A Thorn in his Side

History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.

Collapsing glomerulonephritis in a COVID-19 patient. Case report

Acute renal injury due to collapsing glomerulonephritis is associated with high morbidity and mortality, requiring chronic dialysis, COVID-19 is one of its causes. A 17-year-old male patient presented with a four-month history of edema, foamy urine and reduction in the urine flow;anasarca was observed at physical examination. Laboratory values showed creatinine 4,2 mg/dl;albumin 1,9 gr/dl;cholesterol and triglycerides were high;proteinuria 6,7 gr/24h: leucocyturia and hematuria with negative urine culture. Serologies for HIV, syphilis and hepatitis were negative. Studies for systemic lupus were negative. An antigenic test for SARS-CoV-2 was positive as well as an IgG. Renal Biopsy showed Focal and Segmental Glomerulosclerosis, Collapsing variant. He received corticosteroids and cyclosporine. Creatinine improved;proteinuria remained >3 gr/24 hours.Copyright © Universidad Peruana Cayetano Heredia, Facultad de Medicina Alberto Hurtado. All Rights Reserved.

Severe Headache as an Early Manifestation of Brain Involvement in a Patient with Covid-19 Infection

Purpose of study COVID-19 primarily affects the respiratory system from flu-like syndrome to acute hypoxic respiratory failure. Neurological manifestations are uncommon and can result in serious complications. We report a unique case of sudden onset of rapidly progressive encephalopathy in the setting of COVID-19. Methods used Reviewed the manifestations, clinical course, and outcome for a patient presenting with altered mental status secondary to COVID-19. Summary of results A 48-year-old with no significant past medical history presented to the emergency department complaining of severe headache for four days. His vital signs on presentation showed a blood pressure of 154/90, pulse of 114 bpm, temperature of 99.6 degreeF, and oxygen saturation of 97% on room air. Physical exam was unremarkable. Lab work showed elevated D-dimer 8,500 ng/L, Elevated ESR:42, LDH:340 and Ferritin:692. White blood count: 7.59 uL, Platelets 50 x 103 uL. Computer tomography angiography (CTA) of the chest showed bilateral multifocal pneumonia. CT Head was performed and was negative for an acute hemorrhage, hydrocephalus or territorial infarcts. Patient spiked a fever shortly after admission 103degreeF. Patient was started on Ceftriaxone and Azithromycin. Blood and urine cultures were positive for Klebsiella pneumonia. Patient was re-evaluated in the morning and was found altered with associated neck stiffness. Antibiotics were switched to cover for suspected meningitis. Neurology was consulted and recommended lumbar puncture. Within a few hours, the patient's mental status deteriorated and was found to be hypertensive with a blood pressure of 220/110. Repeat CT Head was negative. The patient was tested and found to be positive for COVID-19. Patient further decompensated within a few hours and became unresponsive, pulseless. ACLS was performed and the patient was transferred to the intensive care unit. Conclusions This case report highlights the heterogenous presentation in patients with COVID-19 and the importance of recognizing a new onset, severe headache as the only initial presentation. Headaches in some cases may precede the respiratory symptoms or may be the only manifestations in COVID-19 patients and it is crucial to be aware of the neurological complications and the rapid decompensation these patients may undergo if not recognized early.

Reversible parkinsonism post combined infection with COVID- 19 and typhoid

Objective: To describe a case of levo-dopa responsive parkinsonism secondary to combined COVID-19 and Enteric fever in a patient Background: The first link between viruses and parkinsonism comes from the possible relationship between lethargic encephalitis and the Spanish flu of 1918.In addition, other viruses, including West Nile virus, herpes viruses, influenza A virus, and human immunodeficiency virus (HIV), have been associated with parkinsonism Methods: A 31 years old presented with fever ,headache for 5 days followed by altered sensorium. At presentation he had neck rigidity ,was localizing to pain ,not fully oriented and not following verbal command but he had hypoxia and need nasal oxygen support.He had D-Dimer 12506,COVID-19 RTPCR positive and was treated with Remdesivir,ceftriaxone ,dexamethasone after which he had improvement in sensorium.At day 6 of illness he had generalized rigidity,bradykinesia with slow hypophonic speech and was needing support to sit and walk . A provisional diagnosis of infection related parkinsonism was considered and Cerebrospinal fluid study,MRI Brain and spine ,Blood culture were done .His Cerebrospinal fluid study has normal protein , glucose,cells, stains and culture and negative autoimmune and paraneoplastic plane . His urine culture,blood culture was positive for salmonella typhi and serum widal titre was 1:640.MRI Brain and spine does not show any new abnormalities except old trauma sequalae. He was treated with Levo-dopa carbidopa and titrated to a dose of 675 mg/day and had sustained improvement with levo-dopa carbidopa .There are 6 other case of COVID-19 associated parkinsonism in literature .There are also few case of typhoid associated case of parkinsonism described in literature . Our patient had combined infection of both COVID-19 and typhoid associated parkinsonism. Result(s): We report a case of Infection related parkinsonism secondary to combined COVID-19 plus typhoid infection Conclusion(s): Exploring the potential relationship of co-infection SARS-CoV-2 and Salmonella typhi infection with development of parkinsonism is essential because of the epidemiological implications,as well as to gain a better understanding of the pathophysiological aspects of these disorders.

Utilization of corticosteroids among patients died with COVID 19: A single center experience from a resource poor setting

Introduction: The use of immunosuppression in patients with severe COVID has been recommended as the standard of care. However, it's use in concomitant bacterial sepsis could result in adverse outcomes. Aim(s): We analyzed the use of immunosuppression in the form of corticosteroids among patients who succumbed to COVID 19. Method(s): Patients died with COVID 19 at the intensive care unit (ICU), National Hospital, Kandy, Sri Lanka from 01.01.2021 to 31.12.2021 were retrospectively studied. Result(s): 79 deaths were analyzed. Majority were males (46/79);median age was 63 years (19, 94). The mean hospital and ICU stay were 11 days (interquartile range-IQR:7,14), 7days (IQR: 2.5,9) subsequently. 75/79 received corticosteroids, Dexamethasone(n=55), Methyl Prednisolone-MPP(n=9), Prednisolone(n=12) had been used either as a single or sequential therapy. The median daily dose and median duration were as follows. Dexamethasone: 6mg (2,10)- 7 days (1,18), MPP 750mg (500,1000)-3days (2,3), Prednisolone: 30mg (5,40)-2days (1,10). 25/46 demonstrated bacterial co-infection either with PCT>1 or blood or urine culture positivity. 24/25 with sepsis received Dexamethasone. One of them received MPP and Dexamethasone sequentially. Conclusion(s): Higher proportion of patients with bacterial co-infection were concomitantly treated with higher doses of corticosteroids,which could resulted in the adverse outcome.

Clinical and laboratory characteristics of patients who succumbed to COVID-19: a single center experience from a resource poor setting

Introduction: The clinical and laboratory characteristics of patients who died with COVID 19 yet to be elucidated. Aims and objectives: We were aiming at identifying potential contributory factors for the mortality in COVID 19. Method(s): Patients died with COVID 19 at the intensive care unit (ICU), National Hospital, Kandy, Sri Lanka from 01.01.2021 to 31.12.2021 were retrospectively studied. Result(s): 79 deaths were analyzed. Males (44/79);median age 63 years (19, 94). Mean hospital and ICU stay were11 days (interquartile range-IQR:7,14), 7days (IQR: 2.5,9) subsequently. Median of 2 comorbidities (0,5) were present;diabetes(n=43), hypertension(n=43), ischemic heart disease(n=21), chronic kidney disease(n=10), post kidney transplant recipients(n=10), other(n=10). 14/79 had none. Mean systolic blood pressure on admission:130 mmHg (IQR: 115,148), mean SpO2/FiO2 ratio was 147(IQR 95,163), mean serum lactate level was 1.9(IQR: 1.08,2.25). The average heart rate 95(IQR: 81,108);mean respiratory rate was 28(IQR: 22, 33);mean random blood sugar was 229(IQR: 156, 289). 15/79 documented to be vaccinated (one =4/11: two=6/15: three=5/15). C-Reactive protein was available in 72/79;mean=122(IQR: 38, 182). Procalcitonin (PCT) on admission was available in 32/79;median=3.70 (0.01, 96), PCT was >1 in 16/32. 8/18 blood culture samples, 4/12urine culture samples detected bacterial pathogens. 25/46 demonstrated either PCT>1 or blood and/or urine culture positivity. Conclusion(s): Higher proportion of patients were unvaccinated, with multiple comorbidities predominantly diabetes. Hyperinflammation was common and significant proportion had bacterial co-infection.

Not always COVID - pulmonary BCGosis as an unexpected cause of severe respiratory failure and massive ground glass opacities in the lungs

Introduction: Instillations with balcillus Calmette - Guerin (BCG) are established adjuvant therapy for superficial bladder cancer. Although generally safe and well tolerated, they may cause a range of different, local, and systemic complications. Case description: We present a patient treated with BCG instillations for three years, who was admitted to our hospital due to fever and progressive dyspnea. Blood test revealed elevated CRP and liver function tests. On CT scan massive bilateral ground glass opacities in the middle and lower parts of the lungs, parenchymal infiltrations, bronchial walls thickening, and hilar lymphadenopathy were visible. PCR test for SARS-CoV-2 as well as sputum, blood, and urine cultures were negative. Initial empiric antibiotic therapy was ineffective and respiratory failure progressed with the need of oxygen supplementation of 15l/min. Finally, positive cultures for M. tuberculosis ssp. bovis (BCG) were available from sputum and bronchoalveolar lavage fluid. Antituberculous treatment (rifampin, isoniazid, etambuthol) was implemented together with systemic corticosteroids resulting in the quick improvement of the patient's clinical condition. Due to hepatotoxicity and finally reported resistance of the BCG strain to isoniazid, it was replaced with levofloxacin with a good tolerance. Follow up CT scan showed partial resolution of the infiltrates. The patient was discharged home and continued treatment without further side effects. Conclusion(s): The diagnosis of BCG infection in the lungs must be taken into consideration in every patient treated with BCG instillations and symptoms of unexplained infection.

Ayurvedic Herbs Advised for COVID-19 Management: Therapeutic Potential and Clinical Relevance

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. There is no effective medication for COVID-19 as of now, so it would be good to take preventive measures that not only boost our immunity but also fight against infections. The use of traditional Chinese medicine in China to treat COVID-19 patients sets the prototype demonstrating that traditional medicines can contribute to prevention and treatment successfully. In India, the Ministry of AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeop-athy) released a self-care advisory during the COVID-19 crisis as a preventive aspect. This review article discusses the therapeutic potential and clinical relevance of some herbs [(Tulsi (Ocimum sanctum), Haridra (Curcuma longa), Tvaka (Cinnamon), Maricha (Piper longum), Shunthi (Zingi-ber officinale), Munakka (Dried grapes), Lavang (Syzigiumaromaticum), Pudina (Mentha arvensis), and Ajwain (Trachyspermum ammi)] advised by AUYSH to take during COVID-19 infection. They are effective in COVID-19 management, therefore, authors have discussed their detailed traditional uses as therapeutics and spotted scientific insight and clinical significance of the herbs mentioned above along with their mechanistic viewpoint, adequately, on a single platform. Provided information could be a treasure to open up a new research arena on natural products to manage human health crises effectively, caused not only by COVID-19 but also by other infectious diseases.Copyright © 2023 Bentham Science Publishers.

Tick-Borne Illness Ticking Off the Heart: A Case of Cardiomyopathy Due to Anaplasmosis

Background Human granulocytic anaplasmosis (HGA) is a tick-borne disease caused by Anaplasma phagocytophilum. The most common presenting features are transaminitis, leukopenia, thrombocytopenia, fever, and malaise. HGA causing cardiomyopathy likely from myocarditis is uncommon but a serious complication. Case A 70 year-old male with a history of coronary artery disease presented with fever (38.3 C) and dyspnea on exertion. He was found to have hypoxic respiratory failure, pancytopenia, acute kidney injury and transaminitis. He was treated empirically with ceftriaxone and doxycline. Baseline electrocardiogram was unremarkable for ischemia. However, he had troponin elevation and was decompensated on exam. Bedside transthoracic echocardiogram (TTE) showed LVEF of 20-25% for which he was administered dobutamine and monitored in intensive care unit (ICU). Repeat TTE illustrated LVEF 30-35% with moderate diffuse hypokinesis of LV. Blood and urine cultures were negative. He tested positive for Anaplasma DNA-PCR with unremarkable rest of the tick borne, viral and parasitic panel. He was then continued with doxycycline for 14 days for sepsis due to Anaplasmosis. Follow up TTE in a month showed improved LVEF to 40% with resolution of his symptoms. Decision-making Our patient presented with common tick-borne illness symptoms and signs, which prompted initiation of empiric antibiotics. However, the significantly reduced LVEF and elevated troponins were concerning for which he was monitored in ICU. Cardiac magnetic resonance imaging was not pursued due to delay in transfer process to the higher center amidst COVID pandemic and ongoing sepsis due to Anaplasmosis. After the results of HGA PCR, he was continued on a 14-day course of doxycycline which eventually resolved his symptoms. Conclusion There must be a high level of suspicion for cardiomyopathy if the patient is being empirically treated for tick-borne illness and has decompensated heart failure symptoms. PCR is the most sensitive test for diagnosing HGA. However, the test results should not delay the treatment as tick-borne illness responds well to doxycycline which should alleviate the heart failure symptoms as seen in our case.Copyright © 2023 American College of Cardiology Foundation

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.

Trends in the Rates of Extended-Spectrum-ß-Lactamase-Producing Enterobacterales Isolated from Urine Cultures during the COVID-19 Pandemic in Ontario, Canada.

Worldwide, extended-spectrum ß-lactamase (ESBL) rates are increasing at an alarming level with increasing rates of health care exposures, international travel, and antibiotic usage. In this study, we investigated whether enhanced social isolation, travel restrictions, and the reduced use of antibiotics in Ontario, Canada during coronavirus disease 2019 (COVID-19) pandemic had an impact on ESBL rates in urine cultures collected from the community and long-term-care (LTC) facilities across the province. Data from a total of 8.6 million urine cultures performed at LifeLabs Ontario from 2016 to 2021 were utilized for analysis. ESBL-producing Escherichia coli (ESBL Escherichia coli) and ESBL Klebsiella pneumoniae were identified using standard operating procedures. Data trends were estimated by interrupted time series (ITS) regression analysis. Among 2.3 million positive urine cultures, 48.9% and 7.2% grew E. coli and K. pneumoniae, of which 5.8% and 3.3% produced ESBLs, respectively. While the overall rate of ESBL isolation was higher in the pandemic period than in the prepandemic period, by ITS regression analysis of the monthly rates of ESBL isolation, decreasing trends were noted for ESBL E. coli in both the community and LTC facilities and for ESBL K. pneumoniae in the community. The ESBL K. pneumoniae rates in LTC facilities continued to increase throughout the COVID-19 period. By subgroup analysis for different genders, age groups, and local health integration network (LHIN) units, similar trends were seen in most cases (P < 0.05), except for a few densely populated LHINs where rate changes were not statistically significant. IMPORTANCE Community-onset urinary tract infections (UTIs) caused by ESBL-producing Enterobacterales, particularly E. coli and K. pneumoniae, are a major public health concern. In this study, we assessed the impact of COVID-19 on ESBL rates in urine cultures in Ontario, Canada. Our results show the recent epidemiology of ESBL-producing Enterobacterales in urine cultures from both the community and LTC facilities in Ontario, Canada, and the impact of COVID-19 restrictions on ESBL trends for the entire province as well as different subgroups of the population based on demographic and geographic characteristics. Our results may have important public health implications in the context of the gradual easing of COVID-19 restrictions.

Evaluation of Secondary Infections in COVID-19 Patients Hospitalized in Intensive Care Unit: Retrospective Observational Study

Objective: Patients infected with severe acute respiratory syndrome-coronavirus-2 may progress with severe clinical symptoms and patients may be hospitalized in intensive care for a long time. In patients with long-term intensive care hospitalization, secondary infections develop as a result of the pathophysiology of the disease and the treatments used. The aim of this study is to investigate the incidence of secondary infections in patients with coronavirus disease-2019 (COVID-19) and to identify common pathogen groups. Material(s) and Method(s): Four hundred and sixty one patients with a diagnosis of COVID-19 who were followed up in the intensive care unit at Afy-onkarahisar Health Sciences University Faculty of Medicine Hospital between 20 March 2020 and 31 May 2021 were included in the study. Demographic data, co-morbidities, clinical features, laboratory data and culture growth data of the patients were recorded retrospectively. Re-sults: Nosocomial secondary infections were detected in 132 (28.6%) of 461 patients. Acinetobacter baumannii 39/53 (73.5%) growth was observed in the majority of the lower respiratory tract sample cultures. There was 28/49 (57.1%) Staphylococcus aureus growth in blood cul-tures, and 21/42 (50%) candida spp. growth in urine cultures. Conclu-sion: In this study, we found that the incidence of infection secondary to COVID-19 pneumonia was high. In addition, it was determined that the secondary infection rate was high in patients with PaO2/FiO2<200. Copyright © 2022 by Turkiye Klinikleri.

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

LONGITUDINAL STUDY ASSESSING THE EFFECTS OF METHENAMINE HIPPURATE ON THE URINARY MICROBIOME OF POSTMENOPAUSALWOMEN WITH RECURRENT UTI

Introduction: Postmenopausal women with recurrent urinary tract infections (RUTI) are repeatedly exposed to antibiotics and therefore at risk for colonization by multi-drug resistant organisms. Methenamine hippurate (MH) is FDAapproved for the prevention of RUTI;however, the mechanism of action of MH or, more specifically, the role of MH in the alteration of the urobiome is not known. Since preliminary data has shown that MH may be effective against some bacteria (e.g., Escherichia coli), but not others (e.g., Enterococcus faecalis), we hypothesize that resident bladder microbiota will be altered by administration of MH. Objective: Our objective is to determine the longitudinal effect of MH on the urobiome of postmenopausal women with RUTI. Methods: A longitudinal study with a convenient sample of 10 postmenopausal women with a clinical history of RUTI was conducted (Figure 1). UDI6 questionnaires, voided urine, catheterized urine, and peri-urethral swabs were obtained at baseline and three months after daily MH use. Expanded quantitative urine culture (EQUC) was performed on these specimens. In addition, during the 3-month timeframe, four self-collection windows were completed (windows A-D): (A) prior to initiating MH (baseline urobiome), (B) one week after starting MH, (C) two weeks before the 3-month follow-up, and (D) one week before the 3-month follow-up. Voided urine and peri-urethral swabs were collected daily for one week during windows A-D to determine how the urobiome changed. Sequencing of samples from these collection windows is pending. Results: Ten participants enrolled;however, three participants were not able to complete the study due to allergic reaction, improper handling of samples, and COVID infection. Six participants have completed the study;microbiological studies for one participant are still in process. There were no episodes of acute cystitis for any participant during the length of the study. UDI6 results suggested a trend towards a decrease in frequency, leakage with urgency, and abdominal pain;however, none of these were statistically significant (Table 1). Of the six remaining participants, the average baseline urine pH was 5.8 ± 0.8. For the completed participants, an initial microbiological comparison of EQUC results at baseline and 3-month visits show differences in sample diversity. Specifically, the number of species detected (richness) in catheterized urine increased for all but one participant (Figures 2A and 2B) though there was little or no changes in overall diversity (Shannon Index, Figure 2B) or evenness (Pielou's Index, Figure 2C) for any sample type. Exposure to MH did not result in the loss of uropathogenic species present in catheterized urine at baseline;instead, additional uropathogenic and commensal microbiota were detected at the 3-month visit. Conclusions: UDI6 trended towards symptom improvement in frequency, urge incontinence, and pain, consistent with RUTI prevention and symptoms control. Microbiological results suggest that MH increases the richness of the bladder urobiome. This consistent trend suggests MH may reduce RUTI events by altering the urobiome community richness instead of eliminating uropathogenic microbiota from the bladder. Further studies are needed to understand the interaction between MH and a host that is susceptible to uropathogen overgrowth (Table Presented).

Acute Necrotizing Pancreatitis in COVID-19 Disease: A Case Report

Aims and objectives: Gastrointestinal symptoms like abdominal pain can be atypical presentations associated with coronavirus disease. This case report describes the presentation of acute pancreatitis in a patient with moderate COVID-19 infection. Materials and methods: Data were collected from a patient who was admitted with acute pancreatitis as sequelae of COVID-19 infection in our intensive care unit in June 2021. Case presentation: A 25-year-old female with no comorbidities presented to our emergency department with complaints of fever and dry cough for 10 days for which she had taken treatment at home. COVID RTPCR was negative and CT severity was 10/25. She also complained of abdominal pain with vomiting for 2 days. So she was admitted to our hospital on the tenth day of her illness. Laboratory analysis showed >3 times elevation of serum lipase. CT abdomen showed acute pancreatitis with gallbladder sludge. Causes of pancreatitis like gallbladder stones, alcohol, hypercalcemia, and hypertriglyceridemia were excluded by history and investigations. She was diagnosed with acute pancreatitis due to COVID-19. C-reactive protein and D dimer was highly elevated. She was admitted in ICU and was started on conservative management with IV fluids and bowel rest. Oral intake was resumed gradually as tolerated. The patient was maintaining adequate oxygen saturation on room air. Her repeat COVID RTPCR was again negative. However, her CT severity had increased to 14/25. Her total antibody SARS-CoV-2 was highly reactive. She had severe pain which was not improving despite multimodal analgesia which included opioid infusion. She had bilateral minimal pleural effusion and consolidation and required 2-4 L oxygen support. Repeat CT abdomen after a week showed acute necrotizing pancreatitis with gross pancreatic ascites and partial splenic vein thrombosis (modified CT severity index 8). On day 7 of admission, she developed a fever. Blood and urine cultures were sent and empirical antibiotic was started. Urine culture showed Klebsiella pneumoniae and antibiotic was escalated as per sensitivity pattern. Her pain scores persisted to be high despite all measures. On day 14, she developed abdominal distension. Intra-abdominal pressures were normal and repeat CT abdomen showed extensive free fluid with dilated bowel loops which was likely paralytic ileus. A CT-guided pigtail was inserted for continuous drainage of fluid. The ascitic fluid culture showed no organism. Her abdominal distension gradually reduced. We tapered the requirement of opioids day by day and she got symptomatically better. She could tolerate oral feeds better, off oxygen support, and was shifted to wards with pigtail catheter in situ. She stayed in ICU for 26 days. She was doing better in wards and was discharged home after 5 days with oral anticoagulant and other symptomatic medications and was adviced for gastroenterology follow-up after 10 days. Results: A patient was diagnosed with acute pancreatitis associated with SARS-CoV-2 and was treated accordingly. Other causes of acute pancreatitis were excluded in the patient including alcohol, biliary obstruction/gall stones, drugs, trauma, hypertriglyceridemia, hypercalcemia, and hypotension. Conclusion: This case highlights acute pancreatitis as a complication associated with COVID-19 and underlines the importance of evaluating and treating patients with COVID-19 and abdominal pain.

Decreasing Invasive Urinary Tract Infection Screening in a Paediatric Emergency Department: A Quality Improvement Initiative

Purpose/Objectives: Fever is a common presentation to the Emergency Department (ED) and a urinary tract infection (UTI) often needs to be excluded in young children. Sterile techniques, like catheterization, are invasive, can be traumatizing, and are time-consuming to complete. A two-step approach has been shown to reduce the catheterization rate in febrile, young children without unintended consequences. Our aim was to implement a two-step approach for UTI screening in febrile children 6-24 months to decrease unnecessary urine catheterizations by 50% without impacting ED length of stay (LOS), return visits (RVs). Design/Methods: We first engaged key stakeholders and created a multidisciplinary project team. Using the model for improvement, we adapted a 2-step pathway for UTI testing in children 6-24 months as our change idea. The pathway involved nursing identification of children who met inclusion criteria for UTI screening, followed by application of a urine bag and urinalysis (UA) if deemed indicated by the physician. If the UA was positive, a second urine sample was collected via catheterization, and a repeat UA and urine culture was performed. Through multiple PDSA cycles, our pathway was implemented in the ED along with concurrent staff education and electronic order modifications. Using statistical process control charts, the outcome measure was the percent of ED urine catheterizations. Process measures included the total number of urine cultures sent to microbiology and percent positivity. The balancing measures included ED LOS and the number of RVs. Results: Since project initiation in July 2019, the ED catheterization rate decreased from 70% to 46% (FIGURE 1) saving approximately 30 children from invasive catheterization per month. The number of urine cultures sent to microbiology decreased by 30%, with an increased positivity rate by 4%. There was a slight 10-minute increase in ED LOS (FIGURE 2) and RVs, but with further process changes, ED LOS has now returned to baseline. Conclusion/Discussion: Using improvement methodology, we successfully decreased the number of unnecessary catheterizations and urine cultures sent to microbiology from our ED. We mitigated the initial impact on ED LOS through workflow modifications including optimizing equipment in patient rooms with urine bag kits, poster reminders, re-education for providers, and re-launching a simplified pathway. ED RVs did significantly increase with the COVID-19 pandemic, but was likely due to many factors unrelated to this project, including limited access to community in-person follow-up and increased screening of febrile children for Multi-inflammatory Syndrome in Children (MIS-C). Given the overall project success and cultural change experienced in the ED, this initiative has now spread to the hospital's paediatric wards, and is adopted as part of the hospital's Choosing Wisely campaign. This stewardship initiative can easily be spread to other paediatric and community hospitals caring for children.

A Folk Remedy for a Bellyache

Introduction: This case describes a curious cutaneous finding with a unique etiology from a cultural remedy. Case Description: A 19-month-old female was brought in by ambulance for an acutely progressive abdominal rash. Three days prior to presentation, she had a febrile seizure. The next day, she continued to have low grade temperatures and developed a faint red rash on the abdomen. On the day of presentation, the mother found a dark violaceous rash on the abdomen and called 911. The patient's presenting vital signs were unremarkable except for tachycardia to 133 and lower blood pressure for age of 86/67. She was tired and irritable. She had a large welldemarcated dusky and dark plaque with central denudation over the whole abdomen and right lateral back [Figures]. She was exquisitely tender to light palpation and guarding her abdomen. The remainder of her exam was unremarkable. Given the extent of her skin injuries, differential included intra-abdominal injury, intra-abdominal hemorrhage, burn or bruise from accidental and non-accidental cause, allergic dermatitis and disseminated intravascular coagulation in the setting of sepsis. Laboratory evaluation revealed mildly low hemoglobin for age at 10.5 g/dl with low MCV 74.2fL and a leukocytosis with WBC of 18.41 x10-3 πl with neutrophil predominance. Coagulation factors were normal. CMP revealed mild acidosis with CO2 of 17 mmol/L. Imaging studies included normal: CT head and CT abdomen with mild subcutaneous edema in the anterior abdomen near the umbilicus. Additional infectious studies were negative including nasal SARS-CoV-2 PCR, blood culture and urine culture. After the work-up, findings were consistent with a second-degree burn confirmed by Dermatology and Plastic Surgery. Suspected Child Abuse and Neglect team conducted additional social history with maternal grandmother because she is the caretaker when parents are at work, given parental denial of witnessing or causing the burn. Grandmother had limited English proficiency, so history was taken using a Medical Spanish interpreter. Grandmother explained that one day prior to presentation, she used an Oaxacan folk remedy to alleviate abdominal pain in which green tomato pulp was applied like a salve. Final diagnosis was second degree burn from phytophotodermatitis. Patient's skin improved with daily dressing changes and application of silver sulfadiazine, and she was discharged home to parents. Discussion: The use of tomato salve is a unique etiology of phytophotodermatitis that has not been well-characterized. Typical vegetation that causes burn injuries include figs, lemons and common wildflowers. Tomatillos or green tomatoes contain plant psoralens that can induce a strong phototoxic reaction to ultraviolet A radiation exposure after cutaneous contact. Conclusion: We present this case to highlight the importance of conducting thorough social history in the family's preferred language and to share a unique folk practice that can present as a severe burn and mimic child abuse.

Multisystemic Inflammatory Syndrome in Children in a Pregnant Pediatric Patient

Introduction: Multisystemic inflammatory syndrome in children (MIS-C) is a rare complication of infection by SARS-CoV-19 thought to be due to hyperinflammation adversely affecting multiple organ systems. Most commonly, the gastrointestinal, cardiovascular, hematologic, respiratory and integumentary systems are affected. Patients presenting with this syndrome often require hospitalization given the potential for rapid deterioration. We present a case of MIS-C and associated shock in a pregnant pediatric patient requiring ICU level care. Case Description: A 16-year-old G1P0 female presented to the ED at 25 weeks gestation with complaints of fever, headache, myalgias, cough and congestion. She denied prior COVID-19 exposure and vaccination, and COVID-19 PCR testing returned negative. She was diagnosed with a viral syndrome. She further reported decreased fetal movement. OB performed a biophysical profile that was overall reassuring, and she was discharged. Due to persistent symptoms and new onset chest pain and dyspnea, she returned to the ED six days after her initial presentation. Bedside ultrasound demonstrated fetal tachycardia. Laboratory work up revealed leukocytosis, anemia, hyponatremia and hypokalemia with markedly elevated inflammatory markers concerning for MIS-C. She was treated empirically with ceftriaxone and vancomycin. She developed fluid refractory shock and ultimately required vasoactive support with norepinephrine necessitating admission to the PICU with OB consultation. Infectious evaluation including respiratory viral panel with COVID-19 PCR and blood and urine cultures were negative. SARS-CoV-2 IgG antibody returned positive, confirming the diagnosis of MIS-C associated with COVID-19. She was treated with IVIG and corticosteroids resulting in quick resolution of her shock and clinical improvement with down trending inflammatory markers. Continuous fetal monitors demonstrated normalization of fetal heart rate. She was transferred to the high risk OB floor on hospital day 3. During her stay, she developed a mild transaminitis thought to be associated with MIS-C given her otherwise negative workup. She was discharged home on hospital day 12 on a prednisone taper and oral iron. Discussion: Pregnancy complications associated with COVID-19 are still not well understood, but include preeclampsia, intrauterine growth restriction and premature birth. Although rare, cases of vertical transmission and fetal demise have been reported, as well. Given the profound effects that both pregnancy and MIS-C have on the body, understanding the potential risks of MIS-C in pregnancy is imperative to ensure favorable outcomes. Our current understanding of the effects of maternal MIS-C on a fetus can only be extrapolated from studies on adult women infected during pregnancy and a single reported case of MIS-A in a pregnant adult. Conclusion: We report a case of a pregnant pediatric patient who presented to the ED with shock secondary to MIS-C and associated fetal tachycardia that was successfully treated with vasopressors, IVIG and steroids to enhance knowledge for this presentation and treatment of this condition in a vulnerable population.

De Novo or Increasing Lower Urinary Tract Symptoms during COVID-19 Infection: Long-term Results

Background: How COVID-19 affects lower urinary tract symptoms (LUTS) in men has not been demonstrated by published research. This study examined the de novo development of LUTS and the change in the severity of pre-existing LUTS in men hospitalized with COVID-19. A follow-up period of 12 months after COVID-19 infection provided data on the long-term effect of COVID-19 vs. LUTS. Methods: Data were collected from 70 male patients diagnosed with COVID-19 via nasopharyngeal swab RT-PCR technology between June 2020 and April 2021. The patient’s age, comorbidities, date of COVID-19 diagnosis, date of LUTS, International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA), creatinine, and D-dimer levels, urinalysis, urine culture and duration of hospital stay were recorded. Statistical analyses were conducted to compare between pre-COVID and post-COVID IPSS and other data. Results: 42 patients were included in this study with a, mean age of patients were 54.76 ± 11.95 years. In 8 patients there was no change in IPSS prevs. post-COVID. In the remaining 34 patients (80.9%), the median IPSS increased from a pre-COVID value of 2 to 10 during COVID (p < 0.001). In the subgroup analysis based on age <50 years vs. ≥50 years, statistically significant increase in IPSS were found in both age groups pre- and post-COVID. Conclusions: In male patients of all ages, COVID-19 results in the de novo occurrence of LUTS and an increase in pre-existing LUTS in approximately 80% of patients. These symptoms were found to persist at a 12-months follow-up.