A Case Report of Ivermectin-Induced Liver Failure

Introduction: Ivermectin is an antiparasitic medication that is primarily metabolized by the liver. During the COVID-19 pandemic, researchers demonstrated that Ivermectin successfully inhibited the replication of SARS-COV-2 in vivo, but current research has failed to demonstrate clinical benefit for treatment of COVID-19. Despite this, misinformation campaigns have misled patients to ingest Ivermectin at concentrations meant for domestic animals. Here, we present a case of acute liver failure secondary to the use of Ivermectin. Case Description/Methods: A 61-year-old man with medical history of ischemic cardiomyopathy with last echocardiogram showing ejection fraction at 21%, atrial fibrillation on warfarin for oral anticoagulation, and previously treated Hepatitis C presented with generalized weakness and yellowish discoloration of the skin worsening over the last two weeks. The patient denied significant alcohol use, acetaminophen use, or illicit drugs. He admitted to injecting himself with two doses of weight-based horse ivermectin, for COVID prophylaxis, two weeks prior to his presentation. Physical exam was pertinent for scleral icterus and hepatomegaly with no abdominal tenderness. Initial labs revealed elevated liver chemistries in a mixed pattern (Figure 1). Acute hepatitis panel, HSV, and CMV were negative. Hepatitis C antibodies were positive, but the patient was in sustained virologic response. Full workup for chronic liver disease was unremarkable. Ultrasound revealed hepatosplenomegaly with patent portal and hepatic vasculature. Subsequently, the patient developed hepatic encephalopathy along with his coagulopathy, raising concern for acute hepatic failure. The patient was transferred to the ICU and started on NAcetylcysteine, rifaximin, and supportive care. The patient recovered well and fortunately did not require liver transplant. Discussion(s): While the FDA recommends against the use of Ivermectin for COVID-19, many continue to inappropriately consume it. Ivermectin-induced liver failure is a rare but deadly side effect. Given our patient's rapid onset of symptoms post-self injection of Ivermectin, his liver injury was presumed to be related to Ivermectin. The drug interaction between Ivermectin and warfarin had worsened the patients coagulopathy. Physicians should be aware of the ways Ivermectin overdose may clinically present to avoid delayed treatment. This case demonstrates the detriments of perpetuation of medical misinformation to care.

The Effect Of Covid-19 Infection On Sirolimus Metabolism In Heart Transplant

Introduction: Limited knowledge exists regarding the effect of Covid-19 on heart transplant recipients. Monitoring immunosuppressant levels is an important management strategy concerning the risk of graft rejection. Furthermore, how Covid-19 and its treatment affect sirolimus metabolism in solid organ transplants is not well understood. Here, we present a case of a heart transplant recipient with elevated sirolimus levels following Covid-19 infection. The elevated sirolimus levels occurred after previously being therapeutic on a steady dose and persisted despite significant dose reductions and no other known drug-drug interactions. Case Presentation: The patient is a 58-year-old male with a history of ischemic cardiomyopathy;status post orthotopic heart transplantation on 8/17/2009. The postoperative course was complicated by atrial tachycardia without rejection status post-ablation in 8/2020 and end-stage renal disease on hemodialysis. In January of 2022, the patient was instructed to present to the ER after missing dialysis due to Covid-like symptoms including generalized weakness, nausea, and shortness of breath. Covid-19 PCR returned positive. Before infection, the patient had been maintained on a steady dose of sirolimus 0.5 mg daily for 5 months with associated trough levels between the goal range of 4-8 ng/mL. At the time of infection, the patient's sirolimus was held due to elevated trough levels, and he was subsequently maintained on a dose of 0.5 mg every other day for the next few days. Seeing no improvement, the dose was then decreased to 0.25 mg every other day for the remainder of his admission. He expired on 2/09/2022 from Covid-19. Figure 1 shows the sirolimus trough:dose ratio before and after diagnosis of Covid-19. Discussion(s): To our knowledge, this is the first case presented of a heart transplant recipient with altered sirolimus metabolism status post Covid-19 infection without apparent drug-drug interactions. This may suggest a relationship between SARS-COV-2 viremia with sirolimus metabolism.Copyright © 2022

Exploring Potential Biomarkers and Molecular Mechanisms of Ischemic Cardiomyopathy and COVID-19 Comorbidity Based on Bioinformatics and Systems Biology.

Cardiovascular complications combined with COVID-19 (SARS-CoV-2) lead to a poor prognosis in patients. The common pathogenesis of ischemic cardiomyopathy (ICM) and COVID-19 is still unclear. Here, we explored potential molecular mechanisms and biomarkers for ICM and COVID-19. Common differentially expressed genes (DEGs) of ICM (GSE5406) and COVID-19 (GSE164805) were identified using GEO2R. We performed enrichment and protein-protein interaction analyses and screened key genes. To confirm the diagnostic performance for these hub genes, we used external datasets (GSE116250 and GSE211979) and plotted ROC curves. Transcription factor and microRNA regulatory networks were constructed for the validated hub genes. Finally, drug prediction and molecular docking validation were performed using cMAP. We identified 81 common DEGs, many of which were enriched in terms of their relation to angiogenesis. Three DEGs were identified as key hub genes (HSP90AA1, HSPA9, and SRSF1) in the protein-protein interaction analysis. These hub genes had high diagnostic performance in the four datasets (AUC > 0.7). Mir-16-5p and KLF9 transcription factor co-regulated these hub genes. The drugs vindesine and ON-01910 showed good binding performance to the hub genes. We identified HSP90AA1, HSPA9, and SRSF1 as markers for the co-pathogenesis of ICM and COVID-19, and showed that co-pathogenesis of ICM and COVID-19 may be related to angiogenesis. Vindesine and ON-01910 were predicted as potential therapeutic agents. Our findings will contribute to a deeper understanding of the comorbidity of ICM with COVID-19.

COVID-19 associated spontaneous hemorrhagic cholecystitis

Hemorrhagic cholecystitis is a rare disorder associated with considerable morbidity and mortality. The clinical presentation of hemorrhagic cholecystitis is non-specific and imaging findings can be difficult to accurately interpret without a high level of suspicion. Most recent reports of hemorrhagic cholecystitis have been associated with concurrent therapeutic anticoagulation. Here, we report imaging findings of a case of acute, spontaneous hemorrhagic cholecystitis in a 67-year-old male patient admitted for hypoxic respiratory failure secondary to COVID-19 pneumonia. © 2022

Long-term cardiovascular outcomes in Covid-19 survivors among non-vaccinated population: a retrospective cohort study from the trinetx us collaborative networks

Background: The long-term cardiovascular outcomes in COVID-19 survivors remain largely unclear. The aim of this study was to investigate the long-term cardiovascular outcomes in COVID-19 survivors. Method(s): This study used the data from the US Collaborative Network in TriNetX. From a cohort of more than 42 million records between January 1, 2019 and March 31, 2022, a total of 4 131 717 participants who underwent SARS-CoV- 2 testing were recruited. Study population then divided into two groups based on COVID-19 test results. To avoid reverse causality, the follow-up initiated 30 days after the test, and continued until 12 months. Hazard ratios (HRs) and 95% Confidence intervals (CIs) of the incidental cardiovascular outcomes were calculated between propensity score-matched patients with versus without SARS-CoV- 2 infection. Subgroup analyses on sex, and age group were also conducted. Sensitivity analyses were performed using different network, or stratified by hospitalization to explore the difference of geography and severity of COVID-19 infection. Result(s): The COVID-19 survivors were associated with increased risks of cerebrovascular diseases, such as stroke (HR [95% CI] = 1.618 [1.545-1.694]), arrhythmia related disorders, such as atrial fibrillation (HR [95% CI] = 2.407 [2.296-2.523]), inflammatory heart disease, such as myocarditis (HR [95% CI] = 4.406 [2.890-6.716]), ischemic heart disease (IHD), like ischemic cardiomyopathy (HR [95% CI] = 2.811 [2.477-3.190]), other cardiac disorders, such as heart failure (HR [95% CI] = 2.296 [2.200-2.396]) and thromboembolic disorders (e.g. pulmonary embolism: HR [95% CI] = 2.648 [2.443-2.870]). The risks of two composite endpoints, major adverse cardiovascular event (HR [95% CI] = 1.871 [1.816-1.927]) and any cardiovascular outcome (HR [95% CI] = 1.552 [1.526-1.578]), were also higher in the COVID-19 survivors than in the controls. Moreover, the survival probability of the COVID-19 survivors dramatically decreased in all the cardiovascular outcomes. The risks of cardiovascular outcomes were evident in both male and female COVID-19 survivors. Furthermore, the risk of mortality was higher in the elderly COVID-19 survivors (age >= 65 years) than in the young ones. Sensitivity analyses presented roughly similar results globally. Furthermore, the impact of COVID-19 on cardio-related outcomes appeared to be more pronounced in inpatients than in outpatients. Conclusion(s): The 12-month risk of incidental cardiovascular diseases is substantially higher in the COVID-19 survivors than the non-COVID- 19 controls. Clinicians and patients with a history of COVID-19 should pay attention to their cardiovascular health in long term.

CHARACTERISTICS OF COVID-19 INFECTION-RELATED MYOCARDITIS: AN UPDATED SYSTEMATIC REVIEW

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: This systematic review aims to better understand the clinical characteristics, comorbidities, diagnostic findings, and clinical outcomes associated with COVID-19 myocarditis. METHODS: A search for “COVID-19 OR SARS COV-2 OR Coronavirus AND Myocarditis” was performed on 1/4/2022. 2011 studies from Embase and 1165 studies from PubMed were identified. Selection criteria included studies on SARS COV-2 infection-related myocarditis. 142 PubMed and 104 Embase studies were identified. Studies were appraised per protocols and s, vaccine-related myocarditis, uncertain vaccine/infection-related myocarditis, and, systematic reviews. Duplicate studies were removed. A total of 53 articles from which 57 cases were selected to be part of this systematic review. Data on age, sex, days since diagnosis, comorbid conditions such as morbid obesity, hypertension, hyperlipidemia, CAD, preexisting CHF, ischemic heart disease, D- Dimer, ferritin, high sensitivity troponin, BNP, EKG, echocardiogram, cMRI findings, medications, ventilation requirements, and mortality were extracted from 57 studies and were analyzed using IBM SPSS v26. RESULTS: Mean EF was 32.65 ± 16.57 %. EKG findings of diffuse ST elevation were present in 22% of all cases. Echocardiogram findings of diffuse hypokinesis present in 42.1% and depressed EF in 31.6% of all cases. 21.1% required non-invasive ventilation while 26.3% of all cases ended up requiring mechanical ventilation. Ischemic cardiomyopathy was present in 1.7%, Hypertension in 24.5%, Hyperlipidemia in 7%, Morbid obesity, and a previous diagnosis of CHF was present in 0% of all cases. Overall mortality was seen in 5.3% of all cases. 50% of the cases reported using cardiac MRI (cMRI) and 58% with reported cMRI findings met the Lake Louis criteria for diagnosis of myocarditis. CONCLUSIONS: This systematic review presents findings of demographics, comorbidities, diagnostic findings, and clinical outcomes of adult COVID-19 patients with myocarditis. The mean days since COVID-19 diagnosis has a wide range due to varied presentations noted in case reports. The previously presumed high-risk factors for COVID-19-related myocarditis are not present in a significant percentage of the cases. SARS-CoV2 myocarditis-related mortality is lower in cases than expected. In the setting of the appropriate clinical context, acute/subacute chest pain, with elevated cardiac biomarkers, abnormal EKGs, and echocardiogram findings in patients with recent or /remote SARS-CoV2 infection/ vaccination, a clinical diagnosis of myocarditis can be made in absence of cMRI. CLINICAL IMPLICATIONS: Diagnosis of SARS-CoV2-related myocarditis can be made based on clinical presentation, abnormal EKG, and echocardiogram with or without the added benefit of cardiac MRI. This systematic review aims to update current knowledge on the characteristics of COVID-19 infection-related myocarditis. DISCLOSURES: No relevant relationships by Mubashir Ayaz Ahmed No relevant relationships by Hari Bhattarai No relevant relationships by shyam chalise No relevant relationships by Saral Desai No relevant relationships by Shayet Hossain Eshan No relevant relationships by Sudha Misra No relevant relationships by Zahin Islam Rafa No relevant relationships by Shrungavi Ramanathan No relevant relationships by Monica Sharma

SMARCA4-DEFICIENT UNDIFFERENTIATED TUMOR: A RARE THORACIC MALIGNANCY

SESSION TITLE: Rare Malignancies SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: SMARCA4 deficient undifferentiated tumors (SMARCA4-DUT) are rare and aggressive neoplasms that are most commonly encountered in young male smokers and portend a poor prognosis (1,2). They are characterized by loss of SMARCA4, a subunit of chromatin remodeling complexes, and loss of the tumor suppressor brahma-related gene 1 (BRG1). We present a case of an elderly female with an extensive smoking history who was diagnosed with SMARCA4-DUT. CASE PRESENTATION: An 84 year old female with approximately 70 pack year smoking history, emphysema, ischemic cardiomyopathy, and coronary artery disease, presented to the emergency room with upper abdominal pain which started one day prior to admission. She endorsed an unintentional 10 pound weight loss in the past two months. The patient was admitted for an incarcerated ventral hernia for which she underwent repair. Of note, one and a half years ago, she was found to have a right lower lobe 7mm nodule but was unable to follow up due to the COVID pandemic. On this admission, a CT chest revealed a 4.2 x 3.8 x 3.7cm mediastinal mass and subcarincal lymphadenopathy. She underwent an EBUS with biopsy of the mediastinal mass and subcarinal lymph node. Cytology showed highly atypical epitheloid cells, concerning for a neoplasm with neuroendocrine differentiation and granulomas. Given the high suspicion for malignancy, she had a PET CT (figure 1) which showed FDG activity (SUV 11) in the mass with areas of necrosis and was referred to thoracic surgery. She underwent thoracoscopy with mediastinal mass resection and lymph node dissection and pathology showed diffuse sheets of epithelioid cells with large foci of necrosis. Neoplastic cells showed preserved INI (SMARCB1) expression, non-reactivity for NUT, and complete loss of BRG1 (SMARCA4) expression, consistent with a SMARCA4-DUT with positive margins (figure 2). She was referred to Radiation Oncology with plans to pursue further therapy thereafter. DISCUSSION: SMARCA4-DUT is a new and distinctive clinicopathological entity of aggressive thoracic tumors (1). The novelty of this class of tumors poses challenges in terms of treatment. Immune checkpoint inhibitors have shown compelling outcomes in case reports (3), however larger studies are needed to delineate optimal treatment regimens. CONCLUSIONS: SMARCA4-DUT are are rare but highly aggressive thoracic neoplasms. They present as large tumors and are smoking related. Prompt recognition may aid in early diagnosis. No definitive therapy exists but immunotherapy has shown promising results. Reference #1: Chatzopoulos, K., Boland, J.M. Update on genetically defined lung neoplasms: NUT carcinoma and thoracic SMARCA4-deficient undifferentiated tumors. Virchows Arch 478, 21–30 (2021). Reference #2: Roden AC. Thoracic SMARCA4-deficient undifferentiated tumor-a case of an aggressive neoplasm-case report. Mediastinum. 2021;5:39. Published 2021 Dec 25. Reference #3: Henon C, Blay JY, Massard C, Mir O, Bahleda R, Dumont S, Postel-Vinay S, Adam J, Soria JC, Le Cesne A. Long lasting major response to pembrolizumab in a thoracic malignant rhabdoid-like SMARCA4-deficient tumor. Ann Oncol. 2019 Aug 1;30(8):1401-1403. DISCLOSURES: No relevant relationships by Sathya Alekhya Bukkuri No relevant relationships by Erin Meier No relevant relationships by Mangalore Amith Shenoy No relevant relationships by Alexandra Zavin

POINT-OF-CARE ULTRASOUND FOR DIAGNOSIS AND EFFECT ON CLINICAL DECISION-MAKING DURING EVALUATION OF RESPIRATORY SYMPTOMS IN AN AMBULATORY PULMONARY CLINIC

SESSION TITLE: Technological Innovations in Imaging SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 PM - 2:30 PM PURPOSE: Point-of-Care Ultrasound (POCUS) has become an indispensable tool for clinicians evaluating patients with acute illness in hospital settings. Trained clinicians can rapidly detect cardiopulmonary disease with high sensitivity, guiding diagnosis and therapeutic management based on real-time findings. Despite this revolution to bedside care, POCUS has rarely been employed in the ambulatory setting. We aimed to evaluate the role of POCUS in the diagnosis and effect on clinical-decision-making in patients presenting to a pulmonary clinic with respiratory complaints. METHODS: This is a prospective case series of adult patients presenting to a pulmonary clinic in an urban medical center between January and February 2022. POCUS was performed by trained pulmonary faculty and triggered at the discretion of the clinician. Studies triggered by POCUS were followed-up, and a diagnosis if made was recorded. RESULTS: Between January-February 2022, the clinic saw N=53 patients for whom POCUS was triggered for N=10. Reasons included: no prior imaging on record (N=4), physical exam findings (N=5) and/or unclear clinical picture (N=4) after review of history, exam, and the medical record. Average age was 59.5±12.7 years. The chief complaint was dyspnea for all patients. In 4 patients, POCUS revealed diffuse B-lines with irregular pleural line suggestive of ILD. The work-up eventually diagnosed UIP-pattern ILD related to rheumatoid arthritis (N=1), non-specific interstitial pneumonitis (N=1), and sarcoidosis (N=1). Work-up remains pending for 1 patient. POCUS revealed new left ventricular dysfunction in 2 patients: one subclinical post-viral cardiomyopathy following COVID-19 and one ischemic cardiomyopathy from coronary artery disease. POCUS revealed new biventricular failure in one patient, for whom cardiac sarcoidosis is currently being worked-up given a history of anterior uveitis. In 1 patient, POCUS revealed a massive echogenic mass within the right hemithorax, prompting urgent chest x-ray and referral to ER. With a personal history of leiomyosarcoma, this mass was eventually diagnosed as recurrence of cancer. In 1 patient, POCUS diagnosed new pleural effusion, prompting referral for thoracentesis revealing an exudate of unclear etiology. One patient presented with COPD exacerbation, for whom POCUS found a basilar consolidation suggestive of pneumonia, prompting antibiotic therapy. CONCLUSIONS: POCUS can detect in real-time cardiopulmonary disease, and thus may serve as a powerful tool in the diagnosis and clinical-decision-making by trained clinicians encountering patients with respiratory complaints in an ambulatory setting. CLINICAL IMPLICATIONS: Our case series demonstrates the potential utility of POCUS, when triggered appropriately, can allow additional diagnostic studies to be considered earlier, and potentially narrow the time interval between patient presentation and a made diagnosis. DISCLOSURES: No relevant relationships by Gerardo Eman No relevant relationships by Marjan Islam No relevant relationships by Rahul Nair No relevant relationships by Abhishek Sharma No relevant relationships by Shwe Synn No relevant relationships by Tito Zerpa

A CONFOUNDING CASE OF NON-ISCHEMIC CARDIOMYOPATHY: ACQUIRED MYOCARDITIS FROM COVID-19 AND SYSTEMIC LUPUS ERYTHEMATOSUS LEADING TO CLINICAL HEART FAILURE

CASE: We report a 50-year-old Caucasian female with a history of systemic lupus erythematosus (SLE) in remission and chronic kidney disease (CKD) stage 5. The patient presented with dyspnea on exertion and orthopnea for two weeks. Six weeks ago, she was diagnosed with COVID-19 after presenting to the ED for substernal chest pain, myalgias, and fatigue. During this admission, she denied any current joint pain, chest pain, or rashes. She denies a history of alcohol or illicit drug use. EKG in the ED showed T-wave inversions in lead I and aVL, stable from prior EKG. The brain natriuretic peptide level was elevated at 3,500 pg/ml. There was no transaminitis, and kidney function was at baseline. Chest x-ray showed pulmonary vascular congestion and cardiomegaly. A transthoracic echocardiogram showed a left ventricular ejection fraction of 15-20% with severe global hypokinesis. The patient had a full cardiomyopathy workup. We ruled out ischemic cardiomyopathy with a negative coronary angiogram. Non-ischemic cardiomyopathy (NICMO) workup was initiated, with a focus on viral or autoimmune myocarditis. While a cardiac MRI would have been the gold standard to assess for myocardial scarring, the patient's CKD status prohibited this possibility. Similarly, an endomyocardial biopsy was not performed due to its low sensitivity for diagnosing viral or autoimmune myocarditis. Without evidence of infiltrative disease, or other exposures, it was deemed that the patient's recent history of COVID-19 infection, in conjunction with underlying SLE, were the causes of her new-onset NICMO. The patient's dyspnea responded to intravenous bumetanide. We initiated guideline-directed medical therapy with carvedilol and isosorbide-dinitrate. She continues regular follow-up in the outpatient heart failure clinic. IMPACT/DISCUSSION: Classification and evaluation of NICMO can be broad, and thus the clinical picture plays an essential role in the workup. Acquired cardiomyopathy from prior myocarditis was the most likely etiology of our patient's new-onset NICMO. Our patient had no clinical symptoms of myocarditis prior to her exposure to COVID-19, making it unlikely that SLE was the sole driving factor. There is a known association between COVID-19 and myocarditis. A few proposed mechanisms for COVID-19 induced myocarditis include upregulation of cytokines, particularly interleukin-6, and downregulation of ACE2, leading to microvascular and cardiac pericyte dysfunction. Cytokine release from COVID-19 coupled with subclinical SLE could have acted synergistically to cause this patient's condition. Given the increasing incidence of COVID-19 infections, internists must consider COVID-19 exposures during the workup of new-onset heart failure. CONCLUSION: The workup for NICMO in the COVID-19 era must include detailed history taking for sick contacts and prior history of COVID-19 diagnosis. More research is needed to determine if COVID-19 infection can increase the risk of NICMO in patients with a known history of SLE.

Cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca COVID-19 vaccination: a case report

A 73-year-old man presented with left shin ulceration two weeks after receiving his first dose of the Oxford-AstraZeneca vaccine. Within 24 h of vaccination, the patient became generally unwell with fever and headache. On the third day after vaccination, he developed left shin erythema and blistering, which rapidly ulcerated. This formed two superficial ulcers with a necrotic base and a violaceous edge on the lateral aspect of his left shin, measuring approximately 2 cm × 3 cm. He had a background of atrial fibrillation and ischemic cardiomyopathy, and had been on several longstanding medications including apixaban. Blood tests revealed normal clotting, full blood count, liver and renal function. The differential diagnosis included pyoderma gangrenosum, vasculitic ulceration, and a cutaneous adverse drug reaction to vaccination. A punch biopsy was obtained from the edge of an ulcer, which revealed microthrombi within blood vessels, an ischemic epidermis, and fat necrosis of subcutaneous tissue. The patient experienced slow healing of ulceration with topical clobetasol propionate 0.05%, neomycin sulphate and nystatin ointment, and compression bandaging treatment. To our knowledge, this is the first reported case of cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca vaccination. Recently there have been concerns related to reports of thrombotic events at atypical sites (including cerebral and splanchnic vascular beds) associated with thrombocytopenia following Oxford/ AstraZeneca vaccination (Greinacher A, Thiele T, Warkentin TE et al. Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384: 2092-101). These findings extend the range of atypically located thromboses associated with COVID-19 vaccination and reinforce the necessity for physicians to be vigilant for signs and symptoms related to thromboses at atypical sites in recently vaccinated patients.

FROM SEPSIS TO STEMI: A CASE OF SHIFTING LEFT VENTRICULAR OBSTRUCTION

Background: In the setting of septic shock, an increase in sympathetic tone results in increased heart rate and contractility as well as decreased left ventricular (LV) end diastolic volume;these compensatory mechanisms can result in LV obstruction. Separately, following an MI, varying degrees of hypokinesis may result from infarcted myocardium. Case: A 75-year-old woman with COVID-19, acute respiratory distress syndrome, and septic shock was found to have a dynamic LV mid-cavitary obstruction on transthoracic echocardiogram (TTE). Three days later, the patient suffered a proximal left anterior descending STEMI and underwent percutaneous coronary intervention with drug-eluting stents. Follow-up TTE revealed mid-anterior and apical hypokinesis, with compensatory basal hyperkinesis and new systolic anterior motion of the mitral valve, resulting in an LV outflow tract (LVOT) obstruction, further exacerbated by underlying basal septal hypertrophy. A dynamic shift of the level of LV obstruction, from mid-cavitary to the outflow tract, was identified. Decision-making: Hemodynamic optimization in the setting of LVOT obstruction complicated by ischemic cardiomyopathy and distributive shock focused on supporting preload and afterload, while avoiding inotropic therapy. Conclusion: Prior case reports have demonstrated dynamic LV obstruction as a compensatory response to septic shock or as a sequelae of MI. However, this case highlights a rare presentation of shifting levels of obstruction. [Formula presented]

POS-531 MONOCLONAL GAMMOPATHY PRESENTING AS ACUTE PSEUDOHYPERPHOSPHATEMIA IN A MAINTENANCE HEMODIALYSIS PATIENT: A RARE PRESENTATION

Introduction: Phosphorus is an essential component of many macromolecules found in bone, lipid membranes, and DNA. It circulates in serum as phosphate. Phosphate level is mainly determined by kidney function. Other factors such as 1, 25 vitamin D3, thyroid hormone and low phosphorous intake can increase renal absorption of phosphate. Hyperphosphatemia presents when serum phosphate is above 4.5 mg/dl (1.45 mmol/L). The phosphate target for hemodialysis (HD) patients is 5.5 mg/dl (1.77 mmol/L) or less. Serum phosphate is commonly measured through the colorimetric method and can also be measured isotopically. Depending on the method used to measure the serum phosphate, many factors have been reported to produce falsely elevated levels. Methods: 52-year-old female with past medical history of end stage renal disease on HD, heart failure with severely reduced ejection fraction secondary to ischemic cardiomyopathy status post left ventricular assist device (LVAD), type 2 diabetes, hypertension, upper gastrointestinal bleeding, anemia, was admitted at a rehabilitation center after a hospital stay due to COVID-19 infection and E. faecium bacteremia secondary to a drive-line infection of the LVAD which was treated with daptomycin. On admission, the patient was found to have a phosphorus level of 6.3 mg/dl, PTH 265 pg/mL, corrected calcium 10 mg/dl, and hemoglobin 9.1 g/dL. Results: Patient was started on oral Sevelamer tablets 800 mg every 8 hours and underwent regular full HD sessions. However, the hyperphosphatemia persisted. Sevelamer was increased to 1600 mg every 8 hours, and she was maintained on a strict low phosphorous renal diet. Four days later while on the new regimen, the phosphorous increased to 12.2 mg/dl. She remained asymptomatic. Hemolysis and hyperbilirubinemia were excluded. A serum protein electrophoresis revealed a monoclonal spike in the gamma region with gamma % of 38.5 (normal range 11-20), gamma globulin 3.0 g/dL (normal range 0.6 – 1.6 g/dL), and quantification of the abnormal protein of 0.41 g/dL (5.3% total). Serum immunofixation showed a probable IgG Lambda monoclonal band. A serum free light chain assay demonstrated a Kappa light chain free serum of 548.9 mg/L (normal range 3.3 – 19.4 mg/L) and Lambda light chain free serum 549.7 mg/L (normal range 5.7 – 26.3 mg/L). Patient was diagnosed with a monoclonal gammopathy, and the elevated phosphorus deemed to be pseudohyperphosphatemia secondary to paraproteinemia. Conclusions: Colorimetric assay with phosphomolybdate ultraviolet (UV) is commonly used for measurement of serum phosphate. The ammonium molybdate reacts with the phosphate to form a cloudy complex, UV absorbance is measured at a specific wavelength. Several factors have been reported to cause falsely high phosphate such as hyperlipidemia, hyperbilirubinemia, hemolysis, liposomal amphotericin B, recombinant tissue plasminogen activator, heparin sulfate, and gammopathies. The paraproteinemia present in monoclonal gammopathies creates a cloudier sample which increases the absorbance of UV light leading to spurious elevation of serum phosphate. Although hyperphosphatemia is a common finding in dialysis patients, the presence of persisting or worsening hyperphosphatemia in a compliant patient taking phosphorous binders and adhering to a low phosphorus diet should raise concern for pseudohyperphosphatemia. No conflict of interest

The relevance of specific heart failure outpatient programs in the COVID era: an appropriate model for every disease.

Heart Failure (HF) is characterized by an elevated readmission rate, with almost 50% of events occurring after the first episode over the first 6 months of the post-discharge period. In this context, the vulnerable phase represents the period when patients elapse from a sub-acute to a more stabilized chronic phase. The lack of an accurate approach for each HF subtype is probably the main cause of the inconclusive data in reducing the trend of recurrent hospitalizations. Most care programs are based on the main diagnosis and the HF stages, but a model focused on the specific HF etiology is lacking. The HF clinic route based on the HF etiology and the underlying diseases responsible for HF could become an interesting approach, compared with the traditional programs, mainly based on non-specific HF subtypes and New York Heart Association class, rather than on detailed etiologic and epidemiological data. This type of care may reduce the 30-day readmission rates for HF, increase the use of evidence-based therapies, prevent the exacerbation of each comorbidity, improve patient compliance, and decrease the use of resources. For all these reasons, we propose a dedicated outpatient HF program with a daily practice scenario that could improve the early identification of symptom progression and the quality-of-life evaluation, facilitate the access to diagnostic and laboratory tools and improve the utilization of financial resources, together with optimal medical titration and management.