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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: Thymoma-associated autoimmune encephalitis (TAAE) is an understudied and overlooked diagnosis in patients presenting with abrupt altered mental status. Described as inflammation of brain tissue, autoimmune encephalitis is seen in 5-10 cases per 100,000 across all age groups per year. A rare subtype involves neuronal surface antibodies to alpha-amino-3-hydroxyl-5-methyl-4isoxazolepropionic acid receptors (AMPA-R) encephalitis is seen even less commonly. Given the "unicorn” nature of presenting cases and difficulty of diagnosis, prompt identification and treatment are critical as prolonged courses without treatment are irreversible and deadly. CASE PRESENTATION: A 47-year-old male with no past medical history presented 3 days after a Johnson & Johnson coronavirus-2019 (COVID-19) booster vaccine due to worsening acute altered mental status over the past week. He complained of episodes of fever & chills prior to this. The patient's wife reported abrupt changes in memory and personality. Upon admission, the patient had a Glasgow Coma Scale of 4. The patient was intubated and transferred to the intensive care unit. Intravenous (IV) vancomycin, ceftriaxone and acyclovir was initiated for meningitis. Computed tomography (CT) scan of the head without contrast was unremarkable. Magnetic resonance imaging (MRI) showed enhancements of the right anterior and medial temporal lobe suggesting encephalitis. Cerebrospinal fluid analysis (CSF) revealed lymphocytic pleocytosis. A CT scan of the chest, abdomen and pelvis showed an anterior mediastinal mass measured 1.8 x 2.3 cm (Figure 1). FilmArray Meningitis polymerase chain reaction was negative as well as Herpes Simplex Virus (HSV) 1 and 2. Autoimmune encephalitis antibody was positive for Anti-AMPAR. Pulse dose steroids and intravenous immunoglobulin were initiated but failed. Rituximab was initiated and cardiothoracic surgery completed a thymectomy. DISCUSSION: TAAE is a rare disease, permanently debilitating, and deadly if unrecognized or treatment is delayed. Autoimmune encephalitis is an umbrella disease process seen in 0.00005% of patients per year. AMPA-R positive encephalitis is even less commonly seen with only 22 cases reported between the years 2009 and 2014 [1]. A rapidly progressive cognitive decline or psychiatric disorders are early features of this disease.Our patient had prodromal symptoms of fever and cognitive decline days after receiving his COVID-19 booster vaccine. CONCLUSIONS: Post-vaccine encephalomyelitis has been described in other settings[2]. This patient was free of symptoms prior to the COVID-19 vaccine booster, and demonstrated altered mental status hours after receiving it. This furthers the possibility of an association of the COVID-19 booster vaccine, development of encephalitis, and in this case a thymoma. Despite this, conclusions can not be made on the account of one report, but introduces a new area of focus to study. Reference #1: Höftberger, R., van Sonderen, A., Leypoldt, F., Houghton, D., Geschwind, M., Gelfand, J., Paredes, M., Sabater, L., Saiz, A., Titulaer, M. J., Graus, F., & Dalmau, J. (2015). Encephalitis and AMPA receptor antibodies: Novel findings in a case series of 22 patients. Neurology, 84(24), 2403–2412. https://doi.org/10.1212/WNL.0000000000001682 Reference #2: Huynh, W., Cordato, D. J., Kehdi, E., Masters, L. T., & Dedousis, C. (2008). Post-vaccination encephalomyelitis: literature review and illustrative case. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 15(12), 1315–1322. https://doi.org/10.1016/j.jocn.2008.05.002 DISCLOSURES: No relevant relationships by Matthew Frank No relevant relationships by Justin Ilagan No relevant relationships by Danielle Mahon No relevant relationships by Danielle Mahon No relevant relationships by Harshini Sahani No relevant relationships by Kameron Tavakolian No relevant relationship by Ndausung Udongwo
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Introduction: I will never forget the tightness in my throat and the pressure rising in my chest when I heard those words spoken by the husband of an ICU survivor. How ashamed I felt that despite all we do to alleviate the suffering of our patients, sometimes we create new suffering for those left at home. Main Body: Restricted visiting during the pandemic has created unprecedented challenges for patients, staff, and families. Not able to rely on family visits to communicate news and to help families appreciate any change in the condition of their loved ones, we have had to develop new ways of working. The consultants enthusiastically rallying juniors into daily telephone updates, emailed messages read to patients by nursing staff, pictures on the walls of a hospital room, and wrestling with technology to bring families together in one room via video call. Despite all the energy and innovation, I am sure I'm not the only person who has found themselves thinking that perhaps the call to update the wife/father/daughter of our patient can wait. They had an update yesterday;maybe someone else can speak to them later. This phone call, one of several to ICU survivors and their families, was the first time I had fully understood the reality for the loved ones of so many of our patients. They are barred from the hospital due to covid restrictions, struggling to build a picture of their loved one from the snatches of information given down a phone, desperate for news. Since this conversation, I am incredibly mindful of the responsibility to care for families as well as our patients. Even if they aren't with their loved ones in person, we have an opportunity to include them in the journey. Maybe we remember to share the big things, but sometimes the small things are the ones that matter most: a shave, the music on the radio, ice cream with their lunch. Each member of the ICU team has a different story to share, and it's these human connections this patient's husband was waiting for by the phone. Conclusion: As we slowly arrive at “the new normal” we might be relieved to see the end of some of our pandemic practices. However, I will never forget the lesson this man taught me. I will use my privileged position to make painful times perhaps a little more bearable for the families and friends of those we treat.
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Introduction: The COVID -19 pandemic presented a new range of challenges to clinicians across the world in caring for patients affected by a virus with what at the time was an unknown pathophysiology.1 In meeting this challenge physiotherapists utilised their knowledge and experience in treating patients with acute respiratory distress syndrome (ARDS) to provide the best possible care. Objectives: The aim of this paper is to reviewand reflect on physiotherapy treatment for a patient with COVID - 19 who received ECMOsupport, from admission to discharge home. Methods: A case study design to provide a detailed review of the treatments used with the patient during their journey, including feedback from the patient. Figure 1 outlines a timeline of key events during their patient journey. Results: • Historically the Physiotherapy team within the ECMO centre have believed that chest physiotherapy would be mostly ineffective on patients with low lung volumes. However, in this case study it was shown that with tidal volumes of between 30 - 100mls, expiratory vibrations with saline instillation and suctioning cleared more secretions then suctioning alone. • Despite the use of foot splinting whilst sedated we still faced challenges with contractures in calves which subsequently limited standing. • Effective and safe use of SOEOB and tilt-table built up-to standing with support whilst having ECMO in situ. • The use of PMV whilst ventilated allowed the wider MDT to provide effective support for the patient's overall wellbeing. The use of PMV was timed with chaplaincy and psychology input, in addition to enabling twoway communication during video and phone calls with the patient's wife, who at the time was unable to visit due to restrictions. Patient feedback on the use of the PMVTo be able to communicate normally was wonderful, as you are locked into a world where no one understands you and it can be so frustrating to make people understand what you want. Conclusions: The patient was successfullyweaned fromthe ECMO, ventilator and tracheostomy was de-cannulated;they were transferred back to their local hospital for ongoing rehab and were eventually discharged home. This case study introduces a debate as to the effectiveness of manual techniques and suctioning with saline on patients with low lung volumes as it appeared to be beneficial compared to suctioning alone. The use of the PMV within the ventilator circuit enabled vocalisation much earlier during their admission which not only progressed their swallowing and cough strength rehabilitation but also significantly increased the amount of psychological support they were able to access. On reflection it seemed appropriate to utilise similar rehabilitation treatment options used in the management of ARDS patients on ECMO, despite the challenges associated with the complex logistical and safety factors when managing this patient group.
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STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic highlights the disproportionate burden of disease on communities made vulnerable by structural inequities. The pandemic has increased economic hardship, including housing instability, food insecurity and ability to pay bills. Hospitalization for COVID-19 is an opportunity to address unmet healthrelated social needs (HRSNs) and connect patients with community resources. DESCRIPTION OF PROGRAM/INTERVENTION: Community health workers (CHWs) play a critical role in response to public health crises. To address the inequitable burden of COVID-19 on Austin's Latinx population, we implemented a pilot program at an academic hospital where a CHW helps patients navigate care transitions and address unmet HRSNs. The care team referred patients with COVID-19 to the CHW, who met with patients to establish rapport, provide language-concordant communication between the care team and patient/family, deliver health promotion education, and assess HRSNs. MEASURES OF SUCCESS: This includes three typical cases describing key components of the CHW pilot program. CHWs connected patients and families to community resources and facilitated discharge planning and connection with primary care providers. The CHWs continued to follow patients for at least 45 days after discharge to assist with care coordination. We provide qualitative data from patients and healthcare professionals. FINDINGS TO DATE: Patient 1 is a 38-year-old day laborer with hypertension hospitalized with COVID-19 pneumonia. His family of four is undocumented and faced economic insecurity due to loss of work from the pandemic. The CHW assisted with utilities, bills, food and rent through coordination with local organizations to provide direct financial assistance to the family. Patient 2 is a 45-year-old woman with diabetes hospitalized with COVID-19 pneumonia. She is a mother of three children, two with disabilities. In addition to financial insecurity, she identified transportation as a primary HRSN. The CHW arranged financial resources to fix their car, which allowed the family to access school and clinic resources. Patient 3 is a 36-year-old man hospitalized with COVID-19 pneumonia. The CHW connected the family, including three children, with their school social worker, enabling access to financial support for utilities, food and clothes. The CHW arranged free food delivery to their home for four months. The CHW also secured county-based indigent care coverage for the patient, enabling hospital follow-up with a primary care provider. The patient's wife noted, because of the CHW, “We never felt alone” and now feel “capable of navigating a health system that we never felt we had access to.” KEY LESSONS FOR DISSEMINATION: CHWs, as patient advocates and skilled care navigators, build trust, establish longitudinal relationships with patients and address unmet HRSNs that can enable successful care transitions. CHWs can alleviate the disproportionate burden of COVID-19 on individuals with unmet HRSNs. Supporting the work of CHWs within hospital care teams can improve care transitions.
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Introduction: Conium maculatum, poison hemlock, is native to Europe, North Africa and Western Asia. Over the last 50 years, it has become more prevalent as an invasive species in the United States. Notorious for its role in Socrates' suicide in 399 BC and frequently referenced by Shakespeare, the plant has a rich history of toxicity in man. We present a case of an accidental hemlock exposure leading to acute interstitial pneumonia and acute respiratory distress syndrome. Case Presentation: A 58 year old male presented with acute dyspnea and cough with hemoptysis the morning after clearing wooded brush in his backyard. Other symptoms included tachycardia, diaphoresis, nausea, and diarrhea. His condition rapidly progressed to acute respiratory failure with imaging suggestive of ARDS. Thorough investigation for infectious and inflammatory etiology was unremarkable. Open lung biopsy was consistent with diffuse alveolar damage. Further history from the wife revealed the presence of significant amounts of poison hemlock identified in photos from the yard. Initial treatment included prednisone with prolonged taper with eventual transition to mycophenolate mofetil. After a prolonged hospital course, he was discharged with tracheostomy and continued ventilatory support. Discussion: Hemlock produces piperidine alkaloids akin to nicotine including coniine and γ-coniceine. These inhibit the nicotinic acetylcholine receptors of the central nervous system causing an array of symptoms that without intervention lead to respiratory depression and death. Diagnosis is based on history. Treatment is supportive, in many instances requiring mechanical ventilation. Conclusions: Even in the Covid era, ARDS differential diagnosis is dependent on thorough history taking, including obscure environmental exposures.
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Objective: NA Introduction: Vertigo is an unusual presentation of COVID infection about which there have been only a few case reports focusing on peripheral vestibular dysfunctions. Accumulation of clinical experiences is needed to improve our knowledge and clinical practice. We report a recent encounter with predominant and persistent vestibular symptoms from COVID-19 infection. Design/Methods: NA Case Presentation: A 31 y/o otherwise healthy male suffered rapidly onset severe non-positional vertigo, disequilibrium, and nystagmus associated with nausea and vomiting, which were followed in a few hours with high fever, diarrhea, and generalized fatigue. He and his wife were then both tested positive for SARS CoV-2 by PCR. He denied having other common COVID-19 symptoms. All his systemic symptoms resolved in 2 weeks after treatments. However, he remained having persistent severe and subjectively progressive vertigo and disequilibrium upon the first office encounter 2 months later. Symptoms were enhanced by head pitching and were reduced by maintaining head stationary in supine position with eyes closed. Examination was unremarkable except the findings of slight left-sided peripheral vestibular weakness and mild deviation with Fukuda stepping. Further vestibular studies showed normal water caloric irrigation, impaired vertical gaze holding, abnormal subjective visual vertical testing, and delayed bilateral vestibular evoked myogenic potentials. COVID-19 infection-related peripheral and central vestibular complications were suspected. The patient was referred to vestibular rehabilitation. Discussion: COVID-19 virus is known to cause acute and long-term injuries of peripheral and central nervous systems. Although uncommon, COVID-19 infection can present with acute vestibular symptoms. Like the other reports, our case showed no profound peripheral vestibular losses after recovery from acute COVID-19 infection. However, his debilitating vestibular discomforts have persisted long after the recovery. Our observations suggest that the mechanisms for COVID-19-related vestibular dysfunctions are more complicated and may involve both peripheral and central vestibular systems.
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Introduction: Hashimoto's encephalopathy (HE) is a rare immune–mediated complication of Hashimoto thyroiditis. It is presented as subacute onset of altered mental status with confusion, seizures and myoclonus. It is a diagnosis of exclusion and requires that all other possible causes of cognitive impairment are excluded with a response to steroid therapy and evidence of thyroid autoimmunity in a patient. Here, we present a case of HE in a patient who presented with altered mental status and visual hallucinations despite no history or symptoms of thyroid disorder. Case Description: A 77 year old male with past medical history of hypertension presented with altered mental status, lethargy, and visual hallucinations. Per patient’s wife, patient started to get somnolent and was having memory problems six weeks prior to presentation. His mental status gradually deteriorated, and he started to have visual hallucinations. He was somnolent and noted to have myoclonus and twitching on admission. Magnetic resonance imaging (MRI) of the brain with gadolinium showed chronic microvascular changes with no acute intracranial pathology or masses. Electroencephalogram (EEG) showed no signs of epileptiform activity. Infectious disease work up, including complete blood count, urinalysis, sexually transmitted diseases, and cerebrospinal fluid (CSF) analysis, was negative. Blood glucose levels, serum electrolytes, liver function tests, blood urea nitrogen, and creatinine were normal. Coronavirus disease 2019 (COVID-19) was negative. CSF analysis for autoimmune encephalopathy and Creutzfeldt-Jakob disease was negative. Thyroid function tests were normal. Thyroid peroxidase antibody (TPOAb) was negative (8.6 IU/mL [reference range (RR): < 9.0 IU/mL]) and TgAb was positive (8.2 ng/ mL [RR: < 4 IU/ mL]). With suspicion of Hashimoto's encephalopathy, he was started on intravenous Solu-Medrol 1 g for five days. He was then switched to oral prednisone 60 mg daily, which he received for ten days. His mental status improved upon day 14 of admission. On day 17 of admission, he was discharged on oral prednisone 40 mg daily with taper for five weeks. He was evaluated in the clinic few months after discharge. His mental status had improved significantly, and he was back to his baseline in about two months after discharge as per his wife. Repeat thyroid function tests, TPOAb, and TgAb were negative. Discussion: The incidence of Hashimoto’s encephalopathy (HE) is 2.1 per 100,000 individuals in the general population, and is more common in women than men. This case highlights that HE should be considered in patients with subacute presentation of neurological problems, which cannot be explained with other possible diagnosis, despite no symptoms of thyroid disease such as the patient in this case study. Therefore, HE should be evaluated for in patients with cognitive impairment for prompt diagnosis and treatment with steroid therapy in order to improve the prognosis in these patients.
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Introduction: Hybrid dialysis is traditionally identified as the combined utilization of peritoneal dialysis (PD) and hemodialysis (HD) in patients with end-stage renal disease. From current literature, its reported use is quite limited outside of Japan. We in the past year encountered major family-related and work-related constraints that prevented a 41-yo man with ESRD on home HD from completing the prescribed four-times weekly HD treatments. The resulting HD inadequacy led to worsening of the patient’s physiology and a possible risk of being de-listed from a kidney transplant list. He was successfully transitioned to a new hybrid dialysis regimen of twice-weekly Home HD + twice weekly in-center HD. HD adequacy was re-established and the patient’s physiology improved to acceptable status. This is the first such report. Methods: Case Report. Results: A 41-yo man with ESRD secondary to SLE and hypertension who had successfully been on home HD, 4 x weekly, for 32 months, with the wife as a caregiver, had in the second half of 2020 experienced new family-related stressors with the non-availability of day-care for two young children, ages 3 and 5 years, respectively, due to the COVID-19 pandemic, and concurrent spousal illness. In addition, the patient who is a product delivery driver, had new demands from his employment. As a result of these obstacles, he missed several of his Home HD sessions. The result was inadequate HD delivery and worsening laboratory indices and he was potentially going to be de-listed from the kidney transplant list. In February 2021, he was switched to new hybrid dialysis regimen of twice-weekly Home HD + twice weekly in-center HD - 2 in-center HD treatments on Tuesdays and Thursdays, and 2 Home HD treatments, one during the weekend and one during the week. Each HD session lasts 3.5 hours, 2000 units Heparin bolus, and his left brachiocephalic AVF is accessed by the button-hole method. The Home Dialysis Staff continued to coordinate and monitor his dialysis care. HD adequacy was re-established and the patient’s physiology improved to acceptable status. Conclusions: Hybrid dialysis is traditionally identified as the combined utilization of peritoneal dialysis (PD) and hemodialysis (HD) in patients with end-stage renal disease. A 2020 Italian report described another type of hybrid dialysis that consisted of once-weekly in-hospital HD and home peritoneal dialysis to limit patient exposure to the hospital environment during the COVID-19 pandemic. We have described the successful application of a new Hybrid HD system that combined Home HD + in-center HD. To our knowledge, our report is the first of its kind and was designed and implemented primarily for the patient to suit the new exigencies and circumstances at home on a long-term continuous basis. Overall, patient and family are happy with the new arrangement with improved HD adequacy and normalized laboratory data. We revisit any observed other advantages and problems that may be associated with this form of Hybrid HD care. No conflict of interest