Initial five and ten-minute regional cerebral oxygen saturation as a predictor of the futility of resuscitation for out-of-hospital cardiac arrest

This study aimed to investigate the usefulness of cerebral regional oxygen saturation (rSO2) during the initial 5 and 10 minutes of cardiopulmonary resuscitation (CPR) compared with an initial rSO2 and mean rSO2 during entire CPR to predict the futility of resuscitation for patients without of-hospital-cardiac arrest (OHCA). This was a prospective study involving 52 adult patients presenting in OHCA and whose cerebral rSO2 values were measured until either CPR was terminated or sustained return of spontaneous circulation (ROSC) was achieved. Receiver operating characteristics analyses were used to evaluate which time and type of measurement is better to predict non-ROSC. The area under the curve (AUC) of each rSO2 value according to measurement time (overall, initial 5 minutes and 10 minutes) were the highest value of 0.743, 0.724, and 0.739, mean values of 0.724, 0.677 and 0.701 and rSO2 (Changes in values of regional cerebral oxygen) value of 0.722, 0.734 and 0.724, respectively, while all of the initial values had a poor AUC (<0.7) and also were not statistically significant. The optimal cut-off value of each rSO2 values during overall, initial 5 minutes and 10 minutes were the highest value of 26% (sensitivity, 53.9% specificity, 92.3%), 24% (sensitivity, 56.4% specificity, 92.3%), and 30% (sensitivity, 61.5% specificity, 84.6%), mean value of 15.2%, 15.3% and 16%, respectively. None of the patients with a persistent rSO2 <=18% during the overall period achieved ROSC. Initial 5 minutes and 10 minutes cerebral rSO2 values an out-of-hospital-cardiac arrest (OHCA) are a better predictor in deciding the futility of CPR, compared to initial and overall measurements.Copyright © 2023 The Author(s). Published by MRE Press.

Prevalence of Ophthalmic Manifestations in COVID-19 Positive Indoor Patients during Second Wave at Rural Tertiary Care Hospital of Gujarat: A Prospective Observational Study

Introduction: Coronavirus Disease-2019 (COVID-19) can affect multiple system of body including eye. In eye, it can cause mild conjunctivitis, posterior segment involvement, neurosensory involvement and lethal opportunistic infection like mucormycosis. Associated co-morbidities, severity of COVID-19 infection and corticosteroids used in its management can affect ophthalmic involvement. Aim(s): To determine the frequency and various types of ophthalmic manifestation of patients with COVID-19. Material(s) and Method(s): This prospective observational study was conducted on indoor patients of Shree Krishna Hospital, a rural, tertiary care hospital affiliated with Pramukh Swami Medical College, Karansad, Gujarat, India, from 1st May 2021 to 1st January 2022. Second wave of COVID-19 was from 13th March 2021 to 19th June 2021. Patients' demographic data, details of COVID-19 infection severity score, oxygen requirement, use of corticosteroids, history of various co-morbidities and stages of Rhino-Orbital-Cerebral Mucormycosis (ROCM) (if present) were noted. Bedside ophthalmic examination was done with torch light, fluorescent strip, cobalt blue light of direct ophthalmoscope and fundus examination with indirect ophthalmoscopy under institutional COVID-19 guidelines. Descriptive Statistics {Mean, (SD), Frequency, (%)} were used for analysis of the collected data. Result(s): Out of 649 COVID-19 patients, 368 were male and 281 were female with mean age of 52.58 (+/-15.38) years. All over prevalence of ophthalmic manifestations was 9.86% (n=64 out of 649 patients). A total of 63 patients (9.71%) did not require any oxygen supplement, 352 patients (54.24%) required nasal prongs, 201 patients (30.97%) required non invasive ventilator support and 33 patients (5.08%) required mechanical ventilation. The 378 patients (58.24%) received cortico-steroids in oral or intravenous form. A total of 325 patients (50.1%) had diabetes,267 patients (41.1%) had hypertension, 29 patients (4.5%) had chronic kidney disease and 15 patients (2.3%) had thyroid disease. A total of 52 patients (8.01%) had conjunctivitis. Mean age of patients with conjunctivitis was 50.04 (+/-15.28) with male preponderance (n=30, 57.7%). Most common systemic presentation was fever (n=29,55.8%). Patients with conjunctivitis had high D-dimer (>500 ng/mL) (n=42;80.8%) and C-Reactive Protein (CRP) values (>3 mg/L) (n=39;75%). A total of 144 patients (22.2%) were vaccinated with COVID-19 vaccine first dose while ten patients (19.23%) out of 52 patients having conjunctivitis were vaccinated. Out of 649 patients, prevalence of ROCM was 1.85% (n=12) with mean age 58.58 years (+/-9.71 years) and male preponderance (n=8, 66.66%). Nine out of twelve patients had high blood sugar levels (mean level 340 mg/ dL) at the time of admission. Out of twelve, eight patients had received corticosteroids for management of COVID-19 infection. Six patients of ROCM (50%) did not require any oxygen support while two patient (16.7%) required nasal prongs for mean 7.50 days and four patient (33.3%) required non invasive ventilator support for mean 7.33 days (+/-2.5 days). One patient had stage 2C disease, one had stage 3B, five patients had stage 3C while five patients had stage 4C disease. Conclusion(s): Ocular manifestations of COVID-19 range from conjunctivitis to ROCM. Conjunctivitis has mild and self-limited course while ROCM is sight threatening and life-threatening condition, if not treated appropriately.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.

Dynamic matching of oxygen uptake kinetics and muscle deoxygenation in post-COVID-19

Recent studies showed that post-COVID-19 patients with reduced pulmonary oxygen uptake (VO2p) kinetics, exhibited a lower peripheral oxygen extraction [lower C(a-v) O2 /Ca O2 ] rather than a central cardiac limitation (supernormal predicted exercisepeak cardiac output), opening further questions of what is impacting VO dynamics. We proposed to investigate the dynamic matching of VO2p , increase of heart rate (HR) and muscle deoxygenation (deoxy[Hb + Mb]) at the onset of heavy-exercise in post-COVID-19 patients. We expected to find a slowness of VO unrelated to circulatory impairment. 12 patients (90 days after onset of symptoms) were compared to 10 healthy controls. The VO rate of change, deoxy[Hb + Mb] in vastus lateralis (by near infrared spectroscopy) and HR were analyzed during a constant work-rate exercise test up to limit of tolerance (~70%peak work-rate). Post-COVID-19 patients had significantly slower VO2p kinetics than controls (Tau-VO2p 52+/-9 vs 40+/-11 seconds(s);p=0,001 and MRT-VO 70+/-12 vs 51+/-10 s;p<0,001). In contrast, t1/2 -HR was faster in patients (65+/-28 vs 85+/-20 s, p=0,04). Not only deoxy[Hb + Mb] dynamics were not accelerated compared to controls, suggesting normal muscle microvascular O2 delivery, but significantly slower (MRT-deoxy[Hb + Mb] 25+/-7 vs 20+/-2 s;p=0,02)(Figure 1). In conclusion, a sluggish on-exercise VO2p in these patients seems unrelated to central and peripheral circulatory adjustments. .

A Case of Myositis in Patient with Atypical Bacterial Pneumonia

Case report - Introduction: Bacterial community-acquired atypical pneumonia is sometimes complicated by myositis or by renal parenchymal disease. They can present with myositis and present with muscle weakness, pain or swelling, and elevated muscle enzymes. We present the case of a patient with lower limb weakness and raised creatinine kinase with atypical pneumonia caused by Legionella pneumophila. Case report - Case description: A 76-year-old Caucasian man, who was previously fit and independent and walked 3 miles every day presented with a 1-week history of progressive leg weakness, and inability to mobilize. He had a fall and was on the floor for 2 hours. He had a background history of hypercholesterolemia and was on atorvastatin for 15 years. On his vital observation, he was found tachypnoeic, tachycardic, and hypoxic. He had a right upper lobe crackle but he didn't have respiratory symptoms. His muscle power in his leg was 3/5 with carpet burns on knees and elbow. Initial investigation showed raised inflammatory marker CRP 412mg/L, AKI stage 1, and CK 43400 IU/L. His CXR showed dense right upper lobe consolidation. Legionella urinary antigen was positive. Myositis myoblot, ANA, ANCA negative. COVID-19 swab negative. Treated with IV antibiotic, supplemental oxygen, and IV fluid. Transferred to ITU due to worsening of hypoxia and kidney function. Interestingly, the CK level had improved significantly within 48 hours along with clinical improvement in his symptoms. There was no role of steroid or immunosuppressant due to his significant clinical improvement. On day 7 he was off oxygen, kidney function improved, had physiotherapy, and transferred to ward and on day 10 he was ambulant and discharged home. Case report - Discussion: To date, very few case reports of myositis in a patient with atypical pneumonia have been reported. The mechanism underlying acute myositis in atypical pneumonia is still unknown. The present analysis points out that the organism underlying atypical bacterial pneumonia may occasionally invade the muscle tissue thereby inducing both myositis and secondary kidney damage. Case report - Key learning points: We should be aware of this rare complication of atypical pneumonia and the resolution of symptoms that occur with the treatment of pneumonia. This would avoid unnecessary investigation and use of steroid.

Novelties in the evaluation of microcirculation in septic shock.

Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.

PATHOPHYSIOLOGY OF LACTIC ACIDOSIS IN PATIENTS WITH ASTHMA

SESSION TITLE: Challenges in Asthma SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Asthma is a chronic illness affecting 334 million people worldwide[1]. Asthma affects the respiratory gas exchange, which plays a significant role in acid-base balance. Acid-base disorders in asthma involve respiratory alkalosis, respiratory acidosis, and AG acidosis[2]. CASE PRESENTATION: A 37 years old Hispanic male with a PMH of intermittent asthma presents with progressive dyspnea for three days, worse with activity and decreases with rest. He reported no [cough, fever, rhinorrhea, chest pain]. No orthopnea. He is vaccinated for COVID ( 2 Pfizer doses), has no sickness exposure, and works as a driver. The patient is not a smoker. Physical Exam: Blood pressure 124/72 mmHg. Heart Rate 100 PPM. Temperature 97.1 F.Respiratory Rate 21BPM.SPO2 90% General appearance: acute distress with nasal flaring. Heart: Normal S1, S2. RRR. Lung: Poor air entry with diffuse wheeze bilaterally. He was placed on a 6 LPM NC. CBC and differential were unremarkable. He was started on methylprednisone, Ceftriaxone, and azithromycin. The patient was started on inhaled Salbutamol and Budesonide. Chest X-ray was unremarkable, Chemistry was unremarkable except for elevated Lactic acid 4.7, There was no concern for reduced tissue perfusion or hypoxia, with no evidence of an infectious process because both viral and bacterial causes for pneumonia were excluded, and antibiotics were stopped. A serial lactic acid level trend was 4.5/4.3/ 4.1/ 4 on the first day, while on the next day, it was 3.1/ 2.9/ 2.7/ 2.5/ 3.5, we stopped trending his lactic acid level. He improved and was discharged on an oral taper steroid and inhaled steroids with a B2 agonist. DISCUSSION: There are two types of Lactic acidosis in patients with asthma: 1- Type-A results from impaired oxygen delivery to tissues and reduced tissue perfusion in severe acute asthma may be accompanied by reduced cardiac output. 2- Type B where oxygen delivery is normal, but the cellular function is impaired due to increased norepinephrine in plasma, increasing metabolic rate and lactate production, drugs like beta-agonists increase glycogenolysis leading to an increased pyruvate concentration;pyruvate is converted to lactic acid. B2 agonist increases lipolysis and increases Acetyl CoA, this increase in Acetyl CoA inhibits the conversion of pyruvate to Acetyl CoA, increasing pyruvate which will be converted to lactic acid[2], Theophylline is a non-selective 5'-phosphodiesterase inhibitor and potentiates the activity of ß-adrenergic agents by increasing the intracellular concentration of cAMP, Glucocorticoids are also known to increase the ß-receptor's sensitivity to ß-adrenergic agonists. CONCLUSIONS: Providers are increasingly challenged by hyperlactatemia,it is not harmful but elevated Lactic acid levels and clearance rate is used for prognostication,hyperlactatemia might be misleading,and all possible causes of elevated lactic acid levels must be explored. Reference #1: 10.5334/aogh.2412 Reference #2: https://doi.org/10.3390/jcm8040563 Reference #3: Edwin B. Liem, Stephen C. Mnookin, Michael E. Mahla;Albuterol-induced Lactic Acidosis. Anesthesiology 2003;99:505–506 doi: https://doi.org/10.1097/00000542-200308000-00036 DISCLOSURES: No relevant relationships by Vasudev Malik Daliparty No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib No relevant relationships by MATTHEW YOTSUYA

DYSPNEIC AFTER EVERY COVID-19 SHOT: SUSPECTED BNT162B2 MRNA VACCINE-RELATED, DRUG-INDUCED PULMONARY EOSINOPHILIA

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Eosinophilia is the most commonly reported adverse event following administration of the Pfizer/BioNTech vaccine, accounting for 237 of 372 events (63.7%). Eosinophilic pneumonia has been described noted in 3 of all reported cases. CASE PRESENTATION: We present the case of a 73 year-old male presented to his PCP with a 3 week history of nonproductive cough and wheezing. He completed a 2-shot series of BNT162b2 mRNA (Pfizer/BioNTech) COVID vaccine 1 week prior to symptom onset. He had no history of respiratory symptoms, smoking, sick contacts, recent travel, chemical or biological exposures. On presentation, he was afebrile, tachycardic and required 3LPM supplemental oxygen to maintain peripheral oxygen saturation (SpO2) above 94%. Laboratory findings noted leukocytosis (13,200/mL) and eosinophilia at 5% (Absolute Eosinophil Count (AEC): 580 cells/L). Respiratory viral panel, procalcitonin, ESR and D-dimer were negative. Chest CT scan was unremarkable. He was treated with azithromycin, prednisone and inhaled bronchodilators with improvement in hypoxia. 2 weeks later, he reported intermittent dyspnea during a pulmonary clinic visit. Pulmonary function testing was normal (FEV1/FVC: 76%;FVC: 3.67L (90% predicted);FEV1: 2.80L (88% predicted). IgE level was normal and eosinophilia had resolved. 6 months after initial symptom onset, the patient received his third BNT162b2 mRNA vaccine dose. 2 weeks after vaccination, he presented to the ED with severe dyspnea, wheezing and cough with yellow sputum. He also noted a new itchy, erythematous bilateral forearm rash and painless oral ulcers. On exam, he was afebrile, tachypneic with SpO2 of 93% on 4LPM supplemental oxygen and audibly wheezing with a prolonged expiratory phase. Laboratory studies noted elevated creatinine and leukocytosis (23,100/mL) with marked eosinophilia (29.5 %, AEC: 6814 cells/L). Chest CT scan revealed a 2 cm rounded ground-glass opacity in the right upper lobe. (Figure 1.) Further workup revealed a weakly positive antihistone antibody (1:4 titer). IgE, ANA, ANCA, SS-A/B, anti-CCP, and complement levels were normal. Intravenous methylprednisolone treatment was initiated with rapid improvement in dyspnea, eosinophilia and renal function. A transbronchial biopsy (Figure 2.) of the RUL lung lesion revealed organizing pneumonia with mixed inflammatory infiltrate. Bronchoalveolar lavage analysis revealed elevated WBC (432 cells/L) with neutrophilic predominance (85%). Patient was discharged home on a prednisone taper with resolution of symptoms. DISCUSSION: Subsequent allergy work up did not indicate any apparent etiology of hypereosinophilia. Testing for strongyloides, coccidiosis and aspergillosis were also negative. A final diagnosis of BNT162b2 mRNA vaccine related pulmonary eosinophilia was made. CONCLUSIONS: Additional study is warranted into eosinophilic disease associated with the BNT162b2 mRNA vaccine. Reference #1: 1. United States Department of Health and Human Services (DHHS), Public Health Service (PHS), Centers for Disease Control (CDC) / Food and Drug Administration (FDA), Vaccine Adverse Event Reporting System (VAERS) 1990 - 03/11/2022, CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/vaers.html on Mar 11, 2022 1:18:37 PM DISCLOSURES: No relevant relationships by Matthew Haltom No relevant relationships by Nikky Keer No relevant relationships by Thekrayat Khader No relevant relationships by Muthiah Muthiah

DAPTOMYCIN-INDUCED EOSINOPHILIC PNEUMONITIS

SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Daptomycin is an antibiotic that exerts its bactericidal effect by disrupting multiple aspects of bacterial cell membrane function. It has notable adverse effects including myopathy, rhabdomyolysis, eosinophilic pneumonitis, and anaphylactic hypersensitivity reactions. CASE PRESENTATION: A 46-year-old male with a history of type 2 diabetes presented with a 1-week history of dyspnea and productive cough. 2 weeks prior, he was started on vancomycin for MRSA osteomyelitis of the right foot, but was switched to daptomycin due to vancomycin induced nephrotoxicity. On presentation he was afebrile, tachycardic 100, hypertensive 183/109, tachypneic to 26, hypoxemic 84% on room air, which improved to 94% on nasal cannula. Chest exam noted coarse breath sounds in all fields and pitting edema of lower extremities were present. Labs showed leukocytosis of 15.2/L, Na of 132 mmol/L, and creatinine 3.20mg/dL (normal 1 month prior). COVID-19 testing was negative. Chest X-ray noted new bilateral asymmetric opacifications. Daptomycin was discontinued on day 1 of admission, he was started on IV diuretics and ceftaroline. Further study noted peripheral eosinophilia. Computed tomography of the chest showed bilateral centrally predominant ground-glass infiltrates with air bronchograms and subcarinal and paratracheal lymphadenopathy. On day 4, he underwent bronchoscopy with bronchoalveolar lavage. Cytology noted 4% eosinophil with 43% lymphocytes. Eventually, oxygen requirements and kidney function returned to baseline. He was discharged on ceftaroline for osteomyelitis DISCUSSION: Daptomycin-induced acute eosinophilic pneumonitis (AEP) often results in respiratory failure in the setting of exposure to doses of daptomycin >6mg/kg/day. It is characterized by the infiltration of pulmonary parenchyma with eosinophils and is often associated with peripheral eosinophilia. AEP has been associated with certain chemicals, non-steroidal anti-inflammatory agents, and antibiotics including daptomycin. Renal dysfunction is associated with an increased risk for developing AEP. The mechanism for daptomycin-induced lung injury is unknown but is believed to be related to daptomycin binding to pulmonary surfactant culminating in epithelial injury. Diagnostic criteria include recent daptomycin exposure, fever, dyspnea with hypoxemic respiratory failure, new infiltrates on chest radiography, BAL with > 25% eosinophils, and clinical improvement following daptomycin discontinuation. Our patient met four out of six criteria;we believe that BAL results were due to discontinuing daptomycin days before the procedure was performed. Sometimes stopping daptomycin is enough for recovery, however, steroids may be beneficial and were used in some of the cases reported in the literature CONCLUSIONS: Clinicians should consider AEP in a patient on Daptomycin presenting with respiratory failure, as timely discontinuation favors a good prognosis Reference #1: Uppal P, LaPlante KL, Gaitanis MM, Jankowich MD, Ward KE. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control. 2016;5:55. Published 2016 Dec 12. doi:10.1186/s13756-016-0158-8 Reference #2: Kumar S, Acosta-Sanchez I, Rajagopalan N. Daptomycin-induced Acute Eosinophilic Pneumonia. Cureus. 2018;10(6):e2899. Published 2018 Jun 30. doi:10.7759/cureus.2899 Reference #3: Bartal C, Sagy I, Barski L. Drug-induced eosinophilic pneumonia: A review of 196 case reports. Medicine (Baltimore). 2018;97(4):e9688. doi:10.1097/MD.0000000000009688 DISCLOSURES: No relevant relationships by Chika Winifred Akabusi No relevant relationships by Shazia Choudry No relevant relationships by Hector Ojeda-Martinez No relevant relationships by Mario Torres

In it for the long run! Long-Term ECMO as a Bridge to Recovery in Severe COVID-19 ARDS

Introduction: During the pandemic, various guidelines were developed for the utilization of extracorporeal membrane oxygenation (ECMO) for COVID-19 ARDS. However, once patients were cannulated for ECMO, the timeframe for lung recovery and referral for lung transplantation was less clear. To date, there are few reported cases of successful long-term (>28 days) ECMO as a bridge to lung recovery. Method(s): We present three patients who were referred for lung transplantation for severe COVID-19 associated respiratory failure and ultimately achieved successful lung recovery following long-term venovenous ECMO support. Patients presented at different stages of the pandemic, were of different ethnicities, aged 35-54 years old, average BMI of 27.6 and two were male. Prior to cannulation, all patients failed mechanical ventilation, prone positioning, neuromuscular blockade and pulmonary vasodilators. Patients were cannulated within 7 days of intubation, underwent early tracheostomy and participated in ambulatory physical therapy. Complications during ECMO included acute renal failure requiring renal replacement therapy, pneumothorax, right ventricular dysfunction and concomitant bacterial pneumonia with bacteremia. The median duration of ECMO was 104 days (range 84-142 days). Radiographic imaging reported end stage restrictive changes in all patients. Survival to hospital discharge was 100%. All patients had complete renal recovery, resolution of RV dysfunction and functional independence without oxygen. Radiographic changes and pulmonary function continued to improve after decannulation. Conclusion(s): Long-term ECMO is an effective strategy for lung recovery in severe COVID-19 ARDS. Duration of ECMO support and radiographic findings should not be used alone to determine recoverability or need for lung transplantation.

Optical Monitoring of Breathing Patterns and Tissue Oxygenation: A Potential Application in COVID-19 Screening and Monitoring.

The worldwide outbreak of the novel Coronavirus (COVID-19) has highlighted the need for a screening and monitoring system for infectious respiratory diseases in the acute and chronic phase. The purpose of this study was to examine the feasibility of using a wearable near-infrared spectroscopy (NIRS) sensor to collect respiratory signals and distinguish between normal and simulated pathological breathing. Twenty-one healthy adults participated in an experiment that examined five separate breathing conditions. Respiratory signals were collected with a continuous-wave NIRS sensor (PortaLite, Artinis Medical Systems) affixed over the sternal manubrium. Following a three-minute baseline, participants began five minutes of imposed difficult breathing using a respiratory trainer. After a five minute recovery period, participants began five minutes of imposed rapid and shallow breathing. The study concluded with five additional minutes of regular breathing. NIRS signals were analyzed using a machine learning model to distinguish between normal and simulated pathological breathing. Three features: breathing interval, breathing depth, and O2Hb signal amplitude were extracted from the NIRS data and, when used together, resulted in a weighted average accuracy of 0.87. This study demonstrated that a wearable NIRS sensor can monitor respiratory patterns continuously and non-invasively and we identified three respiratory features that can distinguish between normal and simulated pathological breathing.

Translating critical incidents to service development in urban critical care transfer

Introduction: Clinicians in retrieval and transfer medicine face increased diagnostic uncertainty by virtue of their operational environment.1 Integral to our quality improvement and clinical governance framework is individual case analysis, clinical incident interrogation and follow up of every single patient to the point of discharge from critical care. We describe a case where an adverse clinical incident several hours post patient handover was a driver for implementing process and diagnostic change within our own service. Objectives: Describe the translation of after-action review of a critical incident into service improvement. Methods: A 61-year-old patient with severe acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) developed an ischaemic lower limb. A diagnosis of femoral artery thrombosis was confirmed by computed tomography angiography, necessitating transfer to the regional vascular centre. The transfer was undertaken following emergent intubation of the patient by the referring unit and patient followup proceeded as per our standard operating procedures. Results: The transition to invasive ventilation demonstrated low lung compliance and a poor alveolar-arterial (Aa) gradient in keeping with established ARDS secondary to COVID-19.2 Deterioration in oxygenation and respiratory mechanics was partially (falsely) attributed to switching from semi-recumbent to supine positioning. Within 3 hours of handover to the receiving team, a rapid deterioration in oxygenation and ventilation occurred with subsequent diagnosis of tension pneumothorax. This was managed with an intercostal drain which resulted in a significant drop in peak airway pressure (24cm H2O). Close collaboration between our service and the involved hospitals enabled a detailed multi-service review. A number of missed opportunities were identified for prevention of deterioration due to a tension pneumothorax: 1. Immediate post-intubation x-ray imaging regardless of time-critical nature of transfer 2. Lung POCUS post-intubation or at any point whilst transitioning care 3. Highlighting post-intubation imaging as an immediate post-arrival need at handover Pre-departure, post-intubation x-ray was added to our checklist as a cognitive aid. We further identified lung point of care ultrasound (POCUS), an established adjunct to clinical examination,3,4 as a potentially missing diagnostic safety-net. Consequently, we set out to introduce a lung POCUS operating policy. This includes a device optimised for the pre-hospital environment (VScan Air, GE Healthcare, USA), training package, decision-aid algorithm, and overarching governance. We will monitor the diagnostic impact of this tool and benchmark against previously published literature.3,4 Conclusion: Robust followup, governance, and stakeholder engagement allowed us to identify an adverse event detected several hours post patient disposition at the receiving site. With an increasing volume and complexity of transfers, diagnostic adjuncts formerly considered the exclusively the domain of in-hospital practice may well become core techniques in retrieval medicine.

Unexplained hypoxia requiring prone ventilation in a patient with acute disseminated encephalomyelitis

Introduction: Acute Disseminated Encephalomyelitis (ADEM) is a rare, immune-mediated, demyelinating disorder of the central nervous system characterized by acute encephalopathy with neurologic deficits and MRI findings consistent with multifocal demyelination requiring immunosuppression for therapy.1,2 Patients seldom develop hypoxia during the course of the illness, requiring prone ventilation to improve oxygenation which is the first line of therapy and a proven standard of care in patients with ARDS.3,4We would like to present a case of ADEM where a patient developed unexplained hypoxia requiring prone ventilation. Case description: A 35-year-old male with no significant past medical history presented to our neuro-specialist centre with one day history of severe lower back pain associated with lower limb weakness and numbness. His symptoms, which commenced 10 days post his Covid vaccination, rapidly progressed over 2 days of hospital admission to involve right upper limb & facial weakness. MRI scan of brain and spine showed features of ADEM and pulse Methylprednisolone was initiated. CT thorax and abdomen on admission was unremarkable. He was transferred to the critical care unit in view of progressive ascending paralysis and was intubated on his 5th inpatient day due to involvement of respiratory muscles. Following 4 cycles of plasma exchange with albumin (day 6,7,9 and 10 of hospital admission), he developed unexplained hypoxic episodes which eventually resulted in sustained hypoxia, requiring 100% oxygen. Airway pressures and lung compliance were within normal range. Bedside ultrasound demonstrated good lung sliding in all lung fields and good left ventricular contractility with no evidence of right ventricular dilatation. There was no evidence of pericardial/pleural effusion. CT thorax repeated on day 9 showed no features of acute thromboembolic disease and there were no signs of lung parenchymal involvement. Formal echocardiography with bubble test showed normal heart with no evidence of patent foramen ovale. Multi-disciplinary discussions involving cardiology, respiratory, neurology teams and regional ECMO centre could not explain the enigma of impaired oxygenation. The patient responded well to 16 hours of prone ventilation on day 10 with decreasing oxygen requirements. In the subsequent 3 months of his inpatient stay, he was weaned off oxygen and was tracheostomised in view of his neurological illness. He continues to receive physiotherapy and neuro rehabilitation which had led to clinical improvement. Conclusion: The possible reason for hypoxia could be impaired tissue oxygenation post plasma exchange. However, it could be a coincidental finding and there is not much literature to explain this phenomenon and warrants further research.5.

ACUTE INTERSTITIAL NEPHRITIS AS A PRIMARY PRESENTATION OF CANDIDA INFECTIVE ENDOCARDITIS

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

Are short course corticosteroids as effective as longer course in determining days of oxygen requirement and hospital stay in patients with moderate COVID-19 disease?

Background: In past 2 years, COVID-19 pandemic has affected the health care system adversely. World statistics showed a huge rise in the incidence of this highly infectious disease. Abnormal and unregulated immune response was found to be the key deciding factor for the outcome of this disease. A lot of studies showed a promising role of corticosteroids as immunosuppressant agents. They reduce morbidity and mortality in patients with moderate-to-severe COVID-19 disease. However, steroid therapy comes with a huge concern in form of their adverse effects, especially on prolonged use. Optimum duration of steroid therapy is not standardized. Aim and Objectives: The present study was carried out to determine days of oxygen requirement and duration of hospital stay in patients receiving short course steroid vis-à-vis long course steroid therapy. Materials and Methods: A retrospective observational study was conducted in tertiary care teaching hospital after prior permission of the Institutional Ethics Committee. All patients diagnosed as having moderate COVID-19 illness with age group of 18–80 years with minimum 03 days of 6 mg dexamethasone or other equivalent steroid administration were included in the study. Patients who were living with HIV/AIDS, cancer, hepatic and renal illness, ischemic and other valvular diseases, and chronic pulmonary diseases affecting oxygenation status were excluded from the study. A total of 203 study participants were enrolled during study period (68 in short course while 135 in long course steroid group). Data were enrolled in predesigned structured and validated case record form. Results: Short course steroid therapy was found more frequent in <60 years of age. Mean and SD of days of oxygen administration were (4.36 vs. 8.88) and (2.15 vs. 3.43) in short course and long course steroid therapy, respectively. Oxygen requirement for ≥7 days was in (10, 7.41%) patients and (45, 66.18%) patients in short course steroid group and long course steroid group, respectively. Mean and standard deviation of duration of hospital stay were (6.64, 2.87) and (11.9, 4.03) in short course and long course steroid group, respectively. Hospital stay for more than 9 days was (20, 14.81%) and (47, 69.12%) in short course and long course steroid group, respectively. Conclusion: A positive association was found between duration of hospital stay and long course steroid therapy and was statistically significant. Similarly, a positive association between days of oxygen requirement and long course steroid therapy was found and again it was statistically significant. The study findings indicated that short course steroid therapy was found to be more effective in treatment outcome of COVID-19 illness as far as the duration of hospital stay and oxygen administration parameters are concerned.

A REVIEW ON MUCORMYCOSIS BLACK AND WHITE PHASE OF FUNGUS

Mucormycosis started during COVID 19 when patients were treated with number of steroids oxygen, that further lead to increase in diabetes mellitus which was main cause of mucormycosis increase in black fungus further caused rhino-orbito-cerebral mucormycosis and angio invasive behavior of fungal hype that is from Mucoraceae family is main cause of the infection increases rapidly also damages the facial tissues vigorously uncontrolled diabetes, immunosuppressive, steroids poor glycemic control are main causes MRI is a technique that is been used for observing the growth of fungal hype from Epidermiological data its been proven that the mucormycosis is been spreading in countries such as India, Nepal, and Bangladesh rapidly its serious health concern in future.

Clinical course and outcomes of critically ill COVID-19 patients after hemoperfusion in combination with standard therapy

Introduction: Cytokine release syndrome is associated with multiple organ dysfunction in COVID-19 infection. Implementing extracorporeal blood purification could be benefit in omitting inflammatory mediators and supporting organ systems. We aims to investigate the effectiveness of hemoperfusion in combination with standard therapy in critically ill COVID-19 patients and examine factors associated with in-hospital mortality. Methods: The observational study included critically ill COVID-19 patients on HA-330 hemoperfusion (Jafron Biomedical Co, Ltd). Clinical and laboratory findings were monitored after hemoperfusion. Factors associated with death after hemoperfusion were also examined. Results: Fifty-five patients with COVID-19 pneumonia on hemoperfusion were analyzed. A total of 43 patients (78.2%) received mechanical ventilation and in-hospital mortality was 58.2%. Overall, mean Sequential Organ Function Assessment (SOFA) score was 8.56 ± 3.62. The hemoperfusion resulted in a significant increase in the PaO2/FiO2, white blood cell count and a significant decrease in the hsCRP and platelet counts of patients. Multi-factor Cox analysis showed increasing odds of in-hospital death associated with older age (HR 1.08, 95%CI 1.02-1.14), high body mass index (HR 1.16, 95%CI 1.07-1.26), high serum LDH level (HR 1.01, 95%CI 1.01-1.02), and high SOFA score (HR 1.26, 95%CI 1.02-1.55). Additionally, changes in patient profiles after hemoperfusion including increase in white blood cell count of > 60%, serum creatinine of > 20%, serum ferritin of > 50%, SOFA score of > 40%, norepinephrine dosage of > 25% and PaO2/FiO2 of < 50% was associated with increased risk of death. Conclusions: In this study of patients with severe COVID-19, hemoperfusion therapy improve respiratory distress and cell response, and decreased inflammatory mediators. Aging, obesity, worsening in inflammatory response, renal function and no critical improving oxygenation were associated with in-hospital mortality.

Post COVID-19 mucormycosis: A case series

Objective: To evaluate the associated factors between COVID-19 and mucormycosis. Methods: Twenty-two patients of COVID-19 associated mucormycosis (including 3 asymptomatic patients who were cured of COVID-19) from a single medical unit of our institute were included. A detailed history was noted, with special emphasis on the time of onset of mucormycosis symptoms, presence of comorbidities, including new onset diabetes, severity of COVID-19, oxygen requirement, details of receipt of steroids and immunomodulators such as tocilizumab, imaging findings, including the number of sinuses involved, bony erosions, orbital and cerebral involvement, microscopy, culture and histopathology reports and antifungals given. Surgical interventions including number of debridements, orbital exenteration, maxillectomy, and the vaccination status were noted. Results: All 22 patients had rhino-orbital cerebral mucormycosis, 27.27% in the first wave and 72.73% during the second wave. Diabetes was the commonest comorbidity, and 40.91% patients were newly detected diabetics. The time of presentation in relation to their COVID-19 symptoms was 8-15 days (average 12.5 days). Ten out of 22 (45.45%) had asymptomatic or mild COVID-19 and 40.91% did not require supplemental oxygen. Five out of 22 (22.73%) did not receive steroids. Twelve out of 22 (54.55%) had orbital involvement, 3 (13.64%) had palatal ulcer and 4 (18.18%) had cerebral involvement and all these had progressed in spite of treatment with appropriate antifungals. Conclusions: COVID-19 associated mucormycosis is a frequent, lethal, post COVID-19 complication, occurring even in mild and asymptomatic cases who have not received steroids or oxygen.

Mucormycosis (The black fungus) associated with COVID-19 patients- epidemiology, pathogenesis, diagnosis and treatment regimes

Mucormycosis is an opportunistic fungal infection caused by a member of the order Mucorales. It is an angio-invasive fungal infection because of its propensity to invade blood vessel walls, resulting in catastrophic tissue ischemia (restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism), infarct (tissue death that is necrosis) due to inadequate blood supply to the affected area. Mucorales fungi are distributed worldwide and found in soil and decaying organic substrates. The most common microbiologically confirmed infecting members of the order Mucorales are Rhizopus, Mucor, Cunninghamella bertholletiae, Apophysomyces elegans, Absidia, Saksenaea and Rhizomucor pusillus. The incidence of mucormycosis has increased significantly in patients with diabetes which is the commonest underlying risk factor globally. Recently, COVID-19 caused by SARS CoV-2 has further worsened the incidence of this disease. Diagnosis of mucormycosis remains challenging. The clinical approach to diagnosis has a low sensitivity and specificity;however, it helps raise suspicion and prompt the initiation of laboratory testing. Histopathology, direct examination, and culture remain essential tools, although the molecular methods are improving. The review highlights the current status on epidemiology, pathogenesis diagnosis and treatment regime available for mucormycosis.

COVID-19 and the biliary tree: Atypicall manifestations of disease during the pandemic

Case report-IntroductionCOVID-19, the infectious disease caused by the novel coronavirus SARS-CoV-2, and first described in Wuhan, China in December 2019, has affected more than 19 million patients worldwide and resulted in more than 700,000 deaths at the time of writing1. Patients with rheumatic diseases and those receiving immunosuppressive treatment are felt to be at greater risk of complications from this illness, though registry and trial data should help refine our understanding of these risks. We hereby describe a case of COVID-19 complicating an unusual rheumatic illness, resulting in severe multi-system disease and premature death.Case report-Case descriptionA 69 year-old male presented to rheumatology and haematology with symmetrical polyarthritis, thrombocytopenia (18 x 109/L), eosinophilia (25.4 x 109/L), raised C-reactive protein (CRP, 43 mg/L), positive rheumatoid factor (>200), antinuclear antibody (ANA) and anti-Ro. Bone marrow biopsy did not demonstrate evidence of haematological malignancy.Seropositive rheumatoid arthritis and connective tissue disease overlap were diagnosed, and treatment with Prednisolone 60mg daily was initiated. Despite rituximab and intravenous immunoglobulins, thrombocytopenia deteriorated on reducing corticosteroids, however the addition of mycophenolate mofetil (MMF) allowed gradual prednisolone tapering to 3mg daily. Hydroxychloroquine was briefly added but discontinued due to headaches. MMF was discontinued after he developed fungal pneumonia followed by jaundice. Liver biopsy was consistent with drug-induced cholestasis, attributed to co-amoxiclav, and his liver function tests (LFTs) improved on ursodeoxycholic acid. Following a further deterioration in thrombocytopenia, hyperferritinaemia and new onset erythema nodosum, he had a repeat bone marrow examination. This demonstrated large areas of fibrosis and granulomatous inflammation with a dense, pleomorphic T-cell infiltrate, but no haemophagocytosis. Haematologists felt this was reactive and prednisolone dose was increased to 10mg daily.Six months later he developed cholangitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a tight 4cm stricture of the distal common bile duct (CBD) within the head of pancreas, which was diffusely swollen without any clear focal mass. Serum amylase was mildly elevated (316 units/L). Concurrent CT thorax, abdomen and pelvis demonstrated bilateral ground-glass changes within the lungs, and a SARS-CoV-2 nasopharyngeal PCR test was positive, though he had no respiratory symptoms or oxygen requirement at that stage.Sadly, four days after the CT scan and before a planned endoscopic retrograde cholangiopancreatography (ERCP) could be performed, he became markedly hypoxic with plain chest X-ray features suggestive of COVID-19 pneumonia. Despite medical management, including doubling of his prednisolone dose, he rapidly deteriorated and died.Case report-DiscussionThis case highlights an unusual presentation of COVID-19 in a patient with a complex background of inflammatory arthritis with immune-mediated thrombocytopenia. At the time of his final illness, these conditions were managed with steroid monotherapy. Based on the COVID-19 risk matrix recommended by the British Society for Rheumatology, he was not identified as a patient requiring shielding.Cholangitis was the major problem precipitating his final admission to hospital, and at the time of admission he had no respiratory symptoms. One week prior to this admission, his father-in-law had died of COVID-19 pneumonia, though they had not been in recent direct contact. Interstitial lung changes were incidentally noted on a CT performed to identify the cause of cholangitis, which prompted the nasopharyngeal PCR that detected SARS-CoV-2. This occurred prior to widespread routine testing of hospital inpatients for SARS-CoV-2 by PCR. Unfortunately he then rapidly developed COVID-19 pneumonia and died before the underlying cause of cholangitis could be definitively identified, though an MRCP demonstrated an obstructed CBD within a diffusely swollen pancreas, where a differential diagnosis of pancreatic malignancy or autoimmune pancreatitis was suggested by the reporting radiologist.There are emerging case reports of COVID-19 resulting in significant pancreatic injuryand a further recent laboratory analysis has suggested that ACE2 receptors, which are utilised by SARS-CoV-2 to gain entry to host cells, are highly expressed on cholangiocytes at a comparable level to type II alveolar cells. Whilst the ultimate cause of cholangitis will remain unknown in this patient, this case highlights the potential for atypical presentations and extra-pulmonary manifestations of COVID-19.Case report-Key learning points COVID-19 is a multi-system illness which can cause significant extra-pulmonary as well as pulmonary pathology, with emerging reports that the biliary tract and pancreas are frequently affected.Evidence to inform accurate prediction of which patients with rheumatic diseases are at highest risk of acquiring severe COVID-19 disease remains insufficient, with current shielding guidelines based on expert consensus.This case highlights the importance of widespread testing for COVID-19 in hospital patients, as not all patients carrying the SARS-CoV-2 virus will demonstrate classical respiratory features of the disease at the point of admission.

Hyperbaric oxygen therapy and its suitability as an adjuvant for treatment of covid-19 patients: A review

The outbreak of the SARS CoV2 ’Coronavirus pandemic’ is believed to have originated in Wuhan in 2019 as a zoonotic spread from bats to humans. It is a highly communicable infection-causing rapid human to human transmission of the virus by virtue of its infectious and pleomorphic nature. The virus has affected millions of people worldwide, with numbers still rising with each passing day. Depleting oxygen saturation levels is amongst the prime concerns in the majority of infected patients. Nasal prongs, face masks, mechanical ventilation and extracorporeal membrane (ECMO) are the commonly used modes of oxygen delivery in such patients. These methods though mostly successful, at times fail to restore the depleting oxygen levels to normal. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% O2 in a special chamber whose pressure is maintained at a level greater than 1 ATP. The main purpose for raising the pressure within the chamber is that as the atmospheric pressure increases, the saturation levels of oxygen in the blood also increase, which eventually result in increased overall tissue oxygenation. This article provides a systematic and wholesome review on the basic principle of hyperbaric oxygen therapy, its effects on the body at a microscopic and macroscopic level, its various uses and its suitability as an adjuvant for the treatment of select COVID-19 infected patients.