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.

Potential Association of Remdesivir and Hyperkalemia: A Disproportionality Analysis in USFDA Adverse Event Reporting System Database

Background: Signal detection is one of the most advanced and promising techniques in the world of pharmacovigilance. Remdesivir is approved for emergency use by the US Food and Drug Administration (FDA) for patients with coronavirus disease 2019 (COVID-19). Its benefit- risk ratio is still being explored because data in the field are rather scant. On the other hand hyperkalemia is a potentially life-threatening electrolyte disorder. Severe hyperkalemia can occur suddenly and can cause life-threatening heart rhythm changes (arrhythmia) that cause a heart attack. Even mild hyperkalemia can cause heart related problems over time if not treated. Objective(s): To evaluate the potential association of Remdesivir with risk of Hyperkalemia by analyzing the spontaneous reports through disproportionality analysis. Method(s): Data were obtained from the public release of data in FAERS. Case/non-case method was adopted for the analysis of association between Remdesivir use and Hyperkalemia. The data-mining algorithm used for the analysis were Reporting Odds Ratio(ROR) and Proportional Reporting Ratio (PRR). A value of ROR-1.96SE>, PRR>=2 were considered as positive signal. Result(s): A total of 7 DE's associated with Remdesivir use and hyperkalemia were reported. The mean age of the patients of Remdesivir associated events was found to be 75 years [95% CI]. The reports by gender were distributed with a male to female ratio of 3:1, though gender was not revealed in 3 reports. The data mining algorithms exhibited positive signal for hyperkalemia (PRR: 2.349, ROR: 2.354) upon analysis as those were well above the pre-set threshold. Three case reports were identified which strengthened these findings and highlighted the importance of laboratory parameters for the early detection of hyperkalemia Conclusion(s): The current study found a potential risk of hyperkalemia with the use of Remdesivir and there is an urgent need to thoroughly investigate the same and take the necessary action to avoid or minimize the risk.Copyright © 2023

Updates in Nephrology for the Hospitalist

This chapter gives a broad overview of nephrology as it affects hospitalists while also hoping to answer a few of the essential questions hospitalists may ask their nephrology colleagues. Evaluation and treatment of both acute and chronic kidney disease is constantly evolving as the small but tight-knit community of hospital-nephrologists continue to collect, review, and research data. The majority of the chapter will be focused on discussing a few new updates in the field of nephrology and how these updates could potentially change hospital care. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Rates of Hypoglycemia with Reduced- vs. Standard-Dose Insulin for Hyperkalemia Treatment in Renal Insufficiency

Objective: The primary objective was to assess the difference in rates of hypoglycemia (blood glucose (BG) <=70 mG/dL) when using reduced-dose (5 units) vs. standard-dose (10 units) of IV regular insulin for hyperkalemia treatment in renal insufficiency. Secondary objectives include the efficacy of insulin dose on potassium reduction and evaluating the difference in rates of severe hypoglycemia (BG <=54 mG/dL) between the groups. Method(s): This was a retrospective chart review of patients with renal insufficiency treated with IV regular insulin for hyperkalemia at a tertiary care teaching hospital from June 2020 to June 2021, with institutional review board approval. Inclusion criteria encompassed patients aged 18 years and older with elevated baseline potassium (>=5.5 mEq/L), estimated glomerular filtration rate < 30 mL/min/1.73m2, end stage renal disease, or presence of acute kidney injury, having received either 5 or 10 units of IV regular insulin for hyperkalemia, and had documented glucose and potassium levels after insulin administration. Patients who were pregnant, had diabetic ketoacidosis, or a baseline BG <=70 mG/dL were excluded. Data collection included patient demographics, diabetes history, relevant labs at time of elevated potassium, doses of insulin and dextrose administered for hyperkalemia treatment, presence of coronavirus-19 infection, glucose levels within 6 hours and first potassium level within 24 hours following insulin administration, concurrent use of potassium-lowering agents, insulin outside of hyperkalemia treatment, or steroids, and mortality. Result(s): Out of 409 patients included, 92 were in the 10-unit group and 317 in the 5-unit group. The rate of hypoglycemia in the 5-unit arm vs. the 10-unit arm was 6.9% vs. 8.7% (p=0.649), respectively. The rate of severe hypoglycemia between the 5-unit arm and the 10-unit arm was 3.2% vs 5.4% (p=0.682), respectively. The percent normalization of potassium was not statistically different between the 5-unit group and the 10-unit group (59% vs. 68%;p=0.115), with the same mean reduction in potassium from baseline (0.8 mEq/L (p=0.947)). Administration of concurrent treatments for hyperkalemia was similar between the groups, with dialysis being the only one with statistical significance in normalization of potassium. Patient characteristics that could have an impact on risk of hypoglycemia were studied and analyzed, including pre-treatment BG, history of diabetes mellitus, insulin naive, and patient weight. In patients with hypoglycemia (n=30) vs. those without hypoglycemia (n=379), there was a significantly different mean pre-treatment BG (113 mG/dL vs. 178 mG/dL, p<0.001). Discussion/Conclusion: There was no significant difference in rates of hypoglycemia and severe hypoglycemia between the 5-unit vs. 10-unit groups. There was no significant change in potassium normalization between the two insulin doses. Because of the small number of hypoglycemia events, larger studies are needed to better understand if 5 units of regular insulin is a safer option for the treatment of hyperkalemia in renal insufficiency.Copyright © 2023

Successful matched unrelated donor hematopoietic stem cell transplantation for infantile Wolman disease

Introduction: Wolman disease is a rare genetic disorder with an autosomal recessive inheritance. A mutation in the LIPA gene causes lysosomal acid lipase (LAL) deficiency results in lipid storage and adrenal insufficiency. Death in early infancy is due to liver failure. Patients and methods: We describe the clinical course of a three-month-old infant diagnosed with Wolman disease. A rapid mutational analysis confirmed a LIPA gene defect. Results: He underwent matched unrelated donor peripheral blood stem cell hematopoietic stem cell transplantation (HSCT) at 3 months of age, with a treosulfan-based conditioning, which resulted in engraftment with donor-derived hematopoietic cells. He required supportive care for sinusoidal obstruction syndrome and mucositis. He was administered low dose prednisolone for grade I skin graft versus host disease, and a complete donor chimerism was documented on several occasions. At one year post HSCT, his growth and development were optimal, and there was no hepatosplenomegaly. He is maintained on glucocorticoid and mineralocorticoid supplements for primary hypoaldosteronism. Conclusion: The case emphasizes the timely diagnosis and the potential for successful treatment of Wolman disease by HSCT. © 2022 Pediatric Hematology Oncology Chapter of Indian Academy of Pediatrics

Cirrhosis and COVID-19: Diffuse venous thrombosis and its clinical implication

A 60-year-old woman with Hepatitis C infection, cirrhosis, recurrent hepatic hydrothorax, and hepatocellular carcinoma was hospitalized with Coronavirus disease-2019 (COVID-19). After her initial discharge, she was re-admitted three weeks later with decompensated liver disease. Imaging revealed extensive thrombosis in the portal vein, superior mesenteric vein, splenic vein and bilateral brachial veins. Given the acute onset and extent of the thrombosis, the patient received therapeutic anticoagulation despite elevated prothrombin time/ international normalized ratio, thrombocytopenia and low fibrinogen. Cirrhotic patients with COVID-19 maybe at high risk of thrombosis, which can present with significant hepatic decompensation.Copyright © 2022 The Author(s)

Hyperkalemia caused by Qingfei Paidu decoction() in a patient with novel coronavirus pneumonia.

A 23-year-old male patient received moxifloxacin, recombinant human interferon alpha-2b for injection, and lopinavir and ritonavir for 7 days for novel coronavirus pneumonia. There was no abnor-malityof serum potassium. Moxifloxacin was stopped, Qingfei Paidu decoction() was given, and then the patient's serum potassium began to rise. On day 10 after taking the decoction, laboratory tests showed serum potassium 5.7 mmol/L and the patient was diagnosed with hyperkalemia. Insulin injection 4 U diluted to 5% glucose injection 250 ml was given once by IV infusion, and then the serum potassium decreased to 5.0 mmol/L 6 hours later and 4.6 mmol/L 2 days later. After 5 days, the serum potassium rose again and finally to 5.4 mmol/L on day 17 after taking the decoction. Insulin was given once that day and 2 days later once daily according to the previous method. Then the serum potassium decreased and did not rise again. The patient recovered from novel coronavirus pneumonia and was discharged on day 28 after hospitalization.Copyright © 2020 by the Chinese Medical Association.

Sarcomatoid urothelial carcinoma accompanied by elevated serum beta-HCG: Two case reports

Sarcomatoid urothelial carcinoma is a rare and aggressive variant. Serum beta-hCG levels are used as a tumor marker in gestational trophoblastic diseases and germ cell tumors, but may also be elevated in high-grade bladder cancers. Here, we report two urothelial carcinoma cases with sarcomatoid differentiation that relapsed early after surgery with elevated serum beta-hCG levels. The first case was a 65-year-old female and the second case was a 67-year-old man with sarcomatoid urothelial carcinoma located in the ureter and renal pelvicalyceal system, both of them relapsed with elevated beta-hCG serum level to 146.8 mIU/ mL and 242 mIU/mL, respectively. They died a few months after initial diagnosis;4.9 and 2.5 months respectively. Both sarcomatoid variant and beta-hCG expression were associated with poor prognosis and advanced stage. However, beta-hCG is not used as a tumor marker in urinary tract cancers yet, and its relationship with variant pathologies has not been clarified. We need multi-centered studies to reveal this relationship.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Analysis of Survival in Patients with End-End Chronic Kidney Disease Switching from Peritoneal Dialysis to Hemodialysis Due to Refractory Peritonitis

Introduction: Peritonitis associated with peritoneal dialysis (PD) has complications such as transfer from PD to HD and increased morbidity and mortality. In our environment, there is little information regarding survival in this population. Method(s): Retrospective cohort, 147 PD patients, 18 years, with PD catheter removal between 2018-2021. Clinical, biochemical and technique-related variables were measured. Patients who died of cancer and other unrelated causes were excluded. Descriptive statistics, Kaplan-Mayer analysis and Cox regression analysis were used Results: Age 42 +- 17 years, 65% men, 65% unknown cause of CKD. The time between peritonitis diagnosis and catheter removal was 37 (25-61) days. Nine patients (6%) returned to PD, the rest (94%) remained on HD due to unfit abdomen (55%), patient decision (9%), unknown (17%), others (19%). Mortality was 31% and the causes of death were: sepsis (33%), COVID-19 (29%), pneumonia (19%), pulmonary edema (5%), hyperkalemia (5%), CVD (5%), others (4%). Survival after the refractory peritonitis event was 25 (95% CI 22-28) months. Survival at 3, 12, 24, and 36 months was 87%, 71%, 61%, and 35%. In the bivariate analysis, age, DM, time on dialysis, and serum albumin were associated with a higher risk of death. However, in the multivariate analysis, only time on dialysis was significant (OR 1.014, 95% CI 1.002-1.027). [Formula presented] Conclusion(s): Mortality was 31% and the most frequent cause of death was sepsis. Patient survival was 25 (95% CI 22-28) months. Time on dialysis was associated with a higher probability of death. It is necessary to compare these results with a group of patients who do not present failure of the technique. No conflict of interestCopyright © 2023

Beta-Blocker and Calcium Channel Blocker Toxicity With BRASH Syndrome: A Case Report.

Atrioventricular (AV) nodal blockers have a wide variety of medical uses, including the management of hypertension and cardiac arrhythmias. Like any other drug, they can carry side effects and toxicity. We present a case of a patient with a constellation of findings consistent with bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia (BRASH) syndrome. A 75-year-old female with a history of paroxysmal atrial fibrillation and heart failure with preserved ejection fraction presented to the hospital with shortness of breath. She was discharged two weeks prior to the presentation from another hospital after being treated for atrial fibrillation with a rapid ventricular response. She was discharged on metoprolol and diltiazem. Upon presentation to the hospital, the patient was noted to be bradycardic and hypotensive with blood work notable for acute kidney injury and hyperkalemia, consistent with BRASH syndrome. She received a dose of intravenous (IV) glucagon followed by infusion and received epinephrine infusion. Once clinically stable, she was discharged with her home dose of metoprolol and a reduced dose of diltiazem with a close follow-up with cardiology. Early recognition of BRASH syndrome as a unique clinical entity rather than different pathologic conditions is important to improve morbidity and mortality in these patients.

Identification of Modifiable Causes of Hypoglycemia in the Icu

INTRODUCTION: Hypoglycemia is associated with increased mortality in the ICU. Studies have shown that modifiable causes of hypoglycemia may include antihyperglycemic medication, reduced caloric intake & change in nutrition without insulin adjustment. The primary objective of the study was to identify modifiable risk factors for hypoglycemia in our ICUs in order to decrease its incidence. METHOD(S): This was a retrospective review from July to September 2020 of adult ICU patients at a tertiary medical center with a hypoglycemic event (glucose < 80mg/dL) given intravenous rescue dextrose. Medical, surgical, cardiac & neuro ICU patients were included. Exclusion criteria were COVID-19, comfort measures & hyperkalemia. Descriptive statistics were used for statistical analysis. RESULT(S): A total of 56 out of 784 patients (median age 64;60.7% male) had 180 discrete hypoglycemic events. Common risk factors were nothing by mouth orders (NPO) at the time of the event (69.2%), a timeframe of 1900 to 0700 (64.2%), active insulin orders (48.3%), being within 24 hours of a procedure (42.8%) or 24 hours of admission (33.9%), or having AKI (42.8%), diabetes (39.3%) or sepsis (41.1%). Of the 48.3% of patients on insulin, 40% were on an insulin infusion, 39% sliding scale & 21% long-acting. As compared to weekdays, hypoglycemia occurred 37.5%, 87.5%, and 137.5% more often on weekend days, weeknights, and weekend nights, respectively. CONCLUSION(S): The most common iatrogenic risk factors for hypoglycemia in the ICU identified in this review were the initial 24 hours of ICU admission, active insulin orders and both periprocedural and NPO status. Hypoglycemia was more common overnight but this is also when daily BMPs are collected. Interventions such as dextrose-containing maintenance fluids while NPO, removal of periprocedural NPO at midnight orders, the addition of fingerstick checks to ICU admission order sets and when a patient is NPO, and cautious insulin use are warranted to help mitigate these events. This pharmacy resident project led to a multidisciplinary policy change to hold tube feeds for patients with an ET tube or trach immediately before they travel to a procedural area instead of at midnight, or 6 hours prior to procedures with planned airway interruption or NPO status needed for bowel cases.

Hyperkalemia Is Associated With Increased Mortality Rates in COVID-19 Patients

Background: Abnormal potassium (K) levels are strongly associated with higher mortality rates among all hospitalized patients. In this study we aim to identify a correlation between abnormal K levels and mortality in coronavirus disease (COVID-19) patients may likely optimize inpatient management. Method(s): Using an observational database, we analyzed 3310 unvaccinated hospitalized COVID-19 PCR-positive patients at Methodist Health System from March 2020 to December 2020. We compared in-hospital death or hospice referral rates between patients with normal K levels (K= 3.5 to 5.0meQ/L), hypokalemia (K < 3.5meQ/L), or hyperkalemia (K > 5.0meQ/L) on first encounter. Chi-square (X2) and odds ratio tests were used to analyze observed variables. Result(s): Of the 3310 COVID-19 patients, 463 (14.0%) died in the hospital or were discharged to hospice and 2747 (86.0%) were discharged home or to a post-acute care facility. In this study cohort, 285 (8.6%) patients had hyperkalemia, 453 (13.7%) had hypokalemia, and 2572 (77.7%) had normal K levels. Patients with abnormal K levels on initial encounter had a higher mortality rate than those who had normal K levels (OR 1.32, 95% CI 1.05 - 1.64, p = 0.02). However, upon closer examination we found that hyperkalemia had a strong association with increased mortality in COVID-19 patients compared to normal K levels (OR 2.00, 95% CI 1.49 - 2.69, p < 0.001);however, hypokalemia did not (p = 0.66). Conclusion(s): Hyperkalemia on presentation is associated with a significantly increased risk of in-hospital death or hospice discharge among hospitalized COVID-19 patients.

Impact of Inpatient Tele-Nephrology Treatment Outcomes in Rural Alabama

Background: Access to nephrology care including dialysis in rural Alabama (AL) hospitals is lacking. The University of Alabama at Birmingham (UAB) with Sanderling Inc. started inpatient tele-nephrology (TN) services in 2019 and currently serves 3 rural AL hospitals. Since the COVID-19 pandemic, transfer to TN-equipped hospitals in AL played a pivotal role for patients needing nephrology services when primary referral centers were at capacity. Method(s): TN services were 100% virtual and video-based. Consults were completed by UAB nephrology faculty. Home hemodialysis machine (HHD) was used to provide kidney replacement therapy (KRT) in the hospital, with aid of inpatient dialysis technicians supervised remotely by TN dialysis nurses. TN consults were evaluated from Jun 2019 to Dec 2021. Retrospective chart review for pre-defined outcomes was performed and analyzed. Result(s): There were 694 inpatient TN encounters. Mean age was 64 (18-96) yr. 74% of consultations involved black patients. Mean stay was 6 d. 44% were ICU patients;18% were COVID-19 positive. AKI and known ESKD patients contributed to 48% and 44% consults, respectively. 11% had AKI necessitating KRT. 20% and 13% of consults involved hyperkalemia and dysnatremias, respectively. 792 dialysis treatments were performed with 11% complicated by intradialytic hypotension (IDH). Patients were discharged 64% and transferred to higher level of care 18% of the time. 90 patients expired. 66% of deaths were attributable to COVID-19. Preliminary economics analysis at the hospital with the most consults showed increase in case-mix index and higher census since implementation of TN services. Conclusion(s): Inpatient TN in community hospitals in rural AL provided essential nephrology care to underserved populations amidst a pandemic limiting transfer to nephrology-staffed medical centers at capacity. Most patient encounters resulted in discharge without need for transfer to bigger centers thus saving vital time and resources. Dialysis safety was favorable with low IDH prevalence likely given HHD use. TN services can be beneficial for nephrology care in remote community hospitals with further studies warranted.

AKI in COVID-19 Infection: Role of Hypercatabolic Status

Introduction: Acute Kidney Injury (AKI) is a very common complication of patients with SARS-COV-2 virus (COVID-19) infection. COVID-19 infected patients have longer hospital length of stays and higher mortality rate. There are multiple postulated mechanisms for AKI in the setting of COVID-19. Some researchers reported that the COVID-19 virus directly binds to the ACE-2 receptors in proximal tubules and leads to tubular dysfunction. In rare cases, a hypercatabolic state can be seen that carries a significantly higher mortality rate with ensuing hyperuricemia and hyperphosphatemia. Case Description: We describe a patient presenting with severe AKI with hypercatabolic state in the setting of COVID-19 infection. 40 year old male with a history of hypertension and CHF (EF 35%) presented with fatigue, diarrhea, nausea and vomiting for 10 days after COVID-19 infection. He was found to have severe AKI with blood urea nitrogen of 254 and creatinine of 21 mg/dl which was associated with hyperkalemia, gap acidosis, severe hyperuricemia (23 mg/dl) and hyperphosphatemia (17 mg/dl). Despite aggressive volume resuscitation in the ICU, the patient remained oliguric with no improvement in kidney function for two days. He was subsequently initiated on hemodialysis. After getting 2 sessions of dialysis without ultrafiltration, renal recovery was noted eventually normalizing within 10 days. Extensive work up indicated the patient had no tumor lysis syndrome and rhabdomyolysis on this admission. Discussion(s): There are multifactorial mechanisms for AKI in patients with COVID-19 infection including direct viral invasion of the kidney proximal tubules. Our case demonstrated that a hypercatabolic state may contribute to AKI in these patients. The proposed mechanisms involve elevated serum uric acid levels causing small renal arterial constriction, glomerular auto-dysregulation and tubular crystallization due to supersaturation causing to kidney tubular injury. Thus, clearance of uric acid and phosphorus with dialysis may promote more rapid kidney function recovery.

An Anuric and Hyperkalemic Patient During the COVID-19 Pandemic Without Access to Dialysis due to Social Protests in a Small Municipality in Colombia: What Can I Do?

Introduction: Due to the expenses generated by the pandemic, the Colombian government (image 1) propose raising taxes. This led to a social claim that led to the start of a national strike for several months in Cali city and its small nearby municipalities (Yumbo), indigenous people and other radical groups block main roads into and out of the city (images 2, 3, 4). The blockades prevented the passage of patients to be able to dialyze in Cali. In Yumbo there were no dialysis clinics, since the local hospital only has primary care. We present the case of an anuric patient who, due to lack of dialysis, presented pulmonary edema and hyperkalemia, and who could not be treated in a renal center, but in a small regional hospital and how his life was maintained with a totally alternative protocol. Case Description: A 69y patient, presented pulmonary edema on the fourth day without dialysis, see Table 1, electrocardiogram showing peak T waves. Telephone communication was maintained. Management: Nebulizations with beta stimulants, oral nifedipine and minoxidil. The patient persists hypervolemic on the second day, raises potassium to 8.8mEq/l and begins to present oxygen desaturation, a protocol is proposed as a vital emergency: enemas every 15 minutes, for 3, Oral castor oil, one ounce every 12 hours. (first dose assumed as zero hour of the protocol). See evolution in table No. 1. Potassium and pulmonary edema were finally controlled. Discussion(s): In the history of humanity, there are countless moments where violence causes medical missions to take measures that are not recommended in theory, but have saved lives. This protocol is clearly a desperate measure, but it can be of support in cases of pulmonary edema or hyperkalemia. (Table Presented).

Refractoriness of Hyperkalemia and Hyperphosphatemia in Dialysis-Dependent AKI Associated with COVID-19.

Background: Persistent hyperkalemia (hyperK) and hyperphosphatemia (hyperP) despite renal replacement therapy (RRT) was anecdotally reported in COVID-19 and acute kidney injury (AKI) requiring RRT (CoV-AKI-RRT). However, observation bias could have accounted for the reports. Thus, we systematically examined the rate and severity of hyperK and hyperP in patients with CoV-AKI-RRT in comparison with the pre-COVID-19 era. Methods: We identified patients with CoV-AKI-RRT treated with sustained low-efficiency dialysis (SLED) for ≥2 days in March-April 2020. As pre-COVID-19 control, we included patients with AKI treated with SLED in December 2019. We examined the rates of hyperK (serum potassium [sK] ≥5.5 mEq/L), severe hyperK (sK ≥6.5 mEq/L), hyperP (serum phosphate [sP] ≥4.5 mg/dl), and moderate or severe hyperP (sP ≥7-10 and >10 mg/dl, respectively) as %SLED-days with an event. Results: Along the duration of SLED, the incidence of hyperK was greater in CoV-AKI-RRT (n=64; mean 19%±2% versus 14%±3% SLED-days, P=0.002) compared with control (n=60). The proportion of patients with one or more event of severe hyperK was greater in CoV-AKI (33% versus 7%, P<0.001). The incidence of hyperP was similar between groups (mean 56%±4% versus 53%±5% SLED-days, P=0.49). However, the proportion of patients with one or more event of moderate and severe hyperP was greater in CoV-AKI-RRT (86% versus 60%, P=0.001, and 50% versus 18%, P<0.001, respectively). Among those with CoV-AKI-RRT, sK and sP correlated with lactate dehydrogenase (LDH; r=0.31, P=0.04, and r=0.31, P=0.04, respectively), whereas hyperP also correlated with shorter SLED runs (hours/run; r=-0.27, P=0.05). Conclusions: Refractory hyperK and hyperP were more frequent in CoV-AKI-RRT compared with the pre-COVID-19 era. Because of the correlation of sK and sP with higher LDH and sP with shorter SLED runs, intracellular ion release from cell injury due to cytokine storm and RRT interruptions may account for the findings.

Effect of magnesium on severity and mortality of COVID-19 patients: A systematic review

Unbalanced magnesium levels in the body, like other minerals, are a factor that is important in the severity and mortality of COVID-19. This study was designed to investigate the relationship between serum magnesium levels and clinical outcomes in COVID-19 patients. In this systematic review, a comprehensive search was performed in PubMed, Scopus, and Web of Science databases until September 2021 by using the keywords COVID-19, severe acute respiratory syndrome coronavirus 2, coronavirus disease, SARS- COV-infection 2, SARS-COV-2, COVID 19, and magnesium. End-Note X7 software was used to manage the studies. Articles that evaluated effect of magnesium on COVID-19 were included in the analysis. After reviewing several articles,12 studies were finally included in the ultimate analysis. The studies show that hypomagnesemia and hypermagnesemia are both factors that increase mortality in patients with COVID-19, even in one study, hypomagnesemia is the cause of doubling thedeaths in COVID-19 patients. Some studies have also found a negative correlation between magnesium deficiency and infectionseverity, while some others have reported no correlation between magnesium level and disease severity. According to the important role of magnesium in the body and its involvement in many physiological reactions, as well as differences in physical and physiological conditions of COVID-19 patients, in addition to the need for studies with larger sample sizes, monitoring and maintaining normal serum magnesium levels during the disease seems necessary as a therapeutic target, especially in patients admitted to the intensive care unit.

ACUTE KIDNEY INJURY AS A PREDICTOR OF MORTALITY IN PATIENTS WITH COVID-19

SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Multiple mechanisms may cause acute kidney injury (AKI) after mechanical ventilation. Cross-talk between the lung and kidney precipitates other complications such as fluid overload, electrolyte derangements and pro-inflammatory cytokine production. In this study, we compared hospital mortality rates in unvaccinated COVID-19 patients with respiratory failure (requiring mechanical ventilation) who developed oliguric AKI. METHODS: Using an observational database, we analyzed 3183 unvaccinated hospitalized COVID-19 PCR-positive patients at Methodist Health System (Dallas, TX) from March 2020 to December 2020. The primary endpoint was all-cause in-hospital mortality in patients with respiratory failure requiring mechanical ventilation who developed AKI (as defined by the kidney disease improving global outcomes (KDIGO) guidelines). We also counted the rate of kidney replacement therapy and degree of kidney recovery among the survivors who developed AKI. Chi-square (X2), Fischer’s exact test, and odds ratio tests were used to analyze observed variables. RESULTS: Of the 3183 COVID-19 patients, 351 (11%) developed respiratory failure requiring invasive mechanical ventilation. Of those, 313 (89%) had previously normal kidney function (no documented CKD). Of the 313 intubated patients, 186 (59.4%) developed AKI and 127 (40.5%) patients did not. Thirty-five (18.9%) of the patients who developed AKI survived hospital admission, while 54 (42.5%) patients without AKI survived (OR = 3.306, 95% CI = 1.98-5.51, P<0.001). Ischemic acute tubular necrosis from septic shock was the most common cause of AKI. Hyperkalemia and metabolic acidosis were the most common indication for kidney replacement therapy, and continuous kidney replacement therapy was the most common modality used. The mean age for the AKI vs no AKI groups were 63.5 (SD 14.5) vs 62 (SD 14.49) years old. Mean BMI was comparable between both groups 32 (SD 9.7) vs 32 (SD 9.64), while the BUN level 26 (SD 26.75) vs 19 (SD 9.9) mg/dl and Cr 1.15 (SD 1.59) vs 0.08 (SD 0.27) mg/dl were higher in the AKI group. In the AKI group, kidney replacement therapy was prescribed in 73(39.2%) patients, of which only 33 (17.7%) recovered meaningful kidney function. CONCLUSIONS: As the world emerged from the COVID-19 pandemic, there are innumerable lessons still to be learned. In our study, we demonstrated that AKI in COVID-19 patients with respiratory failure is associated with a higher incidence of mortality compared to patients without AKI. CLINICAL IMPLICATIONS: The risk of new SARS-CoV-2 variants and the possibility of future pandemics makes the recognition of high-risk medical complications of COVID-19 crucial to improve outcomes in acutely ill patients. A true multi-disciplinary team and an incredible amount of resources is required to identify and treat such patients. This study reminds us that kidney replacement therapy is only a means of supportive treatment rather than a cure to COVID-19-related kidney pathology. DISCLOSURES: No relevant relationships by Victor Canela No relevant relationships by Manavjot Sidhu No relevant relationships by Lucas Wang

REFRACTORY HYPOXEMIA: A CASE OF DAPSONE-INDUCED METHEMOGLOBINEMIA IN A PATIENT WITH COVID-19

SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Methemoglobinemia is an increase in methemoglobin (mHb) level characterized by functional anemia and tissue hypoxia. It can be caused by congenital enzymes deficiencies, but it is usually acquired. Dapsone, an oxidizing agent, is a medication commonly associated with acquired methemoglobinemia (1). We describe the diagnosis and management of a COVID-19 patient with acquired methemoglobinemia due to Dapsone. CASE PRESENTATION: 84-year-old female with history of MPO-ANCA vasculitis with renal involvement, CKD4 and anemia of chronic disease presented with shortness of breath, lethargy and weakness. Initially, the patient was saturating (SpO2) 80% on room air and was placed on 4L nasal cannula (NC) with improvement to 92%. CT of the chest showed b/l GGOs consistent with atypical pneumonia and patient tested positive for COVID-19. About 4 months prior, she had received 2 doses of Rituximab and on high steroid therapy that was tapered to 5mg of prednisone daily. She has been on Trimethoprim/Sulfamethoxazole for PJP prophylaxis, but due to hyperkalemia the medication was stopped. After confirming no G6PD deficiency, she was started on Dapsone 100mg daily. During hospitalization, she was given dexamethasone 6 mg daily and Dapsone was continued. On hospital stay day 6, a rapid response was called after oxygen dropped to 78% while walking on 6L NC. She was placed on high flow NC 100% and SpO2 went up to 90%. An arterial blood gas (ABG) was then obtained showing pO2 of 334, oxyhemoglobin (oxyHb) of 83 and mHb of 17.4. The SpO2-PaO2 gap and elevated mHb lead to the diagnosis of Dapsone-induced methemoglobinemia. Dapsone was discontinued. Patient received a one-time dose of 1mg/kg IV of methylene blue. One hour later her dyspnea had improved and was on 3L NC. Repeat ABG showed improvement of oxyHb (98) and decreased mHb (2.2). DISCUSSION: Physiologically, mHb is less than 1% of total Hb (1) and occurs when the iron in the porphyrin group of heme is oxidized from ferrous to the ferric form (2). Ferric heme binds oxygen irreversibly causing a left shift of the oxygen-hemoglobin dissociation curve. Clinical presentation tends to correlate with mHb levels, and it varies from being asymptomatic to fatigue, dyspnea, confusion, seizure, cyanosis resistant to oxygen therapy (mHb > 15%) and death. Methylene blue is safe and can be consider when mHb level is greater than 10 to 20% (2). Methylene blue was administer to our patient given the presence of COVID (leaving patient more susceptible to medication-induced methemoglobinemia (3)) and chronic anemia which made her less likely to tolerate state of reduced oxygen delivery. CONCLUSIONS: The diagnosis of methemoglobinemia is a rare cause of hypoxemia that is often overlooked. In patients with risk factors (COVID, medication exposure) a high index of suspicion is needed when interpreting an ABG (SpO2-PaO2 gap) for correct diagnosis and appropriate treatment. Reference #1: Toker, Ibrahim, et al. "Methemoglobinemia Caused by Dapsone Overdose: Which Treatment Is Best?” Turkish Journal of Emergency Medicine, vol. 15, no. 4, Dec. 2015, pp. 182–184, 10.1016/j.tjem.2014.09.002. Accessed 31 Aug. 2020. Reference #2: Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothorac Vasc Anesth. 2014 Aug;28(4):1043-7. doi: 10.1053/j.jvca.2013.02.005. Epub 2013 Aug 13. PMID: 23953868. Reference #3: Naymagon, Leonard, et al. "The Emergence of Methemoglobinemia amidst the COVID -19 Pandemic.” American Journal of Hematology, vol. 95, no. 8, 3 June 2020, 10.1002/ajh.25868. Accessed 3 Mar. 2021. DISCLOSURES: No relevant relationships by Mileydis Alonso No relevant relationships by Samantha Gillenwater No relevant relationships by Christine Girard No relevant relationships by Sikandar Khan No relevant relationships by Jose Rivera No relevant relationships by Frederick Ross

COVID-19: A CONFOUNDING MIMICKER OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome involving pathologic immune activation that is often fatal. The link between the cytokine storm related to COVID-19 and development of HLH has been reported since the onset of the pandemic, but little is known about clinical manifestations of HLH, thereby delaying treatment. CASE PRESENTATION: A 50 year-old male presented with a several day history of progressive weakness in the setting of missed dialysis session. Medical history was significant for ESRD on dialysis and diastolic heart failure (EF 35%). Initial vitals were unremarkable. Physical exam was notable for peripheral edema bilaterally. Laboratory studies were consistent with hyperkalemia, elevated ferritin (28,383) and elevated liver function tests. COVID-19 PCR was positive upon admission. Chest x-ray, CTA chest and a right upper quadrant ultrasound were unremarkable. He was admitted to the medical ICU for emergent dialysis. Soon after arrival to the ICU, he became lethargic and confused with increasing oxygen requirements and a subsequent a code blue was called. Cardiopulmonary resuscitation was immediately initiated, with a first rhythm consistent with ventricular fibrillation. He was shocked and placed on an amiodarone infusion with return of spontaneous circulation. TTE revealed a severely reduced EF <10%. Despite initiation of advanced COVID-19 therapies with Solu-Medrol and tocilizumab he remained ventilator dependent. Due to hemodynamic instability and persistent metabolic acidosis, he was transitioned to continuous renal replacement. Further blood work showed worsening inflammatory markers (ferritin 33,500, LDH 6981). Because of the significantly elevated ferritin, there were concerns for possible HLH. Triglycerides and IL-2 receptor were 395 mg/dL and 9300 pg/mL respectively. Total NK cells were decreased to 1.2%. He remained persistently unstable despite aggressive measures. He suffered a second cardiopulmonary arrest, which was unable to achieve return of spontaneous circulation and he ultimately passed away. DISCUSSION: HLH is characterized by uncontrolled activation and proliferation of benign macrophages in reticuloendothelial organs. This results in histiocytic hemophagocytosis, worsening peripheral blood cytopenia(s), cytokine storm, and cytokine mediated biochemical alteration ultimately culminating in multiorgan dysfunction and disseminated intravascular coagulation. Although a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. CONCLUSIONS: As HLH is a medical emergency with poor prognosis, prompt recognition and early treatment is crucial for improving clinical outcomes. We hope this case will create increased awareness and timely diagnosis of cytokine storm syndromes in patients with severe COVID-19 infection. Reference #1: Meazza Prina M, Martini F, Bracchi F, Di Mauro D, Fargnoli A, Motta M, Giussani C, Gobbin G, Taverna M, D'Alessio A. Hemophagocytic syndrome secondary to SARS-Cov-2 infection: a case report. BMC Infect Dis. 2021 Aug 13;21(1):811. doi: 10.1186/s12879-021-06532-7. PMID: 34388982;PMCID: PMC8361241. Reference #2: Schnaubelt, Sebastian MDa,*;Tihanyi, Daniel MDb;Strassl, Robert MDc;Schmidt, Ralf MDc;Anders, Sonja MDb;Laggner, Anton N. MDa;Agis, Hermine MDd;Domanovits, Hans MDa Hemophagocytic lymphohistiocytosis in COVID-19, Medicine: March 26, 2021 - Volume 100 - Issue 12 - p e25170 doi: 10.1097/MD.0000000000025170 DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Resham Pawar