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1.
Environ Res ; 216(Pt 4): 114781, 2022 Nov 11.
Article in English | MEDLINE | ID: covidwho-2104893

ABSTRACT

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has spread rapidly around the world since December 8, 2019. However, the key factors affecting the duration of recovery from COVID-19 remain unclear. OBJECTIVE: To investigate the associations of long recovery duration of COVID-19 patients with ambient air pollution, temperature, and diurnal temperature range (DTR) exposure. METHODS: A total of 427 confirmed cases in Changsha during the first wave of the epidemic in January 2020 were selected. We used inverse distance weighting (IDW) method to estimate personal exposure to seven ambient air pollutants (PM2.5, PM2.5-10, PM10, SO2, NO2, CO, and O3) at each subject's home address. Meteorological conditions included temperature and DTR. Multiple logistic regression model was used to investigate the relationship of air pollution exposure during short-term (past week and past month) and long-term (past three months) with recovery duration among COVID-19 patients. RESULTS: We found that long recovery duration among COVID-19 patients was positively associated with short-term exposure to CO during past week with OR (95% CI) = 1.42 (1.01-2.00) and PM2.5, NO2, and CO during past month with ORs (95% CI) = 2.00 (1.30-3.07) and 1.95 (1.30-2.93), and was negatively related with short-term exposure to O3 during past week and past month with ORs (95% CI) = 0.68 (0.46-0.99) and 0.41 (0.27-0.62), respectively. No association was observed for long-term exposure to air pollution during past three months. Furthermore, increased temperature during past three months elevated risk of long recovery duration in VOCID-19 patients, while DTR exposure during past week and past month decreased the risk. Male and younger patients were more susceptible to the effect of air pollution on long recovery duration, while female and older patients were more affected by exposure to temperature and DTR. CONCLUSION: Our findings suggest that both TRAP exposure and temperature indicators play important roles in prolonged recovery among COVID-19 patients, especially for the sensitive populations, which provide potential strategies for effective reduction and early prevention of long recovery duration of COVID-19.

2.
Atmosphere ; 13(9), 2022.
Article in English | Web of Science | ID: covidwho-2071181

ABSTRACT

In this study, the levels of fine particulate matter (PM2.5), polycyclic aromatic hydrocarbons (PAHs) and nitro-PAHs (NPAHs) in PM2.5 samples were determined from 2020 to 2021 in Singapore. For analysis convenience, the sampling period was classified according to two monsoon periods and the inter-monsoon period. Considering Singapore's typically tropical monsoon climate, the four seasons were divided into the northeast monsoon season (NE), southwest monsoon season (SW), presouthwest monsoon season (PSW) and prenortheast monsoon season (PNE)). The PM2.5 concentration reached 17.1 +/- 8.38 mu g/m(3), which was slightly higher than that in 2015, and the average PAH concentration continuously declined during the sampling period compared to that reported in previous studies in 2006 and 2015. This is the first report of NPAHs in Singapore indicating a concentration of 13.1 +/- 10.7 pg/m(3). The seasonal variation in the PAH and NPAH concentrations in PM2.5 did not obviously differ owing to the unique geographical location and almost uniform climate changes in Singapore. Diagnostic ratios revealed that PAHs and NPAHs mainly originated from local vehicle emissions during all seasons. 2-Nitropyrene (2-NP) and 2-nitrofluoranthene (2-NFR) in Singapore were mainly formed under the daytime OH-initiated reaction pathway. Combined with airmass backward trajectory analysis, the Indonesia air mass could have influenced Singapore's air pollution levels in PSW. However, these survey results showed that no effect was found on the concentrations of PAHs and NPAHs in PM2.5 in Indonesia during SW because of Indonesia's efforts in the environment. It is worth noting that air masses from southern China could impact the PAH and NPAH concentrations according to long-range transportation during the NE. The results of the total incremental lifetime cancer risk (ILCR) via three exposure routes (ingestion, inhalation and dermal absorption) for males and females during the four seasons indicated a low long-term potential carcinogenic risk, with values ranging from 10(-10) to 10(-7). This study systematically explains the latest pollution conditions, sources, and potential health risks in Singapore, and comprehensively analyses the impact of the tropical monsoon system on air pollution in Singapore, providing a new perspective on the transmission mechanism of global air pollution.

3.
Knowl Based Syst ; 258: 109996, 2022 Dec 22.
Article in English | MEDLINE | ID: covidwho-2069433

ABSTRACT

Research on the correlation analysis between COVID-19 and air pollution has attracted increasing attention since the COVID-19 pandemic. While many relevant issues have been widely studied, research into ambient air pollutant concentration prediction (APCP) during COVID-19 is still in its infancy. Most of the existing study on APCP is based on machine learning methods, which are not suitable for APCP during COVID-19 due to the different distribution of historical observations before and after the pandemic. Therefore, to fulfill the predictive task based on the historical observations with a different distribution, this paper proposes an improved transfer learning model combined with machine learning for APCP during COVID-19. Specifically, this paper employs the Gaussian mixture method and an optimization algorithm to obtain a new source domain similar to the target domain for further transfer learning. Then, several commonly used machine learning models are trained in the new source domain, and these well-trained models are transferred to the target domain to obtain APCP results. Based on the real-world dataset, the experimental results suggest that, by using the improved machine learning methods based on transfer learning, our method can achieve the prediction with significantly high accuracy. In terms of managerial insights, the effects of influential factors are analyzed according to the relationship between these influential factors and prediction results, while their importance is ranked through their average marginal contribution and partial dependence plots.

4.
Archives of Disease in Childhood ; 107(Supplement 2):A150-A151, 2022.
Article in English | EMBASE | ID: covidwho-2064024

ABSTRACT

Aims Hospital Miri is a district hospital with NICU that caters neonatal care service in Northern Sarawak. Preterm birth rate in our centre makes up of 10% (n=487) in 2019 and 11% (n=491) in 2020 of the live births, with mortality rate of 3% for preterm infants less than 33 weeks. According to WHO and Cochrane review (2016), Kangaroo mother care helps to reduce mortality, nosocomial infection, hypothermia, and improved growth and exclusive breastfeeding. Methods This is a retrospective observational study. Kangaroo Mother Care (KMC) Project was introduced in 2020 in Hospital Miri NICU as part of quality improvement project. Stable preterm infants with postmenstrual age 30 weeks to 34 weeks 6 days were enrolled with mother's consent into the project. It was carried out in 3 phases, with phase 1 of stable infants under room air or HFNC, phase 2 of stable infants on NIV and phase 3 with intubated infants. As COVID-19 endemic encroached, the project was put on hold at phase 2. Infants' demographic data was analysed using frequency and percentage. Outcomes were measured in mean, frequency and percentage. Maternal mental health score, knowledge score were taken prior to implementation of KMC and upon discharge. The mental health score is described as median and knowledge score is compared by wincoxon signed-rank test. Overall experience score was taken as median and mean. Results A total of 41 infants with the gestation of 32 to 34 weeks 6 days participated, 22 (53.7%) with majority of 41.5% aged 34 to 34 weeks 6 days post menstrual age at the time of enrolment. Mean length of stay was 38.34 days (SD:24.4), time taken to achieve birth weight was 11.4 days (SD: 4.05). Time taken to initiate breastfeeding range from 8 to 14 days to >22 days of life, mean: 24.78. Eighteen infants (43.9%) achieved exclusive breastfeeding on discharge. Mother's mental health, knowledge and experience were measures using Likert scale with the total score of 15 for mental health and 18 for knowledge and experience. For mental health score, pre-KMC median score:14, post-KMC median score was 15. There was improvement in the mother's experience upon discharge (p-value: <0.001). For overall experience, median was 18 with the mean score of 16.88 (SD:1.56). Conclusion Our study was suspended prematurely as per local pandemic control guideline. Knowing about the benefit of KMC to both mother and infants, we suggest that it should be encouraged and continued with adaptation and modification of the procedure during COVID-19 pandemic.

5.
American Journal of Transplantation ; 22(Supplement 3):992, 2022.
Article in English | EMBASE | ID: covidwho-2063425

ABSTRACT

Purpose: Lung transplant is the last resort for COVID-19 refractory ARDS. Dual organ transplant is seen as a relative contraindication at many institutions. We describe a case of simultaneous Lung-Kidney transplant (SLK) in a patient with COVID-19 ARDS. Method(s): A 24-year-old patient with no PMH presented to an outside hospital with a week of shortness of breath, cough, and fever. Despite treatment with Remdesivir and dexamethasone, the patient developed hypoxemic respiratory failure with acute renal injury requiring ICU care and intubation, V-V ECMO, and dialysis. Additionally, Intravenous and inhaled Aviptadil were given under emergency use authorization. While oxygenation improved, the patient could not be weaned off ECMO. With a LAS score of 90.29, the patient underwent an SLK transplant on HD 53, requiring standard induction and maintenance immunosuppression therapy. The patient was treated post-operatively for PGD as well as for subclinical AMR. After successful inpatient rehabilitation, the patient was discharged home after four months and had a one-month follow-up on room air and normal creatinine clearance. Result(s): Patients with pre-existing renal dysfunction who have undergone lung transplants have a significantly higher one- and three-year mortality than patients with normal GFR. The patient's survival after SLK was similar to isolated lung transplants at one and five years, according to an analysis of the UNOS/OPTN database. Still, dual organ transplant in the COVID-19 ARDS population is considered a contraindication at many centers, given these patients' critical illness and frailty. However, the frailty in this population is reversible due to the rapid onset of disease in an otherwise previously healthy younger population with minimal comorbidities. Thus, multiorgan transplantation should be considered in such a patient population. Our patient received Aviptadil as part of an EIND to stabilize patients and improve oxygenation while waiting on the transplant list. Conclusion(s): We propose that SLK transplantation should be considered for carefully selected patients with COVID-19 ARDS.

6.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P174-P175, 2022.
Article in English | EMBASE | ID: covidwho-2064411

ABSTRACT

Introduction: Studies have shown that COVID-19 viral glycoproteins bind to angiotensin-converting enzyme 2 (ACE2) receptors in the airway, causing downregulation of the ACE protein and leading to angioedema-like symptoms. Further, compared with previous variants, the Omicron variant of SARS-CoV-2 appears to replicate more readily in the upper airway than in the lungs. To our knowledge, this is the first case series to explore presentations involving the upper airway in patients with SARS-CoV-2 infection during the Omicron wave of the COVID-19 pandemic. Method(s): We reviewed a case series of adult patients who presented to a single New York City emergency department between December 2021 and January 2022 with acute upper airway symptoms that prompted otolaryngology consultation and who tested positive for SARS-CoV-2. Result(s): Between December 2021 and January 2022, there were at least 3 SARS-CoV-2-positive patients who presented to the New York-Presbyterian Hospital with upper airway conditions requiring evaluation by an otolaryngologist. Conditions included supraglottitis, tracheitis, and epiglottitis. Two patients had received the COVID vaccine;1 had not. One patient required intubation;2 were maintained on room air. One patient was admitted to the intensive care unit, 1 to the step-down unit, and 1 to the floor. Length of stay varied from 3 to 11 days, 1 for nonairway issues. All 3 had methicillinsusceptible/ methicillin-resistant Staphylococcus aureus nasal swabs;2 were positive. All had respiratory viral panels that were negative. One had a throat culture that was negative. All received antibiotics. Conclusion(s): To date, there have been no studies exploring the upper airway manifestations of SARS-CoV-2 infection in the Omicron wave. These data provide important clinical correlates that are highly relevant to otolaryngologists.

7.
Clinical Toxicology ; 60(Supplement 2):51-52, 2022.
Article in English | EMBASE | ID: covidwho-2062732

ABSTRACT

Background: Vertatrum viride (false hellebore) is a perennial commonly found in eastern North America. The most common cause of exposure is misidentification when foraging for wild onion, or skunk cabbage. One regional poison center saw an increase in foraging-related poisonings during initial COVID-19 restrictions. The case report highlights severe delayed cardiac effects after ingestion of Veratrum viride in an otherwise healthy, young, female athlete. Case report: A 24-year-old female presented to an emergency room alongside family with complaints of nausea and vomiting that started 30 min after a meal consisting of foraged wild onion (Allium triccocum). Five others ate the same meal and noted similar symptoms. Vitals upon arrival (3 h post ingestion) are as described: HR 51, BP 88/52, Temp 36.7, RR 18 and O2 sat 100% on room air. The patient had no previous cardiac history and was athletic. Management included D5LR with K replacement, and dopamine infusion at 10mcg/kg/min. Dopamine was tapered slowly, down to 6 mcg/kg/min at 16.5 h. Vitals continued to be stable at 17.5 h post ingestion and dopamine was discontinued. The patient developed severe bradydysrhythmia 15 min later, consisting of complete heart block leading to prolonged sinus pause. She responded to 10 s of CPR with return of spontaneous circulation with a junctional escape rhythm which reverted back to sinus bradycardia. A repeat EKG was unremarkable. The dopamine infusion was reinstituted at 4 mcg/kg/min and continued until 26.5 h post ingestion. She was monitored an additional 9.5 h, and remained in sinus rhythm with mild complaints of dizziness that resolved before discharge. Discussion(s): Veratrum spp. toxicity is due to alkaloids found throughout the plant which cause sodium channel opening when bound to type 2 sodium channels. By increasing sodium ion influx during the resting potential and delaying inactivation to create a late sodium current, these alkaloids increase automaticity in conductive cells. This mechanism, paired with the Bezold-Jarisch reflex, is likely responsible for increased vagal tone leading to bradycardia, hypotension, sinus arrhythmia, and junctional escape rhythm. It is noteworthy that even 18 h post ingestion in a relatively stable patient with no significant cardiac history, cardiac arrest occurred just after treatment tapering. Clinicians should consider prolonged observation time in the setting of discontinuation of vasopressors. Conclusion(s): Both clinicians and amateur foragers should be aware of the risks associated with ingestion of Veratrum viride, especially during early spring when it more closely resembles wild onion. While uncommon, significant delayed cardiac effects are possible. Mistaking the plant for edible wild onions can be the difference between a delectable dinner, and a night in the ICU.

8.
Clinical Toxicology ; 60(Supplement 2):121, 2022.
Article in English | EMBASE | ID: covidwho-2062721

ABSTRACT

Background: Palytoxin poisoning is an uncommon exposure in the US, and is most frequently encountered amongst hobbiests and professionals in the aquarium industry. The toxin is produced by the microalgae Ostreopsis as well as the coral Palythoa toxica. Discovered in Hawaii, the name limu-make-o-Hana translates to "seaweed of death from Hana." Palytoxin interrupts Na+/ K+ ATPase pump, resulting in widespread cellular dysfunction. Persons are at highest risk when cleaning a fish tank housing the coral that produces palytoxin, resulting in cutaneous or inhalational exposure. We present a case of palytoxin inhalational exposure with computed tomography (CT) imaging. Case report: A 41-year-old male presented to the emergency department (ED) with dyspnea, cough, and wheezing after cleaning his saltwater fish tank. He reported that he maintains Zoanthid corals in his home saltwater fish tank and typically wears personal protective equipment when cleaning the tank. He had taken off his mask directly after using hot water to clean the tank, and quickly developed shortness of breath. He contacted Poison Control and was instructed to take loratadine with initial improvement in his symptoms. He then developed decreased appetite, nausea, and chills. The following day, in addition to these symptoms, he developed a fever of 102.5 degreeF and an oxygen saturation of 88% measured with an at-home pulse oximeter. He then proceeded to the ED where he was found to be hypoxic to 91% on room air, tachycardic to 120 bpm, hypotensive to 93/ 70mmHg, febrile to 100.9 degreeF and tachypneic at a respiratory rate of 30. Physical exam revealed clear lung sounds. Application of supplemental oxygen at 2 L resulted in improvement in his oxygen saturation and his hypotension and tachycardia responded to intravenous fluids. Significant laboratory results included WBC count of 20.4 with bands of 14%, elevated lactate of 2.4mmol/L, elevated D-dimer of 0.48 mug/mL and a negative COVID PCR test. CTA thorax revealed patchy ground-glass opacities in the bilateral upper and lower lobes with mosaicism. The patient received doxycycline in addition to broad spectrum antibiotics due to concern for inhalational marine toxicity. He was also started on 60mg prednisone, inhaled steroids, and bronchodilators for symptomatic treatment, with improvement in his symptoms. During his hospitalization, a respiratory viral panel was negative for common viruses associated with atypical pneumonia including influenza, coronavirus, metapneumovirus, rhinovirus, enterovirus, adenovirus, parainfluenza, bocavirus, Chlamydophila pneumoniae, and Mycoplasma pneumonia. His dyspnea gradually improved and he was weaned off supplemental oxygen prior to discharge home on hospital day 2. Discussion(s): It is unclear what changes are expected on thoracic imaging in patients with inhalational palytoxin exposure. Chest radiographs in two previous cases displayed scattered infiltrates, and a chest CT in another case showed pleural based consolidations. The ground-glass mosaicism suggests that a more diffuse reactive airway process after an inhalational palytoxin insult. Conclusion(s): Patients with inhalational palytoxin exposure may be found to have reactive airway symptoms along with ground glass opacities with mosaicism on CT imaging.

9.
Chest ; 162(4):A2575-A2576, 2022.
Article in English | EMBASE | ID: covidwho-2060967

ABSTRACT

SESSION TITLE: Pulmonary Issues in Transplantation Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening complication after transplantation. While there is evidence that hematologic malignancy is associated with increased severity in COVID-19 infection, there is little description of PTLD and COVID-19. CASE PRESENTATION: A 68-year-old man and a 68-year-old female, both of whom had prior renal transplantation, were admitted to the hospital with COVID-19 pneumonia. Both patients were vaccinated against COVID-19, though were negative for spike protein antibodies. The man was treated with remdesivir and the woman was treated with remdesivir and dexamethasone. Both patients improved and were discharged. Within a month, both had recurrent symptoms of dyspnea and fever requiring re-admission. They were hypoxic, the man requiring high flow nasal cannula and the woman requiring nasal cannula to maintain SpO2>90%. They had positive COVID-19 PCR tests, with cycle threshold lower than in their initial admissions, as well as chest imaging with bilateral infiltrates. The man had a pleural effusion with cytology consistent with PTLD and perinephric mass and retroperitoneal lymphadenopathy with biopsy confirming PTLD. The woman had a renal sinus mass with biopsy confirming PTLD. Both patients were treated with another 5 days of remdesivir and started on dexamethasone. The medical team discussed monoclonal antibody treatment, but the patients did not meet EUA criteria and compassionate use request was denied. To treat PTLD, both were initiated on Rituximab, Cyclophosphamide, Hydroxydaunomycin, Oncovin, and Prednisone (R-CHOP). Since then, both patients have had complicated and prolonged hospital courses. The woman developed renal failure and severe C.diff colitis complicated by toxic megacolon requiring total colectomy. The man developed renal failure, CMV viremia, and pseudomonas UTI. The patients were able to be weaned to room air, though ultimately the woman had to be intubated due to poor mental status and remains on low oxygen settings. Both patients continue to be persistently positive for COVID-19 by PCR. DISCUSSION: This case illustrates diagnosis and treatment of PTLD in two patients with COVID-19 infection. Of particular interest was the use of Rituximab, an anti-CD-20 antibody which impairs humoral immunity, in the treatment of PTLD, as the drug has been associated with increased risk of severe COVID-19 infection. Rituximab was particularly concerning as both patients had persistent COVID-19 without development of immunity despite prior vaccination, and both continue to be positive despite two months of active infection. The patients had improvement of their respiratory status, though have had poor and complicated clinical courses with renal and infectious complications. CONCLUSIONS: Treatment of PTLD in patient's with active COVID-19 may impair ability to clear virus, though impact on outcomes is unclear. Reference #1: Simpson-Yap, S., de Brouwer, E., Kalincik, T., Rijke, N., Hillert, J. A., Walton, C., Edan, G., Moreau, Y., Spelman, T., Geys, L., Parciak, T., Gautrais, C., Lazovski, N., Pirmani, A., Ardeshirdavanai, A., Forsberg, L., Glaser, A., McBurney, R., Schmidt, H., … Peeters, L. (2021). Associations of Disease-Modifying Therapies With COVID-19 Severity in Multiple Sclerosis. Neurology, 97(19). https://doi.org/10.1212/WNL.0000000000012753 Reference #2: Andersen, K. M., Bates, B. A., Rashidi, E. S., Olex, A. L., Mannon, R. B., Patel, R. C., Singh, J., Sun, J., Auwaerter, P. G., Ng, D. K., Segal, J. B., Garibaldi, B. T., Mehta, H. B., Alexander, G. C., Haendel, M. A… Chute, C. G. (2022). Long-term use of immunosuppressive medicines and in-hospital COVID-19 outcomes: a retrospective cohort study using data from the National COVID Cohort Collaborative. The Lancet Rheumatology, 4(1). https://doi.org/10.1016/S2665-9913(21)00325-8 Reference #3: Passamonti, F., Cattaneo, C., Arcaini, L. Bruna, R., Cavo, M., Merli, F., Angelucci, E., Krampera, M., Cairoli, R., della Porta, M. G., Fracchiolla, N., Ladetto, M., Gambacorti Passerini, C., Salvini, M., Marchetti, M., Lemoli, R., Molteni, A., Busca, A., Cuneo, A., … Corradini, P. (2020). Clinical characteristics and risk factors associated with COVID-19 severity in patients with haematological malignancies in Italy: a retrospective, multicentre, cohort study. The Lancet Haematology, 7(10). https://doi.org/10.1016/S2352-3026(20)30251-9 DISCLOSURES: No relevant relationships by Ian Mahoney No relevant relationships by Caroline Motschwiller

10.
Chest ; 162(4):A2554, 2022.
Article in English | EMBASE | ID: covidwho-2060960

ABSTRACT

SESSION TITLE: Lung Transplantation Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: A shortage of lungs persists despite the addition of increased-risk donors to the transplantation pool. Waitlist mortality increased from 14.7 to 16.1 deaths per 100 waitlist years from 2019 to 2020. (1) Novel strategies are needed to further expand the donor pool. We report a case of intentional transplant of recently infected acute respiratory virus syndrome 2 (SARS-CoV-2) donor lungs to a patient with end-stage Idiopathic Pulmonary Fibrosis (IPF). CASE PRESENTATION: A 67 year old man with IPF, former tobacco and alcohol abuse, hypertension and gastroesophageal reflux disease underwent a sequential bilateral lung transplant on cardiopulmonary bypass. His post-operative course was complicated by Pseudomonas Aeruginosa pneumonia and bilateral pleural effusions status-post bilateral chest tube placement. He was extubated 4 days after surgery and had his chest tubes removed within 1 week. He discharged on room air 17 days after transplant and appeared well at his 3 week post-operative clinic visit. The donor lungs came from a 28 year old woman with chronic hepatitis C and recent asymptomatic SARS-CoV-2 infection. She tested positive for SARS-CoV-2 on reverse transcriptase polymerase chain reaction (RT-PCR) nasopharyngeal (NP) swabs at 12 and 7 days prior to surgery. She had negative SARS-CoV-2 results on lower respiratory tract testing via bronchioalveolar lavage (BAL) at 7 and 2 days prior to surgery. Recipient RT-PCR NP testing was negative on post-operative days 3, 10, and 17. Two subsequent BAL samples were negative in the first week post-operation. The recipient consented to transplant and was aware of the donor's recent SARS-CoV-2 and chronic hepatitis C infections. Infectious disease did not recommend any SARS-CoV-2 anti-viral therapy or post-exposure prophylaxis. Hepatology prescribed treatment for donor derived hepatitis C viremia on discharge. DISCUSSION: Emerging pathogens present a challenge in minimizing donor-derived diseases. The utilization of lungs, including patients with recent SARS-CoV-2 infection, should be considered carefully. Institutional guidelines vary in donor exclusion criteria based on history of prior SARS-CoV-2 infection, severity of prior infection, timing of last SARS-CoV-2 result, and type of screening test. (2,3) We report a case of intentional lung transplant with asymptomatic SARS-CoV-2 infection on NP swab 1 week prior to transplant and negative lower respiratory tract testing 2 days prior to transplant. Our recipient patient has remained SARS-CoV-2 free at 3 weeks post-operation on serial testing. We propose that the timing of recent donor infection, even within 10 days of positive results, is less important as infectious status based on lower respiratory tract testing at the time of transplant. CONCLUSIONS: We demonstrate that donor lung donation following very recent asymptomatic SARS-CoV-2 infection can be done safely with good short-term outcomes. Reference #1: (1) 2020 Annual Data Report. Scientific Registry of Transplant Recipients https://srtr.transplant.hrsa.gov/annual_reports/2020/Lung.aspx Accessed [03/23/22] Reference #2: (2) Querrey, M, Kurihara, C, Manerikar, A, et al. Lung donation following SARS-CoV-2 infection. Am J Transplant. 2021;21: 4073– 4078. https://doi.org/10.1111/ajt.16777 Accessed [03/23/22] Reference #3: (3) Summary of Current Evidence and Information– Donor SARS-CoV-2 Testing & Organ Recovery from Donors with a History of COVID-19. Version Release Date: January 21, 2022. US Department of Health & Human Services. Organ Procurement and Transplantation Network https://optn.transplant.hrsa.gov/media/kkhnlwah/sars-cov-2-summary-of-evidence.pdf Accessed [03/23/22] DISCLOSURES: No relevant relationships by Thomas Meehan No relevant relationships by Jagadish Patil No relevant relationships by Huddleston Stephen

11.
Chest ; 162(4):A2545-A2546, 2022.
Article in English | EMBASE | ID: covidwho-2060958

ABSTRACT

SESSION TITLE: Signs and Symptoms of Chest Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaping products have been rapidly gaining popularity, with studies showing increasing use, even among school-going children and adolescents. E-cigarette or Vaping Associated Lung Injury (EVALI) is defined as respiratory failure within 90 days of e-cigarette use with pulmonary infiltrates on imaging, in the absence of infectious or alternative causes of respiratory failure.[1] Vitamin E acetate, a thickening agent in THC containing e-cigarettes, is thought to be the main causative agent of EVALI and has been found in the bronchoalveolar lavage samples in almost all cases of EVALI.[2] However, diagnosing EVALI in this era of COVID -19 is a challenge due to striking similarities in clinical symptoms and imaging findings. CASE PRESENTATION: A 32-year-old male with anxiety and polysubstance abuse, presented with headache, cough, low-grade fevers and chills of 1 week. In the ED, he was febrile to 102 F and hypoxic to 89% on room air and was started on 3 liters of oxygen. Labs showed leukocytosis and elevated inflammatory markers. Urine toxicology was positive for THC. Chest X-ray showed bilateral interstitial opacities. CT angio of the chest showed bilateral ground glass opacities. Despite 2 negative PCR tests, suspicion for COVID was high and the patient was initially started on dexamethasone and other supplements, along with antibiotic coverage for a possible bacterial etiology. Despite this, respiratory symptoms and hypoxia continued to worsen. Infectious work up including blood, sputum cultures with AFB staining, urine streptococcus and legionella tested negative. The patient however now revealed the regular use of THC containing vape and procuring the THC oil from a new street vendor. This prompted us to suspect vaping induced chemical pneumonitis. He was restarted on steroid therapy with methylprednisolone and within 1 week, had symptomatic improvement and resolution of hypoxia. The patient was eventually discharged on prednisone taper over 7-10 days. DISCUSSION: Our patient was initially treated for COVID pneumonia despite repeated negative PCR tests, as findings were suggestive of SARS-COV-2 infection. Fortunately, the patient eventually revealed about regular use of THC-oil vapes, making us consider a diagnosis of vaping induced chemical pneumonitis. The mainstay of treatment is steroid therapy and cessation of e-cigarette use. The severity of the pandemic has led to a low threshold for suspecting COVID, causing increased anchoring and availability bias, and potentially under-diagnosing conditions like EVALI which resemble COVID infection.[3] CONCLUSIONS: While it is important to have a low threshold for suspecting COVID-19, considering other mimics of COVID is prudent for providing treatment in an appropriate and timely manner. Detailed inquiry of e-cigarette use, particularly THC-oil containing vapes, duration of use and source of procurement, goes a long way in diagnosing of EVALI. Reference #1: EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review Lydia Winnicka, MD and Mangalore Amith Shenoy, MD PMCID: PMC7351931 PMID: 32246394 Reference #2: Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study Denitza P Blagev 1, Dixie Harris 2, Angela C Dunn 3, David W Guidry 2, Colin K Grissom 4, Michael J Lanspa 5 PMID: 31711629 DOI: 10.1016/S0140-6736(19)32679-0 Reference #3: EVALI: A Mimicker of COVID-19 Mitchell M. Pitlick, MD,a Daenielle K. Lang, MD,a Anne M. Meehan, MBBCh, PhD,b and Christopher P. McCoy, MDb, PMCID: PMC8006188 PMID: 33817560 DISCLOSURES: No relevant relationships by Kaushik Darbha No relevant relationships by Rashmikant Doshi No relevant relationships by Ishan Sahu No relevant relationships by sara samad

12.
Chest ; 162(4):A2508-A2509, 2022.
Article in English | EMBASE | ID: covidwho-2060955

ABSTRACT

SESSION TITLE: Rare Cases with Masquerading Pulmonary Symptoms SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: COVID vaccinations have been encouraged by many healthcare providers but many adverse effects have also been reported. The adverse effects of the vaccine can vary based on each individual. Common adverse effects of the vaccine included fatigue, fever, chills, sore throat, muscle pain, headache, rash at injection site. Pleurodynia, also known as Devil's Grip, is a viral myalgia which causes sharp chest pain or the sensation of a grip around one's chest. Pleurodynia treatment is mostly supportive like anti-inflammatories (NSAIDS), pain management, and antibiotics (if bacterial inflammation is suspected). CASE PRESENTATION: We present a case report of a 63-year-old female who presented with complaints of pleuritic chest pain worse with inspiration. She had a history of atrial fibrillation and HTN. Patient had received the Pfizer COVID booster vaccine a few days prior to onset of the pleuritic chest pain. She was obese and had a 40 pack year smoking history. She was on room air saturating 92% with no increased work of breathing. Lung sounds were diminished due to body habitus but clear. Chest x-ray showed low lung volumes with no evidence of acute pulmonary disease. Computed Tomography Angiography (CTA) chest showed no pulmonary embolism and small left partially loculated pleural effusion with peripheral airspace opacities abutting the pleura. Acute coronary syndrome was ruled out and other cardiac workup was negative. COVID PCR was negative. Patient was treated empirically for bacterial infection with ceftriaxone and azithromycin. She was given NSAIDS to decrease inflammation and pain. Patient's symptoms improved significantly with treatment. She was discharged on NSAIDS and advised to follow up outpatient with her primary care and pulmonology. DISCUSSION: Research studies have indicated that the COVID vaccines (like Pfizer) can cause exacerbation of inflammatory or autoimmune conditions. Multiple mechanisms may be responsible for myocarditis, pericarditis, and other inflammatory conditions post vaccines. One mechanism describes that lipid particles of SARS mRNA vaccines can induce inflammation by activating the NLR pyrin domain containing 3 inflammasome of mRNA which are recognized by toll like receptors and cytosolic inflammasome components leading to inflammation. Another mechanism explains that viral proteins can cause immune cross reactivity with self-antigens expressed in the myocardium leading to an inflammatory process. CONCLUSIONS: As per current literature review there are no case reports about pleurodynia post COVID vaccination but pericarditis and myocarditis have been described. Further research studies are indicated to assess the cause and pathophysiology of pleurodynia post COVID vaccine. Physicians should have a high index of clinical suspicion for pleurodynia when assessing a patient with pleuritic chest pain with a recent history of COVID vaccination. Reference #1: 1. Analysis of COVID 19 Vaccine Type and Adverse Effects Following Vaccination. Beatthy, A;Peyser, N;Butcher, X. AMA Netw Open. 2021;4(12):e2140364. doi:10.1001/jamanetworkopen.2021.40364 Reference #2: 1. Association of Group B Coxsackieviruses with Cases of Pericarditis Myocarditis, or Pleurodynia by Demonstration of Immunoglobulin M Antibody. Schmidt, N;Magoffin, R;& Lennette, E. Infection and Immunty Journal. 1973 Sep;8(3): 341–348. PMCID: PMC422854 Reference #3: 3. Autoimmune phenomena following SARS-CoV-2 vaccination. Ishay, Y;Kenig, A;Toren, T;Amer, R;et. al. International Journal of Immuno-pharmacology. 2021 Oct;99: 107970. DISCLOSURES: No relevant relationships by Olufunmilola Ajala No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by iran Zaman

13.
Chest ; 162(4):A2492-A2493, 2022.
Article in English | EMBASE | ID: covidwho-2060953

ABSTRACT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal

14.
Chest ; 162(4):A2480-A2481, 2022.
Article in English | EMBASE | ID: covidwho-2060951

ABSTRACT

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The incidence of acute pericarditis is 3.32 per 100,000 person-years (11). Patone et. Al, found that 0.001% had acute pericarditis after a dose of the COVID-19 vaccine, while 11.9% were COVID-19 positive (11). 1.5% of patients with COVID- 19 developed new onset pericarditis and six-month all-cause mortality was 15.5% (2). CASE PRESENTATION: 48-year-old male with no known past medical history who presented with acute onset of sharp, left-sided chest pain and associated with dyspnea on exertion. He was not vaccinated for COVID-19 and denied being around any sick contacts. On physical examination he was afebrile, normotensive and saturating 99% on room air. EKG initially showed diffuse ST elevations in leads II,III, aVF, V2-V6. Initial high sensitivity trop was <6. He was incidentally found to be COVID positive. Initial echocardiogram was not suggestive of wall motion abnormalities or pericardial effusions. He was not initiated on management for COVID-19 pneumonia as he was asymptomatic and on room air. He was started on colchicine 0.6 mg BID and ibuprofen 400 TID for pericarditis treatment and symptoms resolved on follow up. DISCUSSION: COVID-19 causing pericarditis is relatively rare and our patient presented with pericarditis and no associated respiratory symptoms. The clinical signs of pericarditis include: a pleuritic or sharp chest pain relieved by leaning forwards, a pericardial friction rub auscultated near the left sternal border and EKG changes including diffuse ST elevations or PR depressions seen in the leads I,II,III, aVL, aVF and the precordial leads V2-V6 (3). The common complications seen with pericarditis are pericardial effusion, cardiac tamponade, and constrictive pericarditis (1). A common etiology for pericarditis is a viral illness which can be seen to precede the cardiac symptoms and be seen as flu-like symptoms or as gastrointestinal symptoms. Treatment is with colchicine and NSAIDs. Aspirin has been the drug of choice in patient's who present with pericarditis following a myocardial infarction, solely because the other NSAIDs have been studied and shown to interfere with myocardial healing (3)(4). NSAIDs were believed to be harmful in patient's diagnosed with COVID, due to upregulation of ACE2 receptors in multiple sites which is used by SARS-COV-2 as a point of entry into cells (9). Drake et. Al, looked at patients with COVID-19 pneumonia, and found use of NSAIDs did not play any significant role in mortality (10). First-line therapy for pericarditis is NSAIDs and colchicine. Second line therapy can be with corticosteroids and refractory therapy is generally with intravenous human immunoglobulins, Azathioprine or anti-IL1 agents such as Anakinra (12). CONCLUSIONS: COVID 19 continues to present with varying levels of comorbidities. Timely diagnosis and intervention of pericarditis precipitated by COVID-19 can lead to near complete recovery and prevent fatal outcomes. Reference #1: Dababneh E, Siddique MS. Pericarditis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431080/ Reference #2: Buckley BJR, Harrison SL, Fazio-Eynullayeva E, Underhill P, Lane DA, Lip GYH. Prevalence and clinical outcomes of myocarditis and pericarditis in 718,365 COVID-19 patients. Eur J Clin Invest. 2021 Nov;51(11):e13679. doi: 10.1111/eci.13679. Epub 2021 Sep 18. PMID: 34516657;PMCID: PMC8646627.1 Reference #3: Little WC, Freeman GL. Pericardial disease. Circulation. 2006 Mar 28;113(12):1622-32. doi: 10.1161/CIRCULATIONAHA.105.561514. Erratum in: Circulation. 2007 Apr 17;115(15):e406. Dosage error in article text. PMID: 16567581. DISCLOSURES: No relevant relationships by Atika Azhar No relevant relationships by Berty Baskaran No relevant relationships by Andres Cordova Sanchez No relevant relationships by Harvir Gambhir No relevant relationships by Hanish Jai

15.
Chest ; 162(4):A2478, 2022.
Article in English | EMBASE | ID: covidwho-2060950

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumomediastinum is the presence of air or other gas in the mediastinum which can be due to trauma related to mechanical ventilation or spontaneous in preexisting lung diseases. Here, we present the case of Covid-19 pneumonia, who developed pneumomediastinum without any trauma or other risk factors. CASE PRESENTATION: A 56-year-old male COVID unvaccinated with a history of essential hypertension presented to the ED with shortness of breath and worsening cough for one week. He was living with his father, who was admitted to the ICU and receiving treatment for COVID pneumonia. The patient appeared to be in respiratory distress. His initial vital signs were temperature of 99.6 F, respiratory rate of 26 breaths per minute, blood pressure 125/71 mm Hg, heart rate 109 beats per minute with a regular rhythm, and oxygen saturation of 50% while he was breathing ambient air. Pulmonary examination revealed use of respiratory accessory muscle and widespread bilateral coarse rhonchi on auscultation. The rest of the physical examination was within normal limits. RT- PCR COVID -19 test was positive. The blood gas analysis reported respiratory alkalosis. Inflammatory markers were elevated: erythrocyte sedimentation rate (35.2 mg/L), C-Reactive Protein (17.70 mg/dL), Ferritin (1108.1 ng/mL), Lactate Dehydrogenase (813 U/L), Lactate (2.4 mg/dL), D-Dimer (35.20 mg/L) and Troponin High Sensitivity-236.6 ng/L. His CBC, electrolytes, and kidney function were normal. Chest X-ray showed Pneumomediastinum with dense basilar predominant consolidation. CT Angio Chest with contrast reported Pneumomediastinum likely from the left central airway source and bilateral dense ground glass consolidation. An echocardiogram showed an ejection fraction of 60-65%, no valvular abnormalities. He was placed on vapotherm(Oxygen 40L/min) with 100% FiO2. He was given Dexamethasone 6mg for ten days, Remdesivir, Barcitinib, and a 7-day course of Azithromycin and Ceftriaxone for community-acquired pneumonia. He was advised to practice prone positioning for 12 hours or more per day. Pulmonology, Infectious Disease, and Cardiology were consulted. Gradually, his oxygen requirement was weaned down and Pneumomediastinum resolved on serial chest x rays. He was discharged on home oxygen in a clinically stable condition. DISCUSSION: Pneumomediastinum in viral pneumonia is rare. The exact mechanism is unknown. Covid-19 pneumonia causes diffuse alveolar wall damage, which might cause air leakage into the mediastinum. The development of pneumomediastinum is an ominous sign in these patients. Fortunately, our patient did not worsen and was weaned off high flow oxygenation requirement. CONCLUSIONS: Few isolated reported cases of pneumomediastinum in a COVID-19 patient have been associated with life-threatening complications. It should be used as a prognostic marker, and close monitoring of these patients is advisable. Reference #1: Damous, S.H.B., dos Santos Junior, J.P., Pezzano, Á.V.A. et al. Pneumomediastinum complicating COVID-19: a case series. Eur J Med Res 26, 114 (2021) DISCLOSURES: No relevant relationships by Saad Ansari No relevant relationships by Akshit Chitkara No relevant relationships by Sudeshna Ghosh No relevant relationships by Femina Patel

16.
Chest ; 162(4):A2348-A2349, 2022.
Article in English | EMBASE | ID: covidwho-2060936

ABSTRACT

SESSION TITLE: Bedside Ultrasound Cases: Beyond Our Sight SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: A thrombus-in-transit (TT), although rare, occurring in approximately 4-18% of pulmonary embolism (PE) cases, carries a high risk of mortality. One study commenting on 80-100% without treatment;therefore, TT should be considered a medical emergency and treated immediately. CASE PRESENTATION: A 64 years old female patient with history of Hypertension and morbid obesity presented to the Emergency department complaining of shortness of breath for 2 weeks with rapid worsening of symptoms and new chest pain in the previous 2 days. Patient blood pressure was 110/70, heart rate 160 irregularly irregular saturating 91% on room air, respiratory rate of 25. Patient tested positive for SARS-CoV-2, and her basic blood work showed elevated BNP and troponin with significant elevation of D-Dimer. The patient never smoked, had no recent travel and not taking OCPs. Bed side point of care echocardiogram showed large right atrial thrombus floating between the right atrium and right ventricle. Subsequent lower extremity ultrasound showed extensive left femoral thrombosis and pulmonary CT Angiogram showed a PE. The treatment options were discussed with the patient including giving full or half dose thrombolytics, or just anticoagulation with heparin. The patient opted for anticoagulation alone. Unfortunately, the patient had a cardiac arrest few hours later. Thrombolytics were given during CPR but the patient passed away. DISCUSSION: TT refers to free-floating right heart thrombi that travel from a venous source in the lower extremities to the pulmonary arteries. Although rare, the presence of a right heart thrombi in the setting of PE predicts a worse prognosis with a high mortality rate and thus, should be treated as a medical emergency. The diagnostic test of choice for TT is an echocardiogram, which shows an elongated right-sided mass illustrating high and chaotic motility with changing shape that continuously prolapses in and out of the right ventricle. Management of TT is still not well established. Options include anticoagulation with heparin, thrombolysis, or surgical removal. A particular study done by Greco et al. in 1999 used recombinant tissue plasminogen activator (rt-PA) with continuous echocardiogram monitoring, that revealed complete lysis of heart clots in all 7 patients within 24 hours. It also showed no changes in symptoms and ultimately showed improvement in blood pressure and heart rate. CONCLUSIONS: Available treatment options include anticoagulation alone, thrombolysis, or surgical embolectomy. Although anticoagulation can prevent clot propagation, it carries a mortality rate of up to 29%, comparable to surgical intervention. Surgical embolectomies could be an alternative option if contraindications to thrombolytics exist. Ultimately, no significant difference was found among the treatment options, suggesting the need for further research and clinical trials. Reference #1: Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(23):2950–73. Reference #2: Cameron, James, et al. "Right Heart Thrombus: Recognition, Diagnosis and Management.” Journal of the American College of Cardiology, vol. 5, no. 5, 1985, pp. 1239–1243., https://doi.org/10.1016/s0735-1097(85)80031-0. Reference #3: Greco, Francesco, et al. "Successful Treatment of Right Heart Thromboemboli with IV Recombinant Tissue-Type Plasminogen Activator during Continuous Echocardiographic Monitoring.” Chest, vol. 116, no. 1, 1999, pp. 78–82., https://doi.org/10.1378/chest.116.1.78. DISCLOSURES: no disclosure on file for Ahmad alkhatatneh;No relevant relationships by Mohammad Alnabulsi No relevant relationships by Mohd Hazem Azzam No relevant relationships by Kelianne Comitalo

17.
Chest ; 162(4):A2300, 2022.
Article in English | EMBASE | ID: covidwho-2060934

ABSTRACT

SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Covid 19 virus has impacted nearly 450 million people across the globe;ranging from an asymptomatic carrier state to respiratory symptoms, cardiovascular symptoms, hematologic manifestations and multiorgan failure to death. Thrombotic events are one of its devastating complications. CASE PRESENTATION: A 66 year old man with a history of diabetes mellitus, hypertension and 30 pack years smoking history presented to the emergency room with hypoxia and altered mental status. On exam, his GCS was 8/15 and oxygen saturation was 85% on room air. He was subsequently intubated. CTA chest demonstrated bilateral diffuse ground glass opacities and left pulmonary embolism (PE). CT abdomen and pelvis showed multifocal infarcts in the right kidney with findings suggestive of renal artery thrombosis. Initial platelet count was 80,000/ul with creatinine of 3.9 mg/dl and creatine kinase (CK) of 3977 u/l. His INR was 1.4. Patient was not a candidate for thrombolysis given his thrombocytopenia. He was started on intravenous (IV) heparin and given IV hydration. On day 3 of his admission, he developed dry gangrene of the toes. Ankle brachial index of the right lower extremity (LE) was 1.16 and left LE was 0. Duplex ultrasonography of left LE showed mid to distal popliteal artery thrombus occluding below knee popliteal and tibial arteries. Echocardiogram showed ejection fraction of 55% and bubble study was negative for any intra atrial or pulmonary shunting. On day 4 of his admission, he developed oliguria and his gangrene got worse. His platelet counts decreased to 36,000/ul. Other pertinent labs showed INR 1.2, PT 15.3, PTT 34, D dimer 14.82, fibrinogen 498, CK 6434 mg/dl, hemoglobin 13.2 g/dl, haptoglobin 243 mg/dl and LDH 1041 U/l. Given his poor prognosis in the setting of ventilator dependent respiratory failure, multiple thrombosis and kidney failure requiring hemodialysis, the family decided to withdraw care. DISCUSSION: There are multiple hypotheses of thrombus formation in Covid 19 infection such as interleukin 6 and other cytokines induced endothelial injury, angiogenesis and elevated prothrombotic factors such as factor VIII and fibrinogen. Our patient had PE, renal artery thrombosis and popliteal artery thrombosis. Despite being on full dose anticoagulation, he developed gangrene of the toes. His lab results were not consistent with disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and he was not known to have any baseline hypercoagulable disorder. He did not have any intra cardiac shunts. Hence, it is most likely Covid 19 induced multiple arterial and venous thrombosis. CONCLUSIONS: The treatment of Covid 19 related thrombosis has become very challenging especially in the setting of multiple clots. It is crucial to have large multicenter studies to investigate vascular complications of Covid-19 and to formulate management strategies to ensure good patient outcomes. Reference #1: https://www.nejm.org/doi/full/10.1056/nejmoa2015432 Reference #2: https://journal.chestnet.org/article/S0012-3692(21)01126-0/fulltext DISCLOSURES: No relevant relationships by Devashish Desai No relevant relationships by Swe Swe Hlaing no disclosure on file for Jean Marie Koka;No relevant relationships by Hui Chong Lau No relevant relationships by Subha Saeed No relevant relationships by Anupam Sharma No relevant relationships by Muhammad Moiz Tahir

18.
Chest ; 162(4):A2259-A2260, 2022.
Article in English | EMBASE | ID: covidwho-2060924

ABSTRACT

SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Methemoglobinemia is an increase in methemoglobin (mHb) level characterized by functional anemia and tissue hypoxia. It can be caused by congenital enzymes deficiencies, but it is usually acquired. Dapsone, an oxidizing agent, is a medication commonly associated with acquired methemoglobinemia (1). We describe the diagnosis and management of a COVID-19 patient with acquired methemoglobinemia due to Dapsone. CASE PRESENTATION: 84-year-old female with history of MPO-ANCA vasculitis with renal involvement, CKD4 and anemia of chronic disease presented with shortness of breath, lethargy and weakness. Initially, the patient was saturating (SpO2) 80% on room air and was placed on 4L nasal cannula (NC) with improvement to 92%. CT of the chest showed b/l GGOs consistent with atypical pneumonia and patient tested positive for COVID-19. About 4 months prior, she had received 2 doses of Rituximab and on high steroid therapy that was tapered to 5mg of prednisone daily. She has been on Trimethoprim/Sulfamethoxazole for PJP prophylaxis, but due to hyperkalemia the medication was stopped. After confirming no G6PD deficiency, she was started on Dapsone 100mg daily. During hospitalization, she was given dexamethasone 6 mg daily and Dapsone was continued. On hospital stay day 6, a rapid response was called after oxygen dropped to 78% while walking on 6L NC. She was placed on high flow NC 100% and SpO2 went up to 90%. An arterial blood gas (ABG) was then obtained showing pO2 of 334, oxyhemoglobin (oxyHb) of 83 and mHb of 17.4. The SpO2-PaO2 gap and elevated mHb lead to the diagnosis of Dapsone-induced methemoglobinemia. Dapsone was discontinued. Patient received a one-time dose of 1mg/kg IV of methylene blue. One hour later her dyspnea had improved and was on 3L NC. Repeat ABG showed improvement of oxyHb (98) and decreased mHb (2.2). DISCUSSION: Physiologically, mHb is less than 1% of total Hb (1) and occurs when the iron in the porphyrin group of heme is oxidized from ferrous to the ferric form (2). Ferric heme binds oxygen irreversibly causing a left shift of the oxygen-hemoglobin dissociation curve. Clinical presentation tends to correlate with mHb levels, and it varies from being asymptomatic to fatigue, dyspnea, confusion, seizure, cyanosis resistant to oxygen therapy (mHb > 15%) and death. Methylene blue is safe and can be consider when mHb level is greater than 10 to 20% (2). Methylene blue was administer to our patient given the presence of COVID (leaving patient more susceptible to medication-induced methemoglobinemia (3)) and chronic anemia which made her less likely to tolerate state of reduced oxygen delivery. CONCLUSIONS: The diagnosis of methemoglobinemia is a rare cause of hypoxemia that is often overlooked. In patients with risk factors (COVID, medication exposure) a high index of suspicion is needed when interpreting an ABG (SpO2-PaO2 gap) for correct diagnosis and appropriate treatment. Reference #1: Toker, Ibrahim, et al. "Methemoglobinemia Caused by Dapsone Overdose: Which Treatment Is Best?” Turkish Journal of Emergency Medicine, vol. 15, no. 4, Dec. 2015, pp. 182–184, 10.1016/j.tjem.2014.09.002. Accessed 31 Aug. 2020. Reference #2: Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothorac Vasc Anesth. 2014 Aug;28(4):1043-7. doi: 10.1053/j.jvca.2013.02.005. Epub 2013 Aug 13. PMID: 23953868. Reference #3: Naymagon, Leonard, et al. "The Emergence of Methemoglobinemia amidst the COVID -19 Pandemic.” American Journal of Hematology, vol. 95, no. 8, 3 June 2020, 10.1002/ajh.25868. Accessed 3 Mar. 2021. DISCLOSURES: No relevant relationships by Mileydis Alonso No relevant relationships by Samantha Gillenwater No relevant relationships by Christine Girard No relevant relationships by Sikandar Khan No relevant relationships by Jose Rivera No relevant relationships by Frederick Ross

19.
Chest ; 162(4):A2203, 2022.
Article in English | EMBASE | ID: covidwho-2060911

ABSTRACT

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatous polyangiitis (GPA), previously known as Wegener's granulomatosis, is a rare syndrome characterized by inflammation of small and medium sized vessels. The clinical presentation can be very heterogenous and differentiation from an infectious disease can be challenging initially. Here, we present a case of a young male presenting with respiratory symptoms during the pandemic, presumed to have coronavirus disease 2019 (COVID-19) though after extensive workup was later diagnosed with GPA. CASE PRESENTATION: A 19-year-old male presented to the emergency department (ED) with complaints of low-grade fever and dry cough for one week. He reported having abdominal pain, fatigue, loss of appetite and polyarthralgia. An outpatient upper gastrointestinal endoscopy revealed gastritis and duodenitis. In the ED, his vitals included a temperature of 101.8°F, blood pressure of 115/65mmHg, heart rate of 99/min, respiratory rate of 18/minute and oxygen saturation of 99% on room air. COVID-19 testing was negative. A computerized tomography of the chest revealed extensive ground glass opacities. He was presumptively diagnosed with COVID-19 and started on dexamethasone therapy along with azithromycin for atypical pneumonia. However multiple tests for SARS-CoV-2 were negative. Another consideration was COVID-19 induced multisystem inflammatory syndrome given the patients young age. Infectious workup included negative testing for human immunodeficiency virus, Legionella, tick borne diseases and mycoplasma. As febrile episodes continued, he developed microcytic anemia, microscopic hematuria, and petechial rash on his ankles. Antinuclear antigen screen was negative, but C-antineutrophil cytoplasmic and anti-proteinase-3 antibodies were positive. Renal biopsy revealed GPA. He was prescribed pulse dose steroids and transitioned to immunotherapy. DISCUSSION: GPA is a challenging diagnosis given multiple system involvement, though early identification and initiation of treatment are important to prevent long term sequalae. In our case, acute onset febrile illness and pulmonary ground glass opacities led to repeated COVID-19 testing potentially delaying the diagnosis. Ultimately, the correct diagnosis was made and confirmed on renal biopsy. We believe our case highlight the importance of keeping a broad differential and considering vasculitis in these situations for prompt diagnosis. CONCLUSIONS: GPA can often mimic respiratory infectious processes, a high index of suspicion is necessary for timely diagnosis. Reference #1: Selvaraj V, Moustafa A, Dapaah-Afriyie K, et alCOVID-19-induced granulomatosis with polyangiitis. BMJ Case Reports CP 2021;14:e242142 Reference #2: Qurratulain, Q., Ahmed, A., & Jones, Q. (2021). Lesson of the month: Severe granulomatosis with polyangiitis (GPA): a diagnostic challenge during the COVID-19 pandemic. Clinical Medicine, 21(1), 79. DISCLOSURES: No relevant relationships by Aamna Khan No relevant relationships by Usama Sadiq No relevant relationships by Rehan Saeed

20.
Chest ; 162(4):A2195, 2022.
Article in English | EMBASE | ID: covidwho-2060910

ABSTRACT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Both COVID-19 infection and sarcoidosis have been associated with long-term systemic complications with current research attempting to link these two diseases based on inflammatory properties. This case presents a patient with previously biopsy proven asymptomatic sarcoidosis who progressed to symptomatic sarcoidosis following severe COVID-19 infection. CASE PRESENTATION: A 58-year-old previously active female with known asymptomatic, biopsy proven pulmonary sarcoidosis presented to hospital in February 2021 with severe COVID-19 pneumonia requiring treatment with Decadron and Remdesivir. She was discharged home on room air but continued to have fatigue, shortness of breath, wheezing and coughing. Due to persistent respiratory symptoms and new onset vomiting with anorexia, she sought evaluation in the emergency department in July 2021. She was febrile with blood work significant for leukopenia and thrombocytopenia. She was found to have Anaplasmosis and despite adequate treatment continued to have persistent hypoxia with oxygen saturation of 82%. CT chest showed new areas of bilateral upper lobe predominant ground glass opacities and ill-defined soft tissue density in the subcarinal region. She was started on inhalers and underwent bronchoscopy with negative infectious disease work-up. She was discharged home on both inhalers and oral prednisone. Upon subsequent follow-up with pulmonology, she reported significant improvement in respiratory symptoms. Repeat CT chest after two of months of oral prednisone showed near resolution of all previous findings. After three of months of steroids, she began a prolonged steroid taper of one month. She reported absence of respiratory symptoms off of steroids. DISCUSSION: Current research is focusing on patients at greater risk of developing symptomatic sarcoidosis due to Th17 cells and the specific cytokines these cells produce. Several case reports suggest correlation between the inflammatory cascade induced by sarcoidosis and COVID-19 infection. One such case report suggests that COVID-19 infection can be a trigger for developing symptomatic pulmonary sarcoidosis. Our patient would be the first reported case of biopsy proven previously asymptomatic sarcoidosis developing into symptomatic sarcoidosis following severe COVID-19 infection. CONCLUSIONS: Therefore, COVID-19 infection may not only predispose individuals to developing pulmonary sarcoid but may also contribute to the progression of once asymptomatic sarcoid to symptomatic sarcoid. Reference #1: Capaccione, K. M., McGroder, C., Garcia, C. K., Fedyna S., Sagi, A., & Salvatore, M. M. (2022). Covid-19-induced pulmonary sarcoid: A case report and review of the literature. Clinical Imaging, 83, 152-158. https://doi.org/10.1016/j.clinimag.2021.12.021 Reference #2: Chen, Edward S. "Reassessing Th1 versus Th17.1 in Sarcoidosis: New Tricks for Old Dogma.” The European Respiratory Journal, vol. 51, no. 3, 2018, p. 1800010. Reference #3: Xu, Zhe, et al. "Pathological Findings of COVID-19 Associated with Acute Respiratory Distress Syndrome.” The Lancet Respiratory Medicine, vol. 8, no. 4, 2020, pp. 420–422. DISCLOSURES: No relevant relationships by Skylar Hartmann No relevant relationships by Jessica Wiseman

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