Pirfenidone Induced Dress Syndrome Post COVID-19 Infection-An Unusual Case Report

Drug Reaction, Eosinophilia and Systemic Symptoms (DRESS) is an idiosyncratic drug reaction characterised by extensive skin rash, fever, lymphadenopathy and internal organ involvement. Since eosinophilia may or may not always be present, the condition is now more preferably called Drug-Induced Hypersensitivity Syndrome (DIHS). The authors here report a case of DRESS syndrome, secondary to Pirfenidone, an anti-fibrotic given to the patient for post COVID-19 fibrosis. The 51 years old male patient, presented with multiple pus-filled erythematous lesions, 3 months after the initiation of Pirfenidone. Laboratory results showed deranged liver and renal functioning, along with reactive Dengue Nonstructural protein 1(NS 1) antigen. He showed significant improvement in the dermatological lesions and multisystem laboratory involvement with tapering doses of steroids.

Antibiotic Guidance for OMFS inpatients

Introduction/Aims: Implementation of local antimicrobial guidelines is essential for optimal use of antibiotics and reduction of antibiotic resistance. The aims are: * To assess current antibiotic use for inpatients. * To assess which antibiotics are commonly prescribed in OMFS. * To assess dose/duration of antibiotics. * To assess second line antibiotic options for allergies. Material(s) and Method(s): Retrospective data was collected for elective and emergency admissions from October 2018 - October 2019. Data collection included: Antibiotic prescribed, clinical reason for antibiotics, dose, duration, administration method, discharge antibiotics, alternatives for penicillin allergic patients and microbiology swab results if applicable. Results/Statistics: Elective procedures included osteotomies, salivary gland surgery, TMJ surgery, cysts and major resections. 92% of osteotomies received prophylactic IV co-amoxiclav. 26% of salivary gland patients received antibiotics, majority co-amoxiclav. 58% of cyst patients received IV co-amoxiclav (43%), amoxicillin (43%) or amoxicillin and metronidazole (14%) and all major resection patients received IV antibiotics, majority amoxicillin and metronidazole (45%) 70 dental abscesses received IV antibiotics. 30% received amoxicillin and meronidazole, 22% received benzylpenicillin and metronidazole and the remaining 48% were prescribed a variety of combinations. 65% of abscesses had a microbiology pus swab taken. 48% were sensitive to penicillin, metronidazole or both. 33% had no growth. 91% of fractured mandibles received IV antibiotics, with co-amoxiclav and metronidazole the most common (30%). Conclusions/Clinical Relevance: Current practice was extremely varied. A guidance document was created for the department by a multidisciplinary team. A further round of data collection will be completed in due course following lifting covid restrictions to assess compliance. Copyright © 2022

Brain hypoxia caused by respiratory obstruction which should not be forgotten in COVID-19 disease.

DISCUSSION: None. The authors declare that there are no potential conflicts of interest.

SEPTIC SHOCK SECONDARY TO FUSOBACTERIUM NECROPHORUM LIVER ABSCESSES AND QUESTIONABLE RELATIONSHIP WITH COVID-19 INFECTION IN A HEALTHY YOUNG FEMALE

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Fusobacterium (FB) are anaerobic, Gram-negative bacilli found in the normal flora of the oral, gastrointestinal, vaginal and upper respiratory tract mucosa. It can cause soft tissue infections and rarely causes bacteremia, yet Fusobacterium bacteremia is associated with high rate of ICU admission, extended hospitalization and significant mortality. Pyogenic liver abscess is a rare indolent disease and is mostly secondary to bacterial infection. CASE PRESENTATION: A 39-year-old female with no comorbidities presented with nausea, vomiting, fatigue, diarrhea, fatigue, heavy menstrual bleed, and high-grade fever. Symptoms started four days before the presentation. She reported a positive COVID-test two weeks earlier and a new IUD placement five weeks before presentation. She is sexually active with one male partner and does not use a contact barrier. On presentation, she was hypotensive, tachycardic, ill-looking with rapid shallow breathing, and fever of 100.7. EKG showed sinus tachycardia, CXR showed no pulmonary disease. Blood tests were significant for leukocytosis, elevated serum lactic acid, and elevated D-dimer. CTA chest was remarkable for two 2x3 cm liver cysts. Patient was admitted to the MICU and started on IV fluids Boluses, Norepinephrine drip, Ceftriaxone and Azithromycin. Gynecology was consulted and recommended against removing the IUD as patient had no signs of IUD infection. Patient continued to be critically sick. Gynecology team was recontacted and removed the IUD and was uninfected on culture. Antibiotics were switched to Vancomycin and Piperacillin-Tazobactam. MRI liver with contrast confirmed the diagnosis liver abscess. Patient received bedside US-guided aspiration, it was remarkable for 16 cc of frank pus. Patient showed significant improvement after procedure and was transferred to the medical floor within 24 hours. Blood culture grew F. Necrophorum and antibiotics were switched to Clindamycin. DISCUSSION: FB is part of the vaginal flora. Mucosal disruption during IUD placement can precipitate disseminated infection with liver abscesses and/or sepsis. Absence of signs of GU tract infection or a non-infective IUD doesn't rule out FB sepsis. Patient Presented five weeks after IUD placement which fits the indolent nature of pyogenic liver abscess. Four cases of F. Nucleatum bacteremia were reported recently in Belgium in COVID patients. One of the cases was healthy young female. Our similar scenario raises a question about a potential association between COVID and risk of floral septicemia. Our patient has F. necrophorum. CONCLUSIONS: Patient presenting with sepsis and liver cyst should be evaluated for liver abscess as appropriate. Recent procedures and mucosal instrumentation can precipitate liver abscess and should be considered if the timing suggest an indolent course. Further studies are needed to evaluate a potential link between COVID infection and FB bacteremia. Reference #1: Goldberg EA, Venkat-Ramani T, Hewit M, Bonilla HF. Epidemiology and clinical outcomes of patients with Fusobacterium bacteraemia. Epidemiol Infect. 2013 Feb;141(2):325-9. doi: 10.1017/S0950268812000660. Epub 2012 Apr 17. PMID: 22717143. Reference #2: Garcia-Carretero R. Bacteraemia and multiple liver abscesses due to Fusobacterium nucleatum in a patient with oropharyngeal malignancy. BMJ Case Rep. 2019 Jan 29;12(1):e228237. doi: 10.1136/bcr-2018-228237. PMID: 30700472;PMCID: PMC6352811. Reference #3: Wolff L, Martiny D, Deyi VYM, Maillart E, Clevenbergh P, Dauby N. COVID-19-Associated Fusobacterium nucleatum Bacteremia, Belgium. Emerg Infect Dis. 2021 Mar;27(3):975-977. doi: 10.3201/eid2703.202284. Epub 2020 Dec 8. PMID: 33292922;PMCID: PMC7920680. DISCLOSURES: No relevant relationships by Zainab Abdulsada No relevant relationships by Ahmed Abomhya No relevant relationships by Richard Fremont

TUBERCULOUS TAMPONADE WITH A TWIST: A CASE OF TB AND COVID-19

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: We present a case of tuberculous pericarditis and cardiac tamponade due to suspected sequela of SARS-Coronavirus 19 (COVID-19) infection. It is important for clinicians to include tuberculosis (TB) in the differential diagnoses for patients presenting with presumptive viral pericarditis and tamponade. CASE PRESENTATION: A 52-year-old Hispanic man with chronic kidney disease not on hemodialysis was admitted with shortness of breath, fluid overload, hypoxemia and concern for uremic pericarditis. The patient tested positive for COVID-19 to which the symptoms were initially attributed, and he was treated with steroids, remdesevir, tocilizumab and hemodialysis. The patient incidentally had a positive QuantiFERON gold test obtained before initiating hemodialysis. On day 60 of hospitalization, the clinical exam abruptly deteriorated with stuporous mentation, hypotension, and cool skin. Bedside point of care echocardiography revealed a new large circumferential pericardial effusion with right ventricular diastolic collapse and increased respiratory variation in peak E-wave mitral inflow velocity consistent with tamponade physiology. Emergent pericardiocentesis was performed, and hemodynamic instability resolved immediately after aspiration of 750 milliliters of frank pus. Empiric antibiotics were initially given for pyogenic pericarditis. When the pericardial fluid later tested positive for acid-fast bacilli and adenosine deaminase, anti-TB therapy was started. The hospitalization was further complicated by septic shock and cardiac arrest. Though found to have a re-accumulated pericardial effusion on bedside ultrasound peri-arrest, there was no tamponade physiology (suggestive of at least a partial response to the TB treatment in the setting of overall poor underlying reserve). DISCUSSION: The coexistence of COVID-19 and tuberculous pericarditis with tamponade has been reported to date in one other case to our knowledge. COVID-19 with massive pericardial tamponade is rare and a careful diagnostic approach involving multi-modality imaging with bedside echocardiogram is invaluable in the evaluation and treatment of obstructive shock. In this case, we hypothesize that the COVID-19 infection may have led to re-activation of latent TB despite treatment of COVID-19 with corticosteroids (which are an adjunct tuberculostatic treatment in patients with tuberculous pericarditis). Tuberculous pericarditis with tamponade is a relatively uncommon manifestation of extrapulmonary TB and is a major cause of cardiovascular death and morbidity. Even with aggressive antituberculosis therapy, 30-60% of patients may need surgical pericardiectomy for constrictive pericarditis. CONCLUSIONS: This case highlights the need to consider possibility of concomitant viral and TB pericarditis in the diagnostic differential for tamponade. More histopathologic or post-mortem examinations of COVID-19 pericarditis cases are needed. Reference #1: Asif T, Kassab K, Iskander F, Alyousef T. Acute pericarditis and cardiac tamponade in a patient with COVID19: a therapeutic challenge. Eur J Case Rep Intern Med. 2020 May 6;7(6):001701. Reference #2: Barrett et al. Increase in disseminated TB during the COVID19 pandemic. Int J Tuberc Lung Dis. 2021 Feb 1;25(2):160-166. Reference #3: Wong SW, Ng J. K.X., Chia YW. Tuberculous pericarditis with tamponade diagnosed concomittantly with COVID19: a case report. Eur Heart J Case Rep. 2020 Dec 28;5(1):ytaa491. eCollection 2021 Jan. DISCLOSURES: No relevant relationships by Jaskiran Khosa No relevant relationships by Walter Klein No relevant relationships by Amy Tran No relevant relationships by Michael Ulrich

Abdominal Wall Fungal Co-infection-Mucormycosis Associated with COVID-19: A Case Report

Aim and objective: To present a rare case of abdominal wall fungal coinfection with Mucormycosis in a patient of COVID-19. Materials and methods: A 33-year-old female operated case of laparoscopic ectopic pregnancy removal with salpingectomy and tubectomy, at postoperative day 5 had redness and pus discharge from the operative site and was diagnosed with abdominal wall cellulitis. She underwent local exploration and wound wash. On postoperative day 21, the patient came to the emergency room with cellulitis, and pain at the port insertion site. On examination, we highlight BP 90/50 mm Hg and blood test analysis with HB-8.3, leucocyte count 29.91 × 109/L, CRP 333 mg/L. Results: CT scan revealed necrotizing fasciitis. She underwent wide local excision and debridement. Post debridement the next day during dressing, the wound showed a cotton fluffy appearance at the edges and part of the base with black necrotic areas. A wound swab was sent for fungal culture, KOH mount, pus culture, and tissue for histopathology. In the meantime, she was started on empirical antifungal amphotericin B, meropenem, and minocycline antibiotics. On history, the patient remarked that she did have fever, sore throat, and cough for 5 days, 4 weeks before laparoscopic ectopic pregnancy removal. Also one of her family members had tested positive for COVID-19. COVID antibodies test was done which were reactive: 1.96. Tissue histopathology revealed mucormycosis. MRI abdomen findings showed a 15 cm large defect involving the entire thickness of subcutaneous fat. A high degree of suspicion and promptness in starting antifungal treatment prevented the fatal outcome. Conclusion: COVID-19 is associated with immune dysregulation and consequently life-threatening infections. The prolonged and indiscriminate use of steroids for the treatment of COVID-19 could contribute to this problem of fungal superinfection of mucormycosis. It seems prudent to have a very high suspicion supplemented with thorough clinical examination and low threshold for imaging in order to diagnose secondary fungal infections, such as mucormycosis. Early so that the treatment can be instituted as soon as possible.

Clinical study of pyogenic liver abscess in patients with history of COVID 19

Objectives: SARS COVID-19 was associated with thrombosis and vascular events, also associated with liver injuries but data and study of liver pathologies in relation to COVID-19 is scarce. The aim of this study was to evaluate the incidence of pyogenic liver abscess in patients with history of COVID-19. Materials and Methods: A current retrospective observational study is done during study period of 6 months (march 2021-august 2021) duration on patients diagnosed with pyogenic liver abscess on ultrasound or computed tomography, which was conformed with pus culture sensitivity reports from fluid obtained with fine needle aspiration or during pigtail catheter insertion. History of COVID-19 and incidence of pyogenic liver abscess was evaluated according to age, gender, comorbidities, severity of covid19. Results: Total 78 patients with pyogenic liver abscess History of COVID-19 in 64 patients 27 males, 37 females Age wise distribution< 20 = 9,20-40 = 8,40-60 = 22, 60-80 = 19, >80 = 6 13 patients were diabetics, 24 patients were hypertensive. Distribution according to severity of COVID-19, asymptomatic = 23, mild illness = 11, moderate illness = 19, severe illness = 8, critical illness = 3. Conclusion: The study concluded that high incidence rate of pyogenic liver abscess in post COVID-19 infection which may require further study.

HYPOTENSION WITH ST ELEVATIONS.NOT A STEMI OR EVEN THE HEART

CASE: Mr. S is a 60 yo man with DM, HTN and HLD who presents to the urgent care (UC) clinic complaining of sore throat and phlegm in the throat. He is noted to have normal vital signs except for a BP of 75/47. Exam showed slight erythema of the oropharynx, normal cardiac and pulmonary exams. Initial treatment of fluid resuscitation is started for his presumed sepsis, thought secondary to presumed COVID-19 as this occurred during the Omicron surge. An EKG was performed showing anteriolateral ST elevations. The patient was transported emergently to the hospital. An immediate cardiac catheterization was performed which showed mild coronary artery disease, but no obstruction. At this time, COVID-19 PCR test returns negative. The patient is transfered to the MICU for further evaluation and treatment for hypotension/septic shock. At this time, a chest x-ray demonstrated subcutaneous gas in the soft tissues of the neck. CT imaging showed subcutaneous gas extending from the neck to the mediastinum. Patient was taken to the operating room and found to have significant pus in the neck and mediastinum. He was diagnosed with necrotizing mediastinitis requiring multiple surgical wash-outs and prolonged SICU stay. The source was a suspected dental extraction. His ST elevations were presumed to be secondary to a pericarditis effect from the mediasinitis. IMPACT/DISCUSSION: Overall, this case presents necrotizing mediastinitis which is a very unusual and rare presentation, however, it is a surgical emergency so internists need to be aware of this disease and its presentation. Additionally, this case identifies four important points. The first is to make a broad differential, specifically for hypotension. In the setting of a sore throat during the Omicron surge, it was easy to assume this was COVID-19 but thinking of other etiologies led to the EKG being performed. The second is the importance of the physical exam. After the CXR was seen, the patient was examined and noted to have subcutaneous gas which could have been noted at the initial UC visit but that piece of the exam was not performed as the focus was on the hypotension. Third, there is a differential for etiologies of ST elevation on EKG which include STEMI, pericarditis, early repolarization, etc. that should be considered while preparing for treatment of STEMI. Lastly, taking a extensive history, to include dental work, is important as there may be systemic effects of these experiences/treatments. CONCLUSION: -Make a broad differential for atypical patient presentations and physical exam findings -Review EKGs carefully and make a differential for those findings -Necrotizing mediastinitis is a rare presentation but life threatening and needs immediate surgical attention.

Rare Bilateral Invasive Pulmonary Mucormycosis with Tracheo-Esophageal Fistula and Left Mainstem Bronchus Disruption

Introduction: Mucormycosis is a rare invasive opportunistic fungal infection caused by Zygomycetes. [1,2] It is associated with worse outcomes in immunocompromised patients.[3,4] Invasive pulmonary infections can lead to bronchial necrosis from angioinvasion.[1,3] Here, we present a case of invasive pulmonary mucormycosis (IPM) caused by Rhizopus spp, resulting in tracheo-esophageal fistula. Case : An 18-year-old male with uncontrolled type 1 diabetes was admitted to the intensive care unit for diabetic ketoacidosis (DKA) and acute hypoxia due to COVID 19 pneumonia requiring ventilatory support. Chest imaging showed bilateral opacities. He was treated with dexamethasone for COVID 19 and broad-spectrum antibiotics for superimposed bacterial pneumonia. Clinical course was complicated by acute respiratory distress syndrome and pneumomediastinum. Computed tomography of the chest showed large pneumomediastinum with air leak within the distal thoracic trachea. Bronchoscopy revealed a disfigured main carina with erosions (figure 1), a tracheo-esophageal fistula, necrotic blood-tinged left mainstem bronchus tissue, and a necrotic pus-filled superior segment of the right lower lobe. Left mainstem bronchial tissue specimen culture grew Rhizopus and Klebsiella spp. Liposomal amphotericin was initiated. Given his poor prognosis, the patient's family refused aggressive thoracic surgical intervention and pursued palliative care. Discussion: Rhizopus spp is the most common cause of mucormycosis in immunocompromised populations.[6] IPM is the second most common clinical form reported after the central nervous system.[3,6] Typically, IPM lesions are localized, and invasive presentations are infrequent. Rarely, IPM can cause invasive disease by angioinvasion, obstructing blood flow, and ischemic tissue necrosis.[6] Airway tissue necrosis can lead to fistulas between the airway and adjacent structures, including pleura, pericardium, and mediastinum.[2,3,4,5] Published clinical literature review revealed only a few cases due to IPM. Common predisposing factors include diabetes, DKA, and immunosuppressive medications, as observed in our patient.[3] Lobar bronchi are the usual locations of endobronchial erosions, with a predilection for the upper lobes.[3] In contrast, the left mainstem bronchus and right lower lobe were involved in the case presented here. In addition to antifungal treatment, surgical debridement is the mainstay of therapy due to necrosis.[7] The survival rate is between 35-46% in medically managed compared to 51-90% in surgically treated patients.[3]Conclusion: IPM is a life-threatening invasive disease associated with high mortality rates. Clinicians should suspect it in immunocompromised patients, including diabetes. The clinical history may include uncontrolled diabetes, recent DKA, and infections predisposing patients to develop superimposed fungal infections. The concurrent use of systemic steroids may also contribute to worse outcomes. (Figure Presented).

Determiners of pressure ulcers formation – analyses from hospital information system

Introductions: Pressure ulcers (PUs) represents an undesirable complication during hospitalization. Aim: Retrospective data analysis to verify the prevalence of PUs since 2015 (since the mandatory registration of the PUs an adverse event) by principal diagnosis, type of surgery and length of hospital stay in the period 2015–2021. Sample and methods: Retrospective analysis of data from the hospital information system (HIS), at 0.05 level of significance (T-Test) with the variables: age, number of pressure ulcers, principal diagnosis, operation, length of hospitalization and prevalence of COVID-19 to length of hospitalization. Results: A total of 2,350 PU cases in 1,539 patients (1.52 PUs/patient) were registered in the HIS, and 930 (40%) patients were admitted to hospital with PUs. The most common locations of PUs were: heel (33%), sacrum 6% less, buttocks (17%). Between 2015 and 2021;17,247 patients were operated on, of whom 289 had a Pus. The most common principal diagnosis in the occurrence of PUS was femoral neck fracture (14.35%) and neurological (9.09%) or oncological disease (12.03%). The incidence of PUs was surprising in patients with ileal conditions (11.57%). COVID-19 was found in 163 patients in 2020 and 2021, six of whom had PUs and prolonged hospitalization. Conclusion: It is important to view the health status of people with chronic wounds and PUs in a comprehensive manner and to develop an individualized care plan to improve patients‘ lives and chances of recovery.

Immune thrombocytopenia secondary to COVID-19 vaccine: a rare case

Background: SARS-CoV-2 associated COVID-19 was declared as pandemic in March'20.It led to accelerated scientific development leading to production of several vaccines.In India,first vaccine used was ChAdOx1 nCoV-19.Reports of pro-thrombotic and hemorrhagic complications with it are there but isolated immune thrombocytopenia is rare.We are reporting secondary immune thrombocytopenia (ITP) possibly attributed to COVID-19 vaccine. Aims: A 21-years female came to General Medicine with complaints of weakness,rashes all over body,bleeding from gums, menorrhagia and reddish discoloration of urine.She had history of COVID-19 vaccination 2 days back.On examination, she was mildly febrile, showed multiple pin-point petechial haemorrhages over face,abdomen,both limbs and sub-conjunctival haemorrhage with no complaints of headache/visual disturbances/pain abdomen/respiratory distress.Systemic examination showed no significant findings.She had no previous history of bleeding/drug intake/no family history of bleeding or any other significant conditions. Methods: Lab investigations showed Hb:8.6gm%,TLC:14,400/cmm, platelet counts:10,000/cmm.Peripheral blood smear showed normocytic normochromic RBC with leucocytosis and marked thrombocytopenia with absent hemoparasites.Urine examination showed numerous RBCs with no pus cells.S. electrolytes were normal, SGOT/ SGPT were mildly increased, total proteins were normal.S. bilirubin,urea,creatinine were normal.HIV,HCV,HBsAg,CMV IgM were negative.To rule out connective tissue disorders,ANA and dsDNA were performed which came negative.Her USG abdomen and CTchest were normal.COVID-19 RT-PCR was negative.ITP secondary to COVID-19 vaccination was suspected. Results: She was started with i.v. methylprednisolone pulse therapy for 3 days and IVIG for 2 days and also received trenexamic acid for menorrhagia.She received 6 units of random donor platelets which improved platelet count.After haematology consultation,oral prednisolone for 7 days with alternate day platelet count monitoring was started.She improved symptomatically with no new bleeding.She was discharged after 10 days with an advice to follow up. Summary/Conclusions: ITP is autoimmune disorder with autoantibodies against platelets,more common in females.It is usually idiopathic,but occasionally secondary to viral infections/vaccinations. Incidence of vaccine associated ITP is <1%.Previously reported with various vaccines like influenza,measles,mumps,rubella,etc.Vaccine induced thrombotic thrombocytopenia (VITT) with COVID-19 vaccine has been well documented,but ITP is rare.VITT is usually characterized by major thrombotic episodes at unusual locations like sagittal sinus,splanchnic circulation,etc. with visual, neurological and abdominal features.No such findings seen in our case.Although she had low platelet count,yet mild symptoms which improved with conservative management with steroid and IVIG.Although we could not establish a temporal link;yet based on findings,ITP secondary to COVID-19 vaccine could not be ruled out.It is important to be aware of this complication as although rare,it could lead to significant morbidity and fatal bleed if not managed promptly. Steroids and IVIG is highly effective in ITP irrespective of cause.However,more investigations need to be done to establish a temporal relationship with COVID-19 vaccine. Nevertheless,occurrence of ITP should not be a deterrent in vaccination,though caution should be exerted in history of thrombocytopenia.

COVID-19: INTRAPULMONARY INJECTION OF HYDROGEN PEROXIDE SOLUTION ELIMINATES HYPOXIA AND NORMALIZES RESPIRATORY BIOMECHANICS

Severe SARS is complicated by respiratory obstruction, which is caused by swelling of the mucous membranes of the airways and obstruction of mucus, pus, and thick sputum streaked with blood. A particularly significant decrease in airiness occurs in the peripheral regions of the lungs. This is why the air introduced through the upper respiratory tract does not reach the alveoli, primarily in the peripheral regions of the lungs. Under these conditions, traditional ventilation of the lungs provides a back-andforth movement of air only in the trachea, large and small bronchi, since only these parts of the respiratory tract remain not clogged with mucus and pus. But these parts of the respiratory tract do not provide effective oxygenation of the patient's blood. Therefore, conventional mechanical ventilation (ALV) cannot normalize the biomechanics of breathing until the respiratory obstruction is eliminated. Therefore, with the inhibition of the biomechanics of respiration caused by respiratory obstruction, it is now customary to oxygenate the blood by the extrapulmonary route - using extracorporeal membrane oxygenation (ECMO). However, ECMO is a very dangerous and poorly accessible method of treatment. Therefore, to save the life of patients with severe hypoxia, it is proposed to urgently restore pulmonary oxygenation of the blood by oxygenating the lungs by injecting a solution of a pus solvent into the peripheral regions of the lungs. At the same time, intrapulmonary injection of an alkaline peroxide solvent of pus ensures the immediate appearance of oxygen gas in the peripheral parts of the respiratory tract, since pus and blood veins contain the enzyme catalase, which immediately decomposes hydrogen peroxide into oxygen and water gas. In this case, mucus, pus and sputum streaked with blood immediately turn into oxygen foam, which is easily removed through the upper respiratory tract to the outside. © 2021. Urakov A.L., Urakova N.A. All Rights Reserved.

Clinical correlations delirium and other comorbid in elderly with COVID-19 infection

Background: Delirium is a common condition in geriatric patients. One of the trigger factors for this condition is an infection, such as COVID-19 infection. Elderly with COVID-19 show atypical symptoms such as delirium. Elderly patients with COVID-19 who present with delirium, either as a primary symptom or showing symptoms or signs, have a poor prognosis. This study were aimed to presents covid-19 elderly patient with comorbid delirium. Case presentation: A 77-year-old woman with disorientation for one day came to Emergency Department with her family. She had no history of headaches, blurred vision, or seizures. However, she had a fever, did not want to eat for three days, and had a purulent decubitus ulcer. The patient was diagnosed with acute delirium syndrome, confirmed COVID-19 with sepsis, malnutrition, hypercoagulation, grade III decubitus ulcer, suspected dementia, immobilization, total dependence. The patient admitted to the isolation ward. The patient had meropenem 500 mg every 12 hours, anticoagulants and favipiravir according to the dose and parenteral nutrition.

Removal of rubber earphonecover inside nose after 2 years in a general practitioner setting during covid-19 pandemic

Inserted a big size of rubber ear phone cover into the nose is a rare case.Foreign body regarding children is common and need to be seriously considered.Nowadays, using an earphone for music players and games isverycommon among children that need to be more cautious.In general practitioner’s practice, several limitations seen with no fully equipped and emergency trolley, no general anaesthetic set up and no X ray. In this case report, we reported a 10-year-old child with bad smelling breath for 2 years with on and off pain and difficulty in breathing. It has become worsened until the child informshis mother regarding this incidence last weeks. Last 2 weeks, the child was examined in dental clinic for this bad smelling breath and no dental problem identify. The parents were refused to bring the child to the hospital because of this Covid-19 situation worsening in this state currently. They decided to cometo nearby general practitioner where the smelly and soaked with pus in this ear was removed without any complication in that clinic without any anaesthesia using blunt crocodile forceps.

Tuberculosis and COVID-19 co-infection in Cancer patients

Background: COVID-19 has been affecting mankind round the globe. Coinfection of Mycobacterium tuberculosis (TB) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has implications beyond morbidity at the individual level and can lead to unintended TB exposure to others. The present study was conducted to better understand the implication of TB and COVID-19 co-infection in Cancer patients. Methods: The study was conducted in the department of MIcrobiology, Tata Memeorial Hospital, Mumbai. Records of all cancer patients tested for Mycobacterium Tuberculosis using Genexpert and /or MGIT during March 2020 to October 2020 in the institute were analysed.We determined if these patients were also tested for SARS CORONAVIRUS 2 during the course of their treatment. If postive for COVID 19, the outcome of the disease was analysed and various demo- graphic paramateres were compared. Results: A total of 1830 samples were analysed for Mycobacterium tuberculosis (MTB) (886 - MGIT & 944 - Genexpert) between March 2020 to October 2020. Of these 171 detected postive for MTB on Genexpert & 75 Detected positive in MGIT. Majority of the sample types were Respiratory samples 121 (39 - MGIT & 82 - GENEXPERT) and pus/ tissue 120 (31 - MGIT & 89 - genex-pert). Of the patients diagnosed with TB, 57 patients were also tested for COVID 19 virus using RTPCR test. 03 among them tested positive for the SARS COVID 19 virus and results of 54 came back negative. [Formula presented] Conclusions: co-infections with TB must always be suspected in addi- tion to COVID-19 in current scenario in patients with RTI with non- specific clinical features and unexplained or prolonged clinical course and utmost consideration should be given to all above concerns impli- cated.

Omentoplasty technique in a patient with COVID-19 infection complicated with pulmonary abscess and bronchopleural fistula

One of the described complications in patients with SARS-CoV-2 is the occurrence of a lung abscess in the presence of ventilator-associated pneumonia. In cases of lung abscess indicated for surgical treatment, we face a number of challenges, the main of which is the treatment of the residual cavity and bronchial fistula. Omentoplasty is a method for treatment of various intrathoracic complications but its use in the filling of cavity defects and bronchial fistula is not much represented. We present the case of a 33-year-old patient with a severe form of COVID-19 infection who developed a massive lung abscess complicated by bronchopleural fistula and empyema during.

POS-162 'COLA COLOURED URINE' : NOT ALWAYS GLOMERULAR HEMATURIA

Introduction: Hematuria is a common condition for which a patient seeks nephrology consultation. The presence of gross hematuria is a frightening experience for patient. The reasons for this gross hematuria can be various like nephrolithiasis, malignancies, glomerular diseases, trauma, urinary tract infections, drugs, hemoglobinuria, etc. To differentiate between the various causes of gross hematuria one must begin by taking good history and clinical examination, followed by urine examination and then other tests. Glomerular hematuria is smoky or cola coloured and is usually accompanied by signs and symptoms of fluid overload, high blood pressure, and proteinuria. However cola coloured urine should not be considered synonymous with glomerular hematuria Methods: We report a case of 22 year old pregnant female who was Gravida-3 (22 weeks gestation) but no live issues. Her previous 2 pregnancies ended up in Intra Uterine Death (IUD) of foetus at 6 months gestation. She was referred to us in view of history of cola coloured urine. History of similar episodes of hematuria in previous 2 pregnancies were also present.The history taking was limited because of the prevailing 2ndpeak of COVID-19 pandemic in India and hence most history taking was done indirectly via phone. Clinically she had mild pedal edema and her BP was 110/70 mm of Hg. Her workup showed that she had severe anaemia. Her Complete Blood Count showed Hb-5.8 gm/dL,TLC-3600/mm3,Plt-1.64lakh/mm3,PBS-Microcytic hypochromic with target cells. Renal function was normal. Liver function showed mild indirect hyperbilirubinemia. Urinalysis showed 3+ protein, 50-60 RBCs, 5-10 Pus cell, No casts. Urine culture was sterile. 24 hour urine protein was 1.29 grams. Ultrasonography-bilateral normal sized kidneys. Her COVID-19 RTPCR was negative Results: Differentials we considered were : Primary Glomerulonephritis;Pregnancy Induced Hypertension (PIH);Anti-Phospholipid Antibody Syndrome (APLA) & Atypical Hemolytic Uremic Syndrome (a-HUS). These were ruled out based on further relevant tests.Kidney biopsy was not offered as there was no nephrotic syndrome. Anti-Nuclear Antigen was negative. Complements were normal. APLA antibodies were negative.BP was always normal making PIH less likely. However LDH was raised (2700 U/L) & serum haptoglobulin was low. So a clear cut evidence of hemolytic anaemia but normal renal function, compelled us to revisit the history by calling the patient in-person despite the pandemic. She admitted that anaemia was present since her childhood days and she had suppressed this history due to social issues. Also the hematuria was episodic with clear urine in between. Hence Flowcytometry for Paroxysmal Nocturnal Hemoglobinuria was done which confirmed the diagnosis as PNH. Conclusions: Our case report highlights the fact that while evaluating cases of hematuria one must keep all possibilities open. Especially when dealing with cola coloured urine it should not be assumed to be glomerular hematuria It also stresses the well established fact that history taking is the key to making any diagnosis. In situations where social factors may lead to suppression of facts,efforts must be made to gain the confidence of patient and provide a conducive environment for complete history. Finally, even after diagnosis of PNH, the definitive treatment is still out of reach for many patients in this part of world. No conflict of interest