Cerebral Air Embolism During a Flight

Introduction: We report a case of a 67 year old lady with an acute drop in conscious level whilst on a transatlantic flight. She had a background history of TII DM and recent mild COVID. Past surgical history of a gastric bypass, at which time a CXR had incidentally shown a bulla, with no underlying respiratory symptoms, or history of COPD. Method(s): On arrival in the emergency department, her GCS was 7/15, and she required immediate intubation. Non-contrast CT head showed multiple tiny gas locules in keeping with air emboli. CT Chest, Abdo, Pelvis showed an 88mm bulla within the left lung lingula with a bronchus and many large pulmonary vessels running on its edge. Result(s): It was thought the change in air pressure during the flight caused a communication to open between the bulla and the pulmonary circulation resulting in the release of air emboli. Conclusion(s): She required ITU admission for 8 days. After initial stabilisation she was stepped down to HASU. Neurologically she was dysphagic, dysarthric, quadriplegic and GCS 14 due to confusion. MRI whole spine ruled out spinal cord pathology. Repeat CT head showed air initially present had completely resorbed leaving multifocal, small areas of cortical and subcortical ischaemia in both cerebral hemispheres. MRI head confirmed innumerable small early subacute embolic ischaemic infarcts across multiple vascular distributions.

THROMBUS IN TRANSIT CAPTURED BY BEDSIDE ULTRASOUND: A LIFE-SAVING TOOL

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Point of care ultrasound used by the provider is rapidly expanding in internal medicine. Thrombus in transit (TIT) is defined on ultrasound as mobile echogenic material temporarily present in the right heart chambers to the pulmonary circulation via the tricuspid valve or systemic circulation via an atrial septal defect. In this case, we were able to identify echogenic material traversing the tricuspid valve into the pulmonary circulation, which confirmed the diagnosis of pulmonary embolus [1] CASE PRESENTATION: This is a 71-year-old female with a history of hypertension who presented to the emergency room with 4-day pleuritic chest pain, productive cough, fever, and exertional dyspnea. She was hemodynamically stable, afebrile, tachycardic, and tachypneic. Initial diagnostic workup demonstrated elevated cardiac enzymes and creatinine, ground-glass opacities on chest CT, positive COVID PCR, and sinus tachycardia with nonspecific T wave abnormalities. Given her renal insufficiency, CTA was initially held off. The patient was found to have right lower extremity deep venous thrombosis, and a heparin infusion was started while waiting for a V/Q scan. Shortly after admission, she had a syncopal episode after using the bathroom. CPR was initiated for suspected cardiac arrest, and a bedside ultrasound demonstrated a sizeable mobile thrombus in the right atrium traversing the tricuspid valve into the right ventricle. Given this finding, we elected to move forward with CTA chest, and this study confirmed extensive bilateral PE with right heart strain. DISCUSSION: TIT is a rare emergency in PE (4%) with a staggering mortality rate twice as high as PE without TIT [2]. The gold standard for diagnosis of PE is CT angiogram, and early echocardiography is a cornerstone in diagnosis and risk stratification. However, patients similar to the one discussed in this care may present with conditions preventing timely utilization of these tools. POCUS allows for the rapid assessment and implementation of time-sensitive treatments. Historically, it has been a must-have skill set among ER and critical care physicians. Only 35% of internal medicine residency programs have fully integrated formal diagnostic POCUS within the past decade despite increasing interest among trainees. The expeditious medical decision made for our patient was possible following a focused echocardiogram performed by an internal medicine resident. In patients with massive PE, only 35% of echocardiograms obtained within 24 hours were done in the ER, and still, 1 in 6 happened after 6 hours [3]. CONCLUSIONS: As with any operator-dependent skill, proficiency in POCUS is a prerequisite for reliable findings and time-sensitive medical decision-making. POCUS only becomes a lifesaving tool in experienced hands. Hence, it is imperative that internal medicine residency programs consider this tool an essential component of resident training. Reference #1: Arboine-Aguirre L, Figueroa-Calderón E, Ramírez-Rivera A, et al. Thrombus in transit and submassive pulmonary thromboembolism successfully treated with tenecteplase. Gac Med Mex. 2017;153(1):129–33. Reference #2: Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. doi:10.1016/s0002-9149(97)00162-8 Reference #3: Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. doi:10.1016/s0735-1097(03)00479-0 DISCLOSURES: No relevant relationships by Varinder Bansro No relevant relationships by Olayiwola Bolaji No relevant relationships by clarence findley No relevant relationships by Faizal Ouedraogo

RELATIONSHIP BETWEEN ADMISSION BMI AND POSTHOSPITALIZATION DIFFUSION STUDY ABNORMALITIES IN SURVIVORS OF COVID-19 HOSPITALIZATION

SESSION TITLE: Post-COVID-19 Outcomes SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Obesity, a risk factor for severe COVID-19 disease, multiplies the risk of hospitalization and mortality. Its impact in lung disease is mediated by altered inflammatory responses and respiratory mechanics. Studies of lung function among COVID-19 disease survivors have identified reduced TLC and DLCO as prominent changes in this population. Obesity, however, is associated with elevated DLCO in otherwise healthy individuals. The objective of this study was to evaluate whether this relationship was preserved among COVID-19 disease survivors. Additionally, we sought to analyze whether maximum FiO2, peak neutrophil-to-lymphocyte ratio (NLR), diabetes or smoking status had any effect in DLCO. METHODS: The charts of adult patients hospitalized with confirmed SaRS-CoV-2 infection between 3/20/2020 and 12/31/2021 were reviewed. Those who survived and later had a PFT were selected, and 73 patients met these criteria. Eighteen were excluded due to radiographic or prior PFT findings of emphysema (COPD or AATD) or ILD, and missing diffusion study data. Patients were stratified by BMI class. Patient characteristics were compared using ANOVA and Pearson correlation. Other outcomes were analyzed using linear regression. RESULTS: A total of 55 patients were included. Average age was 55.6 years. Average BMI and DLCO were distributed as follows: healthy (23.76;16.94), overweight (28.3;17.50), obesity classes I (32.3;18.86), II (37.8;17.68), and III (48.2;24.56). ANOVA shows a significant effect of BMI class on DLCO (F4,50=4.067, p=0.006). A significant positive correlation between BMI and DLCO was observed (r=0.392, p=0.003). When comparing BMI classes, Tukey’s HSD test shows that there was a significant difference only when patients classified as overweight (-22.9, p=0.01), or with obesity classes I (-20.2, p=0.02) or II (-24.0, p=0.005), were individually compared to obesity class 3. Regression analysis showed no significant effect of peak FiO2 (-0.056, p=0.07), NLR (-0.051, p=0.60), diabetes (-0.932, p=0.50), or smoking status (0.764, p=0.505). Overall regression between dependent and independent variables is not significant (F4,50=2.21, p=0.082). CONCLUSIONS: These findings suggest that higher obesity is associated with higher DLCO. This is consistent with the known effect of obesity on diffusion capacity, resulting from increased blood volume in the pulmonary circulation. The relationship was preserved even though most patients had DLCO below the percent predicted, as observed in studies of lung function among COVID-19 survivors. Notably, FiO2 and NLR did not have a significant effect on DLCO. CLINICAL IMPLICATIONS: Though patients surviving a COVID-19 hospitalization may have a reduced DLCO, the positive relationship between BMI and DLCO is similar to that observed in otherwise healthy obese individuals. DISCLOSURES: No relevant relationships by Mohammad Arabiat No relevant relationships by Justin Horner No relevant relationships by Harold Matos Casano No relevant relationships by Doug McElroy No relevant relationships by Karan Singh No relevant relationships by Michael Smith

LIFE CYCLE OF A COVID-19-INDUCED LUNG CYST

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: COVID-19 has affected over 200 million people worldwide. Clinicians continue to observe unusual manifestations of this disease. In an attempt to improve our understanding of COVID-19 pneumonia, we present the details of one patient who developed large bilateral pulmonary cysts. CASE PRESENTATION: A 40-year-old woman with no known medical problems presented with the chief complaint of fever, nausea, vomiting, generalized weakness followed by difficulty breathing that developed over a few days. Her vital signs on admission included temperature 98.4° F, heart rate 104 beats/minute, respiratory rate 48 breaths/minute, O2 saturation 88 percent on 15 liters of oxygen through a non-rebreather mask, and Body Mass Index 42 kg/m2. The patient tested positive for COVID-19. Computed tomography (CT) of the chest to rule out a pulmonary embolism showed bilateral extensive ground-glass opacities and reticular and nodular opacities. She was intubated for acute hypoxic respiratory failure. Twenty days into the hospital admission, she was noted to have a bulla in the right lower lobe. A repeat CT chest on day 45 revealed an increase in the number and size of cysts bilaterally. Patient was discharged to rehab and later readmitted for worsening respiratory status. This time she tested positive for human metapneumovirus. A CT chest showed increase in the size of the right sided lung cysts;the left sided lung cysts had resolved. DISCUSSION: The first COVID-19 related pulmonary cystic lesions were reported in May 2020(1). Since then, several reports have now established a relationship between an infection and cyst formation. The most common distribution is peripheral in the lower lobes. The pathogenesis remains uncertain, but several mechanisms have been proposed. Microthrombi in the pulmonary circulation could lead to ischemia and subsequent remodeling of interstitial matrix and bronchial obstruction with distal hyperinflation due to check valve mechanism. (1,2). Hamad et al. propose that pneumatoceles are formed by air leaked in to the interstitium which causes stripping and separation of a thin layer of lung parenchyma with further injury to the small blood vessels and bronchioles. The rate of barotrauma in non-COVID-19 related ARDS is 0.5%;the rate in COVID-19 ARDS is 15% (3). This suggests a close relation between COVID-19 pneumonia and subsequent development of pulmonary cysts. Our patient had no preexisting pulmonary disease and was noted to have pulmonary cysts after being on mechanical ventilation for almost 2 weeks. The patient later contracted the human metapneumovirus infection and CT showed that the right-sided lung cysts had become bigger in size. However, the left-sided cysts which had a maximum diameter of 4.8 cm had resolved. CONCLUSIONS: We need to follow patients with COVID 19 induced lung cysts clinically and radiologically to understand the clinical course and best management strategies. Reference #1: Kefu Liu et al. COVID 19 with cystic features on Computed tomography;Medicine (Baltimore) 2020May;99(18): e20175. PMCID: PMC7486878 Reference #2: Galindo J, Jimenez L, Lutz J et al. Spontaneous pneumothorax with or without pulmonary cysts, in patients with COVID 19 Pneumonia. Journal of infections in developing countries 2021;15(10);1404-1407 Reference #3: McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, Thomas KM, Moore WH. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology. 2020;297(2): E252–E262. doi: 10.1148/radiol.2020202352 DISCLOSURES: No relevant relationships by Arunee Motes No relevant relationships by Kenneth Nugent No relevant relationships by Tushi Singh No relevant relationships by Myrian Vinan Vega

Silicone pulmonary embolism: A case report

INTRODUCTION: SPE is a rare entity reported in medical literature. Clandestine silicone application has been increasing in Mexico, leading to increased rates of SPE and death. Symptoms include dyspnea, chest pain, fever, cough, diffuse alveolar hemorrhage (DAH), and acute respiratory distress syndrome. In Mexico, from 2005-2014, 21.8% SPE deaths have been reported related to cosmetic procedures. DESCRIPTION: A 21-year-old, previously healthy transgender patient, with a history of multiple cosmetic surgeries, underwent to a gluteal augmentation procedure through injection of 1000 cc of liquid silicone in an outpatient clinic. The procedure was canceled after administration of 500 cc of silicone due to dyspnea and cough, and the patient was discharged. Two days later, the symptoms worsened, and she was admitted to the emergency department, with a blood pressure of 90/64 mmHg, SpO2 60%, respiratory rate of 40 bpm, and heart rate of 125 bpm. She was intubated and admitted to ICU. On clinical examination, we identified basal crackles, petechial hemorrhage, and erythematous puncture sites. CT pulmonary angiogram showed bilateral basal ground-glass opacities, ruling out thrombus in pulmonary circulation;and lung ultrasound with B pattern. Blood test showed thrombocytopenia, hypoxia (Pa02:FiO2 97 mmHg), elevated alveolar-arterial gradient, negative PCR SARS-CoV-2, and no renal failure. She was diagnosed with SPE;supportive management with lung protective ventilation, prone positioning (PP) and systemic steroids (SS) was initiated. She also had hemoptysis, new pulmonary infiltrates, and abnormal liver enzymes at ICU, which resolved spontaneously. After 8 sessions of PP, oxygenation improved, tracheostomy was performed due to ICU acquired weakness and was discharged home after 20 days of hospital stay. DISCUSSION: There is a paucity of reports of this complication. Our patient showed a significant improvement after administration of SS, which consists with an immunomediated mechanism. Studies have reported mortality from 24 to 33%, but can reach up to 100% if neurological symptoms are present. It is important to recognize that silicone injections are not safe and can lead to serious complications. Recognizing rare manifestations can help to distinguish this entity from other etiologies.

Long term sequelae after COVID-19: The different impact on the right and left ventricles

Aims: Most patients who had COVID-19 are still symptomatic after many months post infection, but the long-term outcomes are not yet well-defined. The aim of our prospective/ retrospective study was to define the cardiac sequelae of COVID-19 infection. Methods and results: This monocentric cohort study included 160 consecutive patients (64 females, 60+12 years) who had been discharged from the ward or from the outpatient clinic after a diagnosis of COVID-19 and subsequently referred for a follow-up visit. Clinical features as well as lab and instrumental data about the acute phase of the disease, such as haemodynamic instability (HI), cardiac biomarkers, Ddimer, C-reactive protein (CRP), high resolution CT (HRCT) score along with information about the follow-up visit, including ECG and Conventional and Doppler Tissue Echocardiographic (DTE) parameters, were recorded. The median follow-up time after symptom onset was 5 months. At follow-up visit, the majority of the patients reported dyspnoea and asthenia. Moreover, echocardiography showed morphofunctional changes of both right (RV) and left (LV) ventricles, such as RV dilation, increased pressure in the pulmonary circulation, and by-ventricular systolic-diastolic dysfunction. When examined using multivariate analysis, independent of age, sex, and co-morbidities, RV and LV changes were significantly associated (P<0.05) with HRCT score and HI and with CRP, respectively. Conclusions: Our results suggest that COVID-19 may impact RV and LV differently. Notably, the extent of the pneumonia and HI may affect RV, whereas the inflammatory status may influence LV. A long-term follow-up is warranted to refine and customize the most appropriate therapeutic strategies.

Consequences on the right ventricular to pulmonary circulation coupling of COVID-19 infection

Background: Right Ventricular (RV) dysfunction and pulmonary hypertension (PH) are two very likely acute and long term targets of COVID-19 pneumonia, with a potential prognostic implications. Purpose: To determine the COVID-19 pneumonia effects on the right ventricular to pulmonary circulation coupling through bedside echocardiography and extend its implications to prognostic assessment. Methods: Single-centre study including consecutive subjects hospitalized for COVID-19 pneumonia who underwent a clinical indicated echocardiogram between March 2020 and December 2020. Extensive analysis of cardiac function was performed offline by an operator blinded to clinical data, laboratory findings and CT scans. Results: 133 patients were enrolled (mean age 69±12 years, 57% men), 38% of whom already had cardiac disease in their medical history. Inhospital mortality was 26% (35 pts), during a mean hospital stay of 26±16 days. Non survivors had higher pulmonary artery systolic pressure (PASP) and worse RV function, assessed with both standard parameters (i.e. TAPSE) and with the novel speckle tracking analysis by RV-Global Longitudinal Strain (RV-GLS) and RV-Free Wall Longitudinal Strain (RV-FWLS). The combination of these two variables in TAPSE/PASP ratio allows assessment of RV to pulmonary circulation (Pc) coupling and was strongly associated with in-hospital death (HR 0.73, 95% CI 0.59-0.89, p=0.003) and patients with TAPSE/PASP<0.57 mm/mmHg had a more than 4-fold increased risk of in-hospital death (HR 4.8, 95% CI 1.7-13.1, p=0.003). In patients where speckle tracking analysis was feasible, we examined RVGLS/ PASP and RV-FWLS/PASP and found that it was associated with inhospital mortality. The best cut-offs for predicting in-hospital mortality was 0.51 for RV-GLS/PASP (94% sensitivity and 59% specificity) and 0.49 for RV-free wall LS (87% sensitivity and 70% specificity). At the multivariable analysis RV to Pc remained associated with in-hospital death after adjustments for age, PaO2/FiO2, LVEF, and severity of lung involvement at the CT. Conclusions: Either PH and RV dysfunction predict in-hospital mortality in patients with COVID-19 pneumonia. The assessment of RV to Pc coupling, however, better describes the adaptive RV response to increased PASP and gives additional prognostic information in a population with a relevant prevalence of comorbidities. (Figure Presented).

Increased incidence of Persistent Pulmonary Hypertension of the Newborn following third trimester maternal COVID-19 infection

Background: Novel coronavirus (COVID-19) has been a world concern since December 2019. The knowledge about vertical transmission and fetal morbidity and mortality from maternal COVID-19 infection is limited.We detected an increase in the number of cases of term and near-term neonates with persistent pulmonary hypertension (PPHN) during the COVID-19 pandemic in 2020. Methods and results: We collected data on all newborns with PPHN born between 2018 and 2020. We excluded premature infants (<34+0 weeks) and infants with other significant pathology or genetic syndromes. Compared to 5 cases of PPHN of 22930 live births in 2018, and 6 cases of PPHN of 22270 live births in 2019 (2-year average 0.02%, 95% CI 0.013%- 0.043%), there were 16 PPHN cases from 22323 live births in 2020 (0.07%, 95% CI 0.044%-0.12%), a 3 fold increase (p<0.01). We report 5 cases of term and near-term neonates born to mothers who had highly suspected (2) and PCR proven (3) COVID-19 infection during the third trimester of pregnancy, who presented with PPHN during COVID-19 pandemic in 2020. All had otherwise unexplained pulmonary hypertension, right ventricular hypertrophy (RVH) and dilatation. Two patients needed endotracheal intubation, one was supported by nasal continuous positive airway pressure (CPAP) without intubation, two needed O2 support by nasal cannula only ant two newborns (one of them was intubated) needed Nitric oxide (NO) as pulmonary vasodilator therapy. No patient required Extracorporeal membrane oxygenation (ECMO) or died, and no prolonged residual cardiovascular or pulmonary morbidity was recorded during a median follow up of 4.8 months (range 4-6 months). Conclusions: The increase in the incidence of PPHN during the COVID- 19 pandemic, and the cases presented, suggest an intrauterine effect of maternal COVID-19 infection on the fetal pulmonary circulation. It is possible that the maternal infection affected the fetal pulmonary vascular resistance, or altered the normal decline in the resistance after birth. The right ventricular hypertrophy and dilatation with reduced function may be secondary to this hypothetical increased afterload or a direct effect of the infection. Further studies are warranted to elucidate the pathogenesis and clinical implications of this phenomenon.