may overestimate Hct by 5-15%, even downsizing all values by 15%, Hct was still ≥65% in 9/73 neonates (12.3%), much higher than 0.4-5% prevalence of polycythemia reported in healthy newborns. All those newborns were singleton and healthy, with no clinical signs of hyperviscosity and no underlying factors predisposing to polycythemia. Out of 73 newborns, 13 (17.8%) developed hyperbilirubinemia requiring phototherapy. Their mean Hct value was 66.3 ± 8.2%. Since hyperbilirubinemia is common in the offspring of women with SARS-CoV-2 infection and we recorded increased rates of neonatal hyperbilirubinemia in the first phase of COVID-19 pandemic, it could be hypothesized that even asymptomatic Sars-CoV2 infection during pregnancy might cause placental vascular malperfusion, eliciting polycythemia in the fetus as a compensatory response, that could be the link between COVID-19 in the mothers and hyperbilirubinemia in the newborns.

The spectrum of ABO hemolytic disease of the fetus and newborn in neonates born to Group O mothers

Background: ABO hemolytic disease of the fetus and newborn (ABOHFDN) is a frequent event, and usually a problem of the neonate rather than the fetus, however, it is difficult to predict the disease severity. Thus, there is a need to increase awareness towards ABOHFDN for optimizing care in terms of early diagnosis and adequate monitoring. Aims: To determine the frequency of ABO-incompatibility in neonates born to group O mothers and to assess the severity of ABO-HDFN in neonates and determine the neonatal outcomes. Methods: This prospective observational study was carried out from February 2020 to May 2021 after obtaining a written informed consent from the mothers. A total of 260 neonates born to blood group O mothers were recruited. The maternal red cell antibody screen (ABS) using a 3-cell panel (Diacell, Bio-Rad, Switzerland) and the neonatal direct antiglobulin test (DAT) were done by column agglutination technique (CAT). For DAT positive samples, the IgG subclass of anti-A/anti-B was determined using DAT IgG1/IgG3 screening cards (Bio-Rad, Switzerland) and a heat elution at 56°C was also performed. The maternal anti-A/anti-B IgG titers was determined by tube technique after treating the serum sample with 0.01 M di-thiothreitol (DTT). The neonatal total serum bilirubin (TSB) and other relevant parameters were also recorded. The requirement for treatment in terms of phototherapy and/or exchange transfusion (ET) and the neonatal outcome were also recorded. Due to travel restrictions during the ongoing COVID-19 pandemic, the follow-up was performed telephonically with parents 6-8 weeks after discharge. Results: Of the 260 group O mothers, none had positive ABS. Of the 260 neonates born to them as an outcome of singleton pregnancies, 84 with blood group O were excluded from the study. The overall frequency of ABO-incompatibility between mother and neonates was 67.69% (176/260). Out of 176 neonates, 77 (43.8%) were group A and 99 (56.2%) were group B, and 15 (8.5%) of them had a positive DAT. Overall, 26.7% (47/176) neonates received phototherapy and 172 (97.7%) neonates survived. The mean (±SD) duration of phototherapy (hours) was 34.17 (±25.67) hours and it ranged from 12- 120 h. Only 1 neonate required ET. None of the neonates required readmission. The median maternal IgG anti-A titre was 16 (8-64) (range: 2-512), while the IgG anti-B titre was 32 (32-64) (range: 4- 512) (p = <0.001). The maximal TSB in neonates had a significant positive association with neonatal birth weight (p = 0.045), maturity at birth (p = 0.037), positive DAT (p = 0.006) and requirement of phototherapy (p = <0.001). Neonatal DAT positivity was significantly associated with maternal IgG titers (p = <0.001), neonatal PCV (p = 0.017), maximal TSB (p = 0.006), requirement (p = <0.001) and duration of phototherapy (p = 0.024). At a cut-off of maternal IgG titre ≥64, it predicted the requirement of phototherapy with a sensitivity of 72.3% and a specificity of 72%. The relative risk (95% CI) of a DAT positive neonate requiring phototherapy was calculated to be 4.55 (3.12-6.33). Summary/Conclusions: The frequency of ABO-incompatibility in neonates born to group O mothers was 67.69% (176/260). The maternal IgG titre of anti-A/anti-B of 64 or more could be a good predictor for identifying the neonates at-risk for developing hyperbilirubinemia requiring further management and combining it with neonatal DAT further enhances the sensitivity to identify such at-risk neonates.

COVID-19 and SARS-CoV-2. We learn that there's still so much more to learn

Background: Current COVID-19 pandemic exposes health staff to a new and potentially fatal disease Case history: Male, 37 yo, entered ER referring worsening asthenia, feeling non-specifically unwell for 7 days, recent history of SARSCoV- 2 infection with interstitial pneumonia requiring hospitalization two weeks prior admission. Blood tests showed severe anemia (Hb 4gr/dl), mild hyperbilirubinemia, markedly raised LDH, positive direct/ indirect Coombs' reaction. Autoimmune haemolytic anemia was suspected because of symptomatic anaemia, evidence of ongoing haemolysis on blood tests, history of a viral infection. Chest XRay and CT pulmonary angiogram were negative for features suggestive of Covid-19 but highlighted lower right lobar pneumonia. Nasopharyngeal molecular swab was negative, while antibody test showed high titer G Immunoglobulin, confirming recent infection. He was initially treated with high doses steroids (1 gr/Kg bw) as well as antibiotics for pneumonia;but, due to lack of efficacy, on the fourth day we started ev immunoglobulins, obtaining gradual improvement in Hb towards baseline and tests normalization. Discussion: SARS-CoV2 infection frequently meets complications;although the pathophysiology underlying COVID-19 remains poorly understood, evidence argues for hyperinflammatory syndrome and/or various autoimmune disorders, which may appear after pneumonia recovery, highlighting need of medium and longterm follow up, to identify possible presentations of COVID-19 complications.

Yellow Urticaria in a patient with gallbladder stones: A case report and review of literature

Yellow urticaria is a rare type of urticaria and the exact etiology behind it is still unclear. We report a case of 53-years-old medically free male with pruritic yellow to orange wheals over his trunk and extremities after receiving his first dose of COVID-19 Vaccine (Pfizer-BioNTech) with no evidence of angioedema or anaphylaxis. All the reported cases of yellow urticaria almost share the same cause which is hyperbilirubinemia due to wide spectrum of liver diseases. In conclusion, it is crucial for clinicians to be familiar with this presentation of yellow urticaria and correlate it with the patient history related to liver disease , as this urticaria often signify the presence of various liver disorders.

To Evaluate the Clinical Profile of Neonates Born to COVID Positive Mothers during Pandemic at GIMS Hospital, Kalaburagi

Background: The incidence of mother-to-newborn Covid 19 transmission is low. However, data are limited on the factors associated with neonatal clinical or viral testing outcomes. This study aims at evaluation of clinical profile of neonates born to COVID positive mothers. Objective: To determine the number of neonates from 01 April 2020 to 30 August 2021 with lab confirmed COVID-19 infection born to Covid 19 positive mothers. To assess the clinical features of neonates born to Covid 19 positive mothers. Methods & Materials: Study design: Retrospective cohort study Study period: 01 April 2020 to 30 August 2021 Study Place: Gulbarga institute of medical science kalaburagi, Karnataka India. Conclusions: Perinatal covid 19 infection may have adverse effects on newborns causing problems such as fetal distress, premature labour, Hyperbilirubinemia, respiratory distress, oxygen requirement, sepsis, birth asphyxia and even death. However vertical transmission of Covid 19 is yet to be confirmed Aims and objectives: To determine the number of neonates from 01 April 2020 to 30 August 2021with RTPCR confirmed COVID-19 infection born to Covid 19 positive mothers. To assess the clinical features of newborns born to Covid 19 positive mothers. Inclusion criteria: All neonates born to Covid 19 positive mothers METHODS: Manual medical records of mother and baby were reviewed. Data on maternal demographic factors (age, residence, socioeconomic status), co morbidities, symptoms of COVID 19, Data on newborn demographic factors (gestational age, sex, birth weight, mode of delivery, Apgar score) were collected . All neonates born to covid 19 positive mother were reviewed for clinical and lab data till time of discharge. Clinical data such as respiratory distress, oxygen desaturation, poor feeding, apnea, seizures, tachycardia, fever, hypothermia, jaundice in those neonates was reviewed. Associated morbid factors such as Birth asphyxia, prematurity, relative sepsis were analysed. Lab data such as TLC, CRP, Sr Ferritin, Sr LDH, D-Dimer, Procalcitonin, RTPCR analysis of nasopharyngeal and throat swab of neonates born to covid positive mothers were reviewed. Chest x ray was reviewed. Those having clinical symptoms/ signs were admitted in NICU. Asymptomatic hemodynamically stable Covid19 negative neonates were isolated on mother side. Sample size: 200 neonates born to covid19 positive mothers. Sample size was determined based on the incidence of covid19 positive rates of neonates born to covid positive mothers, using formula 4PQ/L2. Results: Among these 200 pregnant women with confirmed Covid 19 infection, fever and cough were the common symptoms noted. Of the newborns born to these mothers, 92 were male neonates and 108 were female neonates, 153 were full-term neonates and 32 were born premature;15 were small-for-gestational-age (SGA) neonates. Clinically, the initial presentations in the neonates were respiratory distress(n=5) and failure to breathe at birth(n=4), but other presentations such as fever(n=1), poor feeding(n=3),rapid heart rate(n=4), hyperbilirubinaemia (n=5) abnormal Xray(n=3) and oxygen requirement(n=4) were also observed. All neonates were improved and discharged. Nasopharyngeal and throat swab specimens were collected from these neonates 2to3days after birth for Covid 19 RT-PCR tests, out of which 02 neonates showed positive results. One COVID-19 positive baby presented with failure to breathe at birth was treated with antiviral and antibiotics. The other baby also had similar presentation was treated with antiviral and oxygen. Both neonates improved and discharged.