Complex presentations in people with diabetes: Does HbA1c help or hinder?

HbA1c measurement is widely used for diagnosis/ management/remission of diabetes with international schemes certifying comparability. A) 75 year-old Chinese female with type 2 diabetes was admitted in April 2020 with Covid-19 and diabetic ketoacidosis. Glucose was 35mmol/l and HbA1c 150mmol/mol with previous HbA1c of 45mmol/mol on metformin and alogliptin. She was treated for ketoacidosis and once-daily Lantus introduced along with supportive management of viral illness. B) 68 year-old Afro-Caribbean with type 2 diabetes on metformin before admission, presented with new onset, jerky ballistic movements of high amplitude in right arm, 10-15 movements every 5 min. Admission glucose was >33mmol/l, ketones 1.8mmol/l and HbA1c >217mmol/ mol. Hemichorea-hemiballism, a hyperglycaemia related movement was diagnosed and insulin commenced. Glucose decreased to 8-20mmol/ l, reaching 5-15mmol/ l by time of discharge. Ballistic movements resolved when glycaemic control improved with HbA1c 169mmol/mol, 25 days after discharge. C) Several days before admission, a female with diabetes over 20 years required attention from paramedics on four occasions for hypoglycaemia. Months beforehand metformin was replaced by gliclazide due to chronic kidney disease with HbA1c 50mmol/mol, and she was transfused six weeks before admission for microcytic anaemia. Gliclazide was discontinued and her diet modified which prevented further hypoglycaemic episodes. Variant haemoglobin, beta-thalassaemia which can overestimate glycaemia;undetected by HbA1c HPLC method, invalidated HbA1c as did the blood transfusion. These cases highlight that inadequate understanding of HbA1c can lead to acute presentations of dysglycaemia. As HbA1c accuracy can be affected by multiple factors, clinical assessment and triangulation are key to the management of such patients.

Functional movement disorders during the COVID-19 pandemic

Functional movement disorders (FMDs) are a heterogenous group of movement abnormalities that greatly affect the quality of life of patients. They usually manifest as a result of underlying psychological or psychiatric illnesses without any known structural or neurochemical diseases. Various neurological disorders such as encephalitis, stroke, demyelination, seizures, and neuropathy have been reported by otherwise healthy individuals during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Here, we describe the case of a 27-year-old woman who presented to our outpatient department with episodes of deviation of angle of mouth with variability and distractibility. Following thorough clinical evaluation and appropriate investigation, the underlying etiology was identified as FMD secondary to the restrictions imposed during the COVID-19 pandemic to contain the transmission of the virus. The lockdown, isolation, financial strain, and other pandemic-related issues are stressors that may contribute to psychogenic disorders in people.Copyright © 2021 Annals of Movement Disorders Published by Wolters Kluwer - Medknow.

Acute ischemic stroke due to floating thrombus of ascending aorta: An acute and subacute complication of SARS-CoV-2 infection

Objective: To describe ischemic stroke due to floating thrombus of ascending aorta occurring as acute and subacute complication of SARS-CoV-2 infection. Material(s) and Method(s): consecutive identification in clinical practice of ischemic strokes secondary to aortic arch thrombosis and history of acute or recent Covid-19 infection. Result(s): two patients had ischemic stroke with evidence of aortic arch thrombosis. The first case had concomitant acute Covid-19 infection, the second had recent Covid-19 infection. Both patients underwent intravenous thrombolysis, and subsequent anticoagulation. One patient died due to cerebral hemorrhage. Discussion and Conclusion(s): aortic arch thrombosis can be an incidental finding in acute ischemic stroke in patients with concomitant and recent COVID-19 disease. However, the infection may lead to thrombosis in non-atherosclerotic vessels and to cerebral embolism. Our findings support active radiological search for aortic thrombosis during acute stroke in patients with acute or recent COVID-19 disease.Copyright © 2022

Tsukamurella and mycobacterium tuberculosis pneumonia co-infection

Case Report: Tsukamurella species are aerobic, partially acid fast saprophytes commonly isolated from soil and water. They are opportunistic pathogens known to infect multiple organs and can contribute to significant pathologies such as bacteremia, peritonitis, and respiratory tract infections. Moreover, Tsukamurella shares certain characteristic properties to Mycobacterium tuberculosis and Actinomyces species, including the acid fast stain, which can contribute to misdiagnosis of patients. A 68 year old female patient presented to the ED for shortness of breath, fatigue, and weight loss for 6 months. The patient's past medical history includes pulmonary fibrosis, type 2 diabetes, coronary artery disease with stent, hyperlipidemia, hypertension, and M. tuberculosis infection when she was 3 years old in Finland. On admission, labs revealed thrombocytosis (reactive 555 000/microL), leukocytosis (14 450/microL), and microcytic anemia (9.4 microg/dl). Moreover, C reactive protein was elevated and procalcitonin was normal (0.06 microg/l);a COVID-19 PCR was negative. An X-ray revealed severe patchy and interstitial infiltrates throughout both lungs with parenchymal scarring and pleural thickening in the periphery of the left mid-lung zone with multifocal pneumonia. Blood and sputum cultures were performed under the impression of pneumonia, and treatment with azithromycin and ceftriaxone was started. A M. tuberculosis infection was suspected due to a positive AFS. Further chest CT suggested multifocal pneumonia within the left lung in addition to apparent cavitary lesions versus bulla, a chronic interstitial lung disease with traction bronchiectasis, calcified right lower lung nodule, and calcified hilar lymph nodes suggesting a history of granulomatosis diseases. A bronchoscopy with Bronchoalveolar lavage was performed. The initial sputum specimen direct smear showed acid-fast stain positive with Actinomyces growth, and Penicillin G was added to the treatment. Samples were sent to the state department lab, and biopsy revealed granulomatous inflammation negative for malignant cells. One month later, the patient's sputum culture showed Tsukamurella for High-performance liquid chromatography (HPLC). Moreover, a rifampicin sensible M. tuberculosis complex by NAA was also positive six weeks later. The patient was started on a complete TB regimen and continued in the outpatient pulmonology clinic with the addition of levofloxacin for three months and rifampicin substituted for rifabutin. As demonstrated in the case above, a Tsukamurella infection can present similarly to a Mycobacterium infection. Patients may be misdiagnosed or potentially be co-infected. Our patient was further tested and appropriately treated for Tsukamurella after further extensive diagnostic screenings. Due to a high rate of missed cases, it is important to keep Tsukamurella infection on the differential diagnosis as the patient presentation may initially appear to be a Mycobacterium or other pulmonary infection. Copyright © 2023 Southern Society for Clinical Investigation.

More Than Meets the Eye: Orbital Swelling in an Adolescent with Sickle Cell Disease

Periorbital swelling is a clinical presentation with a broad differential and potentially deleterious consequence. Causes range from benign, including allergic reaction, to vision-and life-threatening, including orbital cellulitis and orbital infarction. The recent climate of SARS-CoV-2 has further complicated this differential, as the virus poses broad clinical presentations with new manifestations reported frequently. Rapid identification of the underlying etiology is crucial, as treatment approaches diverge greatly. Here, we report the case of an African American adolescent male with a history of homozygous sickle cell anemia presenting to an inner city hospital with bilateral periorbital swelling amid the coronavirus pandemic. Differentials including orbital cellulitis, COVID-MIS-C, orbital inflammatory syndrome, Hoagland sign, and orbital infarction secondary to sickle cell crisis are contrasted. We contrast our case with 12 case reports of orbital infarction in the setting of sickle cell crisis within the past 10 years, highlighting how these presentations, along with commonly reported findings of orbital infarction, compare with our patient. Copyright © 2022 Tehran University of Medical Sciences.

GRANULOMATOSIS POLYANGIITIS MASQUERADING AS COVID-19: A DIAGNOSTIC DILEMMA DURING THE PANDEMIC

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatous polyangiitis (GPA), previously known as Wegener's granulomatosis, is a rare syndrome characterized by inflammation of small and medium sized vessels. The clinical presentation can be very heterogenous and differentiation from an infectious disease can be challenging initially. Here, we present a case of a young male presenting with respiratory symptoms during the pandemic, presumed to have coronavirus disease 2019 (COVID-19) though after extensive workup was later diagnosed with GPA. CASE PRESENTATION: A 19-year-old male presented to the emergency department (ED) with complaints of low-grade fever and dry cough for one week. He reported having abdominal pain, fatigue, loss of appetite and polyarthralgia. An outpatient upper gastrointestinal endoscopy revealed gastritis and duodenitis. In the ED, his vitals included a temperature of 101.8°F, blood pressure of 115/65mmHg, heart rate of 99/min, respiratory rate of 18/minute and oxygen saturation of 99% on room air. COVID-19 testing was negative. A computerized tomography of the chest revealed extensive ground glass opacities. He was presumptively diagnosed with COVID-19 and started on dexamethasone therapy along with azithromycin for atypical pneumonia. However multiple tests for SARS-CoV-2 were negative. Another consideration was COVID-19 induced multisystem inflammatory syndrome given the patients young age. Infectious workup included negative testing for human immunodeficiency virus, Legionella, tick borne diseases and mycoplasma. As febrile episodes continued, he developed microcytic anemia, microscopic hematuria, and petechial rash on his ankles. Antinuclear antigen screen was negative, but C-antineutrophil cytoplasmic and anti-proteinase-3 antibodies were positive. Renal biopsy revealed GPA. He was prescribed pulse dose steroids and transitioned to immunotherapy. DISCUSSION: GPA is a challenging diagnosis given multiple system involvement, though early identification and initiation of treatment are important to prevent long term sequalae. In our case, acute onset febrile illness and pulmonary ground glass opacities led to repeated COVID-19 testing potentially delaying the diagnosis. Ultimately, the correct diagnosis was made and confirmed on renal biopsy. We believe our case highlight the importance of keeping a broad differential and considering vasculitis in these situations for prompt diagnosis. CONCLUSIONS: GPA can often mimic respiratory infectious processes, a high index of suspicion is necessary for timely diagnosis. Reference #1: Selvaraj V, Moustafa A, Dapaah-Afriyie K, et alCOVID-19-induced granulomatosis with polyangiitis. BMJ Case Reports CP 2021;14:e242142 Reference #2: Qurratulain, Q., Ahmed, A., & Jones, Q. (2021). Lesson of the month: Severe granulomatosis with polyangiitis (GPA): a diagnostic challenge during the COVID-19 pandemic. Clinical Medicine, 21(1), 79. DISCLOSURES: No relevant relationships by Aamna Khan No relevant relationships by Usama Sadiq No relevant relationships by Rehan Saeed

INVESTIGATING IDA: LARGE-SCALE DATA SHOWING PERSISTENT GAPS AT THE FRONT DOOR

Introduction Iron deficiency anaemia (IDA) can be a sign of serious underlying disease but often overlooked. Recently updated guidelines of the British Society of Gastroenterology (BSG) recommend male and postmenopausal female patients with IDA should be screened for coeliac disease and undergo dual endoscopy (or CT). Aims This project looked to assess current adherence to these guidelines at the Queen Elizabeth Hospital in Birmingham. Methods A retrospective audit was performed using health informatics for patients who attended AMU/CDU from April 2018 to March 2021. The number of patients with IDA in this time frame was identified. A further analysis of this group was made to determine the proportion of patients with IDA who had IgA TTG measured as well as those who had OGD and colonoscopy/CT colonoscopy requested. Results There were 67797 patients in this study period. 32422 (47.8%) were anaemic (Hb < 120g/dl for women, <130g/dl for men as per WHO guidelines) of which 6357 (19.6%;9.38% of total) had a microcytic anaemia (MCV <83 as per University Hospitals Birmingham laboratory reference range). Ferritin was tested in 3337 (52.5%) of this group, and of those, 1041 (31.2%) were found to have overt IDA (ferritin <30 mg/mL). Rate of investigation The patient cohort with confirmed IDA comprised 334 males (32.0%), 556 post-menopausal females (53.4%, defined as age ≥45) and 151 pre-menopausal females (14.5%). A further analysis was made to explore how male and postmenopausal female cases were investigated, and if the rate of investigation was affected by the COVID-19 pandemic from 1st March 2020 onwards in this subgroup. Results are shown in the table below. In general, only a minority of patients underwent further investigation with males more likely to undergo OGD than females. Surprisingly, apart from increased TTG check latterly, little difference was seen after onset of the COVID-19 pandemic. Conclusions This large-scale study found that only a small minority of patients with IDA underwent further investigation. Whilst the study period includes the pandemic era, our results don't suggest this made a significant impact on practice. Nevertheless, these findings indicate a strong need for increased awareness and quality improvement about optimising IDA investigation according to BSG guidelines.

CULTURAL BARRIERS AND PANDEMIC RESTRICTIONS RESULT IN A DELAYED DIAGNOSIS OF DRUG INDUCED LUPUS (DIL) AND SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

CASE: A 58-year-old female with a history of hypertension, type 2 diabetes and hyperlipidemia presented with a two- week history of abdominal pain and fevers. Per the patient, family history was unremarkable, and she denied alcohol, tobacco, or recreational drug use. She denied recent travel or sexual activity and had moved to the U.S. in the 1970s from Cambodia. Medications included amlodipine, atorvastatin, dapagliflozin, lisinopril, metformin and sitagliptin. Physical exam was notable for bilateral axillary lymphadenopathy, hepatomegaly, and right sided abdominal tenderness. Laboratory data was notable for microcytic anemia, thrombocytopenia, and elevated transaminases, D-dimer, and C- reactive protein. Urinalysis demonstrated microscopic hematuria and proteinuria. Imaging showed diffuse lymphadenopathy and hepatomegaly. Autoimmune work-up was strongly positive for ANA, anti-histone, and anti DS DNA. Kidney biopsy was suggestive of glomerulonephritis. Liver biopsy was suggestive of drug induced liver injury or autoimmune hepatitis. A diagnosis of DIL and SLE was not reached until additional historical data from the patient's son was provided on hospital day 4;namely that the patient had a 30-lb unintentional weight loss, took unknown herbal supplements and had a daughter who passed away from complications of lupus. IMPACT/DISCUSSION: DIL is a rare adverse reaction to many drugs that generally manifests with mild systemic symptoms such as low-grade fevers, anorexia, and fatigue and rarely involves classic symptoms of SLE such as skin findings and major organ involvement. Notably, DIL can unmask clinically silent SLE and thereby lead to lupus like syndromes. This patient presented with mild symptoms and underwent an extensive workup due to missing key historical data which led to a delayed diagnosis. Due to COVID-19 restrictions on visitation, it was not until hospital day 4 when the patient's son visited that the team became aware of an unintentional 30-lb weight loss, unknown herbal supplement use, and a family history of SLE. The lack of such critical information stemmed from the fact that we did not ask about the use of supplements properly and never revisited it in a different manner. The patient did not share the cause of her daughter's passing as she was unaware of it, which may speak to cultural limitations in sharing health information among family members. It is imperative that as clinicians we constantly revisit the history and diversify our questions. A more complete history would optimize our workup and limit unnecessary testing, including blood draws and painful biopsies, which unfortunately occurred in this patient. CONCLUSION: A thorough history is important to achieving a timely diagnosis and to avoid excessive testing and procedures. Revisiting the history is necessary to finding key information and clinicians should consider incorporating available family members early in the diagnostic work up, especially if the diagnosis is unclear.

POS-672 EFFLUENT PERITONEAL DIALYSIS FLUID TURBIDITY CAN REVEAL COLON CANCER

Introduction: Infectious peritonitis (IP) is one of the main complications in peritoneal dialysis (PD). Abdominal pain is often the revealing symptom of this complication which can also be clinically silent and diagnosed after the discovery of a cloudy aspect of the effluent dialysis fluid. Other etiologies may mimic the symptoms of IP in PD. Methods: We report the case of a PD patient who presented with abdominal pain and turbid peritoneal fluid with a biological inflammatory syndrome, and the final diagnosis was peritoneal carcinomatosis complicating colon cancer. Results: A 71-year-old female patient with a history of hypertension and vascular end-stage kidney disease. She started two years earlier (2019) on peritoneal dialysis. During these two years, she had undergone only one episode of infectious peritonitis. She presented in January 2021 with deep asthenia. There were no abnormalities in the clinical examination. Laboratory tests were normal except for normocytic normochromic anemia (8g/dl). SARS-CoV-2 infection was suspected given the epidemiological context but we performed a test (Polymerase Chain Reaction) and it was negative. Three months later she presented with abdominal pain and asthenia. The clinical examination found the right-side abdomen sensitive to touch. Dialysis fluid was turbid and the cytobacteriological examination showed hypercellularity with 90% of neutrophils with a negative culture. She also had hyperleukocytosis (12770 e/mm3) with neutrophil predominance, microcytic anemia (6.2d/dl), a high c reactive protein (CRP) level (133.3 mg/l), and procalcitonin level was 1.49 ng/ml. She was put on an empiric antimicrobial therapy. Abdominal pain remained intense after 48 hours with an altered general condition, which motivated the request for computed tomography (CT) scan of the abdomen. The CT scan showed an irregular process tissue of the right colic angle with invasion of segment VI of the liver and peritoneal carcinomatosis. Conclusions: The indication of imaging exams should be broadened so as not to miss out on serious diagnoses that mimic IP No conflict of interest

Not your typical presentation: A case of pediatric systemic lupus erythematous

Case Report Pediatric Systemic Lupus Erythematous (pSLE) is a multi-system autoimmune disease with varied clinical presentations. Although rare, it can be associated with significant morbidity and mortality. We report a case of a newly diagnosed pSLE patient who's presenting symptoms were concerning for viral pericarditis. Our 17-year-old African American female presented with non-radiating substernal chest pain and shortness of breath for three days. Pain was described as a constant pressure, exacerbated by lying down, and improved with leaning forward. Shortness of breath was most notable with ambulation. Other associated symptoms included subjective fever, chills, fatigue, two-week history of mild cough, intermittent headaches, nausea, emesis, pedal edema, myalgias, arthralgias, and a 10-pound weight loss. Detailed enquiry revealed a long-standing history of lymphadenopathy, neutropenia, microcytic anemia, and migraine headaches. Previous evaluation included normal thyroid studies, Hemoglobin A1c, complete metabolic panel, HIV testing, monospot, and a reassuring peripheral blood smear. Initial evaluation for her chest pain revealed normal EKG and chest x-ray. On physical exam at our facility, she was afebrile with normal vital signs. Soft, mobile, non-tender, <2 cm posterior cervical lymph nodes were palpated. Cardiac exam was unrevealing and no arthritis or rashes were noted. Her lungs were clear, but she had conversational dyspnea. Initial differential diagnoses included systemic processes such as rheumatologic, oncologic, and infectious. Testing revealed elevated troponin, proteinuria, pancytopenia, and elevated inflammatory markers. Coombs test and ACE were negative. D-dimer and creatinine kinase to evaluate for deep vein thrombosis and myositis were normal. EKG was concerning for ST elevation in anterolateral leads, and an echocardiogram revealed a small, globally distributed pericardial effusion. COVID PCR was positive concerning for pericarditis secondary to multisystem inflammatory syndrome in children (MIS-C). Though she met diagnostic criteria for MIS-C with her history of fever, elevated inflammatory markers, and multisystem involvement (cardiac and abdominal), the presence of her symptoms over several months was more concerning for a chronic process. Further evaluation into an underlying etiology revealed low C3/C4, positive ANA, positive ds-DNA, and positive SS-A, SS-B, chromatin, Anti-Smith, and RNP antibodies. The immunologic profile along with her clinical presentation was consistent with pSLE. Treatment with high-dose intravenous steroids resulted in complete resolution of her chest pain and she was discharged on oral hydroxychloroquine. pSLE is a multi-faceted and diagnostically challenging disease. Our case highlights the importance of obtaining a thorough history and a low threshold of suspicion for this complex autoimmune condition.

Hemophagocytic lymphohistiocytosis sans triggers

Case Report Hemophagocytic Lymphohistiocytosis (HLH) is an hyperinflammatory state due to hyperactivation of macrophages and T-cells which rarely affects adults. It can be familial or sporadic. Triggers are infections, auto-immune diseases, malignancies, and immune checkpoint inhibitors. HLH diagnostic criteria are fever, splenomegaly, bicytopenia, hypertriglyceridemia, hemophagocytosis, low/absent NK-cellactivity, elevated ferritin, and high-soluble interleukin-2-receptor (IL-2R). Five out of eight criteria are required for diagnosis. A 54-year-old female was noted to have leukopenia during a routine visit with her family physician. Follow up labs revealed worsening leukopenia, anemia and a normal platelet count. She received Amoxicillin/Clavulanic acid for a presumed upper respiratory infection and developed nausea, diarrhea and decreased appetite. She was referred to Hematology Oncology for leukopenia. During workup she developed fatigue, night sweats and high fevers. Workup revealed WBC 2400 mcL, microcytic anemia, transaminitis with lactate dehydrogenase of 1725 U/L and ferritin of >15000 ng/ mL . Peripheral blood smear showed leukopenia without immature cells or blasts and mild microcytic erythrocytes. Further tests detected CXCL-9 of 125050 pg/mL, D-dimer of >5000 ng/mL and interleukin-2-receptor of 20604 pg/ mL. EBV, CMV, HSV, HHV-6, parvovirus, bartonella, leishmaniasis, bacteria and COVID-19 were negative. Computed tomography of the chest, abdomen and pelvis did not reveal lymphadenopathy. Brain imaging showed no abnormalities. Cerebrospinal fluid cytology was unremarkable. Bone marrow biopsy (BMBX) showed prominent histiocytic phagocytosis of erythroid precursors and platelets. HLH-94 treatment protocol including weekly steroid and etoposide initiated. Patient's fever, night sweats and leukopenia resolved during hospitalization, with subsequent down trending of ferritin to 103 ng/ml, CXCL-2 to 2663 pg/mL and interleukin-2-receptor to 2,265 pg/mL. Repeat BMBX revealed significant improvement. HLH is a rare life-threatening diagnosis. This patient with nonspecific symptoms was diagnosed with HLH (fever, bicytopenia, elevated ferritin, high-soluble IL-2R and hemophagocytic lymphohistiocytosis on BMBX). Several HLH gene mutations were tested including PRF1, UNC13D, STXBP2, although none was mutated. No infectious, rheumatologic or oncologic triggers were detected. Early diagnosis and treatment are critical. Without treatment, survival is measured in months due to multiorgan failure. This syndrome rarely presents in the absence of triggers which may cause delay in diagnosis and successful treatment. 5-year overall survival with HLH 94 protocol is 54% as opposed to 0% prior to the advent of this protocol. Etoposide and steroids are the mainstay of HLH-94. Cyclosporine can be added in the maintenance phase and hematopoietic stem cell transplant is reserved for familial or relapsed HLH.

Management of PIMS-TS in children from a low-income country: A single center experience

Introduction: PIMS-TS features a toxic shock-like syndrome or Kawasaki-like syndrome in the setting of SARS-CoV-2 positive diagnostic testing. The main cause is a severe cytokine storm resulting in a wide spectrum of clinical phenotypes, ranging from mild selfresolving to severe life-threatening presentations. Objectives: To report the experience of a single center from a lowincome country, in the management of PIMS-TS. Methods: A retrospective descriptive study of 9 cases with PIMS-TS. Results: We had 4 boys and 5 girls. The mean age was of 11-yearold, with extremes of 7 and 15-yesr-old. Medical history was marked by one case of Churg and Strauss syndrome under steroids, one case of recurrent idiopathic pancreatitis under steroids and azathioprine, one case of sarcoidosis under steroids and mycophenolate mofetil, and one case of nephrosis. All cases had history of contact with a COVID-19 positive case. SARS-CoV-2 RT-PCR was positive in 5 cases, while SARS-CoV-2 IgM antibodies were positive in one case and SARS-CoV-2 IgG antibodies were positive in all cases. Telltale symptoms were acute fever in one case, protracted fever in 4 cases, respiratory tract infection (rhinitis, caught, polypnea) in one case, Kawasaki -like symptoms (cheilitis, conjunctivitis, cervical lymphadenopathies and rush) in 2 cases, myocarditis in 3 cases, gastrointestinal symptoms (abdominal pain, vomiting, diarrhea) in 3 cases, toxic shock in one case, uveitis in one case, acute kidney injury in 8 cases, and liver failure in 4 cases. All patients had high acute phase reactants (ESR, CRP, ferritin). Hematological involvement was in the form of microcytic anemia in 3 cases, hemolytic anemia in 2 cases, polynuclear neutrophils' leukocytosis in 4 cases, leucopenia in 4 cases, lymphopenia in 3 cases, thrombocytosis in 5 cases, and thrombocytopenia in 3 cases. Two children had hepatic cytolysis, while 6 had high D-dimers and LDH levels, 5 had high fibrinogen level, and 3 had high triglycerides level. Management was based on steroids in all cases (3 pulses of methylprednisolone at 1g/1.73 m2/ day, followed by oral prednisone for a mean time of 3 weeks). Meanwhile, one case was put under tocilizumab and one case was put under intravenous immunoglobulins. Hemodialysis was needed in the acute phase in 4 children. Two cases were put under intravenous noradrenaline, while 3 cases were treated by antibiotics. Anticoagulation was prescribed in 3 cases. Evolution was marked by complete remission in 8 cases and in a mean time of 2 weeks. We deplore one death from multiple organ dysfunction Syndrome following septic choc. Conclusion: In our experience, PIMS-TS was more prevalent in immunocompromised children. Steroids were effective as a first line treatment. Complete remission with no sequela is the rule.

Unusual back pain

Background: Often the onset symptoms of a disease don't easily direct towards the correct diagnosis. Furthermore, the CoViD-19 pandemic has often been an obstacle to obtaining a quick diagnosis. Description of the case: Male 49-year-old patient admitted to emergency room for persistent back pain, asthenia and weight loss. Physical examination revealed a palpable mass in the right gluteal region, chest X ray an enlargement of mediastinum. Nasopharingeal swab for CoViD-19 was positive (even if negative for CoViD-related symptoms);he was so hospitalized in our Internal Medicine CoViD Ward. Blood samples found microcytic anemia (thalassemic trait carrier);high ferritin (1072 ng/ml), aptoglobin (297 mg/dl, nv <200) and B2 microglobulin (3.25 mg/l, nv <2.53);K and L chains normal with K/L serum ratio reduction, increase in urine sample. Lymphocyte subpopulations were indicative of lymphopenia. Suspecting a lymphoproliferative disease, he performed a chest and abdomen CT scan that found: multiple bilateral pulmonary nodules, the largest one 10x9 cm in the left lung;a left renal lesion11x10 cm;a mass 9.5 cm of the sacroiliac left wing and splenomegaly (145 mm). We thus performed a US-assisted biopsy of the mass in the gluteal region. The histological examination allowed to identify metastasis from clear cell renal carcinoma. Conclusions: We report this case to highlight the peculiarity of onset of this renal carcinoma, in absence of genitourinary symptoms. Diagnostic autonomy can be a winning weapon in accelerating the diagnostic process, even more so in times of CoViD-19 pandemic.