IT'S NEXT TO THE PLEURA

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan

SLE After SARS-COV-2 Infection

SARS-COV-2 infection is often associated with exaggerated immune response, also referred to as a ‘cytokine storm’. There is growing concern that it may be linked to autoimmunity, with many cases of autoimmune diseases either triggered by or related to SARS-COV-2 having been reported, ranging from Guillain-Barre syndrome, Graves’ disease, multiple sclerosis, Kawasaki-like disease. Our patient was a 20-year-old female with a history of hidradenitis who presented with malaise, feet and ankle swelling, asthenia, anorexia, weight loss of 50 Ibs of 4 months. She had COVID pneumonia 7 months prior and was also seen in the ER thrice afterwards for ankle pain and fatigue managed with antibiotics and analgesics. Exam findings included tender bilateral lower extremity edema, diffuse hyperkeratotic and hyperpigmented purpuric rashes and bilateral suppurative axillary swellings. She was admitted for protein-energy malnutrition. Blood work showed WBC 13.5, low Hb 9.3, AST 509, ALT 104, BUN 29, Creatinine 0.9, Protein 7.5, albumin 1.5 (globulin gap of 6). Urine assay showed 3+ proteinuria Hb 3+ with RBC 3-10/hpf, absent nitrite, LE 1+, protein/creatinine ratio was 2949 mg/g. Blood cultures returned negative. US showed trace pericardial effusion and normal kidneys. Infectious workup returned negative for anti-streptolysin O, HIV, hepatitis B and C. Two days after, she developed AMS, fever, tachycardia and neck stiffness concerning for possible meningoencephalitis. CT head was normal. Lumbar puncture was performed. IV vancomycin and piperacillin-tazobactam was started. CSF fluid analysis revealed total protein of 125mg/dl, elevated IgG 79.8, concerning for an underlying inflammatory pathology. EEG was unremarkable. She became oliguric with creatinine and BUN both peaking at 2.6 and 58 respectively. Renal ultrasound revealed medical renal disease. Urine microscopy showed granular cast and no dysmorphic RBCs. ANA, anti-smith SSA, SSB, DS-DNA, RF, smooth muscle, anti-histone, anti-centromere, JO-1 and RNP antibodies were markedly elevated. She was unstable for CT trocar biopsy of the kidney. She subsequently went into cardiac arrest multiple times about a week into admission, before eventually expiring. Though causation was not established in our patient, SARS-COV-2 infection causing exaggerated immune response may unmask SLE or be associated with SLE.

Infestation of pest of pulses legume grains Callosobruchus spp and substantial loss of dietary vegan protein

The current study is the reviews of the work done for pest infestation in different legume pulse grains Pulse grains have been found to have different susceptibility for the attack of pulse beetle. An insect has varied fecundity on different varieties of pulses. India is agriculture based country and agriculture is the key sector of Indian economy. Including many kharif and rabbi crops, pulses are cultivated in all parts of country. Pulse cultivation has its own significant place in agriculture as it has been considered as complimentary to cereal crop in many aspects and positioned as a second most important crop plant [1]. Study indicates 20-40% of dry matter of pulse grains is made up of beneficial dietary proteins [2]. Insufficiency of adequate amount of protein in diet may lead to protein energy malnutrition. Like poverty and hunger, to combat PEM is another great provocation for agriculture and nation. Pulse grains legumes are good source of protein and other nutrient materials. Crop plant of Arhar has its own advantage for agriculture. The leguminous plants are used in crop rotation to improve the fertility of soil as the root nodules harbor the nitrogen fixing bacteria;fixes atmospheric nitrogen to nitrogen compound about 72-350 kg/hectare/year . The current study emphasizes the different facts of pulse beetle and their infestation in arhar seed grains. About eight months of the year have been found to be susceptible for infestation;remarkable growth and development of pests continue during six months of the year. Arhar pulse grains are most suitable for pest infestation. Bold variety of arhar was identified to be the most preferred for maximum oviposition having larger and smooth surface area. Temperature suitable for oviposition was noticed between 28-370c. Developmental period was found to be of lesser duration and survival of adults was more in bold varieties as compared to the smaller variety. Developmental period was recorded as 24-30.3 days in bold legume grains and 26-32.3 days in smaller size grains. Survival of male and female insect pest was also different as male survived for 7-10.6 days and females for 8.3-12.6 days. Increased growth rate of insect population was there with the increase in temperature and humidity. Significant Weight loss, content loss and percent germination loss have been found in the pulse grains of both varieties in the current studies. Indian economy relies significantly on agriculture and loss and damage of complementary crop plant certainly affect it. At this point there is need to consider the condition of Mass poverty of India after pandemic covid -19 which has been ascertained after more than 45 years The outcome of pandemic recession is more than 2 fold increase in the number of poor from 60 million in a year to 134 million (Reports of downtoearth.org.in). Furthermore any rise in price would snatch the accessibility of the easily available protein diet from people living in indigence.

Tackling Protein-Calorie Malnutrition during World Crises.

Undernutrition is still highly prevalent in developing countries and leads to a multitude of problems as it weakens the immune system, which leads to increased risk of infections and diet-related diseases. COVID-19 has worsened the existing situation and has resulted in unprecedented health, social, and economic disruptions across the world. Before COVID-19, about 54% children under 5 years were moderately or seriously malnourished, and after the COVID-19 pandemic, early estimates suggest that an additional 2.6 million children were stunted; 9.3 million were wasted, with an addition of 2.1 million maternal anemia cases; 168,000 child deaths; and USD 29.7 billion in productivity losses. This review is mainly focused on the health and nutrition sectors and highlights the impact of COVID-19 on malnutrition, food system and industry, and it also discusses the various measures implemented across the world to cater the burden of maternal and child malnutrition. Movement restrictions and lockdowns within and across the countries/borders have imposed an unprecedented stress and shock on the food supply chain, affecting harvest, food processing, supply, logistics, food demand, shortages, and cost. Many countries have implemented interventions such as cash transfers, food ration distribution, insurance plans, utility subsidy, and tax exemptions to assist the population to cope with the financial and health issues caused due to the outbreak. Other than these measures, evidence recommends some essential direct and indirect interventions which could help in reducing malnutrition during COVID-19. The COVID-19 pandemic has re-demonstrated the connection between food systems, nutrition, health, and prosperity and the need for a more holistic approach.

Thymic Dysfunction and Atrophy in COVID-19 Disease Complicated by Inflammation, Malnutrition and Cachexia.

Background: The current COVID-19 pandemic has put millions of people, especially children at risk of protein-energy malnutrition (PEM) by pushing them into poverty and disrupting the global food supply chain. The thymus is severely affected by nutritional deficiencies and is known as a barometer of malnutrition. Aim: The present commentary provides a novel perspective on the role of malnutrition-induced thymic dysfunction, involution and atrophy on the risk and severity of disease in children during the COVID-19 pandemic. Methods: A review of pertinent indexed literature including studies examining the effects of malnutrition on the thymus and immune dysfunction in COVID-19. Results: Protein-energy malnutrition and micronutrient deficiencies of zinc, iron and vitamin A are known to promote thymic dysfunction and thymocyte loss in children. Malnutrition- and infection-induced thymic atrophy and immune dysfunction may increase the risk of first, progression of COVID-19 disease to more severe forms including development of multisystem inflammatory syndrome in children (MIS-C); second, slow the recovery from COVID-19 disease; and third, increase the risk of other infections. Furthermore, malnourished children may be at increased risk of contracting SARS-CoV-2 infection due to socioeconomic conditions that promote viral transmission amongst contacts and create barriers to vaccination. Conclusion: National governments and international organizations including WHO, World Food Program, and UNICEF should institute measures to ensure provision of food and micronutrients for children at risk in order to limit the health impact of the ongoing COVID-19 pandemic.