A CASE OF SARS-COV-2 ASSOCIATED WITH QUADRUPLE BACTERIAL COINFECTION

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: SARS-CoV-2 has been associated with co-infecting pathogens, such as bacteria, viruses, and fungi. Little has been reported about community acquired atypical bacterial co-infections with SARS-CoV-2. We present a case of a patient with recent COVID-19 pneumonia and diagnosis of Legionella and Mycoplasma pneumonia, in addition of E. coli and C. perfringens bacteremia, that emphasizes SARS-CoV-2 impact in human immunity and the need to consider community acquired infections. CASE PRESENTATION: A 64-year-old male with history of hypertension, alcohol use disorder, iron deficiency anemia, and recent COVID-19 pneumonia presented to the ED with shortness of breath, dark urine, and increased confusion. The patient was admitted to the hospital a week prior with COVID-19 pneumonia and acute kidney injury. He received dexamethasone, remdesivir, and IV fluids. After 8 days, he was discharged home. Upon evaluation, he was afebrile and normotensive, but tachycardic, 129/min, on 4 L of nasal cannula sating 100%. On exam, the patient was oriented only to person and had decreased breath sounds bilaterally. Labs revealed an elevated WBC, 15.3 K/mcL, with left shift, low Hgb, 7.8 g/dL, with low MCV, 61 fL, increased BUN/Cr, 56 mg/dL and 2.8 mg/dL, and an abnormal hepatic panel, AST 121 U/L, ALT 45 U/L, alkaline phosphatase 153 U/L. Ammonia, GGT, CPK and lactic acid were within normal range;but the D-dimer and procalcitonin were elevated, 4618 ng/mL and 25.12 ng/mL, respectively. A urinalysis showed gross pyuria, positive leukocyte esterase and mild proteinuria. CT head showed no acute abnormalities, but the chest X-Ray revealed a hazy opacity in the left mid and lower lung, followed by a CT chest that demonstrated peripheral and lower lobe ground glass opacities and a CT abdomen that showed right sided perinephric and periureteral stranding. Given increased risk for thromboembolism, a VQ scan was done being negative for pulmonary embolism. The patient was admitted with acute metabolic encephalopathy, acute kidney injury, transaminitis, pyelonephritis and concern for hospital acquired pneumonia. Vancomycin, cefepime and metronidazole were ordered. HIV screen was negative. COVID-19 PCR, Legionella urine antigen and Mycoplasma IgG and IgM serologies were positive. Blood cultures grew E. coli and C. perfringens. Infectious Disease and Gastroenterology were consulted. The patient was started on azithromycin and a colonoscopy was done showing only diverticulosis. After an extended hospital course, the patient was cleared for discharge, without oxygen needs, to a nursing home with appropriate follow up. DISCUSSION: Co-infection with bacteria causing atypical pneumonia and bacteremia should be considered in patients with recent or current SARS-CoV-2. CONCLUSIONS: Prompt identification of co-existing pathogens can promote a safe and evidence-based approach to the treatment of patients with SARS-CoV-2. Reference #1: Alhuofie S. (2021). An Elderly COVID-19 Patient with Community-Acquired Legionella and Mycoplasma Coinfections: A Rare Case Report. Healthcare (Basel, Switzerland), 9(11), 1598. https://doi.org/10.3390/healthcare9111598 Reference #2: Hoque, M. N., Akter, S., Mishu, I. D., Islam, M. R., Rahman, M. S., Akhter, M., Islam, I., Hasan, M. M., Rahaman, M. M., Sultana, M., Islam, T., & Hossain, M. A. (2021). Microbial co-infections in COVID-19: Associated microbiota and underlying mechanisms of pathogenesis. Microbial pathogenesis, 156, 104941. https://doi.org/10.1016/j.micpath.2021.104941 Reference #3: Zhu, X., Ge, Y., Wu, T., Zhao, K., Chen, Y., Wu, B., Zhu, F., Zhu, B., & Cui, L. (2020). Co-infection with respiratory pathogens among COVID-2019 cases. Virus research, 285, 198005. https://doi.org/10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Albert Chang No relevant relationships by Eric Chang No relevant relationships by KOMAL KAUR No relevant relationships by Katiria Pintor Jime ez

A Single Center, Retrospective Analysis of Inpatient Neurologic Consultations of Patients Infected with SARS-CoV-2

Objective: To determine if inpatient neurological consultations differ between COVID-19 and non-COVID-19 respiratory infections. Background: The COVID-19 pandemic has posed challenges to healthcare systems across the world, and neurological complications of COVID-19 have garnered increased concern in medicine and the public. Neurological consultation for patients with viral-mediated disease is common;it is unknown whether the neurologist's approach to inpatient consultation of patients with COVID-19 should be altered. Design/Methods: We performed a retrospective chart analysis of inpatient neurologic consultations at three major hospitals comprising the University of Pennsylvania Health System. We compared the reason for neurologic consultation and final diagnosis of 62 patients with COVID-19 between March 2020 and April 2021 to 56 patients with non-COVID-19 respiratory virus (defined as Influenza A, Influenza B, Respiratory Syncytial Virus, Rhinovirus, or Adenovirus) between January 2019 and January 2020. Secondary metrics included mortality and level of care. A frequency and means analysis were completed to evaluate the relative difference between groups on all primary and secondary metrics. Results: Stroke was the only diagnosis more common in the COVID population as compared to the non-COVID virus population (14% vs. 9%). Neurology was consulted more frequently for altered mental status in the COVID-19 population (27% vs. 18%);however, the ultimate diagnosis was toxic-metabolic encephalopathy due to infection, not a consequence of COVID-19 itself. Neurology was consulted significantly later in the hospital course of COVID-19 (3.1 vs. 0.96 days), despite a higher mortality in the other population (30% vs. 19%). Conclusions: Patients requiring inpatient neurologic consultation with a diagnosis of COVID-19 or another respiratory virus were found to be remarkably similar in terms of their ultimate neurologic diagnosis, with the exception of stroke, which was more common in the COVID-19 population. These results suggest the neurological approach to patients with COVID-19 should be similar to that in patients with other respiratory infections.

Hiding from the drug screen: a case of extensive nitrous oxide misuse

Objective: To describe a case of extensive nitrous oxide (NO) misuse in a commercial airline pilot to specifically avoid detection on employer urine drug screens (UDS). Case report: A 48-year-old male commercial airline pilot was evaluated in a Medical Toxicology clinic for history of NO misuse. He started using NO and cannabis as a teenager. When he became an airline pilot, he stopped his cannabis use to ensure he passed frequent employer drug screens. He researched that NO was not detected on UDS and continued its use. During the COVID-19 pandemic, the patient's use grew to 1,200 eight gram NO canisters daily in an attempt to alleviate his stress. He described inhaling the gas until he passed-out. Upon waking, he, would use more until he again passed-out, repetitively cycling throughout the night. His developed paresthesias, progressive weakness in legs, and difficulty walking to the point where he had to crawl to the front door to receive his shipments of NO canisters. His cognition declined and he was brought to the hospital for help after being found in his home garage. Magnetic resonance imaging (MRI) imaging of the brain showed atrophy from chronic toxic metabolic encephalopathy. MRI of the spine did not show abnormalities. Upon referral to the Medical Toxicology clinic, he had not used NO for 3 months and had been taking vitamin B172. Symptoms had improved, but he still had extremity paresthesias, memory difficulties, and required a cane to walk. The patient's NO misuse had been reported to the Federal Aviation Administration (FAA) during his hospitalization and he was no longer allowed to pilot commercial airlines. Conclusion: Random drug testing of airline pilots is required by the FAA and the UDS test for D-9-tetrahydrocannabinol-9-carboxylic acid, benzoylecgonine, codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, 6-acetylmorphine, phencyclidine, amphetamine, methamphetamine, methylenedioxymethamphetamine and methylenedioxyamphetamine [1]. Negative drug screens may give an employer a false sense of security that a pilot is not using/misusing substances but the UDS does not pick up numerous abused substances, including inhalants. This case illustrates the dangers in relying solely on the UDS to ensure pilots are clear from illicit substances. This patient was misusing nitrous oxide for decades which lead to permanent cognitive decline that negatively impacted his ability to safely fly.

The Impact of COVID-19 Infection on a Neurologically Compromised Male With Fahr's Disease Presenting With Acute Delirium and Aspiration Pneumonia: A Case Report.

Fahr's disease or idiopathic basal ganglia calcification is a rare, sporadic, genetically dominant, and inherited neurological condition that manifests with dysphagia and Parkinson's disease. The computed tomography (CT) scan is the method of choice to diagnose basal ganglia calcifications seen in Fahr's disease. This case report elaborates on the emergency management of a 58-year-old male patient with acute respiratory distress, acute delirium, schizophrenia, Fahr's syndrome, and history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 or COVID-19) infection. The patient's chest X-ray, laboratory workup, and vital signs were suggestive of aspiration pneumonia-induced sepsis and acute hypoxemic respiratory failure. Post-admission antibiotic management reduced sepsis complications without improving the altered mental status. A comprehensive clinical assessment suggested the attribution of Fahr's disease to the patient's aspiration pneumonia and other clinical complications. In addition, COVID-19 infection, sepsis-induced inflammatory processes, and pre-existing neurological compromise possibly deteriorated the patient's neurological outcomes, overall prognosis, and recovery.

A RARE COMPLICATION FROM PERCUTANEOUS TRACHEOSTOMY PAVING WAY FOR PREOPERATIVE ULTRASOUND

TYPE: Case Report TOPIC: Procedures INTRODUCTION: With the emergence of COVID-19, our institution has seen an increase in the number of tracheostomies performed. We describe a case of a bedside percutaneous tracheostomy complicated by injury to an innominate artery that prompted multidisciplinary discussions on best practices for preoperative evaluation. CASE PRESENTATION: A 63-year-old lady presented with acute metabolic encephalopathy after suffering a seizure the day prior. She was intubated for airway protection but failed to extubate despite her chief complaint resolving. The decision was made to perform a bedside percutaneous tracheostomy on day thirteen of ventilator support. The procedure was complicated by an incidental injury to a high-riding innominate artery. The patient was emergently taken to the operating room where she underwent a sternotomy and coronary artery bypass with repair to the innominate artery. She was then transferred to the cardiovascular transplant unit in critical condition. DISCUSSION: Bedside tracheostomies are becoming more frequent due to convenience, lower cost, and lower infection rates. There are no official recommendations to perform imaging prior to performing a bedside tracheostomy to evaluate for vascular structures that could be damaged and lead to significant morbidity and mortality unless palpated pulses are present. Portable ultrasonography has the ability to lower the frequency of hemorrhagic complications by detecting pre-tracheal vessels. CONCLUSIONS: As bedside tracehsomties increase in prevalence, there should be a standardized preoperative assessment that includes portable ultrasound prior to tracheostomies to decrease hemorrhagic complications. DISCLOSURE: Nothing to declare. KEYWORD: tracheostomy

Multi-Organ Failure in a Patient With Diabetes due to COVID-19 With Clear Lungs.

The pandemic of coronavirus disease 2019 has emerged in late 2019 infecting millions of people worldwide. Diabetes mellitus (DM) has been associated with severe illness and mortality mainly due to acute respiratory distress syndrome. We report a case of a middle-aged man with DM and COVID-19 who developed seizure and altered mental status, found to have diabetic ketoacidosis (DKA), acute kidney injury, hypovolemic shock, and hyperammonemia all contributing to metabolic encephalopathy. He was admitted to the ICU and subsequently intubated for airway protection; with appropriate management his condition improved and was successfully extubated. The patient had no lung involvement throughout the illness. We report this case to highlight that COVID-19 can lead to multi-organ failure in patients with DM even in the absence of lung involvement which all physicians should be mindful of.