Evaluation of Quality-of-Care Indicators Among Patients With Crohn's Disease and Ulcerative Colitis in the United States: 2019-2020

Introduction: Crohn's disease (CD) and ulcerative colitis (UC) can be difficult to manage and, due to a lack of meaningful quality measures, patient (pt) care may vary by provider. To understand where gaps in care may exist for these pts, this study assessed specific healthcare resource utilization (HRU) and medication metrics that may be potential quality of care (QOC) indicators. Method(s): Using a large commercial US claims database (2019-2020), pts with CD or UC were identified. Potential QOC indicators were selected based on clinical guidelines and recommendations from measures of quality organizations and included CD or UC prevalence;gastroenterologist (GE) and IBD-related non-GE outpatient visits;IBD-related emergency department visits or hospitalizations;excessive steroid use (prednisone equivalent >=10 mg/day for >=60 consecutive days or a single prescription of >=600 mg prednisone);excessive steroid users on corticosteroid (CS)-sparing therapy;excessive steroid users with central dual-energy X-ray absorptiometry (DEXA) or osteoporosis pharmacologic treatment;use of targeted immunomodulators (TIMs) and oral mesalamine (CD only);imaging assessments;and assessment of inflammatory biomarkers. National percentages of pts achieving each metric are reported. Result(s): In total, 41,555 CD and 52,507 UC pts were identified in 2019, resulting in a 0.3% and 0.4% prevalence, respectively (Table). Over a third of CD pts (39.8%) and almost half of UC pts (45.5%) did not visit a GE in 2019. Around 10% CD pts, and up to 6.4% of UC pts, had IBD-related ED visits or hospitalizations. 17.1% CD and 14.5% UC pts were excessive steroid users, yet < 9% CD and UC pts, received DEXA scans and/or bone treatments. A third of excessive steroid users with CD (34.5%), and over half (53.0%) of those with UC, did not receive CS-sparing therapy. The rate of TIM use was over two times higher in CD vs UC pts (CD: 44.3%;UC: 18.9%). Despite evidence that mesalamine is ineffective in CD, 18.7% of pts with CD were prescribed it. Inflammatory biomarker level testing rates were < 50% in both CD and UC. Similar outcomes were reported in 2020, with lower HRU, possibly due to COVID-19. Conclusion(s): This analysis of QOC indicators highlights various areas for improvement that may provide better treatment outcomes and reduce HRU for pts with CD and UC. Future research is needed to assess outcomes in pts that are not being routinely monitored. (Table Presented).

A Rare Etiology for Ulcerative Colitis Flare

Introduction: Prior to colonoscopy, it is well understood that patients must undergo bowel cleansing. Based on the type of laxative, colonoscopy preparations fall into two categories - polymer-based formulas (PEG) and saline-based formulas (NaP). Both types of bowel preparations are deemed to be relatively safe and part of routine practice. However, we describe the rare case of an ulcerative colitis (UC) flare due to the bowel preparation formula. Case Description/Methods: A 29-year-old female with diagnosis of UC, presently in clinical and biochemical remission on oral mesalamine, contracted COVID-19 and had reactivation of UC symptoms. After being on budesonide tablets and rectal foam for two months, patient achieved clinical remission, and a surveillance colonoscopy was performed which revealed normal colon and terminal ileum except mild congestion in the cecum (Figure A). Pathology revealed unremarkable mucosa in the entire colon except for chronic active colitis in the cecum. Immediately following this colonoscopy, the patient started to experience another severe UC flare requiring hospitalization. The patient's laboratory work-up was normal except for an elevated fecal calprotectin (1710). Stool infectious work-up was negative and the patient denied any NSAID or antibiotic use. The patient underwent a repeat colonoscopy which revealed severe Mayo 3 pancolitis (Figure B) in comparison to a stable colonoscopy a few weeks prior. It was revealed that for her initial colonoscopy, she had used SUPREP bowel prep kit. On prior colonoscopies she had used MiraLAX bowel prep with no adverse effects. During hospitalization, the patient was started on biologic therapy with good effect. Discussion(s): There are no clear guidelines on appropriate bowel preparation formula for the inflammatory bowel disease (IBD) population. Sufficient literature exists to confirm that NaP can irritate the intestinal mucosal wall. Moreover, numerous animal experiments have employed dextran sodium sulfate for chemical induction of intestinal inflammation to mimic UC flares in humans [1]. Thus, it can be surmised that because SUPREP ingredients contain sodium sulfate, the potential for UC flare is higher. It is pertinent for practitioners to be aware of the possible rare adverse effects of saline-based formulas, especially when treating the IBD population.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Rectum Incidentally Found in a Patient with Ulcerative Colitis

Introduction: Mucosa-associated lymphoid tissue (MALT) lymphomas are extra-nodal marginal zone B-cell lymphomas, most commonly found in the stomach, associated with Helicobacter pylori infections, and generally not linked with inflammatory bowel disease. Rectal MALT lymphoma is very uncommon and often associated with painful defecation, change in bowel habits, or rectal pressure/prolapse. Here, we present a rare case of an asymptomatic female with ulcerative colitis (UC) found to have benign-appearing rectal polyps during a routine screening colonoscopy. Case Description/Methods: The patient is a 56-year-old female with a history of left-sided UC, diagnosed in 1993, with one flare after receiving the 2nd dose of the Moderna COVID-19 vaccine, taking oral Olsalazine 500 mg twice daily, low-dose Prednisone, and mesalamine suppositories as needed presenting for screening colonoscopy. The patient was asymptomatic, citing regular non-bloody bowel movements and normal stool consistency. Colonoscopy revealed two 7 mm sessile, non-bleeding rectal polyps, surrounded by congested, erythematous, friable, and ulcerated mucosa in the rectosigmoid colon. Cold forceps biopsies were taken. Hematopathology evaluation of the routine colon biopsy samples revealed chronic nonspecific colitis while pathology of the rectal polyps showed marked lymphoplasmacytic infiltrate and extra-nodal marginal zone lymphoma of MALT. Ancillary studies, immunohistochemistry, and molecular studies for B-cell gene rearrangement confirmed extra-nodal marginal zone lymphoma of MALT with prominent plasmacytic differentiation. The patient was informed and close follow-up in Gastroenterology clinic was arranged. (Figure) Discussion: Rectal MALT lymphoma is rare with unclear management options. Treatments of UC include watchful waiting, surgical resection, endoscopic mucosal resection, radiation, and/or chemotherapy. Helicobacter pylori infections, though strongly linked with gastric MALT lymphoma, have not been shown to be strongly correlated with rectal MALT lymphoma. Given that patients with UC have chronic UCassociated colonic inflammation, lymphoma is often difficult to distinguish visually during colonoscopy, frequently masked by ulcerations and pseudo-polyps. In cases like these, more definitive treatments such as surgical resection could therefore be warranted. Long-term follow-up data is sparse and definitive management remains a clinical conundrum, thus these patients require reliable long-term multidisciplinary close follow-up. (Figure Presented).

The impact of COVID-19 on patients with Inflammatory Bowel Disease: A population-based study using artificial intelligence

Background: Coronavirus disease 2019 (COVID-19) has been a pandemic that is still very prevalent. Patients with Inflammatory Bowel Disease (IBD) represent a special population considering their already altered immune system and their exposure to several immunosuppressive therapies. We pretend to study the impact of COVID-19 on IBD patients in our community, Castilla-La Mancha (a region in central Spain). Method(s): Retrospective observational study using an artificial intelligence with natural language processing capability, the SAVANA manager, we analyzed data from 1 808 010 patients with Electronic Medical Records (EMR) within the public health system of Castilla-La Mancha from March 1st 2020 to January 1st 2021. Data on demographic characteristics, hospitalization, ICU admission and mortality were collected. We compared COVID outcomes between IBD and non-IBD patients. We compared COVID outcomes in IBD patients according to their treatment (comparing each treatment group to those IBD patients with no treatment);we considered: Immunomodulators (azathioprine, mercaptopurine, methotrexate), antiTNF alone or combined with immunomodulator, vedolizumab, ustekinumab and tofacitinib;mesalazine and corticosteroids were not analyzed. Result(s): 2 243 patients with IBD suffered COVID-19, compared to COVID-19 cases without IBD there were less females, they suffered more arterial hypertension, diabetes mellitus, dyslipidemia, obesity, or tabacco use (TABLE 1). And yet, despite these being proven risk factors for worse outcomes for COVID-19, no differences were appreciated in hospitalization rate, ICU admission, or mortality between those with or without IBD (TABLE 2). COVID-19 was more frequent in IBD patients (32.59 vs 13.28%). Comparing IBD patients with COVID-19 according to their treatments (TABLE 3), vedolizumab is the only treatment with a higher risk for COVID-19 infection, however the hospitalization risk for vedolizumab is lower than for those without it. Immunomodulators do also have a lower hospitalization risk both alone or in combination with antiTNF, no differences were found for antiTNF monotherapy, ustekinumab or tofacitinib. ICU rate and mortality are no different between treatments, except for tofacitinib (0.00% ICU rate, 10.00% mortality), however the small number of patients using this treatment may bias this result. Conclusion(s): COVID-19 in IBD patients is no different in hospitalization, ICU admission or mortality compared to non-IBD population. IBD patients exposed to immunomodulators and vedolizumab have less hospitalization risk than those not exposed, no differences were found for antiTNF alone or ustekinumab. The impact of tofacitinib in COVID outcomes requires further investigation.

Inflammatory Bowel Disease in the elderly, a survey of elderly patient demographics, diseaserelated complications and compliance with vaccination and screening services

Background: Inflammatory Bowel Disease (IBD) in the elderly (>60yrs) is becoming more prevalent in concordance with the ageing population and the rising incidence of IBD. An increasing number of patients are receiving a diagnosis of IBD in later years in addition to those with known IBD transitioning to elderly. The presentation, disease course, risk of complications and choice of medical therapies differ in this group from younger cohorts. We aimed to examine patient demographics and the incidence of adverse effects/complications amongst elderly IBD patients. We also sought to identify appropriate vaccination rates and uptake with screening services. Method(s): In a single tertiary centre, IBD patients aged >60 attending the outpatient clinic or admitted acutely were invited to complete an anonymous written survey. Result(s): 28 patients surveyed to date. 61% (n=17) had a diagnosis of UC. 54% were female (n=15). Mean age was 67.5, while mean age at diagnosis was 50 (range 19-65). 25% (n=7) received a diagnosis of IBD after 60 years, of which 57% were female. Mean BMI was 25.9. 25% (n=7) reported an infection in the last 6 months, all of whom required treatment with antibiotics. There was only one case of infection requiring hospitilisation, a patient on biologic therapy who developed a clostridium difficile infection. COVID-19 affected 39% (n=11), none required hospitilisation. 21% (n=6) report 2 or more comorbidities, of which 50% report a recent infection requiring treatment. All patients who required IBD surgery (n=5) had a high BMI. 57% (n=16) had a smoking history, with 14% (n=4) being active smokers. Infliximab and salofalk granules were the most prescribed IBD treatments. 46% were on biologics (n=13), with anti-TNF being the most common (29%). 25% (n=7) reported steroid use in the last year while 14% were not currently on IBD treatment. 21.4% (n=6) reported prior malignancy, skin cancer being most common. 50% of cancer sufferers were smokers. 100% have had a minimal of two COVID-19 vaccines. 64% (n=18) have had a flu-vaccine in the last 12 months with 75% (n=21) report annual flu-vaccine uptake. 61% (n=17) had the pneumococcal vaccine. Bowel screening participation was 46.5% (n=13). Conclusion(s): Smoking, high BMI and multiple comorbidities were common in elderly IBD patients. Infections were common in this cohort and typically required treatment with antibiotics, however, were rarely severe or required hospitalisation. Severe infections were seen in those on biologic therapy. Biologics were commonly prescribed to elderly IBD patients. Skin cancer was the most common malignancy. There was suboptimal uptake with vaccinations and bowel screening. (Figure Presented).

Methodology, efficacy and safety of fecal microbiota transplantation in treating inflammatory bowel disease

Fecal microbiota transplantation (FMT), as an emerging therapy, can be used to treat microbiota related diseases. Progresses in donor screening, washed microbiota preparation, microbiota delivery routes, clinical administrative strategies, and long-term safety are moving FMT forward. Increasing clinical studies, especially those randomized controlled trials about ulcerative colitis and pilot real-word studies about serious inflammatory bowel disease (IBD), have been conducted. This review presents the latest findings about the efficacy, safety and methodology of FMT in treating IBD.Copyright © 2020 The Authors

Differences in ulcerative colitis patients regarding COVID-19 status

Background: Severe acute respiratory syndrome coronavirus 2 is the novel coronavirus that caused the coronavirus disease 2019 (COVID- 19) outbreak. Studies have increasingly reported the involvement of other organs, including the gastrointestinal system, in addition to the respiratory system. Ulcerative colitis is an inflammatory bowel disease with an unknown cause. Emerging data suggest that the gastrointestinal system may be influenced by COVID-19 via the expression of angiotensin-converting enzyme-2, but data on the association between COVID-19 and ulcerative colitis, are lacking. Method(s): In 6-month time (June to December 2021) 49 ulcerative colitis (UC) outpatients from Riga East Clinical University Hospital were included in a cross-sectional study. All patients were divided into groups according to medically proven COVID-19 status (COVID-19+ vs COVID- 19-) in the last 6 months. Information about diet, IBD medications, food supplements, vitamins, sports activities, marital status, education level, and income level was collected. Data were analyzed with SPSS 20.0. Result(s): Out of 49 patients, 33(63.3%) were males and 13(36.7%) were females, median age was 38.0 [IQR=17] years. Fourteen patients (28.6%: 7(50%) in each gender) were Covid-19+ within last 6 months. Median time patients suffered from COVID-19 was 7 [IQR=15.3] days. The most common symptoms were: 11(19.6%) fever, 6(10.7%) rhinitis and 5(8.9%) weakness. The most common diet among all patients was IBD diet 33(67.3%) from those 12(21.4%) were COVID-19- and 4(78.6%) were COVID-19+, p=0.00. Out of 49 patients, 25(44.6%) were using food supplements (fish oil, curcumin, collagen, zinc, calcium) of those 17(30.4%) patients were COVID-19-, 8(14.3%) COVID-19+, p=0.00. Most commonly used vitamins were vitamin D 18(64,3%), from those 15(42.9%) were COVID-19-, 3(21.4%) COVID-19+, p>0.5;vitamin C - 7(32,8%), from those 4(11.4%) were COVID- 19-, 3(21.4%) COVID-19+, p>0.5. Twenty-four (49%) were doing sports, of those 18(51.4%) were COVID-19-, 6 (42.9%) COVID+;p>0.5. Most common sports activities were cycling 8(16.3%), running 8(16.3%) and fitness 6(12.2%). Most commonly used IBD medications were mesalazine 35(71.4%), azathioprine 7(14.3%) and biologics 4(8.16%), there were no statistically significant differences between COVID-19+ and COVID-19-. There were no statistically significant differences between marital status, education level, and income regarding COVID-19 status. Conclusion(s): COVID-19 was less common among patients who were using food supplements and followed IBD diet.

Ulcerative Colitis: Rapid Evidence Review

Ulcerative colitis is a relapsing and remitting inflammatory bowel disease of the large intestine. Risk factors include recent Salmonella or Campylobacter infection and a family history of ulcerative colitis. Diagnosis is suspected based on symptoms of urgency, tenesmus, and hematochezia and is confirmed with endoscopic findings of continuous inflammation from the rectum to more proximal colon, depending on the extent of disease. Fecal calprotectin may be used to assess disease activity and relapse. Medications available to treat the inflammation include 5-aminosalicylic acid, corticosteroids, tumor necrosis factor-alpha antibodies, anti-integrin antibodies, anti-interleukin-12 and -23 antibodies, and Janus kinase inhibitors. Choice of medication and method of delivery depend on the location and severity of mucosal inflammation. Other treatments such as fecal microbiota transplantation are considered experimental, and complementary therapies such as probiotics and curcumin have mixed data. Surgical treatment may be needed for fulminant or refractory disease. Increased risk of colorectal cancer and use of immunosuppressive therapies affect the preventive care needs for these patients. (Am Fam Physician. 2022;105(4):406-411. Copyright © 2022 American Academy of Family Physicians.)Copyright © 2022 American Academy of Family Physicians. All rights reserved.

Guillain-Barre syndrome in patients with Coronavirus disease-2019: Report of six cases and review of literature

Background: Few studies have reported the association of Guillain-Barre syndrome (GBS) and coronavirus disease-2019 (COVID-19) infection. In this study, we reported GBS in six patients infected with COVID-19 and reviewed all existing literature about GBS in association with COVID-19. Method(s): This study was performed in three referral centers of COVID-19 in Iran, and six patients with the diagnosis of GBS were enrolled. Patients enrolled in the study with acute progressive weakness according to the demyelinating or axonal variant of GBS, according to Uncini's criteria. Result(s): Four of our patients had axonal polyneuropathy, two patients had demyelinating polyneuropathy, and one patient required mechanical ventilation. All our patients had a favorable response to treatment. In one patient, the GBS symptoms recurred four months after the first episode. Conclusion(s): Limited case reports suggest a possible association between GBS and COVID-19. Such associations may be an incidental concurrence or a real cause-and-effect linkage;however, more patients with epidemiological studies are necessary to support a causal relationship. Copyright © 2020 Iranian Neurological Association, and Tehran University of Medical Sciences.

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION: A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam: faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs: CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 1:40, dsDNA 1:640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR: opacification of the left lung up to midfield. CT chest: moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon: negative. Thoracentesis: 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura: necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity: pan-sensitive M. tuberculosis. Sputum: negative for TB. She was discharged on RIPE treatment for reactivation of TB. DISCUSSION: The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high. CONCLUSIONS: Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1: Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus: case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2):563-568. Reference #2: Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3: Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8):1211-7. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic

LEFLUNOMIDE-INDUCED COLITIS IN IMMUNOSUPPRESSED PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND RHEUMATOID ARTHRITIS

Background: Leflunomide is an oral disease-modifying antirheumatic drug (DMARD), with anti-inflammatory and immunomodulatory properties that has been in use since 1998. Common leflunomide side-effects include gastrointestinal symptoms (nausea, abdominal pain and diarrhea), occurring in 10-20% of patients treated with leflunomide. Scarce evidence exists that leflunomide can cause colitis. Aims: We present the case of a 61-year-old female, with Lupus Erythematosus who presented with colitis induced by long-term leflunomide treatment. Methods: Case report and review of literature Results: A 61-year-old female was seen by the gastroenterology team with complaints of diarrhea ongoing for 6 weeks associated with 10 lb weight loss. The patient had a complex medical history, including lupus, hypothyroidism, asthma, atrial fibrillation, recurrent C. difficile infection, Bell's palsy and avascular necrosis secondary to long-term corticosteroid therapy. Previous immunosuppressive therapies included prednisone, mycophenolic acid (Myfortic), hydroxychloroquine, azathioprine, mycophenolate (CellCept) but due to multiple intolerances, she was initiated on leflunomide in 2014 and has been maintained on it since. Stool analysis ruled out infectious causes. COVID-19 testing was also negative. A CT of the abdomen revealed pancolitis. This was confirmed on colonoscopy, which revealed mild, Mayo 1 pancolitis and normal terminal ileum. She was initiated on Mezavant as a treatment for possible ulcerative colitis. However, during the hospitalization her symptoms, worsened and bloody diarrhea was noted. She underwent a subsequent endoscopic evaluation which revealed more severe disease, Mayo 2-3 colitis, with mucosal hyperemia and ulcerations, as well as effacement of the vasculature. Initial pathology results revealed mild colitis, but repeat pathology results revealed moderate active colitis, with cryptitis, crypt abscesses and significant apoptosis consistent with drug-induced colitis. Given these findings, the diagnosis of leflunomide-induced colitis was made. Leflunomide was therefore discontinued, the patient was initiated on a higher dose of corticosteroids and cholestyramine was initiated. Following these measures, her diarrhea resolved. Conclusions: Leflunomide may cause diarrhea in up to 33% of patients. Challenges related to the diagnosis of leflunomide-induced colitis exist, including the rarity of the diagnosis, a not completely understood mechanism for acute leflunomide-induced diarrhea, as well as variable endoscopic and histologic findings associated with the diagnosis. This report illustrates a case of leflunomide-induced colitis which should be considered in patients on leflunomide, who present with symptoms of abdominal pain and diarrhea, even years after medication initiation.

[Features of the intestine conditions at patients with a new coronavirus infection].

COVID-19 infection may present with gastrointestinal lesions in up to 25% of patients. One of the target organs of the SARS-CoV-2 virus is the intestine. The pathogenesis of intestinal damage in a new coronavirus infection remains unclear and requires further in-depth study. Possible mechanisms include a direct cytotoxic effect of the virus, a persistent reduction in butyrate-producing bacteria, side effects of drugs, Clostridioides difficile infection, microvascular thrombosis, and the immune-mediated inflammatory reactions in the intestine. The most common symptom of intestinal damage during coronavirus infection, both in the acute phase and in the post-COVID period, is diarrhea. The impact of many aggressive factors on the intestines can form both long-term functional disorders and be the cause of the onset of organic diseases. Treatment should be aimed at possible causes of intestinal damage (Clostridioides difficile), as well as reducing inflammation, restoring intestinal permeability, cytoprotection of mucosal cells, replenishing butyric acid deficiency. When choosing a therapy for intestinal disorders, preference should be given to drugs with a pleiotropic effect in order to influence various possible pathogenetic mechanisms.

MORE THAN A COINCIDENCE: RECURRENT COVID-19 DRIVEN ULCERATIVE COLITIS FLARES

CASE: A 61-year-old male with no prior medical history presented with hematochezia, significant weight loss, and abdominal cramping for the past three months. Abdominal pain was predominantly present in the suprapubic area and alleviated with bowel movements. He reported acute worsening of diarrhea frequency with 15 episodes of bowel movement daily. He had similar symptoms in the past when he was diagnosed with a parasitic infection. Physical exam demonstrated diffuse, mild tenderness in all four abdominal quadrants with hyperactive bowel sounds. Infectious workup was negative at the time for stool parasites or bacteria. Lab results were significant for elevated non-specific inflammatory markers including ESR and CRP. CT abdomen revealed diffuse circumferential wall thickening of the entire colon and rectum and multiple associated pericolonic adenopathies, consistent with an inflammatory process. The patient was admitted for management of ulcerative colitis for intractable pain and worsening diarrhea. Of note, he was also found to test positive for COVID19, without significant respiratory symptoms. Colonoscopy confirmed active ulcerative colitis throughout the colon. He was subsequently treated with a course of steroids and initiated on mesalamine upon discharge. Four months later, he was readmitted for an acute flare-up;he developed increased frequency of bowel movements and severe abdominal pain despite adherence with his medication regimen. He was found to have a new COVID19 infection. Other infectious work up was once again negative, with no evident exacerbating factors for his new flare. He was started on adalimumab with routine infliximab infusions with effective control of symptoms. After resolution of his COVID-19 infection, he since then had no further flares from his ulcerative colitis. IMPACT/DISCUSSION: Studies have now demonstrated links between COVID-19 and the sequelae of certain systemic inflammatory pathologies. Here, the evident trigger for our patient's flares were his underlying, concurrent COVID-19 infections. Even though this may initially appear coincidental during his index hospitalization, his later flare highlights a plausible clinical correlation. Though the pathophysiology of COVID-19 associated inflammatory states remains unclear, it could very likely be implicated in primarily exacerbating ulcerative colitis flare ups. CONCLUSION: Ulcerative colitis flares in the inpatient setting require urgent clinical attention, yet often the exacerbating trigger may be unknown. Here, we describe the importance of taking into consideration COVID-19 infection as an independent risk factor for ulcerative colitis flares.

ITS NOT AN ALLERGIC REACTION TO THE COVID VACCINE: HERPES ZOSTER FOLLOWING COVID MRNA VACCINE

CASE: A 72 year old male presented to the outpatient clinic with a “vaccine reaction” after he developed a left arm rash following his Moderna COVID-19 booster. He had received the Moderna vaccines in March & April with the only side effect being arm soreness. On 10/30/2021, he received his booster in his lateral left upper arm. Three days later, he reported arm soreness that progressed in intensity by day 6 and developed a rash. Patient had no prior history of shingles and had received the SHINGRIX vaccine. Medical history was remarkable for subtotal colectomy with ileostomy 2/2 to Crohn's disease, stage III CKD, hypertension, HLD, amputations of the right big toe and left metatarsal 2/2 to osteomyelitis. Home medications included daily allopurinol 100mg, amlodipine 5mg, mesalamine 1,000 mg and octreotide 200 mcg/mL injection 0.5mL SQ BID. Presenting vital signs were normal. A physical exam revealed vesicles on an erythematous base in a C5 dermatome distribution. Incidentally, there was a concentration of vesicles located at the Moderna Booster vaccine site. Rash collected in groups of vesicles on the anterior forearm. Due to delay in presentation and stage III CKD, antivirals were not prescribed. Patient was prescribed Gabapentin 300mg nightly for pain and instructed to continue OTC Tylenol. After several weeks the rash resolved and pain subsided. IMPACT/DISCUSSION: Approximately 4% of patients with a history of Varicella develop a recurrent episode later in life with people who are immunosuppressed most affected. Possible triggers of zoster (HZ) include external reexposure to the virus, acute or chronic diseases such as malignancies or infections (i.e COVID-19), medications and stress. As of 12/5/21, the Vaccine Adverse Event Report System (VAERS) reported shingles in 1200 patients after receiving Pfizer vaccine, 1201 Moderna, and 1203 in Janssen vaccine recipients. While these reports are unable to be validated, it is important for clinicians to recognize the suggested relationship. Hypotheses of why our patient developed shingles include: 1) the immune activation from the vaccine activated dormant varicella, 2) the patient being older & immunocompromised puts him at a higher risk of developing HZ in general, and 3) the vaccine triggers a transient lymphopenia similar to being infected with COVID-19 and lymphopenia causes reactivation. As we continue to reach higher percentages of individuals receiving vaccines, we likely will continue to encounter cases such as described. CONCLUSION: It is important for clinicians to be aware of HZ reaction post COVID vaccination and to have this in their differential when a patient complains of a “reaction” to the vaccine. We regret that the patient being mis-triaged as an “allergic reaction” led to the patient being evaluated outside of the possible window of acute treatment of HZ. By describing this case we hope clinicians will be more aware of this relationship and prevent delay to treatment or misdiagnosis.

COVID-19 VACCINE HESITANCY REMAINS HIGH IN INFLAMMATORY BOWEL DISEASE PATIENTS

Introduction Despite the global impact of the COVID-19 pandemic, vaccine hesitancy remains common in the general public. Adults who were on immunosuppressive medications were among the earlier groups recommended by the Centers for Disease Control and Prevention to receive the COVID-19 vaccine. It is unclear whether similar vaccine hesitancy is seen in patients with inflammatory bowel disease (IBD), especially those who are on immunosuppressive medications. We sought to examine rate of vaccine hesitancy in patients with IBD as well as associated demographic and socioeconomic risk factors. Methods We performed a retrospective chart review in November 2021 of 1383 patients with IBD seen at University of Maryland Medical Center, a tertiary referral medical center, between November 2020 and October 2021. Data obtained from patients' charts included demographics;disease characteristics including disease phenotype, number of years since diagnosis, number of IBD-related surgeries;and IBD therapy including biologics, thiopurines or methotrexate, corticosteroids, and mesalamine. Information on COVID vaccination and routinely recommended vaccines were also collected which included annual influenza vaccine, Prevnar/ Pneumovax, and Shingrix. Those with no recorded COVID-19 vaccine were contacted by nurses for updated vaccine status. Results 72% (990/1383) of patients in this cohort were on a biologic, 17% (232/1383) were on corticosteroids, and 16% (224/1383) were on thiopurine or methotrexate, indicating a cohort of patients with moderate to severe disease phenotype. Fifty-seven percent (792/1383) of patients received either the Pfizer, Moderna, or Johnson & Johnson vaccine. In a multivariate regression analysis, COVID vaccination was found to be positively associated with a number of factors including older age (p-value= 4.92e-4), female sex (p=1.61e-3), Asian and Caucasian races (p=9.13e-3, 6.47e-06), number of years since diagnosis (p=2.73e-2), number of clinic visits in the past 12 months (p= 2.66e-10), and biologic use (p=4.41e-4). This remained the case while controlling for IBD disease type;marital status;insurance (Commercial vs Medicaid vs Medicare);and tobacco, alcohol, and substance use history. Patients who received other routinely recommended vaccines (influenza, Prevnar/Pneumovax, Shingrix) were not more likely to receive COVID- 19 vaccine. Discussion Although majority of patients in this cohort were on an immunosuppressive medication, COVID-19 vaccination rate is only recorded to be at 57%. Number of clinic visits, presumably more education and conversation with healthcare providers, had a positive impact on COVID-19 vaccination. In this cohort, younger adults, males, and African Americans were less likely to receive COVID-19 vaccine. Healthcare providers need to recognize these potential risk factors for COVID-19 vaccine hesitancy.

IMPACT OF INFLAMMATORY BOWEL DISEASE THERAPIES ON DURABILITY OF HUMORAL RESPONSE TO SARS COV-2 VACCINATION

IMPACT OF INFLAMMATORY BOWEL DISEASE THERAPIES ON DURABILITY OF HUMORAL RESPONSE TO SARS COV-2 VACCINATION Background and Aim: Immunization against the spike protein of SARS-CoV-2 reduces the risk of severe outcomes and previous data show that most inflammatory bowel disease (IBD) patients mount SARS-CoV- 2 anti-spike (S) antibodies (Ab). However, no data exist on the durability of these antibodies over time. We sought to investigate the impact of IBD and its therapies on post-vaccination antibody response and decay rates. Methods: Data were retrospectively ed from patients with IBD who underwent one Anti-S Total Ab (Labcorp®) test ≥2 weeks post 2nd dose, between April 15th-October 19th, 2021. Analyses included t-tests/1-way ANOVA, Mood's medians tests, chi-square and Fisher-exact tests. Linear regression estimated linear log(e)(Anti-S Total Ab) decays post-vaccine dose #2 (excluding patients with COVID-19 history). Exponentiated decay coefficients (EDC) represent % change from geometric mean titer (GMT). Results: We identified 176 patients with Anti-S Total Ab (Labcorp®) titer testing following two doses of the BNT162b2 (Pfizer/BioNTech;n=111) or mRNA-1273 (Moderna;n=65) vaccines. We compared non-immunosuppressed (IS) patients (non-anti- TNF biologics/Mesalamine/Budesonide/No therapy) to patients on IS (anti-TNF-a ± immunomodulators). Patients on systemic steroids (n=7) or tofacitinib (n=7) were excluded due to low sample size. Median interval from dose #2 to titer testing was 126 days (IQR:89-162), similarly distributed among vaccine/medication groups (p=0.4). Overall GMT was 306 u/ mL (95%CI 234-401), non-significantly different between vaccines (p=0.6). Four patients had undetectable antibodies (three on tacrolimus and one on renal dialysis). One had breakthrough COVID-19 infection (S-titer=13u/mL). Patients receiving IS had significantly lower titers (mean log) for both vaccines, compared to those without IS overall (Fig 1A). Patients receiving IS had lower proportions with Anti-S Total Ab above 100U/mL, 300 U/ mL, 500U/ml and 1000U/mL at all timepoints up to 6 months post-second dose (Fig 1B). Patients on IS had significant titer decay (Fig 1C, n=42, EDC 1.8%/day, p=0.012, t½≈38 days) and was significantly faster (Δ-slope p<0.05) than those not on IS (n=74, p=0.058, EDC 0.05%/day, t½≈153 days). Among anti-TNF monotherapy patients (Fig 1D), there was faster decay in BNT162b2 (n=25, EDC 2.4%/day, p=0.002, t½≈28 days) compared to mRNA- 1273 (n=10, EDC 0.9%/day, p=0.188, t½»76 days), with near-significant Δ-slope (p=0.109). Conclusions: While IBD patients initially exhibit robust responses to SARS-CoV-2 vaccination, far fewer patients on IS achieve high titers. Titers decay faster in those on anti-TNF agents, and data suggests this decay is more pronounced with BNT162b2 (Figure Presented)

Sudden cardiac death in a case of Crohn's disease with COVID-19: A case report

Rationale: The mechanism of sudden cardiac death in COVID-19 can be multifactorial. Cardiac hypersensitivity to 5-ASA therapy leading to myocarditis has been reported in some cases. Cytokine storm syndrome and idiosyncratic reaction with mesalazine use may lead to sudden cardiac death in COVID-19. Use of immunosuppressants in hospitalized COVID-19 patients should be continued with caution, especially in patients with inflammatory bowel disease. Patient's concern: A 75-year-old man who was tested positive for SARS-CoV-2 was admitted with a history of shortness of breath for the last two days. He was a known case of Crohn's disease treated with mesalazine. Diagnosis: COVID-19 pneumonia with underlying Crohn's disease leading to sudden cardiac death. Intervention: Remdesivir, antibiotics, steroids, low molecular weight heparin, tablet zinc, tab vitamin C, and other supportive treatment were started. Because of increased inflammatory markers, itolizumab was given to the patient on the 2nd day. Outcome: On the 5th day of the intensive care unit, the patient complained of sudden chest pain with respiratory distress leading to bradycardia and asystole and could not be resuscitated. Lessons: Causes for sudden cardiac death in COVID-19 pneumonia patients with Crohn's disease is multifactorial. Although mesalazine may be a safe and effective drug in the management of inflammatory bowel disease, it can induce sytokine strom syndrome and idiosyncratic reactions that could be one of the reasons of sudden cardic death. Therefore, we should be aware of its serious and potentially life-threatening complications, especially in COVID-19 infected patients.

Unusual Presentation of Pneumonic-Type Lung Adenocarcinoma and Diffuse Air-Space Consolidation

Introduction: Pneumonic-type lung adenocarcinoma (P-ADC) exhibits a pattern of lung cancer that is radiologically like pneumonia1. It may be misdiagnosed and represents a diagnostic challenge in the setting of progressive respiratory failure. We report a case of P-ADC which presented with rarely described extensive diffuse air-space consolidation. Case Presentation: This is a 74-year-old female with a history of Crohn's disease on Mesalamine, Diabetes Mellitus, Hypertension, Hyperlipidemia and former smoker of 40 pack years admitted to the ICU for hypoxic respiratory failure requiring 100% O2 via HFNC. Twenty-two months prior to admission the patient underwent an EBUS following abnormal low dose lung cancer screening CT (Figure 1A-B). The CT demonstrated left infrahilar consolidation and multiple ground-glass nodules. The EBUS with biopsy/brushings of the mass in addition to bronchoalveolar lavage (BAL) were negative. She was lost to follow-up due to the COVID-19 pandemic. Two weeks prior to admission she was admitted for cough and dyspnea, treated for a community acquired pneumonia following CT showing excessive nodular opacities with left dense consolidations. On day of admission the patient presented from outpatient PFT with hypoxemia requiring 8LPM O2 and saturation of 90%, admitted to ICU on HFNC. Associated symptoms were recent unintentional 20 lbs weight loss and fatigue. CT imaging was remarkable for progressive, fulminant left lung consolidation and contralateral lung nodules (Figure 1C-D). The patient underwent a bedside bronchoscopy which showed normal anatomy and copious thin clear secretions. BAL samples showed malignant cells favouring nonsmall cell carcinoma. Further CT guided FNA showed the tumor cells were consistent with adenocarcinoma and positive for TTF1/Napsin A, negative for p40, and KRAS mutation detected. The patient was started on methylprednisolone, Carboplatin and Pemetrexad and discharged home on 6 LPM oxygen. The patient was shortly after re-admitted for a post obstructive pneumonia and progressive hypoxemic respiratory failure, she transitioned to hospice care and passed away during the hospitalization. Conclusion: P-ADC is uncommon and often misdiagnosed due to unusual presentation mimicking infectious and inflammatory diseases2. It is unclear whether P-ADC represents an extreme form, later stage, or entirely different entity of lung cancer and large airspace consolidations are rarely reported3. Lesions of pneumonia type that extend beyond one lobe on CT are associated with microscopy involvement of both lungs and pathologic correlation shows that CT is unable to reveal multifocality in a high percentage of cases which makes the extend of multifocal consolidations in this case rarely described4-6. (Figure Presented).

Similar risk of infection with SARS-CoV-2 in immunocompromised and immunocompetent patients with inflammatory bowel disease and healthy controls

Background: The information on seroprevalence rates of COVID-19 infection among patients with inflammatory bowel disease (IBD) and its comparison to healthy controls is sparse. We compared the seroprevalence rates in immunocompromised and immunocompetent IBD patients and healthy controls. Methods: Patients with IBD under follow-up at the IBD clinic, All India Institute of Medical Sciences, New Delhi, were included. After obtaining informed consent, patients underwent SARS-CoV-2 antibody testing (chemiluminescent immunoassay: Seimens kit IgG against antigen S1RBD) and information on demography, drug history, past history of COVID infection and vaccination status were noted. Patients with IBD on 5-aminosalicylic acid or not on any treatment were considered immunocompetent and those who had received steroids, thiopurines or methotrexate within 6 months of sample collection were considered immunocompromised. Results: 235 patients (51.9%-males;mean age at enrolment- 38.7±12.4 years;median disease duration-60 months [IQR:36- 120]) (UC-69.4%, CD-28.9%, IBDU-1.7%) and 73 healthy controls (HCs- mean age-39.6± 10.9 years, 79% males) were enrolled from July 2020 - April 2021 (Table1). 128 (54.5%) patients were immunocompromised and 107 were immunocompetent (treatment details: 5 ASA-72.3%, steroids-15.3%, Thiopurines-40%, methotrexate-2.6%). Seventy-four (31.5%) patients were positive for IgG antibody against SARS CoV2, 2 patients (0.9%) had previous history of COVID infection and none received COVID vaccine. Seroprevalence rates between immunocompromised and immunocompetent patients with IBD and healthy controls was similar (28.1% vs 36% vs 28%, p>0.05) (Figure1). Demographic and disease characteristics such as age, gender, disease type, disease activity in last 6 months, disease duration and medication use was similar between patients with positive and negative serology (Table2). There was progressive increase in seroprevalence from July 2020 to April 2021 Conclusion: Upto 1/3rd patients with IBD were seropositive for IgG SARS Cov2 antibody indicating asymptomatic COVID-19 infection. The seroprevalence was similar to healthy controls and was not different between immunocompromised and immunocompetent patients with IBD.

Mild COVID-19 disease and breakthrough cases among children with inflammatory bowel disease: An update from an international registry

Background: Coronavirus disease 2019 (COVID-19) tends to cause mild disease in children, although severe disease occurs rarely. Children with inflammatory bowel disease (IBD) often receive immunosuppressive medications that may increase risk of infectious complications. Little is known about the severity of breakthrough infection after COVID-19 vaccination in children with IBD. We describe COVID-19 outcomes among children with IBD, including those with breakthrough infection. Methods: The Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) is a database created to evaluate COVID-19 outcomes in IBD patients. We included children (age ≤18) from the SECURE-IBD database through November 17th, 2021. We used descriptive statistics to summarize demographic/disease characteristics of the study population, both overall and stratified by hospitalization status, and performed bivariate comparisons. We reported demographic and clinical details of patients requiring an intensive care unit stay and those with breakthrough infection (defined as ≥1 COVID-19 vaccination prior to infection), respectively. Results: We analyzed 606 pediatric IBD COVID-19 cases from 37 countries. The most common IBD medications were tumor necrosis factor (TNF) antagonist monotherapy (48%) and sulfasalazine/ mesalamine (20%). Most patients (85%) had no non-IBD comorbidities. No patients died, and 28 children (5%) were hospitalized. Factors associated with hospitalization included non-IBD comorbid conditions (43% hospitalized vs 13% not;p <0.01), moderate/severe IBD disease activity (61% vs 15%;p <0.01 overall), gastrointestinal symptoms (68% vs 16%, p <0.01), and steroid use (29% vs 6%, p <0.01). TNF antagonist monotherapy was associated with a decreased likelihood of hospitalization (29% vs 49%;p value 0.03) (Table 1). Seven patients needed intensive care, and three (0.5%) required mechanical ventilation (Table 2). There were nine fully vaccinated and five partially vaccinated patients who developed breakthrough infection, of whom only one required hospitalization but did not need a ventilator (Table 3). The majority of patients with breakthrough infection (13/14) were on systemic immunosuppressants at the time of COVID-19 infection (10/14 on TNF antagonists). Conclusion: We found that children with IBD have a relatively low risk of severe COVID-19 outcomes. Among children with IBD who developed COVID-19 after vaccination, the majority were on immunosuppressants and had mild disease that did not require hospitalization. These data may reassure families and providers of children with IBD during the COVID-19 pandemic and support public health recommendations for COVID-19 vaccination among eligible children with IBD.