THE RELATIONSHIP BETWEEN THE FUNCTIONALITY OF CHILDREN WITH DISABILITIES AND ITS EFFECTS ON PARENTS DURING THE COVID-19 PANDEMIC PROCESS.

Purpose: The aim of this study was to investigate the relationship between the functionality of disabled children and its effects on parents during the Covid-19 pandemic. Method(s): A total of 168 people, including 84 disabled children and 84 mothers, were included in the study. The Pediatric Disability Assessment Inventory (PEDI) and Gross Motor Function Classification System (GMFCS) were used for children with disabilities. The Zarit Burden Scale (ZBS), Fatigue Severity Scale (FSS) and The Nordic Musculoskeletal Questionnaire (NMQ) were applied to the mothers to question musculoskeletal disorders. Result(s): There was no correlation between care burden score and PEDI, total score, self-care and mobility scores (p>0.05). A moderately negative (r=-0.306;p<0.01) significant linear relationship was found between care burden score and social function score. There was no significant linear relationship between the fatigue severity score and PEDI total score, self-care, mobility and social function scores (p>0.05). No correlation was found between care burden score and fatigue severity score (p>0.05). For the last 12 months, only the pain in the lumbar region of the parents prevented them from doing their usual work. It was determined that the most aching body parts of the parents who complained of musculoskeletal pain during the last 12 months were in the waist, neck, shoulder, back, and knee regions. Conclusion(s): As a result, no relationship was found between the functionality of disabled children and their parents' influences during the Covid-19 pandemic.Copyright © 2022 Turkish Physiotherapy Association. All rights reserved.

Shoulder Weakness Following Intramuscular COVID- 19 Vaccine

History: Transient and generalized adverse effects are common following COVID-19 vaccination;among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted. Physical Exam: Left Shoulder-No calor or erythema;significant atrophy of the anterior and middle deltoid muscle relative to right side;abduction 4/5;external rotation with shoulder adducted 4/5;range of motion for active forward flexion was 150 degrees and passive was 170 degrees;passive range of motion for external rotation was 70 degrees;internal rotation to the level of L5;sensation to light touch was intact. Right Shoulder-Range of motion, strength, and sensation were intact. Cervical Spine-Full ROM;no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests. Differential Diagnosis: 161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity 162. Brachial Neuritis 163. Mechanical Axillary Nerve Palsy 2/2 Vaccination 164. Partial-Tear of Left Supraspinatus Tendon 165. Acromioclavicular Osteoarthritis Test Results: Left Shoulder-XR:Mild pseudo-subluxation;MRI w/o contrast: 8x9mmpartial-thickness articular surface tear of the distal supraspinatus tendon (<50%fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency;Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine. Discussion(s): We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID- 19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia. Outcome(s): The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment. Follow-Up: The patient did not follow-up for a repeatEMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.

True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation.

STUDY OBJECTIVE: To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE). DESIGN: Comparison of characteristics of patients with diaphragmatic endometriosis (DE) with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study. SETTING: Tertiary referral center; endometriosis center. PATIENTS: A total of 1372 patients with histologically proven endometriosis. INTERVENTIONS: Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the χ2 test and the Mann-Whitney t test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65 of 1372). There was no significant difference between the 2 groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often preoperatively (27.7% vs 1.8%, p <.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (revised American Fertility Society III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p <.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p <.05). CONCLUSION: Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.

Ultrasound-guided glenohumeral joint injections for shoulder pain in ALS: A case series.

Introduction: Shoulder pain is a common secondary impairment for people living with ALS (PALS). Decreased range of motion (ROM) from weakness can lead to shoulder pathology, which can result in debilitating pain. Shoulder pain may limit PALS from participating in activities of daily living and may have a negative impact on their quality of life. This case series explores the efficacy of glenohumeral joint injections for the management of shoulder pain due to adhesive capsulitis in PALS. Methods: People living with ALS and shoulder pain were referred to sports medicine-certified physiatrists for diagnostic evaluation and management. They completed the Revised ALS Functional Rating Scale and a questionnaire asking about their pain levels and how it impacts sleep, function, and quality of life at baseline pre-injection, 1-week post-injection, 1 month post-injection, and 3 months post-injection. Results: We present five cases of PALS who were diagnosed with adhesive capsulitis and underwent glenohumeral joint injections. Though only one PALS reported complete symptom resolution, all had at least partial symptomatic improvement during the observation period. No complications were observed. Conclusions: People living with ALS require a comprehensive plan to manage shoulder pain. Glenohumeral joint injections are safe and effective for adhesive capsulitis in PALS, but alone may not completely resolve shoulder pain. Additional therapies to improve ROM and reduce pain should be considered.

Postoperative rehabilitation of shoulder pain.

Background: Shoulder joint diseases such as rotator cuff tear, adhesive capsulitis, calcific tendinitis, shoulder instability, and glenohumeral osteoarthritis often require surgical treatment. Surgical outcomes can change significantly depending on whether the postoperative rehabilitation was appropriately performed. Current Concepts: The focus of postoperative rehabilitation should be to remove pain and restore functional movement through improving the dynamic stability of the rotator cuff and shoulder muscles. However, rehabilitation should not include activities that aggravate the injury. Therefore, rehabilitation treatment should be carried out with gradual increments in exercise intensity. Postoperative rehabilitation is not only related to exercise but may also include drug administration, such as steroid injection. In particular, many investigations have been performed to identify the clinical risks and benefits of steroid injection after rotator cuff repair. Notably, telemedicine can be used as a solution for the problematic situations that have been caused by coronavirus disease 2019 pandemic. Discussion and Conclusion(s): A thorough understanding and appropriate application of postoperative rehabilitation protocols are essential to improve surgical outcomes.Copyright © Korean Medical Association.

Physiotherapy results of a patient with critical illness polyneuropathy due to COVID-19: A case report

The aim of this study is to examine the results of physiotherapy in a patient with critical illness polyneuropathy (CIP) due to coronavirus disease 2019 (CO-VID-19). The 48-year-old male patient with CIP due to COVID-19 was enrolled in a physiotherapy program for 3 months with 5 sessions/week. Pain intensity, motor skills, daily living activities, fatigue level, cognitive status, and decubitus ulcer were evaluated with a visual analogue scale, the Medical Research Coun-cil-Sum Score, the Functional Independence Scale, the Fatigue Severity Scale, the Standardized Mini-Mental Test, and pressure wound staging, respectively. Positive improvements were achieved in functional level, fatigue, pain, and pressure sores with the physiotherapy program for this patient with CIP due to COVID-19. This report provides an idea about the effects of physiotherapy programs for COVID-19-related CIP to academics and clinicians working in this field.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Covid-19 Vaccine safety and adverse event analysis from Pakistan

Covid immunization commenced on 2nd Feb 2021 in Pakistan and as of 7th Sep 2021, over 84 million vaccine doses were administered in Pakistan, of which 72% procured by the government, 22% received through Covax and 6% were donated. The vaccines rolled out nationally included: Sinopharm, Sinovac and CanSinoBIO (China), AstraZeneca (UK), Moderna and Pfizer (USA), Sputnik (Russia), and PakVac (China/Pakistan). About half of the eligible population in Pakistan (63 m) had received at least one dose of Covid vaccine as of Sep 2021. Pakistan National Pharmacovigilance Centre (PNPC) in coordination with WHO, MHRA and Uppsala Monitoring Centre (UMC) established pharmacovigilance centers across Pakistan. The Covid vaccine AEFIs in Pakistan were mainly reported via NIMS (National Immunization Management System), COVIM (Covid-19 Vaccine Inventory Management System), 1166 freephone helpline and MedSafety. There have been 39,291 ADRs reported as of 30th Sept 2021, where most reported after the first dose (n = 27,108) and within 24-72 h of immunization (n = 27,591). Fever or shivering accounted for most AEFI (35%) followed by injection-site pain or redness (28%), headache (26%), nausea/vomiting (4%), and diarrhoea (3%). 24 serious AEFIs were also reported and investigated in detail by the National AEFI review committee. The rate of AEFIs reports ranged from 0.27 to 0.79 per 1000 for various Covid vaccines in Pakistan that was significantly lower than the rates in UK (~4 per 1000), primarily atrributed to underreporting of cases in Pakistan. Finally, Covid vaccines were well tolerated and no significant cause for concern was flagged up in Pakistan's Covid vaccine surveillance system concluding overall benefits outweighed risks.Copyright © 2022

A rare occurrence of tumoural calcinosis of long head biceps tendon post-COVID-19 infection

Tumoural calcinosis is a rare entity commonly caused by hyperphosphatemia due to bone mineral disease, hyperparathyroidism of chronic renal failure. However, our case demonstrated a normo-phosphatemic tumoural calcinosis post-COVID-19. This is a 36-year-old with a multiple history of soft-tissue calcification presented with acute onset severe right shoulder pain associated with anterior shoulder swelling at day 20 post-COVID-19. The clinical examination reveals anterior shoulder swelling at bicipital groove with severe restriction of range of motion due to pain. Ultrasound revealed an initial solid mass arising from the sheath of long head of biceps tendon which turns into cystic mass at week 4 of the disease. Computed tomography scan demonstrate sedimentation sign. His blood parameters revealed normo-calcemic, normo-phosphatemic bone profile, normal renal function and no sign suggestive of rheumatological disease. He was started on short course on non-steroidal anti-inflammatory drugs (NSAIDs) for 3 week and does not require surgical intervention. His symptoms completely resolved after 4 weeks with persistent shoulder swelling. He was started with prophylaxis low phosphate diet to prevent future recurrence. Our case demonstrates that conservative management using the short course of NSAIDs can be beneficial in treating primary normophosphatemic tumoural calcinosis.

Shoulder Pain and Injury after COVID-19 Vaccination

Shoulder injury related to vaccine administration (SIRVA) is a term given to describe shoulder pain and dysfunction arising within 48 hours after vaccine administration and lasting for more than one week. While SIRVA is most commonly seen after influenza and tetanus vaccines, there have been a few recent case reports describing SIRVA-like symptoms after COVID-19 vaccine administration. Two patients presented to the shoulder surgeon's practice center with complaints of shoulder stiffness and pain following the COVID-19 vaccine. The first patient was a 33-year-old man;he presented within 2 days of onset of the pain and 14 days from the vaccine date. He had a complete restriction of shoulder motion (0degree flexion, and no external or internal rotation) at presentation. This patient was treated with non-steroidal anti-inflammatory drugs (NSAID) and rested in a sling for a week. The second patient was a 53-year-old woman;she presented with a 6-week duration of mild restriction of active shoulder motion and shoulder pain. Her magnetic resonance imaging (MRI) revealed the presence of subacromial-subdeltoid bursitis. She was treated with subacromial steroid injection and range of motion shoulder exercises. Both patients recovered a near-normal range of motion recovery within a month, and their pain improved significantly. The main lessons from this case report were: (1) patients presenting with a recent increase in pain and acute loss of shoulder movements after vaccination may be managed conservatively with rest and NSAID medications and (2) in case of a subacromial-subdeltoid bursitis in the MRI, subacromial injection of steroid may provide good pain relief. Copyright © 2022, Yale Journal of Biology and Medicine Inc. All rights reserved.

Postoperative rehabilitation of shoulder pain

Background: Shoulder joint diseases such as rotator cuff tear, adhesive capsulitis, calcific tendinitis, shoulder instability, and glenohumeral osteoarthritis often require surgical treatment. Surgical outcomes can change significantly depending on whether the postoperative rehabilitation was appropriately performed. Current Concepts: The focus of postoperative rehabilitation should be to remove pain and restore functional movement through improving the dynamic stability of the rotator cuff and shoulder muscles. However, rehabilitation should not include activities that aggravate the injury. Therefore, rehabilitation treatment should be carried out with gradual increments in exercise intensity. Postoperative rehabilitation is not only related to exercise but may also include drug administration, such as steroid injection. In particular, many investigations have been performed to identify the clinical risks and benefits of steroid injection after rotator cuff repair. Notably, telemedicine can be used as a solution for the problematic situations that have been caused by coronavirus disease 2019 pandemic. Discussion and Conclusion: A thorough understanding and appropriate application of postoperative rehabilitation protocols are essential to improve surgical outcomes. © Korean Medical Association.

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.

The Effects of Frequent Coffee Drinking on Female-Dominated Healthcare Workers Experiencing Musculoskeletal Pain and a Lack of Sleep.

Previous research has demonstrated that chronic diseases can occur due to musculoskeletal (MS) pain and poor sleep. It is also worth noting that the caffeine in coffee can reduce overall sleep duration, efficiency, and quality. Thus, the present study examines the effects of frequent coffee drinking (two cups per day) on individuals experiencing MS pain and a lack of sleep during the COVID-19 period. This observational and cross-sectional study recruited 1615 individuals who completed the self-reported (Nordic musculoskeletal) questionnaire. Long-term, frequent coffee drinking and a sleep duration of less than 6 h per day were significantly associated with neck and shoulder pain among healthy individuals. The mediation model demonstrated that the shorter sleep duration and drinking multiple cups of coffee per day had a two-way relationship that worsened such pain over the long term. Specifically, individuals who experienced such pain frequently drank multiple cups of coffee per day, which, in turn, shortened their sleep durations. In summary, long-term coffee drinking creates a vicious cycle between MS pain and sleep duration. Therefore, the amount of coffee should be fewer than two cups per day for individuals who sleep less than 6 h per day or suffer from MS pain, especially neck and shoulder pain.

Parsonage-Turner syndrome after SARS-CoV-2 vaccination: A case report.

Parsonage-Turner syndrome is a neurological disease characterized by pain, muscle weakness, sensory deficits, and reflex abnormalities. Although its exact etiology is unknown, it can be observed after infection, surgery, trauma, and vaccination. This syndrome, which can occur after various vaccines, has been reported in a few cases worldwide after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. In this case report, Parsonage-Turner syndrome developed after the SARS-CoV-2 BioNTech vaccination in a 56-year-old male patient. To the best of our knowledge, this is the first case reported in Türkiye.

Postoperative rehabilitation of shoulder pain

Background: Shoulder joint diseases such as rotator cuff tear, adhesive capsulitis, calcific tendinitis, shoulder instability, and glenohumeral osteoarthritis often require surgical treatment. Surgical outcomes can change significantly depending on whether the postoperative rehabilitation was appropriately performed. Current Concepts: The focus of postoperative rehabilitation should be to remove pain and restore functional movement through improving the dynamic stability of the rotator cuff and shoulder muscles. However, rehabilitation should not include activities that aggravate the injury. Therefore, rehabilitation treatment should be carried out with gradual increments in exercise intensity. Postoperative rehabilitation is not only related to exercise but may also include drug administration, such as steroid injection. In particular, many investigations have been performed to identify the clinical risks and benefits of steroid injection after rotator cuff repair. Notably, telemedicine can be used as a solution for the problematic situations that have been caused by coronavirus disease 2019 pandemic. Discussion and Conclusion: A thorough understanding and appropriate application of postoperative rehabilitation protocols are essential to improve surgical outcomes.

DIAPHRAGMATIC PARALYSIS FOLLOWING SECOND DOSE OF THE BNT162B2 MRNA COVID-19 VACCINE

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The vaccines against SARS-CoV-2 or COVID-19 have been shown to be safe and effective at preventing severe disease and death. In a phase 3 trial the BNT162b2 mRNA COVID-19 vaccine showed a 52% and 95% efficacy after the first and second doses, respectively (1). Side effects following vaccination are common but are typically mild and self limited (2). The most common side effects are headache, fever, fatigue, arthralgias and pain at the injection site (2). More severe and devastating side effects have been reported including cerebral venous thrombosis and myocarditis (3) (4). Here we report a case of unilateral diaphragmatic paralysis following the second dose of the BNT162b2 mRNA COVID-19 vaccine. CASE PRESENTATION: The patient was a 56 year old female with a past medical history of reactive airways disease and hypertension who was seen in the pulmonology clinic shortly after receiving her second dose of the BNT162b2 mRNA COVID-19 vaccine. After her second dose she developed burning shoulder pain, erythema and swelling that extended to the neck and axilla. She went to an urgent care and was advised to treat with ice and NSAIDs, she had a chest radiograph performed which was reported to be negative. Her symptoms persisted and she was sent to the emergency room, chest x-ray showed interval development of an elevated left hemidiaphragm. A CT Chest with inspiratory and expiratory films was performed and the left diaphragm was noted to be in the same location during inspiration and expiration consistent with diaphragmatic paralysis. PFT showed a reduction in her FVC, TLC and DLCO compared to 13 years prior. DISCUSSION: Diaphragmatic paralysis is a well described clinical entity that is most often associated with cardiothoracic surgery where hypothermia and local ice slush application are thought to induce phrenic nerve injury (5). It has also been described as a complication of viral infections, including a recent report of unilateral diaphragm paralysis in a patient with acute COVID-19 infection (6). In a case series of 246 patients with amyotrophic neuralgia which can include diaphragm paralysis, 5 patients received a vaccine in the week before developing symptoms (8) Additionally, Crespo Burrilio et al recently described a case of amyotrophic neuralgia and unilateral diaphragm paralysis following administration of the Vaxzevri (AstraZeneca) COVID-19 vaccine (7). This case highlights a potential side effect of the BNT162b2 mRNA COVID-19 vaccine that has not been previously reported CONCLUSIONS: Reference #1: Polack FP, Thomas SJ, Kitchin N. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med. 2020;383:2603–2615. Reference #2: Menni, C., Klaser, K., May, A., Polidori, L., Capdevila, J., Louca, P., Sudre, C. H., Nguyen, L. H., Drew, D. A., Merino, J., Hu, C., Selvachandran, S., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., Modat, M., Joshi, A. D., Mangino, M., … Spector, T. D. (2021). Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. The Lancet. Infectious diseases, 21(7), 939–949. https://doi.org/10.1016/S1473-3099(21)00224-3 Reference #3: Jaiswal V, Nepal G, Dijamco P, et al. Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221074450. doi:10.1177/21501319221074450 DISCLOSURES: No relevant relationships by Jack Mann No relevant relationships by John Prudenti

CAVITATORY LUNG RHIZOPUS INFECTION IN RENAL TRANSPLANT RECIPIENT: RARE CASE REPORT

Introduction: Mucormycosis is a life threatening fungal infection commonly seen in diabetics and immunocompromised individuals. It is caused by one of the members of mucoraceae family which includes mucor, rhizopus, rhizomucor, absidia and others. Its prevalence has become more common in covid pandemic. Methods: We report a rare case of large cavitatory Rhizopus infection in a renal transplant recipient. Patient was initiated on antitubercular therapy for tubercular lymphadenitis two months prior to transplant. He was given rabbit ATG as induction agent and was on triple maintenance immunosuppression with tacrolimus/ mycophenolate mofetil/ steroids. Patient developed post transplant Diabetes mellitus. Four months post transplant he presented with cough, fever and left sided chest and shoulder pain for 10 days. Covid RT PCR was done twice and it came out to be negative. High Resolution Computed tomography Chest revealed thick walled cavity abutting the chest wall (10.3 x 7.1cm) in left upper lobe. Blood culture was sterile after five days of incubation. Serum Beta galactomannan was negative. He was empirically started on broad spectrum antibiotics and antifungals (oral voriconazole). He underwent bronchoscopy on day 4 of admission. As tuberculosis was a differential, gene expert, tubercular culture and AFB stain was obtained on Bronchoalveolar(BAL) fluid which all came out to be negative. Microbiological sample from BAL Fluid revealed growth of Rhizopus species. He was started on Liposomal amphotericin B. Since the cavitatory lesion occupied almost the entire left lung, surgical resection was offered to the patient to which patient refused. Results: He improved symptomatically after 10 days of Liposomal amphotericin B. Total of 10 weeks of Liposomal amphotericin B was given. Follow up CT after 40 days showed significant reduction in size of cavity to 7.5cm. A surprising complete resolution of the lung cavity was seen after 4 months. Conclusions: This case is one of the very few reported cases of invasive pulmonary rhizopus infections. It emphasizes how medical treatment alone can lead to complete resolution of such large cavitatory lesions without surgical intervention. No conflict of interest

THE TRUTH THE TEETH TOLD: THE UNUSUAL CASE OF A SUBPHRENIC MASS

CASE: A 75-year-old man with a history of aortic stenosis status post transcatheter aortic valve replacement (TAVR), compensated cirrhosis in the setting of alcohol use disorder, and osteoarthritis presented with hyper-acute dyspnea and chest pain that awoke him from sleep. Three years prior to admission, an abdominal computed tomography (CT) for his TAVR evaluation revealed a 2 cm, irregular, peripherally-enhancing mass in the right subphrenic space, most concerning for malignancy but stable in size a year later. Further work-up was delayed due to the COVID-19 pandemic. One week prior to this presentation, he returned to care with 6 months of progressive right shoulder pain, pleuritic chest pain, and 5 kg of unintentional weight loss and was found to have growth of the right subphrenic mass to 4.9 cm, for which he underwent interventional radiology-guided aspiration and biopsy from a subxiphoid approach. Pathology on the core biopsy was inconclusive, revealing granulation tissue with chronic inflammatory changes and negative routine cultures. He was hemodynamically stable and discharged home. On admission, he was afebrile, tachypneic to 26, tachycardic to 120, hypotensive to 80/40, and saturating 94% on room air. He was found to have a large pericardial effusion with tamponade physiology, upon which 500 mL of serous fluid was drained via emergent pericardiocentesis. Laparoscopic biopsy of the subphrenic mass revealed a purulent fluid collection. 16S/18S sequencing and MALDI cultures were most consistent with Actinomyces spp. With further history-taking alongside an Italian language interpreter, he was found to have had prior dental abscesses, the likely origin of his Actinomyces infection, although the curious propensity for the subphrenic location remains unknown. Periodontal disease had been diagnosed but not fully treated given lack of insurance coverage and perceived importance. His pericarditis and ensuing tamponade was attributed to irritation and seeding from the subxiphoid approach for attempted fluid aspiration. IMPACT/DISCUSSION: Actinomyces spp. are a part of the normal human gut and oral cavity flora, but when pathogenic, they are often associated with dental, pulmonary, and urinary tract infections. In addition to periodontal disease, this patient's risk factors for Actinomyces abscess formation include cirrhosis (via transient gut translocation from elevated portal pressures) and alcohol use disorder (via increased aspiration risk). There have been several reports of Actinomyces spp. causing pericarditis and tamponade following seeding from liver, lung, and oral cavity abscesses- to our knowledge, however, none from subphrenic abscesses. CONCLUSION: This case highlights the importance of an oral health history in work-up of an indolent growing thoracic mass and the challenges in comprehensive history-taking in patients with limited English proficiency. Increasing coverage of dental services (e.g. a Medicare dental benefit) is key to health and health equity.

WHY YOU SHOULDN'T AIM TOO HIGH ALL THE TIME: A CASE OF SHOULDER INJURY RELATED TO VACCINE ADMINISTRATION (SIRVA) OF COVID-19 MRNA

CASE: A 23-year-old female presented to resident clinic for 7 months of right shoulder pain. She received her second COVID-19 mRNA vaccine just prior to onset of pain. She noted vaccine administration was “traumatic” with significant bleeding and bruising. She started noticing pain with overhead activities several days later. She is very active with cardiovascular exercises. She lifts weights but none requiring overhead motions. The pain was worst at the front of the shoulder but radiated to the lateral aspect. She had not tried, ice, heat, medications or physical therapy. Because of her injury, she was hesitant to receive her COVID-19 booster. BMI was low at 16.65. Exam showed thin build and overall low muscle bulk. Right shoulder showed no signs of muscle atrophy. There was tenderness of subacromial and coracoid areas. No pain along biceps tendon or AC joint. She had full ROM with shoulder abduction, internal and external rotation. She had full strength of supraspinatus, infraspinatus, teres minor, and subscapularis muscles. She noted pain with abduction, internal rotation and lift-off maneuver. Her Hawkins and Neer's maneuvers were positive. No pain with Yergason's and Speed's maneuvers. The patient was diagnosed with right shoulder subacromial bursitis and impingement syndrome. IMPACT/DISCUSSION: Mild shoulder pain is expected after vaccine administration and typically resolves in days. However, SIRVA is an increasingly recognized complication of improper vaccine administration particularly in the occupational setting. SIRVA results from vaccine being delivered inadvertently within the subdeltoid bursa or joint space. It is thought to result from an immune mediated reaction to the vaccine components as injury tends to be greater than expected from a needle injury. We were able to find 5 cases of reported SIRVA related to the COVID vaccine. All included some form of subacromial, subdeltoid, or subcoracoid bursitis. One case noted a supraspinatus tear. Ultrasound has demonstrated the subacromial bursa can extend distal to the acromion by up to 6 cm, so administration to bursa is possible in the superior deltoid. Appropriate injection technique can reduce the risk of injury;administrators should use landmarks of the acromion and distal insertion point of deltoid mid-humerus. Proper needle length is important. It has been suggested a smaller deltoid fat pat and smaller deltoid muscle bulk are risk factors for SIRVA. Women tend to have a higher incidence. CONCLUSION: We presented the case of a slender female who developed shoulder bursitis and impingement following administration of COVID-19 mRNA vaccine. She was referred to PT for rotator cuff strengthening, instructed to refrain from aggravating activities, and provided NSAIDs for pain relief. She reports pain relief. Another option for a more severe case would be a subacromial bursa steroid injection. It is important for providers to be aware of this pathology to provide appropriate treatment and decrease vaccine hesitancy.