Multisystem inflammatory syndrome associated with COVID-19 in adult: the case report

The multisystem inflammatory syndrome associated with COVID-19 coronavirus infection was first described in April-May 2020, mainly among children who had an acute infectious disease. Soon there were reports of the development of MIS in adults (MIS-A). More than 200 cases of MVS in adults have been described and systematized in the world, while in Russia there is no separate registration of MVS, a single description of MVS is given in the literature. Material and methods. We presented Case report of MIS-A in a 21-year-old woman, accompanied by persistent fever, multiple organ failure syndrome, is presented. The stages of diagnosis and treatment of MIS-A. Result and discussion. A positive effect was achieved during therapy with corticosteroids and intravenous immunoglobulin. MIS-A is a rare life-threatening complication of a COVID-19 that requires emergency therapy with the inclusion of corticosteroids and intravenous immunoglobulin in an adequate dose. The given example will be interesting for general practitioners, infectious disease specialists and therapists.Copyright © 2023 The authors.

Multisystem inflammatory syndrome associated with COVID-19 in adult: the case report.

The multisystem inflammatory syndrome associated with COVID-19 coronavirus infection was first described in April-May 2020, mainly among children who had an acute infectious disease. Soon there were reports of the development of MIS in adults (MIS-A). More than 200 cases of MVS in adults have been described and systematized in the world, while in Russia there is no separate registration of MVS, a single description of MVS is given in the literature. Material and methods. We presented Case report of MIS-A in a 21-year-old woman, accompanied by persistent fever, multiple organ failure syndrome, is presented. The stages of diagnosis and treatment of MIS-A. Result and discussion. A positive effect was achieved during therapy with corticosteroids and intravenous immunoglobulin. MIS-A is a rare life-threatening complication of a COVID-19 that requires emergency therapy with the inclusion of corticosteroids and intravenous immunoglobulin in an adequate dose. The given example will be interesting for general practitioners, infectious disease specialists and therapists.Copyright © 2023 The authors.

Clinical Features and Risk Factors for Mortality in Patients with Stenotrophomonas maltophilia Infection

Introduction: It is important to know the risk factors for death in reducing mortality in patients with Stenotrophomonas maltophilia infections. The purpose of this study was to examine the risk factors associated with mortality in hospitalized patients with S. maltophilia infections. Material(s) and Method(s): Patients with S. maltophilia infections aged 18 years and older who were hospitalized in Haseki Research and Training between January 1, 2017, and April 30, 2022, were included in the study. The patients were divided into two groups, non-survivors and survivors, and the clinical features and laboratory parameters of the groups were compared. Mortality risk factors were analyzed by logistic and Cox regression analyses. Result(s): A total of 75 patients with S. maltophilia infections were included. The mortality rate was 38.6% (n= 29). Advanced age (OR= 1.05, 95% CI= 1.012-1.085, p= 0.009), COVID-19 pneumonia (OR= 9.52, 95% CI= 1.255-72.223, p= 0.029), and presence of central venous catheter (CVC) (OR= 18.25, 95% CI= 2.187-152.323, p= 0.007) were risk factors for death. Conclusion(s): Physicians should be aware of the potential risk of S. maltophilia infections for mortality, particularly in patients with predefined risk factors such as advanced age, the presence of CVC, and COVID-19. Performing CVC care in accordance with infection prevention and control measures and timely removal of CVC may be beneficial in reducing deaths due to S. maltophilia infection.Copyright © 2023 Bilimsel Tip Yayinevi. All rights reserved.

Telemedicine implementation for management of COVID19 patients at hospital admission: a single center experience

Introduction: Telemedicine has already been used for the patients with respiratory diseases especially at follow up of long term mechanically ventilated patients and tele-pulmonary rehabilitation. Aim(s): To assess the efficacy of telemedicine consultation system in the management of COVID-19 suspected patients at hospital admission. Method(s): To reduce the risk of SARS-CoV-2 contamination among health-care workers, the COVID-19 pandemic control committee of our centre established a tele-medicine consultation group including pulmonologists, radiologists, emergency medicine and infectious disease specialists. Suspected COVID-19 patients were examined in the pandemic outpatient clinic or emergency department at their first admission by a physician. The physician consulted to the tele-consultation group with a structured medical story and test results after the first examination. Result(s): 469 patients were evaluated through teleconsultation, of 58.2 % were pre-diagnosed with COVID-19. SARS-COV-2 PCR resulted positive in 76.3 % of 273 patients with COVID-19 pre-diagnosis. 288 patients were hospitalized, and 0.9 % of discharged patients were re-admitted to the hospital due to deterioration. Main diagnoses were as follows: COVID-19 (n:289, 62 %), Cardiogenic pulmonary edema (n:40, 8.6 %), non-COVID-19 pneumonia (n:44, 9.4 %), COPD exacerbation (n:8, 1.7 %). Consistency rates between pre- and main diagnosis were 87,2 % for COVID-19 and 63,5 % for non-COVID-19 diseases. Discussion(s): The teleconsultation could be considered an effective method for the management of COVID-19 during the admission to hospital with a reduced risk of transmission of SARS-CoV-2 among health-care workers.

THE BEAST IN THE BEAUTY BOX

SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Enterobacter species are notorious for causing nosocomial infection. They were found to be the third most common pathogen in the respiratory tract amongst isolates in the ICU. What makes the situation grim is the growing antibiotic resistance with regards to treating these infections. Such is the extent of this problem that in certain parts of the world the antibiotic sensitivity of Pluralibacter gergoviae is used as an indicator for the spreading antibiotic resistance in the environment. CASE PRESENTATION: A 73 year old female with past medical history significant for hypertension, atrial fibrillation, and Coronary artery disease s/p stent placement in 2019 presented to our facility with a 4 day history of fever, cough and chest discomfort. She had tested positive for COVID-19 two days prior to presentation and was initiated on remdesivir, tocilizumab, and dexamethasone. She was initially managed on the floors but in view of her increasing oxygen requirement she was transferred to the critical care where she was intubated due to respiratory failure. She continued to spike fevers and was persistently hypoxic. Initially this was attributed to COVID pneumonia and a trial of convalescent plasma was also given. After 3 weeks, she tested negative for COVID-19 while still intubated and precautions were taken off. However, she continued to spike fevers. Repeat chest X-ray was done and it showed multifocal airspace disease with increasing opacification in the left upper lobe. Her endotracheal aspirate grew carbapenemase producing Pluralibacter gergoviae sensitive for ciprofloxacin. Subsequently, she was started on IV levofloxacin and received it for a total of 21 days. Her treatment course was complicated by prolonged intubation requiring tracheostomy and development of Pneumatocele. After stopping the antibiotics, she did not have fever and her white blood cell count was within normal limits. DISCUSSION: P. gergoviae is a known contaminant in intravenous fluids, invasive medical devices, eye cream, children's shampoo, skin cream, hand cleaning paste, and cleansing wipes. Over the decades due to selective pressure especially in the cosmetic industry from preservatives it has gained antibiotic resistance via overexpression of detoxifying enzymes, flagellin, modification of membrane structure/function. Improving patient's oral hygiene, implementing infection control protocols strictly in the ICU, minimizing invasive medical devices/catheters and educating the stakeholders shall help in curbing these incidents. Once identified, early Infectious disease specialist involvement can help choose an apt antibiotic regimen on the basis of existing antibiograms. CONCLUSIONS: This case highlighted the importance of close microbiological surveillance, minimizing occurrence of nosocomial infection and treating atypical organisms. Reference #1: Enterobacter gergoviae adaptation to preservatives commonly used in cosmetic industry M. Périamé,J.-M. Pagès,A. Davin-Regli 14 May 2014 DISCLOSURES: No relevant relationships by Abinesh Sekar

SUBACUTE PULMONARY HISTOPLASMOSIS DISGUISED AS COVID-19 IN A HEALTHY YOUNG MALE

SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary histoplasmosis typically affects immunocompromised individuals. Symptomatic infection in immunocompetent patients is rare, however, important risk factors include living in an endemic region and the size of inoculation. We present a case of subacute pulmonary histoplasmosis in a healthy young male and discuss how availability bias during the COVID-19 pandemic may pose challenges in the diagnosis. CASE PRESENTATION: A healthy 30-year-old male presented to our hospital complaining of left flank and bilateral chest pain for one week. The patient returned from Veracruz, Mexico three weeks prior after spending two months there studying to become a chef. While in Mexico, the patient experienced low-grade fevers, night sweats, and pleuritic chest pain for which he was treated with steroids and antibiotics for presumed COVID-19 infection despite negative testing. Treatment provided the patient temporary relief, however, some of his symptoms returned prompting him to present to the emergency department. Upon presentation, the patient was afebrile and had a normal resting pulse oximetry. CT angiogram of the chest demonstrated three lung nodules and prominent mediastinal lymphadenopathy. A complete infectious and rheumatologic workup was performed. BAL, transbronchial biopsies and EBUS-TBNA were performed. Lung biopsy showed reactive pneumocytes, focal intra-alveolar fibrinous material, congestion, and hemorrhage. Lymph node cytology revealed an aggregate of necrotizing and nonnecrotizing granulomas and GMS stain was positive for yeast. Fungitell and Histoplasma antibodies returned positive. The patient was discharged on Itraconazole and followed up with infectious disease specialists two months later in stable condition. DISCUSSION: Patients with subacute pulmonary histoplasmosis and viral pneumonia may present with similar clinical and radiological findings making the diagnosis arduous. In addition, the prevalence of COVID-19 pneumonia makes clinicians susceptible to using availability bias and further obscuring diagnosis. Some clues that help differentiate subacute pulmonary histoplasmosis include a longer duration of symptoms, pulmonary nodules, and mediastinal and hilar adenopathy. CONCLUSIONS: While pulmonary histoplasmosis is an uncommon finding in immunocompetent patients, suspicion should be raised in patients from endemic regions. Despite the COVID-19 pandemic, clinicians should avoid anchoring biases and keep differential diagnoses in mind. Reference #1: Azar MM, Hage CA. Clinical Perspectives in the Diagnosis and Management of Histoplasmosis. Clin Chest Med. 2017;38(3):403-415. doi:10.1016/j.ccm.2017.04.004 Reference #2: Staffolani S, Buonfrate D, Angheben A, et al. Acute histoplasmosis in immunocompetent travelers: a systematic review of literature. BMC Infect Dis. 2018;18(1):673. Published 2018 Dec 18. doi:10.1186/s12879-018-3476-z DISCLOSURES: No relevant relationships by Steven Douedi No relevant relationships by Justin Ilagan No relevant relationships by TAIMOOR KHAN No relevant relationships by Romany Nightingale No relevant relationships by Mihir Odak No relevant relationships by Noor Salam No relevant relationships by Kameron Tavakolian

Septic arthritis caused by Brucella melitensis - An orthopedic chal-lenge (11194)

Introduction The zoonotic infection with Brucella melitensis can be acquired by inges-tion of unpasteurized goat's or sheep's milk. The infection is common in Eastern Mediterranean countries (EMC), but rare in western Europe (6 cases in Switzerland, 2021). When evaluating patients with symptoms of septic arthritis, brucellosis is not the foremost differential diagnosis. How-ever, with the increasing population of people from EMC in western Eu-rope, the incidence may be rising. We present a patient who was initially suspected to suffer from Long-COVID-Syndrome (LCS), which underscores the relevance of this case in a pandemic situation. Methods/Results A 58-year-old male patient was admitted to the emergency department with a painful right knee effusion after a minor trauma. Additionally, he suffered from fatigue, subfebrile temperatures, back pain and myalgias for more than two months. He was suspected to suffer from LCS after a mild COVID-19 three months earlier. The culture of the arthrocentesis (14.400 cells/mul with 61% polynuclear cells) unexpectedly turned positive for B. melitensis. The patient declared that he had been drinking three liters of unpasteurized goat's milk to cure the presumptive LCS. To ensure staff safety, arthroscopic lavage was postponed until brucella-active antibiotics had been administered for at least 24 hours. Surgery was performed under strict infection control measures to avoid generating aerosols. According to Duke, one major (continuous bacteremia over 14 days) and 2 minor criteria (fever, most probably septic embolic gonarthritis) were fulfilled. Therefore, possible endocarditis had to be assumed although transesophageal echocardiography was normal. Antibiotic treatment was escalated to a quadruple regimen (intravenous gentamicin for three weeks;as well as oral doxycycline, trimethoprim/sulfomethoxazole and rifampin for at least 3 months). The clinical recovery - still under treatment - is protracted with slowly improving knee pain and normalizing signs of inflammation. Conclusion Although B. melitensis is a rare pathogen in Switzerland, orthopedic sur-geons, rheumatologists and infectious disease specialists need to be aware of diseases with low incidence and non-specific symptoms espe-cially in times of a global pandemia. A high index of suspicion is needed in patients related to EMC. When brucellosis is confirmed, strict infection control measures to protect staff involved in aerosol generating proce-dures must be adopted.

ACUTE INTERSTITIAL NEPHRITIS AS A PRIMARY PRESENTATION OF CANDIDA INFECTIVE ENDOCARDITIS

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

Building a system for accepting COVID-19 cases by applying drug management at a cancer hospital

It was expected that the number of patients with COVID-19 requiring hospitalization would increase worldwide. In the context of the worsening pandemic, the Tokyo Metropolitan Government requested the National Cancer Center Hospital to accept patients with COVID-19. Upon acceptance of the request, six working groups (WGs), i.e., the administrative/medical cooperation group, COVID-19 medical care group, cancer medical care group, medical resource management group, staff work/health management group and infectious disease zoning group, were constituted at our cancer hospital. The objective was to provide appropriate medical care for both cancer patients and patients with COVID-19. A COVID-19-dedicated ward was set up with 23 beds for admission of moderate cases and 2 beds for severe cases. A COVID-19 medical care manual was prepared in collaboration with the COVID-19 treatment team and the infection control team. The Pharmacy Department devised a system by which the ward staff confirmed the drugs that the patients were taking and had brought with them at the time of admission to the COVID-19 ward. The Pharmaceutical Affairs Committee reviewed and approved "off-label use" and "limited patient-only use" of the therapeutic agents favipiravir and ciclesonide for COVID-19. In addition, since the treatment for COVID-19 was prescribed by doctors who were not infectious disease specialists, the pharmacists in the Pharmaceutical Information Section of the Pharmacy Department prepared a master list of drugs with information on each drug that could be prescribed to treat COVID-19, and established a drug-ordering sys¬tem so that there were no errors in the prescription. We accepted patients with COVID-19 for the first time at our hospital in April 2020. We report that we have been able to provide appropriate treatment by applying the in-hospital drug supply system that had been established in the past for cancer treatment. © 2021 Japan Society of Chemotherapy. All rights reserved.

CHAGAS SCREENING PROGRAM IN A PUBLIC SAFETY NET HOSPITAL IN QUEENS: CHALLENGES AND SUCCESSES

STATEMENT OF PROBLEM/QUESTION: Chagas disease (CD) is a lifelong protozoan parasitic infection that if left untreated can result in cardiomyopathy in a third of cases;a screening program can identify individuals with chronic asymptomatic disease. DESCRIPTION OF PROGRAM/INTERVENTION: Elmhurst Hospital is a public safety net hospital in Queens serving a diverse community with many immigrants from Mexico, Central and South America. An estimated 8 million people in Latin America and 300,000 in the US are living with CD. We implemented a Chagas screening program in the Elmhurst adult primary care clinic. Our electronic health record (EHR), Epic, captures patient diversity by including 200 ethnic background options;we used this field to identify at-risk patients. Patients waiting for their appointment were brought into a private area and educated about CD by a Spanish-speaking volunteer. They were asked their country of origin, their ability to recognize the Reduviid bug, and the type of house they grew up in. Written educational materials about CD in Spanish provided by CDC website were given to patients. Once a patient accepted screening the provider received a secure chat in the EHR instructing them to order the Chagas serology. All patients have been kept on a secure list, and all are called for follow-up regardless of their results. Patients who test positive receive a follow-up plan that includes cardiac testing and referral to the Infectious Diseases (ID) clinic. Education about immigrant health and CD was provided to faculty, nurses and residents by ID specialists. MEASURES OF SUCCESS: The number of patients accepted and screened for CD. FINDINGS TO DATE: From June to November 2021, 340 patients in the Elmhurst medicine clinic were approached about their risk for CD. Of these migrants 36% were from Mexico, 51% were from S. America and 13% were from Central America. 23% of these patients grew up in an adobe house and 26% recognized the reduviid bug from a picture. Of 324 at-risk individuals asked about previous Chagas knowledge, only 7% were familiar with CD. 203 patients were tested with final results, 18 refused testing, 37 tests are pending for the next visit, and 82 were not ordered. 2 were positive on the screening ELISA with confirmation pending;CDC has suspended testing during the COVID-19 pandemic. Family members will be screened if confirmatory testing is positive. KEY LESSONS FOR DISSEMINATION: For practices serving large atrisk populations, a Chagas screening program can help to address a healthcare disparity. Partnership with ID specialists is essential for this process to succeed. Having an EHR that captures diverse demographic information identifies atrisk patients and is critical to the success of such a program. Challenges include having to obtain confirmatory testing at CDC which involves a patient returning for a follow-up visit and another blood draw. PCP champions can be a useful resource to sustain CD screening in the future. Low awareness of CD in our patient population suggests that community outreach to at-risk individuals is needed to increase awareness.

Uniting Global Efforts on Pediatric Long-COVID: Results of the International Post- COVID Condition in Children Collaboration (IP4C)

RATIONALE4,4-44,4% of children suffer from post-COVID syndrome, commonly known as long- COVID, after an acute SARS-CoV-2 infection. However, an uniform clinical definition, and guidelines to diagnose or treat children suspected of long-COVID are lacking. Multiple careprograms have been initiated worldwide. In this study, we aimed to assess the currently available pediatric international long-COVID care programs and explore the characteristics of their patient cohorts.METHODSWe established an international network (IP4C) and performed a crosssectional analysis from aggregated data collected by its members using a survey. Topics included: the used definition for long-covid in children, the organization of pediatric long-COVID clinics and long-COVID patients characteristics. Descriptive analysis of the aggregated data was used to summarize and compare each of these categories across countries. RESULTSWe included data concerning organization of care from 17 cohorts based in 13 different countries. A wide range of definitions for long COVID was used, which differed mostly in duration of symptoms and the necessity of microbiologically proven SARS-COV-2 infection. 66,6-100% of patients in the long- COVID cohorts suffered from complaints for more than twelve weeks, and 49,5-97,3% of patients had a positive RT-PCR or serology for SARS-CoV-2. Most long-COVID care programs consisted of real-life visits with multidisciplinary teams, consisting of general pediatricians, pediatric lung specialists, cardiologists and infectiologist, a physiotherapist and psychologist. The type of investigations performed at the long-COVID clinics ranged from assessment of medical history (100%) and standardized questionnaires (91%) to in depth evaluation of organ functioning (e.g. spirometry performed in 0-100% of patients). Aggregated data of 431 long-COVID patients from 11 dedicated long-COVID care programs were analyzed. Mean age of patients ranged from 6,5-16,4 years old. Girls were overrepresented in most cohorts (20-65%). 28-81,8% of patient had a positive medical history, most commonly atopic syndrome, asthma and prematurity. Most patients (90- 100%) suffered from asymptomatic or mild acute COVID-19. Frequent long-COVID symptoms were fatigue, headaches, concentration difficulties, dyspnea and sleep disturbances. 5-37% of patients had severe limitations in daily life. CONCLUSIONSThis is the first study to describe the organization of pediatric long-COVID care. It demonstrates that pediatric long-COVID is recognized worldwide as a multisystemic disease, but its definition and care programs for pediatric long- COVID patients differ between cohorts. A clear definition of pediatric long-COVID is needed to improve international scientific collaboration and patient care. Our international network will facilitate further collaboration in investigation pathophysiology and therapeutic interventions in order to provide evidence based medical care for these patients.

COVID-19 VACCINE IN KIDNEY TRANSPLANTED PATIENTS. IS THERE A CLINICAL RELEVANCE? AN ITALIAN SINGLE CENTER EXPERIENCE

BACKGROUND AND AIMS: COVID-19 is a life-threatening infection among elderly, comorbid patients or transplanted patients. In our recently published paper (Campise, M.;Alfieri, C.M.;et al. Pathogens 2021, 10, 964), we described our single Centre experience with 82 adult kidney-transplant patients (KTxp) with COVID-19 infection during the previous two pandemic outbreaks: 27 KTxp (first outbreak) and 65 (second). We observed a relatively low and possibly underestimated incidence of infection (5.1%) with a incidence of death almost four times higher than in general population (13%). The availability of COVID-19 vaccines has undoubtedly changed the outcome of the infection in both immunocompetent and immunosuppressed patients. Aim of this second ongoing observational and descriptive study, is to evaluate if the vaccination performed extensively among our KTxp, has modified the incidence and gravity of COVID-19 infection. METHOD: Data on KTxp with COVID-19 infection (COV+) from the 29 October 2021 to 31 December 2021 were collected. Particularly, we focused our anthropometric, clinical and therapeutic aspects. In the statistical analyses, continuous variables were expressed as median and interquartile range (25%-75%), and nominal variables were reported as percentage of cases. RESULTS: From the 29 October 2021 to the 31 December 2021, 33 KTxp developed COVID-19 infection, 60% were male. Median age was 50[29-58] years. Transplant vintage was 57[27-163] months. Median serum creatinine was 1.30[1.0-1.9] mg/dL and body mass index was 23[21-28] kg/m2. Immunosuppressive schedule included: CNI inhibitors, steroids and mycophenolate (MMF) in 97-90 and 70% of COV + respectively. In 50% of cases native vitamin D supplementation was present, whereas only 30% of cases were treated with renin-angiotensin inhibitors. Only one had insulin dependent diabetes. At the moment of nasopharyngeal swab positivity 64% of COV + had already received three doses of vaccine (Comirnaty (BNT162b2)®) and 30% 2 doses. Only 3% of pts had received a single dose. One patient had refused vaccination for personal reasons. Antigenic nasopharyngeal swab was performed in 70% of COV + and molecular swab in 60%. Thirty-five % of COV + were tested with both methods. The most frequent symptoms were: fever (70%), cough (75%) and headache (40%). In the previous outbreaks dyspnea was present in 33% of cases dropping to 13% in this cohort. Smell and taste alteration were present in 25% and 28% respectively. We did not perform the COVID-19 sequence. But, on the base of the symptoms referred, we are confident that 17 patients had delta variant and remaining had omicron. The first therapeutic approaches were the increase of the daily steroid dosage up to 25 mg (60% of cases) together with MMF temporarily withdrawing in 70% of cases and halving in 10%. Forty % of pts were also treated with monoclonal antibodies (Ronapreve®) upon infectious disease specialist evaluation. During the first two outbreaks, hospitalization was necessary in 45% of cases, and 13% of pts died. In the present cohort only 10% of patients required oxygen support and hospitalization. Nobody died. CONCLUSION: Although very preliminary, our results indicate that the vaccination campaign has noticeably ameliorated the incidence, the clinical presentation and the outcome of COVID-19 in KTxp. This comforting data should further sensitize the medical community on vaccination counseling in KTxp as soon as possible. Study with higher number of patients are needed to further clarify the individual response on antibody production and sensitivity to this still life-threatening infection.

Long-COVID, chronic fatigue and everything in between - what have we learned and where may it impact on fibromyalgia

As the COVID-19 pandemic made its gruesome initial appearance in the first months of 2020, it initially appeared as though nothing could be more distant from this acute, dramatic, life - threatening condition, treated in intensive care units and heroically combated behind personal protective equipment, than fibromyalgia, a chronic pain syndrome treated in clinics by primary care physicians and rheumatologists. Only gradually, as the medical community became more accustomed to the manifestations and complications of COVID-19, did the more chronic aspects of the pandemic come to light with the evolving entity of LONG-COVID syndrome (1). This syndrome was initially treated by a broad spectrum of specialties including infectious disease specialists, pulmonologists, neurologists, with rheumatologists not taking a central role. As more clinical experience was accumulated however, a surprising overlap begins to emerge between LONG-COVID and conditions such as fibromyalgia and chronic fatigue syndrome, an overlap most obvious on a clinical level to rheumatologists well acquainted with the spectrum of fibromyalgia (2). On a clinical level, LONG COVID patients most frequently suffer from fatigue, exercise intolerance, as well as cognitive impairment, all symptoms which overlap with the chronic fatigue syndrome. Sleep disturbances, abdominal complaints, anxiety /depression and myalgia are also not unusual (3). In addition, autonomic dysregulation appears to play a role in LONG COVID (4), as in fibromyalgia. Notably, symptoms typical of fibromyalgia among LONG-COVID patients appear to be particularly common among patients with a previous history of chronic pain, and patients who were actually diagnosed with fibromyalgia before contracting COVID-19 appear to be prone to get worse (5). Notably, an association between fibromyalgia / chronic fatigue and other chronic viral diseases such as EBV/CMV, HIV and viral hepatitis has been well known before the COVID-19 era, so that viral infection has traditionally been considered among the triggers responsible for instigation the syndrome (6). Another aspect of clinical importance regarding the relationship between fibromyalgia and COVID-19 relates to the effect of vaccinations. While vaccinations have previously been speculated to have a causative role in fibromyalgia, mainly based on data relating to the gulf war syndrome, the robustness of this association is not clear. In an era of significant vaccine - hesitancy which often hampers effective attempts at controlling the pandemic, clear data regarding the safety and effectivity of COVID-19 vaccinations regarding fibromyalgia is necessary. Fascinating data has emerged indicating that patients suffering from LONG - COVID may actually have low grade persistent infection, with identification of viral antigens and RNA in tissue as long as one year after initial infection (7). While the general applicability of these findings is not yet clear, they raise the provocative possibility that similar viral vectors might be identifiable in tissues of patients suffering from chronic fatigue or fibromyalgia. Last but not least, the COVID-19 pandemic, including the social distancing measures associated with it, have taken a toll on patients suffering from fibromyalgia even when not personally infected (8). Reduced access to healthcare, lockdown and lack of exercise, anxiety and isolation may all play a role and should be considered by physicians caring for fibromyalgia patients in this era.

Delphi Survey for COVID-19 Vaccination in Korean Children Between 5 and 11 Years Old

Purpose: During the coronavirus disease 2019 (COVID-19) pandemic, we conducted a Delphi survey that included the experts from the field of COVID-19 immunization in children aged 5–11 years. The aim was to organize collective expert opinions on COVID-19 vaccination in young children in the Republic of Korea, and so thus assist the vaccination policy. Methods: The panels included pediatric infectious disease specialists, preventive medicine experts, infectious disease physicians, and COVID-19 vaccine experts consulting the Ministry of Health and Welfare. The Delphi survey was conducted online using a questionnaire from February 14 to February 27, 2022. Results: The Delphi panels agreed that children were vulnerable to COVID-19, and the severity of illness was modest. Furthermore the panels reported that children with chronic illness were more susceptible to a worsening clinical course. There were generally positive opinions on the effectiveness of COVID-19 vaccination in children aged 5–11 years, and experts gathered a slightly positive opinion that the adverse events of pediatric COVID-19 were not numerous. The benefits of COVID-19 vaccination were evaluated at a level similar to the potential risks in children. Currently, the only approved mRNA platform vaccine in children seemed to be sustainable;however, the recombinant protein platform COVID-19 vaccines were evaluated as better options. Conclusions: Due to the surge of the Omicron variant and an increase in pediatric cases, the COVID-19 vaccination in young children may have to be considered. Panels had neutral opinions regarding the COVID-19 vaccination in children aged 5–11 years. Thus monitoring of the epidemiology and the data about the safety of COVID-19 vaccination should be continued.

Immunocompromised Patients with Prolonged Viral Shedding of SARS-COV-2

Background. Most individuals diagnosed with mild to moderate COVID-19 are no longer infectious after day 10 of symptom onset and those with severe or critical illness from COVID are typically not infection after day 20 day of symptom onset. Recovered persons can continue to test positive for SARS-CoV-2 by PCR via detection of non-viable RNA in nasopharyngeal specimens for up to three months (or longer) after illness onset. It is also know known that severely immunocompromised patients may produce replication-competent virus greater than 20 days from symptom onset and may require, per CDC recommendations, "additional testing and consultation with infectious diseases specialists and infection control experts". We aim to discuss four case studies of severely immunocompromised patients who exhibited signs of persistent COVID-19 infection of COVID and how we managed transmission-based precautions in our hospital through sequencing and evaluation of cycle thresholds (CT) values and subgenomic RNA detection. Methods. Residual nasopharyngeal (NP) samples were collected on patients exhibiting persistent COVID like symptoms. These samples underwent N gene and N gene subgenomic RNA (sgRNA) real-time reverse transcription polymerase chain reaction (rRT-PCR) testing. Results. Analysis of longitudinal SARS-CoV-2 sequence data demonstrated within-patient virus evolution, including mutations in the receptor binding domain and deletions in the N-terminal domain of the spike protein, which have been implicated in antibody escape. See Figures 1 and 2. Figure 1. Timelines of Identified Patients 1 and 2 Patient 1: 46-year-old woman with recently diagnosed stage IV diffuse large B-cell lymphoma for which she was treated with 2 cycles of R-CHOP. Patient 2: 38-year-old woman with history of myelodysplastic syndrome, peripheral blood stem cell transplant with chronic graft versus host disease of the GI tract, skin, and eyes as well as CMV enteritis, and she was maintained on rituximab, mycophenolate mofetil, prednisone, and monthly IVIG without recent changes to her immunosuppression. Figure 2. Timeline of Identified Patients 3 and 4 Patient 3: 44 year-old man with prior history of thymoma s/p thymectomy Patient 4: 46 year-old man who was initially diagnosed with marginal zone lymphoma approximately 2.5 years ago. He was initially treated with bendamustine and rituximab and achieved remission. He was then continued on maintenance rituximab without significant complications for a planned two years. Conclusion. Differentiating between prolonged viral shedding of non-infectious RNA and persistent replicating viable virus can be difficult to determine without full evaluation of a patient's clinical picture and timeline. Consultation between laboratory, infectious diseases, and infection prevention experts to provide appropriate level of guidance for precautions and treatment may be warranted. Testing by PCR and analysis of CT values may provide key findings of viral replication in immunocompromised hosts, indicating the need for evaluation of additional treatment and maintaining isolation status in healthcare settings.

Unique Treatment Challenges with Multisystem Inflammatory Syndrome in Children (MIS-C) compared to Kawasaki Disease Shock Syndrome

Background. Kawasaki disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C) associated with Coronavirus Disease 2019 present similarly with mucocutaneous symptoms and fever. Both syndromes can progress to shock. Successful treatments for MIS-C are largely based on proven KD management. As more patients with MIS-C are treated, protocols are adjusted. Infectious Diseases (ID) specialists are often early consultants in these cases. Understanding differences in how body systems are affected in MIS-C versus KD is essential for management. Methods. This is a single hospital comparison of 25 cases of MIS-C with mucocutaneous presentation and symptoms of shock and 25 consecutive cases of KD Shock Syndrome (KDSS). Cases were compared for demographics, symptoms, cardiac abnormalities, medical treatments, and cardiac recovery. Results. Patients with MIS-C develop symptoms of shock including sustained hypotension and tachycardia at 3 times the rate of patients with KD (45% vs 13%;p< 0.001). On echocardiogram, left ventricular myocardial dysfunction, assessed by ejection fraction, is more commonly noted in cases of MIS-C than KDSS (fig 1). About half of patients with MIS-C show left ventricular myocardial dysfunction initially with normalization by 6 months post-presentation in the majority (96%). Conclusion. Cardiac changes and shock events related to KD and MIS-C are thought to be caused by differing inflammatory mediators. By comparing these two syndromes, we can determine ways to manage each optimally. MIS-C often results in left ventricular myocardial dysfunction, which is rarer in KD cases. Fluid resuscitation with multiple fluid boluses followed by inotropes to treat hypotension in cases of in MIS-C puts increased strain on the already weakened myocardium. Early intravenous immunoglobulin (IVIG) administration, even in the presence of mild hypotension, can simultaneously provide the patient with additional fluid and decrease the underlying inflammatory process. This prompt treatment might reduce the need for pressor support while protecting the myocardium from further damage. As early consultants in MIS-C, ID providers should be educated regarding the unique cardiac challenges of MIS-C and avoid delay in IVIG treatment and cardiologist and intensivist consultation.

A Nationwide Survey of COVID-19 Management in the Dominican Republic over the Course of the Pandemic

Background. COVID-19 was declared a global Public Health Emergency by the WHO in January 2020. Limited treatment options existed early in the pandemic. As COVID-19 spread across the globe and new therapeutics emerged, different interpretations of the literature grew, and major societies relayed conflictive recommendations. There is a paucity of data on COVID-19 management in low- and middle-income countries. As a result, we performed a nationwide survey of local treatment practices in the Dominican Republic (DR). Methods. We performed an anonymous survey of infectious diseases specialists in the DR and US. The survey collected hospital characteristics and COVID-19 management protocols during different quarters of 2020-21. Management was categorized by drug and disease severity based on supplemental oxygen requirements. A convenience sample in the US representing community and academic sites was surveyed for point comparison between the US and DR. Results. The survey was completed by physicians from a total of 11 sites located in 4 cities of the DR: Santo Domingo (3), Santiago (4), La Vega (2) and San Francisco (2). These cities were representative of all regions in the country. The survey included 7 (64%) hospitals with < 200 beds, 3 (27%) with 201-300 beds, and 1 (9%) with >400 beds. Seven (47%) were private, 2 (13%) public, and 6 (40%) were teaching hospitals. In the US, 2 academic hospitals with >400 beds and 2 community hospitals with < 200 beds in a major city were surveyed. Management of COVID-19 at sites in the DR and US throughout the pandemic is plotted in Figure 1. Remdesivir use by disease severity is plotted in Figure 2. Conclusion. Throughout the pandemic, as therapeutic options evolved, hospitals and physicians had to adapt to changing guidelines and availability of novel drugs. Variability between countries and sites emerged. The use of hydroxychloroquine and convalescent plasma waned more rapidly in the US. Dexamethasone was widely used at all sites. Tocilizumab and remdesivir were used more liberally in the DR. Antimicrobial stewardship limited these agents at US sites to more narrow therapeutic windows which could explain the discrepancies seen between the US and DR. Uncertainty of benefit in certain disease states, limited availability, and cost may also play a role.

Impact of COVID-19 Pandemic on Telehealth Practices in Pediatric Infectious Diseases

Background. The COVID-19 pandemic has led to changes in clinical practice, including a significant increase in the use of telehealth (TH). We sought to assess the impact of the pandemic on the use and perceptions of TH by pediatric infectious diseases (PID) clinicians. Methods. The PIDS∗ Telehealth Working Group developed a 26-question online survey to assess telehealth practices among PID clinicians. The survey was available via Survey Monkey® from 12/6/2020-2/26/2021 to members of PIDS, PICNIC∗, AAMI and AAP∗. Clinicians in active practice in North America were included in the analysis. Results. The response rate was 10% (n=253) of 2,550 PID clinicians. Physicians accounted for 98.4% of the cohort. The remaining 1.6% were allied health professionals. 81 survey respondents (32%) were in 4 US states (CA, TX, OH and NY) and the province of Quebec. 62.8% of respondents were women, 37% of respondents were 36-45 years old, with 42.7% devoting about 50-99% of their time to direct patient care. TH usage increased during the pandemic with the most gain in provider-patient communications with 65.6% increase for synchronous and 22.1% for asynchronous TH (Figure 1). Gains in provider-provider TH were less than 20%. Respondents reported a 6-fold gain in comfort with TH usage versus pre-pandemic level (Figure 2). Most respondents report being satisfied with their current platform and modality. Once the COVID-19 waivers expire, 70% of respondents plan to continue using TH. The most common TH modality used was an EMR-integrated TH platform (Figure 3). The main perceived barriers to TH adoption were lack of complete physical examination (73.7%), dealing with new technology (21.5%), and insufficient reimbursement (20.8%) (Figure 4). Conclusion. The COVID-19 pandemic has resulted in a significant increase in the use of TH by PID specialists versus pre-pandemic usage. Respondents gained comfort with use of different telehealth modalities during the pandemic. This data can help clinicians and organizations in planning and resource allocation for telehealth programs in a post-pandemic environment.

Online Medical Education Improves Knowledge of Monoclonal Antibody Treatment for COVID-19 among Physicians

Background. Treatments aimed at patients with mild to moderate COVID-19 offer an opportunity to improve rates of hospitalizations and progression to severe disease. The aim of this study was to assess the educational impact of a series of continuing medical education (CME) activities on the knowledge, competence, and confidence of primary care (PCP), infectious disease (ID), and ER/critical care physicians regarding the management of COVID-19 with monoclonal antibody (mAb) therapy. Methods. The educational series consisted of 9 online, CME activities in multiple formats. At the individual activity level, educational effect was assessed with a repeated pairs pre-/post-assessment study including a 3-item, multiple choice, knowledge/competence questionnaire and one confidence assessment question, with each participant serving as his/her own control. To assess changes in knowledge, competence, and confidence data from all clinicians who completed both pre- and post-questions were aggregated across activities and stratified by learning themes. McNemar's test (P< .05) assessed educational effect. Data were collected from 12/20 to 5/21. Results. To date, the 9 activities have reached over 24,000 physicians. Selected improvements in knowledge and competence measured as relative % change in correct responses pre/post education across the learning themes are reported here. (i) 45% improvement in PCPs and a 31% improvement in ID specialists' knowledge/competence in identifying patients who would benefit from mAbs (P < .01). (ii) 83% improvement in PCPs and a 42% improvement in ID specialists' confidence in identifying patients who would benefit from mAbs (P < .001). (iii) 15% improvement in ID specialists' knowledge/competence on the clinical data on mAbs for COVID-19 (P < .001). (iv) 32% improvement in PCPs knowledge/competence in understanding the mechanism of action (MOA) of mAbs for COVID-19 (P < .001) Conclusion. This series of online, CME-certified educational activities delivered in multiple formats resulted in significant improvements in knowledge and competence regarding the management of patients with mild to moderate COVID-19. This analysis also uncovered remaining educational gaps;55% of content related to identifying patients who would benefit from mAbs was not retained post-education.

Utilization of Project ECHO for COVID-19 Medical Knowledge and Best Practices for Health Professionals serving an Underserved Population

Background. During the global COVID-19 pandemic, the release of research and data particularly to guide clinical care evolved rapidly and highlights the critical need for timely, and equitable access to medical knowledge and best practices. Specialized medical knowledge has historically been confined to specialists in academic medical centers and disconnected from healthcare professionals in underserved areas. It is important to bridge this gap and democratize knowledge through a model that supports rapid dissemination of best practices to build capacity in areas of need. Methods. A Project ECHO partnership was implemented between academic infectious diseases specialists and local healthcare professionals involved in COVID-19 screening, diagnosis and management serving an underserved population. BCM COVID-19 ECHO supported the Access2Health SmartPod COVID-19 clinical operations staffed by a charitable community organization. The SmartPod clinical team were engaged in weekly one-hour ECHO sessions with didactic presentations and case discussions on diverse COVID-19 topics. The program was evaluated at 6 months. COVID 19 ECHO Model BCM COVID-19 ECHO Telementoring Program with the United Health Partners in the community BCM COVID-19 ECHO Telementoring Session Topics Curriculum developed for the health professionals seeing patients in the SmartPOD and clinics in underserved communities. Results. In Fall 2020, BCM COVID-19 ECHO facilitated 10 sessions with an average attendance of 8 healthcare professionals per session. Evaluation results indicated high levels of satisfaction with session content and telementoring partnerships, with 80% expressing intent to apply the knowledge and skills acquired from the sessions to their clinical practice. Conclusion. The Project ECHO model successfully engaged healthcare professionals in a continuous learning loop. With the rapid and vast amount of information during the COVID-19 pandemic, it is important to ensure health professionals have equitable access to medical knowledge and feel empowered to implement best practice changes.