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Introduction: Combination of daratumumab (Dara) and lenalidomide (Len) may enhance the function of teclistamab (Tec), potentially resulting in improved antimyeloma activity in a broader population. We present initial safety and efficacy data of Tec-Dara- Len combination in patients with multiple myeloma (MM) in a phase 1b study (MajesTEC-2;NCT04722146). Method(s): Eligible patients who received 1-3 prior lines of therapy (LOT), including a proteasome inhibitor and immune-modulatory drug, were given weekly doses of Tec (0.72-or- 1.5 mg/kg with step-up dosing) + Dara 1800 mg + Len 25 mg. Responses per International Myeloma Working Group criteria, adverse events (Aes) per CTCAE v5.0, and for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) per ASTCT guidelines, were assessed. Result(s): 32 patients received Tec-Dara- Len (0.72 mg/kg, n = 13;1.5 mg/kg, n = 19). At data cut-off (11 July 2022), median follow-up (range) was 5.78 months (1.0-10.4) and median treatment duration was 4.98 months (0.10-10.35). Median age was 62 years (38-75);87.5% were male. Median prior LOT was 2 (1-3), 18.8% were refractory to Dara and 28.1% refractory to Len. CRS was most frequent AE (81.3% [n = 26], all grade 1/2), 95% occurred during cycle1. Median time to onset was 2 days (1-8), median duration was 2 days (1-22). No ICANS were reported. Frequent Aes (>=25.0% across both dose levels) were neutropenia (75.0% [n = 24];grade 3/4: 68.8% [n = 22]), fatigue (43.8% [n = 14];grade 3/4: 6.3% [n = 2]), diarrhoea (37.5% [n = 12];all grade 1/2), insomnia (31.3% [n = 10];grade 3/4: 3.1% [n = 1]), cough (28.1% [n = 9];all grade 1/2), hypophosphatemia (25.0% [n = 8];all grade 1/2), and pyrexia (25% [n = 8];grade 3/4: 6.3% [n = 2]). Febrile neutropenia frequency was 12.5% (n = 4). Infections occurred in 24 patients (75.0%;grade 3/4: 28.1% [n = 9]). Most common were upper respiratory infection (21.9% [n = 7]), COVID-19 (21.9% [n = 7]), and pneumonia (21.9% [n = 7]). Three (9.4%) had COVID-19 pneumonia. One (3.1%) discontinued due to COVID-19 infection and this patient subsequently died of this infection. Overall response rate (ORR, median follow-up) was 13/13 (8.61 months) at 0.72 mg/kg and 13/16 evaluable patients (less mature at 4.17 months) at 1.5 mg/kg. 12 patients attained very good/better partial response at 0.72 mg/kg dose, and response was not mature for 1.5 mg/kg group. Median time to first response was 1.0 month (0.7-2.0). Preliminary pharmacokinetic concentrations of Tec-Dara- Len were similar as seen with Tec monotherapy. Tec-Dara- Len- treatment led to proinflammatory cytokine production and T-cell activation. Conclusion(s): The combination of Tec-Dara- Len has no new safety signals beyond those seen with Tec or Dara-Len individually. Promising ORR supports the potential for this combination to have enhanced early disease control through the addition of Tec. These data warrant further investigation.
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Background: An emerging finding about COVID-19 is its effect on nutrition and weight loss. The COVID-19 symptoms of fatigue, altered taste or smell, and lack of appetite are well known. But COVID-19 may have a more profound effect on clinical nutrition status. Two recent studies have identified that approximately one-third of ambulatory COVID-19 patients are at risk of experiencing weight loss >= 5% (Anker, et al;di Filippo, et al). The case study presented here discusses home start total parenteral nutrition (TPN) in a patient recently diagnosed with COVID-19 at high risk for refeeding syndrome. Method(s): N/A Results: Case Study: A 92-year-old patient was diagnosed with COVID-19 on June 8, 2022. Over the next week, she was hospitalized twice to manage symptoms of acute mental status changes, lethargy, aphasia, hypotension, and loss of appetite. The patient received nirmatrelvir/ritonavir, remdesivir, and bebtelovimab to treat COVID-19 at different times between June 9, 2022, and June 18, 2022. She remained COVID positive and continued to deteriorate clinically. On June 20, 2022, the patient began receiving 24/7 homecare, including intravenous (IV) fluids of dextrose 5% in normal saline (D5NS) 1000 mL daily for three days. She continued to experience loss of appetite and had no bowel movement for 3 days. On June 23, 2022, she was referred to this specialty infusion provider to initiate TPN therapy in the home setting. The patient's BMI was 18.2 kg/m2. Lab results revealed potassium 3.0 mmol/L, phosphate 1.6 mg/dL, and magnesium 1.6 mg/dL. High risk of refeeding syndrome was identified by the level of hypophosphatemia and hypokalemia. The specialty infusion provider's registered dietitian recommended to discontinue D5NS and begin NS with added potassium, phosphate, and magnesium. Thiamine 200mg daily was added to prevent Wernicke's encephalopathy. The patient's clinical status and lab values were monitored closely each day until her electrolyte levels stabilized (Table 1). Home TPN therapy was initiated on June 28, 2022, with <10% dextrose and 50% calorie requirement with 85% protein and 1.0 g/kg lipids. Three-day calorie count and nutrition education were performed four days post TPN initiation. Oral intake met only 25% of estimated needs. Over several days, theTPN formula was gradually increased to goal calories and the infusion cycle was slowly decreased. The following week, the patient's oral intake improved to 60%-75% of estimated needs. Her constipation resolved, and she showed improvement in functional status and mobility. Her appetite drastically improved when the TPN was cycled. Another three-day calorie count was performed when TPN calories reached goals. Oral intake demonstrated 100% estimated calorie and protein needs. TPN therapy was ultimately discontinued on July 14, 2022. As of September 30, 2022, the patient has stabilized at her pre-COVID weight of 45 kg with full recovery of appetite, function, and cognition. Discussion(s): The ASPEN Consensus Recommendations for Refeeding Syndrome (da Silva, et al) describe the repletion of electrolyte levels before introducing calories to prevent end-organ damage associated with refeeding syndrome (respiratory muscle dysfunction, decreased cardiac contractility, cardiac arrhythmias, and encephalopathy). Conclusion(s): This case study highlights the successful initiation of home TPN therapy in a patient at high risk of refeeding syndrome post COVID-19 infection. Although home start TPN and the risk of refeeding syndrome are not new concepts, they must be considered in the setting of COVID-19. Given the effects COVID-19 has on taste, smell, and appetite and the recent finding that one-third of patients with COVID infection may experience weight loss of >= 5%, nutrition support and patient education are vital components of overall patient care. (Figure Presented).
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The proceedings contain 7 papers. The topics discussed include: pediatric burn care: how burn camps survived and thrived during the coronavirus pandemic;a retrospective chart review to determine hypophosphatemia incidence and phosphorus supplementation requirements in patients with severe thermal cutaneous injuries receiving high-volume hemofiltration;setting the standard: using the aba burn registry to benchmark risk adjusted mortality;burn injury from smoking electronic cigarettes while on supplemental oxygen;focused wound care handoff improves burn center physician-nursing communication and wound care education;modified frailty index is an independent predictor of death in the burn population: a secondary analysis of the transfusion requirement in burn care evaluation (TRIBE) study;and topical hemostatic agents in burn surgery: a systematic review.
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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that belongs to the species severe acute respiratory syndrome-related coronavirus (SARSr-CoV), which is related to the SARS-CoV-1 virus that caused the 2002-2004 SARS outbreak. SARS-CoV-2 causes coronavirus disease 2019 (COVID-19). It has been associated with electrolyte abnormalities. In this report, we discuss the case of a SARS-CoV-2-infected person presenting with recurrent seizure episodes resulting from hypophosphatemia. A 52-year-old male patient with questionable prior seizure history presented to the emergency department (ED) twice within eight days with recurring seizure episodes. While the physical examination at the first presentation was significant for a head laceration with post-ictal confusion, that at the second presentation was only significant for post-ictal confusion. Laboratory examination at the first visit revealed SARS-CoV-2 positivity, hypokalemia, hypophosphatemia, and low vitamin D levels. On the second visit, the patient was again found to have hypophosphatemia. CT of the head and the cervical spine, as well as radiographs of the chest done on the first visit, were all normal. On his first visit, the patient's electrolyte abnormalities were corrected, and he was discharged with antiepileptic medications after 24 hours of observation and consultation with neurology. However, his vitamin D levels, the results of which came back only after his first discharge, were corrected only during his second visit. This time, he was discharged from the ED and had an effective resolution of symptoms. SARS-CoV-2 infections can result in vitamin D deficiency and hypophosphatemia, resulting in seizures, and hence should be treated with both replacement therapies and antiepileptic medications. This case also highlights the importance of obtaining phosphorus and vitamin D levels in SARS-CoV-2-infected patients with seizures.
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BACKGROUND: Severe acute respiratory syndrome has led to a pandemic of coronavirus disease 2019 (COVID-19). Malnutrition either biochemically or anthropometrically is a well-known risk factor for COVID-19 and may be the vice versa AIM: The objectives of this study were to investigate the prevalence of malnutrition in children infected with COVID-19 through evaluating the nutritional biomarkers such as serum electrolytes, serum albumin, and hemoglobin together with the anthropometric assessment. METHODS: A cross-sectional study that was conducted at El-Matria Teaching Hospital for all children admitted with confirmed COVID-19 for 6 months from February 1, 2021 to the end of July, 2021. Nutritional biochemical evaluation included serum electrolytes particularly the potassium and other nutritional biomarkers such as serum albumin and hemoglobin. Nutritional anthropometric evaluation depended on body mass index, the height/length, weight for length, and weight for height. The prevalence of malnutrition esp. hypokalemia was the main outcome. RESULTS: Hypokalemia was present in 21.8% of the study participants. Other nutritional biomarkers were found as hyponatremia, hypocalcemia, hypophosphatemia, and hypomagnesemia were detected in 49.1%, 38.2%, 21.8%, and 34.5% of the study subjects, respectively. Anthropometric malnutrition was present in most of the enrolled children with COVID-19 in the study (65.5 % [n = 36]) through which overweight and obese children occupied a greater percentage. CONCLUSION: Malnutrition either biochemically or anthropometrically could be linked to COVID-19 in children. COVID-19 could have negative outcomes on the nutritional status such as electrolytes disturbances. Both malnutrition and COVID-19 are considered synergistic associations.
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CASE: An 80-year-old woman with untreated osteoporosis and suspected primary hyperparathyroidism presents to establish care. Review of systems and physical examination are normal. She has mild hypercalcemia (11.2), and normal albumin and phosphorous. Parathyroid hormone (PTH) is elevated (71). Bone density testing demonstrates osteoporosis at the hip and spine (Tscore -2.9 and -3.0). She reports self-medicating with 12,000 IU of vitamin D daily to prevent COVID-19 infection, which she learned about from a popular news source;she is unvaccinated for COVID-19. Her vitamin D 25-OH level is 172 (normal 30-100). The patient was instructed to stop vitamin D supplementation. Additional work up for hyperparathyroidism was initiated, including 24-hour urine collection for calcium, and she was referred for a parathyroidectomy. IMPACT/DISCUSSION: Adequate vitamin D supplementation has been postulated to reduce the risk and severity of the COVID-19 infection through its immunomodulatory effects that augment the immune cell response, decrease inflammation, and prevent RAAS system dysregulation, which is associated with more severe coronavirus infection. However, trials and metaanalyses have yielded inconclusive data, with most reporting no associations between adequate or high-dose vitamin D supplementation and COVID-19 morbidity and mortality. Nonetheless, popular news sources and social media have called for high-dose vitamin D supplementation, which can result in hypervitaminosis D through patient self-medication. Both hypervitaminosis D and primary hyperparathyroidism present with signs and symptoms of hypercalcemia, including nephrolithiasis, osteoporosis, bone pain, weakness, and neuropsychiatric changes. Hypervitaminosis D is caused by ingestion of too much exogenous vitamin D (normally more than 10,000 IU/day), dysregulation of the vitamin D pathway, or overproduction of vitamin D. Primary hyperparathyroidism is caused by parathyroid adenomas, hyperplasia, and carcinomas. Distinguishing between the two conditions involves a thorough history and physical, laboratory measurements, and occasionally imaging. Hypervitaminosis D patients have suppressed PTH levels, serum 25(OH)D > 150ng/mL, and hyperphosphatemia while primary hyperparathyroidism patients have normal/elevated PTH levels, low/normal 25(OH)D levels, and hypophosphatemia. Primary hyperparathyroidism is the most common cause of hypercalcemia, but this case highlights the importance of screening for and identifying other etiologies of hypercalcemia. This patient's vitamin D toxicity can be treated by stopping vitamin D supplementation. Her primary hyperparathyroidism meets criteria for a parathyroidectomy due to the presence of osteoporosis. CONCLUSION: 1. High dose vitamin D supplementation is ineffective as prophylaxis against the COVID-19 infection. 2. Hypercalcemia secondary to vitamin D toxicity is distinguished from primary hyperparathyroidism by PTH, 25(OH)D, and phosphorus levels.
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Background: Electrolyte imbalances are common in COVID-19 infection and are associated with poor outcomes in hospitalized patients. Objectives: This study examined whether serum phosphate imbalances at admission are associated with mortality in hospitalized COVID-19 patients. Methods: In this registry-based single-center retrospective cohort study, 1349 inpatients with COVID-19 were included from March 2020 to March 2021 in an academic hospital in Ilam (southwest Iran). The Cox proportional hazard (PH) regression model was applied to the data set of COVID-19. Results: The in-hospital median survival time for patients with low, normal, and high serum phosphate levels was 14, 25, and 8 days, respectively. In a multivariate model, adjusted for the other variables, patients with hypophosphatemia (adjusted hazard ratio [HR], 2.53; 95% CI, 1.15 - 5.58; P = 0.02) and hyperphosphatemia (adjusted HR, 1.77; 95% CI, 1.00 - 3.14; P = 0.05) had an increased mortality hazard compared with those who had normal levels of serum phosphate. Conclusions: Our results demonstrate associations of hypophosphatemia and hyperphosphatemia with increased in-hospital mortality in COVID-19 patients. Intensive medical care and more attention must be paid to COVID-19 patients with serum phosphate imbalances at admission.
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Background: Bone loss is a well-recognised complication of myeloma, affecting up to 90% of patients. It is associated with fractures, spinal cord compression and hypercalcaemia. 1,2 Myeloma patients are routinely prescribed zoledronic acid, which has been shown to prevent skeletal-related events, preserve bone density and prolong progression-free survival.3 At NBT, zoledronic acid is prescribed on a paper prescription chart, which is not routinely reviewed by a pharmacist This process is not in accordance with other therapy, which is prescribed on ChemoCare and clinically verified by a pharmacist prior to administration. Objectives • To assess the adherence of zoledronic acid prescribing at NBT against the South West Clinical Network (SWCN) protocol. • To identify areas for improvement in the prescribing of zoledronic acid for prevention of skeletal events. Standards: 100% of patients receiving zoledronic treatment should meet the following go-ahead criteria:4 • Acceptable bloods within seven days of treatment (creatinine, calcium, phosphate, magnesium) • Comprehensive dental examination. • Dose modification based on creatinine clearance. • Treatment deferred if hypocalcaemia or hypophosphataemia. Methodology: The audit was conducted over a one month period between 1/11/2020 and 30/11/2020. A total number of 58 prescriptions were included in the audit. The data collection sheet for the audit included;patient details, date of treatment and zoledronic acid dose. This information was extracted from the drug charts. The information system ICE was used to verify the blood results and validity period. Creatinine clearance was calculated using the Cockcroft and Gault equation. The medical notes were reviewed for evidence of dental checks. Data was recorded on Excel for further analysis by the pharmacist. Results: An overview of all four audit standards is shown in Figure 1. Two of the four audit standards were fully met (standards 2 and 4). 2% of patients (n= 1/58) did not receive an appropriate zoledronic acid dose adjustment based on renal function (standard 3). 36% (n=21/58) of patients did not have bloods within seven days of treatment (standard 1), however all of these patients had bloods within a month of treatment, in line with the Summary of Product Characteristic recommendations.5 Discussion and conclusion: The audit demonstrated that adherence to zoledronic acid prescribing guidelines is generally satisfactory;however several areas for improvement were identified. Feedback was provided to the haematology team and the following recommendations made: • Critical bloods must be done within one week of treatment. • Evidence of a dental examination must be clearly documented. • An approved app must be used for calculating creatinine clearance. • Introduction of a pharmacist clinical verification. • Zoledronic acid should be prescribed on ChemoCare, to assist with the above recommendations. Limitations: This audit was only carried out over a month which will only provide a snapshot of prescribing and results may have been impacted by the COVID-19 pandemic. It was difficult to find documentation for dental checks and treatment delays due to bloods and in some cases, information had to be verified by the prescriber.
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Background: Few reports have addressed the clinical and laboratory features of patients with coronavirus disease-2019 (COVID-19) in mountainous areas, especially in Iran. Objectives: To report the clinical and laboratory data and manifestations predicting mortality of patients with COVID-19 in the west of Iran.
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Introduction: Angioinvasive aspergillosis is a rare opportunistic infection. its occurrence increases the mortality and morbidity of organ transplant recipients. Methods: It is about a 27-year-old patient with a history of end-stage renal failure due to an apparent mineralocorticoid deficiency, hemodialysis for 10 months until he received a kidney transplant from a related living donor sharing 4 HLA identities. He received induction therapy with globulin antithymocyte and methylprednisolone followed by maintenance therapy with Mycophenolate Mofetil, prednisolone, tacrolimus. Since the recipient was not immune to cytomegalovirus (CMV), he received ganciclovir prophylaxis immediately after transplant. Post-transplant evolution was marked by the immediate resumption of diuresis, creatinine figures stagnating between 200 and 250 µmol/l. The remainder of her usual treatment consists of a proton pump inhibitor, β-blocker, cotrimoxazole. Our patient presented 2 months post transplant with febrile neutropenia. Clinically, apart from a fever of 38 °, the examination was without abnormalities. Biologically, pancytopenia, inflammatory syndrome (high CRP and procalcitonin), hypokalaemia, hypophosphatemia and hypomagnesemia, hyperferritinemia and hypertriglyceridemia were noted. A post-infectious macrophagic activation syndrome was suspected, confirmed by a sternal puncture. An etiological investigation has been launched;viral serologies (HBV, HCV, HIV, EBV, CMV, COVID 19, HSV) were negative, a cardiac ultrasound ruled out infective endocarditis, a thoracoabdominal CT scan showed multifocal sub-segmental parenchymal condensations of the right lung surrounded by a halo, an appearance suggesting angio-invasive pulmonary aspergillosis and intracortical graft hematomas. Sputum bacteriological examination did not show pneumocystis but isolated two types of candida crucei and tropicalis. A weakly positive aspergillus antigenemia (index : 0.53) was noticed. Our patient received triple antibiotic therapy (vancomycin / imipenem / levofloxacin) and an antifungal (voriconazole) after adaptation according to the antibiogram for a total duration of 15 days with daily dosage of tacrolimus. In addition, he received venoglobulins for 5 days at a dose of (0.4 mg / kg / day). The clinical and biological course was favorable with apyrexia and improvement in the blood count from the third day of treatment. Aspergillus antigenemia and a follow-up chest CT scan were scheduled after the end of treatment. Results: Initially, In view of the intensity of the induction treatment received, leuconeutropenia and in order of frequency, the 2 most evoked causes were CMV et covid19 but the CT aspect straightened the diagnosis, which was supported by aspergillary antigenemia. The emerging interest of this case report is the clinical and computed tomography discordance and the unusual rapidly favorable outcome to an aspect of angioinvasive pulmonary aspergillosis which usually show respiratory signs such as cough, hemoptysis or even respiratory distress. Conclusions: Invasive mycoses, associated with significant morbidity and mortality, are a frequent difficulty in solid organ transplantation. The clinical pictures differ and we could be faced with an atypical presentation which affects the therapeutic management. No conflict of interest
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Introduction: Third generation intravenous (IV) iron preparations are increasingly used in the treatment of non-dialysis dependent chronic kidney disease (CKD) associated iron deficiency. Such compounds allow rapid delivery of large concentrations of iron safely at a single sitting. Evidence suggests that their use may lead to improved cardiovascular outcomes. Nonetheless, concerns exist regarding the potential induction of hypophosphatemia via fibroblast-growth-factor 23 (FGF-23) following the use of certain compounds. Raised FGF-23 has been associated with mineral bone and cardiac disorders, alongside prognostic implications. No prior study has provided a head-to-head comparison between iron preparations in CKD. This pilot study is designed to primarily investigate the differential impact of two different IV iron compounds on FGF-23 and phosphate in patients with CKD;secondarily we examine the impact of these compounds on bone markers and functional status, quality of life and cardiovascular function. Methods: This is a randomized controlled double-blinded pilot study recruiting patients with CKD stage 3a – 5 (non-dialysis) and iron deficiency +/- anemia. Patients are randomized to receive either ferric carboxymaltose or ferric derisomaltose over two infusions (one-month apart) to achieve full repletion. The initial dose administered is 1000 mg for both medications, with 500 mg or 1000 mg reserved for the second dose depending on weight and hematinics. Follow up is over a period of three months following the first infusion with measurements of intact FGF-23, phosphate, phosphaturia, vitamin D, parathyroid hormone, bone metabolism markers, functional status and quality of life and cardiac markers (figure 1). [Formula presented] Results: 168 patients were referred to the specialist renal anemia services for pre-screening. Ninety-nine were contacted for interest to participate, with 64 individuals declining to join. The commonest reason for not participating, was the COVID-19 pandemic (43.3%) with patients not keen to travel. Thirty-five patients were screened, and 27 patients enrolled in the study, of which 26 were randomized to receive iron (figure 2). One patient withdrew from the study, as they were unable to attend appointments following successful screening. In our baseline cohort the median age was 67.9 (12.4) and 17 participants were male. Mean hemoglobin was 100.3 (13.5) and hematinic markers consistent were consistent with iron deficiency. Median eGFR was 18.0 (11.3) ml/min/1.73 m2;the population as expected had a raised intact FGF-23 (212.1 (116.4) pg/ml). Serum calcium and phosphate were within normal parameters, while parathyroid hormone and 1,25 (OH)2 Vitamin D were deranged (Table 1). [Formula presented] [Formula presented] Conclusions: ExplorIRON-CKD, like a number of trials, experienced significant disruption in recruitment due to COVID-19. This study will provide further insight to the potential induction of FGF-23 following administration of specific intravenous iron compounds, and identify whether such a differential effect exists in patients with CKD. The effect of such induction in terms of phosphate and other markers of bone metabolism, functional status and cardiac functioning will be observed. The results will aid in hypothesis generation for further studies to identify the potential long-term impact of iatrogenic FGF-23 increase in patients with CKD. Conflict of interest Potential conflict of interest: This study received funding support from Pharmacosmos A/S and the Kidney Research Yorkshire Charity Fund. The funders had no role in the study design, data collection and analysis, and decision to publish or preparation of the . I have no potential conflicts of interest to disclose.
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Hypophosphatemia is frequently observed in the ICU and is associated with several impairments such as respiratory failure or infections. We hypothesized that hypophosphatemia on ICU admission is associated with a prolonged duration of mechanical ventilation and ICU length of stay (LOS), particularly in COVID-19 patients. This cross-sectional study analyzed data from 1226 patients hospitalized in the ICU of the Geneva University Hospitals from August 2020 to April 2021. Patients were categorized as having hypophosphatemia (phosphatemia ≤ 0.8 mmol/L) or non-hypophosphatemia (phosphatemia > 0.8 mmol/L) on ICU admission. Linear regressions were performed to investigate the association between hypophosphatemia on ICU admission and ICU LOS and duration of mechanical ventilation. Overall, 250 (20%) patients presented hypophosphatemia on ICU admission. In the univariable analysis, hypophosphatemic patients had longer ICU LOS than non-hypophosphatemic patients, 7.4 days (±10.4) versus 5.6 days (±8.3), (p < 0.01). Hypophosphatemia on ICU admission was associated with a prolonged duration of mechanical ventilation, 7.4 days (±11.2) versus 5.6 days (±8.9), (p < 0.01). These associations were confirmed in the multivariable analysis (p < 0.01). In the subgroup of COVID-19 patients, a significant association between hypophosphatemia and ICU LOS and duration of mechanical ventilation was also observed. In conclusion, hypophosphatemia on ICU admission is associated with a longer ICU LOS and time under mechanical ventilation, both in the general ICU population and in COVID-19 patients.
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Introduction: New cases of type 1 diabetes (T1D) remain commonly found in Indonesia. One of the most typical presenting symptoms is diabetic ketoacidosis (DKA);approximately 71% of all cases. There has been several reports of the negative association between type 2 diabetes (T2D) and Coronavirus disease (COVID-19) cases in adults, but T1D and COVID-19 cases in children are still scantily studied. Mortality of COVID-19 pediatric case could reach higher than 50% in children below 5 years old. Objectives: Early detection and prompt treatment for DKA, T1D and COVID-19 should be emphasized. Methods: This case described new-onset T1D presented with DKA and severe COVID-19 infection. Results: 7-year-old boy was presented with altered consciousness, epigastric pain, dehydration, dyspnea, history of nocturnal enuresis, polydipsia, and polyphagia. Random blood glucose (BG) was 516 mg/dL, blood ketone 5.2 mmol/L, A1c 15%, pH 6.932, pCO2 16 mmHg, pO2 153.8 mmHg, base excess-26.5 mmol/L, HCO3 3.4 mmol/L, and positive polymerase chain reaction COVID-19 with E gene Cq of 30.66. The patient was treated in isolation PICU as severe DKA with hypovolemic shock and confirmed COVID-19 case;received fluid resuscitation, intravenous insulin with saline and dextrose infusion and remdesivir. The patient had recurring hyponatremia, hyperkalemia, hypophosphatemia, increased coagulation markers, and had catecholamine-resistant shock, and received hydrocortisone from 2 mg/kg/day and subsequently titrated. The patient regained consciousness on the 2nd day of admission, and were stable on the 5th day of admission. The patient's condition improved on day 6 of admission and insulin and hydrocortisone were weaned. COVID-19 PCR test yielded negative result on day 9 of admission. Conclusions: The COVID-19 pandemic presents additional unwanted complications in both clinical and non-clinical aspects of DKA and T1D management. Special considerations should be highlighted considering the comorbidities and medications given in addition to the treatment for DKA.
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BACKGROUND: Electrolyte disturbances are commonly observed in patients with coronavirus disease 2019 (COVID-19) and associated with outcome in these patients. Our study was designed to examine whether hypophosphatemia is associated with mortality in COVID-19 patients. METHODS: Patients diagnosed with COVID-19 and hospitalized in Renmin Hospital of Wuhan University between January 30 and February 24, 2020 were included in this study. Patients were divided into two groups, a hypophosphatemia group and a non-hypophosphatemia group, based on a serum phosphate level of 0.8 mmol/L. Logistic regression was performed to analyze the relationship between hypophosphatemia and mortality. A locally weighted scatterplot smoothing (LOWESS) curve was plotted to show the detailed association between mortality rate and serum phosphate level. A Kaplan-Meier survival curve was drawn to compare the difference in cumulative survival between the two groups. RESULTS: Hypophosphatemia at admission occurred in 33 patients, with an incidence of 7.6%. The hypophosphatemia group had a significantly higher incidence of respiratory failure (54.5% vs 32.6%, p=0.013) and mortality (57.6% vs 15.2%, p<0.001). Multivariate logistic regression indicated that age (OR=1.059, p<0.001), oxygen saturation (OR=0.733, p<0.001), white blood cells (OR=1.428, p<0.001), lymphocytes (OR=0.075, p<0.001) and hypophosphatemia (OR=3.636, p=0.015) were independently associated with mortality in the included patients. The hypophosphatemia group had significantly shorter survival than the non-hypophosphatemia group (p<0.001). CONCLUSION: Hypophosphatemia at admission is associated with increased mortality in COVID-19 patients. More attention and medical care should be given to COVID-19 patients with hypophosphatemia at admission.