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SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Due to a wide range of clinical presentations, central venous thrombosis (CVT) is a rare neurologic condition that can be difficult to diagnose. Since the COVID-19 pandemic, more cases of venous thromboembolic events have emerged and been found associated with COVID-19. We detail a potential case of COVID-19 associated CVT. CASE PRESENTATION: A 28-year-old female with past medical history of obesity, polycystic ovary syndrome, recurrent sinusitis, and presumed history of COVID-19 infection with anosmia, ageusia, and sinusitis symptoms three- months prior presented to the hospital with 1-month history of worsening, right-sided pain behind her ear, eye, head, posterior neck and shoulder, nausea, and photophobia, which had worsened in the last 5 days. She initially tried over-the-counter medications with no improvement. Vital signs were unremarkable. Examination was notable for frontal sinus and right postauricular tenderness to palpation. C- reactive protein was elevated at 26.2 mg/L. Non- contrasted brain computed tomography (CT) was concerning for right transverse sinus and superior sagittal sinus thrombosis. Brain magnetic resonance imaging (MRI) showed early signs of cortical edema and venous infarction and findings concerning for right mastoiditis. Intracranial venous MRI showed complete thrombosis of the right transverse and sigmoid sinus, superior sagittal sinus, and most of the superior draining cortical veins. Heparin drip was started. Initial empiric antibiotics for mastoiditis were stopped. Hyper-coagulopathy work-up with beta- 2 glycoprotein 1 antibodies and phospholipid antibodies were negative. As there were no other inciting factors for CVT found and no history of positive COVID-19 test, a COVID-19 antibody immunoassay was obtained and returned positive. The patient did not have a history of COVID vaccination. She was discharged on warfarin and enoxaparin. Anticoagulation was stopped after 6 months with repeat imaging showing resolution of clot burden. DISCUSSION: Usual risk factors associated with CVT are morbid obesity, hormone replacement therapy, oral contraceptive use, hereditary thrombophilia, and pregnancy. Literature on CVT related to COVID-19 is limited. In 41 documented cases, the average age of incidence is 50 years old and median onset of neurological symptoms from initial COVID-19 diagnosis is 7 days [0 to 21 days]. Our patient's neurological symptoms began about 3 months after her initial diagnosis, potentially making it the first known case of COVID-19 associated CVT with symptom onset past 21 days. Anticoagulation is the mainstay treatment for CVT, and duration depends on the presence of provoking factor. CONCLUSIONS: In patients with new neurologic symptoms and recent diagnosis of COVID-19, CVT should be considered in the differential diagnosis as it can initially present in a subtle manner. Early recognition could improve patient morbidity and mortality. Reference #1: Abdalkader, M., Shaikh, S. P., Siegler, J. E., Cervantes-Arslanian, A. M., Tiu, C., Radu, R. A., Tiu, V. E., Jillella, D. v., Mansour, O. Y., Vera, V., Chamorro, Á., Blasco, J., López, A., Farooqui, M., Thau, L., Smith, A., Gutierrez, S. O., Nguyen, T. N., Jovin, T. G. (2021). Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature. Journal of Stroke and Cerebrovascular Diseases. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105733 Reference #2: Idiculla, P. S., Gurala, D., Palanisamy, M., Vijayakumar, R., Dhandapani, S., Nagarajan, E. (2020). Cerebral Venous Thrombosis: A Comprehensive Review. European Neurology (Vol. 83, Issue 4). https://doi.org/10.1159/000509802 Reference #3: Ostovan VR, Foroughi R, Rostami M, et al. Cerebral venous sinus thrombosis associated with COVID-19: a case series and literature review. Journal of Neurology. 2021 Oct;268(10):3549-3560. DOI: 10.1007/s00415-021-10450-8. PMID: 33616740;PMCID: PMC7897893. DI CLOSURES: No relevant relationships by Shu Xian Lee No relevant relationships by Arif Sarwari No relevant relationships by Benita Wu
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Background: Inferior Vena Cava (IVC) abnormalities are a risk factor for the development of lower extremity deep vein thrombosis (DVT). Abnormalities can be congenital or acquired and include IVC atresia, a rare and lesser known problem for adolescents. Adolescents with IVC atresia are at high risk for DVT's that are often refractory to standard anticoagulation methods, including thrombolysis. Objectives: The purpose of this report is to highlight a young patient with extensive lower extremity DVT in the setting of underlying IVC atresia and describe the complex care required. The patient is a 16-year-old with a history of venous insufficiency who presented with low back pain and lower extremity swelling. Thrombotic risk factors included factor V Leiden heterozygosity, oral contraceptive use, and recent COVID-19 vaccination. An MRI completed by the orthopedist for back pain was concerning for abnormal signal in the IVC as well as an IVC aneurysm. A contrast enhanced CT was obtained and demonstrated atresia of the suprarenal IVC, subacute thrombosis of the infrarenal IVC along with an IVC aneurysm, and subacute thrombosis of the bilateral iliac veins. Design/Method: A retrospective chart review of the patient's initial presentation, imaging, and treatments was conducted along with a review of the literature involving similar cases. Results: Initial treatment was intravenous heparin and t-PA mediated thrombolysis. After overnight thrombolysis, venography revealed significant clot lysis;thus, she was transitioned to subcutaneous enoxaparin and discharged home with therapeutic anti-Xa levels. Follow up imaging 3 days later revealed recurrent thrombosis of the deep veins in both lower extremities. She was readmitted, placed on intravenous heparin, and received catheter directed t-PA thrombolysis. Clot burden was so extensive it was further reduced using Angio jet thrombectomy and balloon angioplasty. Because the recurrent clots were attributed to lack of outflow from the underlying IVC atresia, interventional radiology completed endovascular reconstruction of the IVC. She then transitioned from intravenous heparin to therapeutic enoxaparin, clopidogrel, and aspirin. At three month follow up, imaging was negative for clot and her vasculature was widely patent. Conclusion: Pediatric patients with bilateral lower extremity DVTs are uncommon and underlying IVC abnormalities should be considered in the evaluation. Optimal treatment strategies are evolving and include aggressive anticoagulation and endovascular reconstruction.
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Purpose: After the age of fifty years, the incidence of osteoarthritis (OA) increases rapidly in women, suggesting an effect of menopause on the development of OA. Because it is still unclear how menopause precisely influences the development of OA, we aim to investigate this in a novel human model: the Females discontinuing Oral Contraceptives Use at Menopausal age (FOCUM) model. This model consists of women between fifty and sixty years of age, who are currently using a combined oral contraceptive (OC) and aim to stop OC use at short term. When these women stop using OC, a rapid change in hormones is expected, modelling a “sudden menopause”. Therefore, this model provides an opportunity to study changes occurring during menopausal transition. Because the FOCUM model is new, it is unknown if women want to participate, are willing to stop OC use shortly, and will not start hormone replacement after stopping OC use. Therefore, we aim to investigate the feasibility of the FOCUM study. We define the study to be feasible when: 1) 50 participants are included within one year and received their baseline measurements (including questionnaires, blood samples and Magnetic Resonance Imaging (MRI) assessments), 2) the loss of follow-up at 6 weeks is less than 5%, and 3) no hormone replacement therapy is used by the participants at 6 weeks follow-up. Methods: For the inclusion of participants, pharmacies in and nearby Rotterdam were invited to participate. Pharmacies were asked to search in their information systems to identify all possible eligible subjects, based on age and OC use. All eligible subjects received an invitation letter with information about the study. Interested subjects were contacted by the researchers for more information. Inclusion criteria were: 1) woman, 2) between 50 and 60 years of age, 3) currently using a combined OC (with Anatomical Therapeutic Chemical (ATC) code G03AA or G03AB), and 4) started OC use before the age of 45. Exclusion criteria were: 1) already known with osteoarthritis (self-reported or registered by their general practitioner), 2) already known with another inflammatory rheumatic condition, 3) having a contra-indication for MRI assessment, 4) having a terminal or mental illness, and 5) not being able to give informed consent. In this study, measurements are performed at baseline, just before stopping OC use (T0 = 0 to 30 days), and after (T1 = 6 weeks;T2 = 6 months;T3 = 1 year;T4 = 2 years) stopping OC use. At every time point, a digital questionnaire is filled in and a blood sample is drawn. At T0 and T4, also an MRI of one of the knees is performed. Results: In January 2020, invitations were sent to 106 pharmacies of which 48 were willing to participate. Due to COVID restrictions, the first invitations to possible eligible subjects were sent in July 2020. Until April 2021, a total of 1037 invitation letters were sent. 206 subjects replied positively, of which 175 were screened by the researchers. After screening for in- and exclusion criteria, 85 subjects were eligible. The most common reason why subjects were not eligible, was because they did not use their OC anymore. Eventually, 54 subjects gave informed consent and were all seen for their baseline measurements between August 2020 and July 2021. All baseline questionnaires, blood samples and MRI assessments were available. At 6 weeks follow-up, all 54 subjects were still participating in the study. From one participant the blood sample has not been drawn at 6 weeks follow-up and one participant started hormone replacement therapy after baseline measurements (see flowchart 1). [Formula presented] Conclusions: We reached the number of 54 participants within one year, which is more than the initially targeted number of 50. All baseline measurements, including questionnaires, blood samples and MRI assessments, have been collected from these 54 participants. At 6 weeks follow-up, there was no loss of follow-up, of one participant no blood sample was available and one participant started hormone replacement therapy. Therefore, we conclude that the FOCUM study is feasible. The next step will be to investigate differences in cardiometabolic and inflammatory biomarkers, joint complaints and structural OA features between baseline and follow-up measurements.