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1.
Chest Disease Reports ; 9(1) (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2066765

ABSTRACT

We present a case series of patients with pulmonary embolism of unknown etiology who did not have any risk factors. According to the findings, the most likely cause of the pulmonary embolism was undiagnosed, asymptomatic, or mild Corona Virus disease-2019 (COVID-19) infections in the recent past. In the current post-pandemic era, where there has been a surge of sudden unexplained deaths and pulmonary embolism cases, this case series emphasizes the importance of pulmonary embolism evaluation in patients seeking medical care for dyspnea. Physicians should be aware of the possibility of pulmonary embolism as a late complication in patients with mild, asymptomatic, or undiagnosed COVID-19 infection. Copyright © the Author(s), 2022.

2.
Pharmaceutical Journal ; 308(7958), 2022.
Article in English | EMBASE | ID: covidwho-2065022
3.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P113, 2022.
Article in English | EMBASE | ID: covidwho-2064496

ABSTRACT

Introduction: The SARS-CoV-2 pandemic killed over 6 million people worldwide. Children were described to have predominantly mild or asymptomatic infections and to be less exposed to the virus, at least for the initial variants. In the present study, we describe how SARS-CoV-2 can silently infect tonsils and adenoids in children undergoing adenotonsillectomy. Method(s): In this cross-sectional study we assessed children who underwent adenotonsillectomy between October 2020 and September 2021 in a secondary hospital in Brazil. All the caregivers denied any symptom of acute viral upper airway infection in the month prior to surgery. Briefly, nasal cytobrush (NC), nasal wash (NW) and tonsillar tissue fragments posttonsillectomy were tested by RT-PCR, immunohistochemistry (IHC), in situ immunofluorescence (IF), and flow cytometry. Result(s): A total of 48 children (18 females, median age 5.5 years) were enrolled. None of them had been vaccinated against COVID-19 at the time of surgery. Only 2 had a history of previous COVID-19 diagnosis, 3 and 5 months, respectively, before surgery. SARS-CoV-2 RNA was detected in 25% (12) of patients-20% in palatine tonsils, 16.27% in the adenoids, 10.41% in NC, and 6.25% in NW. IHC labeling showed viral nucleoprotein presence in both adenoids and palatine tonsils, in epithelial surface and lymphoid cells from extrafollicular and follicular regions. In 5 out of 7 patients, in situ IF showed the expression of ACE2 and TMPRSS2 and viral spike protein in the tonsillar tissue. Flow cytometry revealed that SARS-CoV-2 is predominantly observed in CD123+ dendritic cells (10.57% of all tested sites), followed by CD14+ monocytes (6.32%). Conclusion(s): According to these results, the prevalence of SARS-CoV-2 infection seems to be higher than expected and underdiagnosed in children at this age group. Palatine tonsils and adenoids are important sites of infection and may be a reservoir for the virus. Nevertheless, it is still unclear the impact of these results on virus transmission.

4.
American Journal of Transplantation ; 22(Supplement 3):660, 2022.
Article in English | EMBASE | ID: covidwho-2063476

ABSTRACT

Purpose: Kidney transplantation (KT) from coronavirus disease 2019 (COVID-19) positive donors has been avoided due to concerns for donor-derived transmission and possibility of the kidney being a viral reservoir. There is no long-term safety data, and sensitive molecular testing for SARS-CoV-2 in donor kidney is not routinely performed. We report a case of successful KT from a deceased donor who died from severe COVID-19 respiratory illness whose donor kidney and aorta were probed for virus using in situ hybridization (ISH) and quantitative reverse transcriptionpolymerase chain reaction (qRT-PCR). Method(s): A 30-year-old female was admitted to the hospital with severe COVID-19 pneumonia with a positive RT-PCR test for SARS-CoV-2 on nasopharyngeal swab. With clinical worsening, she was placed on extracorporeal membrane oxygenation, but developed hypoxic brain injury and progressed to brain death. Renal function was stable during her hospital course with serum creatinine concentration of 0.7 mg/dL. SARS-CoV-2 RT-PCR on bronchoalveolar lavage and nasopharyngeal samples tested again three days prior to donation was negative. A 55-year-old male recipient with an end-stage renal disease secondary to hypertension was transplanted with the left kidney from the above donor. The donor kidney was studied using pre-implantation surgical biopsy tissues to investigate the presence of SARS-CoV-2 RNA. Aorta tissue with the kidney was also studied given high expression of angiotensin-converting enzyme 2 receptors in vasculature. Result(s): ISH analyses did not show any positive signal for SARS-CoV-2 RNA in the donor kidney sample compared to a SARS-CoV-2 positive lung control. All samples tested by qRT-PCR were also negative for SARS-CoV-2. We found no evidence of SARS-CoV-2 mRNA in the donor kidney and aorta. The recipient has been free of COVID-19 related signs or symptoms and tested negative for SARSCoV- 2 by nasopharyngeal swab RT-PCR on days 20, 30, and 90 following KT. After an initial period of delayed graft function requiring hemodialysis, the recipient now has excellent renal recovery over 6 months following the transplant, and the most recent creatinine is 1.3 mg/dL. Conclusion(s): Taken together with recent observations of successful KT outcomes from mild or asymptomatic COVID-19 donors, we believe that the transmission risk of SARS-CoV-2 through KT is likely to be very low. Use of deceased donors who died after severe COVID-19 can be considered for KT. Larger scale studies are needed to confirm our findings.

5.
American Journal of Transplantation ; 22(Supplement 3):702, 2022.
Article in English | EMBASE | ID: covidwho-2063424

ABSTRACT

Purpose: In contrast to high morbidity and mortality of COVID-19 infection (COVIDi) in adult kidney transplant (KT) recipients, these sequelae appear to be muted in the pediatric KT population. Long-term effects of COVIDi in pediatric KT recipients (pKTR), specifically those with absent or mild symptoms, have not been characterized. Thus, we aimed to investigate the impact of subclinical COVIDi on allograft outcomes, specifically allosensitization, and viremias in pKTR. Method(s): This retrospective 1:1 case-control study investigated COVIDi in pKTR transplanted between January 2016 to November 2021 at our center. Each pKTR with COVIDi, was matched with a control patient (by time of KT). Using laboratory values between March 1, 2020 and December 1, 2021, data was collected following COVIDi to baseline include donor specific antibodies (DSA), panel reactive antibodies (PRA), allograft rejection, and development or intensification of viremias. Descriptive statistics were utilized as well as two-sample t-tests, chi square, and logistic regression for tests of significance. Result(s): 22 patients in our cohort of 135 pKTR experienced subclinical COVIDi. 4 patients (18%) had an increase in BK viremia after COVIDi. Of these cases, 75% resulted in a >100-fold increase in BK viral load, compared to controls experiencing no more than a 5-fold increase. Following COVIDi, the proportion of pKTR with PRA>0 significantly increased compared to controls (p=0.03). Additionally, 2 patients with COVIDi developed de novo DSA versus none in the controls (p=0.078). Conclusion(s): Fortunately, acute morbidity and mortality associated with COVIDi in pKTR is muted compared to adults. However, COVIDi has long-term consequences for the pKTR with marked BK viremia and sensitization, potentially compromising allograft function. Pronounced BK viremia combined with increased risk for sensitization requires delicate adjustments of immunosuppression and anti-viral therapies to optimize patient and graft outcomes. The importance of avoiding these complications of COVIDi could lend additional support to vaccination before and after transplant in the pKTR population. (Table Presented).

6.
Cardiology in the Young ; 32(Supplement 2):S40-S41, 2022.
Article in English | EMBASE | ID: covidwho-2062094

ABSTRACT

Background and Aim: With the progressive spread of the coronavi-rus among the youngest and the need for a safe resumption of physical activity, several protocols have been proposed for healed athletes. The aim of the present study is to evaluate the presence of cardio-respiratory complications in the pediatric population after mild or asymptomatic SARS-CoV-2 infection. Method(s): From January 2021 the protocols of the Italian Sports Medical Federation were applied to all the children and adoles-cents who came to our observation for return-to-play after covid infection. The protocols take into account the severity of the infection. In case of mild or asymptomatic infection echocardiogram, electrocardiogram, treadmill ECG test and pul-monary function tests were performed. Result(s): From January 2021 to November 2021, 169 children and adolescents (mean age 14+3 ys;male = 92) with previous SARS-CoV-2 infection were evaluated according to the protocols in force after an average time of 48 + 13 days from SARS-CoV-2 swab negativity. 60,3% of the subjects (N = 102) reported an asymptomatic infection;39,7 % reported a mild symptomatic infection. Results of lung function test have exceeded the limit of 80% of the theoretical value in all patients. No subject presented evidence of cardiovascular function impairment. Conclusion(s): The data obtained showed that, in the pediatric pop-ulation, mild coronavirus infection does not cause cardiorespira-tory complications in the short and medium term. This reinforce the evidence from preliminary studies that return to play after Coronavirus infection seems to be safe and must be strongly recommended. It will therefore be possible to assess the possibility of lightening or even suspending these evaluations in the cases of mild coronavirus infection in the pediatric age groups.

7.
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

8.
Chest ; 162(4):A2245, 2022.
Article in English | EMBASE | ID: covidwho-2060918

ABSTRACT

SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rapidly progressive interstitial lung disease (RP-ILD) is a rare and potentially fatal manifestation of dermatomyositis (DM) and has considerable impact in terms of the prognosis. CASE PRESENTATION: A 52-year-old male demonstrated DM-typical rash, fever, mialgias, and mild muscle weakness 3 months after asymptomatic COVID-19 infection. Two weeks later dysphonia and progressive dyspnea appeared. Lung CT scan showed the picture of organizing pneumonia. His COVID-19 PCR test was negative multiple times. Laboratory tests revealed the following numbers: ALT 210 IU/L, AST 748 IU/L, LDH 613 IU/L, CPK 1165 IU/L, ferritin 1145ϻg/l, CRB 11 mg/l. The patient was tested positive for anti-Ro52 antibodies, while anti-synthetase and scleroderma-associated antibodies were not discovered. Anti-melanoma differentiation-associated gene 5 (MDA5) test was not available due to the lack of the necessary test systems in the country. The patient was diagnosed with DM. Combined immunosuppressive therapy was administered, including: oral prednisolone 60 mg per day and 720 mg intravenously, dexamethasone 64-24 mg intravenously per diem, ciclosporin 200 mg и cyclophosphamide 600 mg, and 3 plasmapheresis sessions followed by an intravenous immunoglobulin. As a result of the therapy, muscle weakness disappeared and CPK levels returned to normal limits, however dyspnea progressed and ferritin levels hit 3500ϻg/l. After the following 3 weeks of intensive combined immunosuppressive therapy, the patient demonstrated symptoms of severe respiratory failure (RF). CT scan showed multiple traction bronchiectasis, wide areas of ground glass opacity, pneumomediastinum and subcutaneous emphysema of a neck and supraclavicular regions. Ciclosporin was replaced with tofacitinib with the dose of 10 mg per diem, IL-6 inhibitor (olokizumab 256 mg) was injected intravenously, massive broad-spectrum antibiotic therapy was administered. RF progressed and the patient was put on mechanical ventilation. The patient died of acute RF and sepsis a week later. DISCUSSION: RP-ILD is a common manifestation of severe MDA5+ DM, which is also associated with necrotizing vasculitis and amyopathic/hypomyopathic muscle involvement. In this case acute ILD in a patient with typical DM could also have been provoked by previous COVID-19 infection. CONCLUSIONS: The courses of disease for COVID-19 and MDA5+ DM have several similarities, which means it can be the same for their pathogenesis and clinical manifestations. In spite of early screening and intensive immunosuppressive therapy in such cases, the prognosis of patients with DM and RP-ILD is still poor and is associated with high mortality. Reference #1: Wang G, Wang Q, Wang Y, et al. Presence of Anti-MDA5 Antibody and Its Value for the Clinical Assessment in Patients With COVID-19: A Retrospective Cohort Study. Front Immunol. 2021 Dec 20;12:791348. doi: 10.3389/fimmu.2021.791348. PMID: 34987516;PMCID: PMC8720853. DISCLOSURES: No relevant relationships by Lidia Ananyeva No relevant relationships by Maria Aristova No relevant relationships by Liudmila Garzanova No relevant relationships by Anna Khelkovskaya-Sergeeva No relevant relationships by Dmitry Kulikovsky

9.
Chest ; 162(4):A2032, 2022.
Article in English | EMBASE | ID: covidwho-2060888

ABSTRACT

SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Two years into the COVID-19 pandemic, knowledge about how infection affects children is still lacking. Unlike adults, prior to the recent surge widespread symptomatic childhood illness has not been seen, likely due to school shutdowns, strict social distancing, and less severe illness course. During the omicron surge in NYC, an increase in pediatric cases was noted likely due to reinstatement of in-person learning and relaxing of social distancing. Though vaccines were available, only 9% of children aged 5-11 years and 35% of adolescents aged 12-17 years were vaccinated. During omicron surge, a large proportion of adult patients positive for COVID-19 were asymptomatic. We aimed to explore incidence of ED visits, hospital admissions, vaccine status and presenting complaints in pediatric population who tested positive for COVID-19 during the omicron surge in NYC. METHODS: A retrospective chart review was conducted of patients <18 years who tested positive for COVID-19 at two multiethnic community hospitals during the Omicron wave (Nov 1, 2021-Feb 28, 2022). Demographics, vaccine status, reason for visit, diagnosis and disposition were extracted from EHR. Data were analyzed according to age group: 0 to <5 years (G1), 5 to <12 years (G2) and 12 to <18 years (G3). RESULTS: During this time, close to 2800 patients tested positive for COVID-19 at presentation to the ED or during hospitalization. Of these, 343 were <18 years of age (~10%). Overall, 53% of these pediatric patients were male. Ethnic make-up mirrored that of our community (approx. 60% Hispanic, 20% Asian, 10% Black). Admission status included 27 (7.8%) admitted to our hospitals, 18 (5.2%) transferred to other hospitals from our ED, and 298 (87%) treated and released from the ED. By age group, 183 (59%) were in G1, 76 (24%) in G2 and 51 (17%) in G3. Patients in G1 were <5 years and therefore ineligible for vaccine. Only 5% of G2 and 33% of G3 were fully vaccinated. In all groups, majority of patients presented for symptoms of viral infection (G1>80%, G2>90%, G3>90%). Symptoms of upper respiratory infection were most frequent in all groups (>80%). Convulsions (4.3%, 1.3%), croup (8.2%, 2.6%) and otitis media (3.3%, 1.3%) were noted in G1 and G2, respectively. In G3, acute appendicitis, diabetic ketoacidosis, and otitis media were present on admission in 2% each. Majority of patients requiring admission were from G1 (74%). CONCLUSIONS: Though adults during the recent surge often presented with asymptomatic COVID-19, pediatric patients in our sample typically presented for viral illness. It is difficult to interpret vaccine data except to say that there was a small group of pediatric patients who were symptomatic despite vaccination. CLINICAL IMPLICATIONS: We present early descriptive data from the Omicron surge in NYC in a pediatric sample. DISCLOSURES: No relevant relationships by Won Baik-Han No relevant relationships by Tamana Bismillah No relevant relationships by Kelly Cervellione no disclosure on file for Gagan Gulati;No relevant relationships by LOCHANA KC No relevant relationships by Lily Lew

10.
Chest ; 162(4):A895, 2022.
Article in English | EMBASE | ID: covidwho-2060719

ABSTRACT

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: SARS-CoV-2 related autoimmune and thrombotic complications due to vigorous immune system stimulation and induction of hypercoagulable state are not uncommon. Two hypotheses have been proposed for thrombotic microangiopathy associated with low ADAMTS13 levels in patients with COVID-19 disease. First underscores a significant increase in von Willebrand factor (vWF), likely due to endothelial activation, that overwhelms ADAMTS13. It is observed in the absence of thrombocytopenia or ADAMTS13 inhibitor. The second highlights the formation of autoantibodies against ADAMTS13 because of an immunological trigger (SARS-CoV-2), resulting in the diagnosis of TTP. CASE PRESENTATION: This is a case of a 72-year-old Caucasian man with a history of hypertension, diabetes, chronic obstructive lung disease, and asymptomatic SARS-CoV-2 infection three weeks ago who was transferred to our institution to initiate plasmapheresis for suspected TTP due to new-onset confusion, anemia and worsening renal function. Patient had presented with confusion a day before transfer. Vital signs were remarkable for tachycardia (heart rate of 105 beats/min). Labs were significant for anemia (hemoglobin:6.7 g/dL), thrombocytopenia (platelet count:13 K/µL), acute kidney injury (creatinine:1.8 mg/dL), elevated lactate dehydrogenase (1983 IU/L), high bilirubin (2.3 mg/dL), low haptoglobin (<4 mg/dL), and demonstration of schistocytes on peripheral smear. The coagulation profile was normal. On arrival, he required emergent intubation due to multiple seizures. Computed tomography scan of the head was normal. SARS-CoV-2 molecular testing was negative. Given a PLASMIC score of six, urgent plasmapheresis and high-dose methylprednisolone were started. Screening for human immunodeficiency virus, hepatitis viruses, Epstein-Barr virus, and Cytomegalovirus were negative. Subsequently, his ADAMTS13 activity resulted as being ≤5% with an elevated inhibitor Bethesda titer of 0.9 (normal < 0.4). The patient completed six sessions of plasmapheresis. He was discharged on steroid taper and weekly rituximab. DISCUSSION: COVID-19 associated de-novo TTP has been mostly reported with typical COVID-19 symptoms within a few days of a positive test. One report described presentation with only neurological symptoms 19 days after a positive test with low autoantibody titers, favoring the hypothesis of consumption of ADAMTS13. To the best of our knowledge, this is the first case of new, late-onset immune TTP developing three weeks after asymptomatic COVID-19 infection with a robust positive inhibitor screen and infinitesimal ADATMS13 levels. The temporal sequence of events and lack of other plausible causes aided in the diagnosis of COVID-19 induced TTP. CONCLUSIONS: Our report aims to make clinicians aware of ruling out TTP as a cause of thrombocytopenia and/or altered mental status in patients with past COVID-19 infection, aiding in early management. Reference #1: 1. Mancini I, Baronciani L, Artoni A, Colpani P, Biganzoli M, Cozzi G, Novembrino C, Boscolo Anzoletti M, De Zan V, Pagliari MT, Gualtierotti R, Aliberti S, Panigada M, Grasselli G, Blasi F, Peyvandi F. The ADAMTS13-von Willebrand factor axis in COVID-19 patients. J Thromb Haemost. 2021 Feb;19(2):513-521. doi: 10.1111/jth.15191. Epub 2020 Dec 18. PMID: 33230904;PMCID: PMC7753796. Reference #2: 2. Tehrani HA, Darnahal M, Vaezi M, Haghighi S. COVID-19 associated thrombotic thrombocytopenic purpura (TTP);A case series and mini-review. Int Immunopharmacol. 2021;93:107397. doi:10.1016/j.intimp.2021.107397 Reference #3: 3. Beaulieu, M.-C., Mettelus, D.S., Rioux-Massé, B. and Mahone, M. (2021), Thrombotic thrombocytopenic purpura as the initial presentation of COVID-19. J. Thromb. Haemost., 19: 1132-1134. https://doi-org.libproxy.uams.edu/10.1111/jth.15231 DISCLOSURES: No relevant relationships by Harmeen Goraya No relevant relationships by PRACHI SALUJA

11.
Chest ; 162(4):A627, 2022.
Article in English | EMBASE | ID: covidwho-2060651

ABSTRACT

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Evans syndrome (ES) is a rare autoimmune disorder characterized by the combination of two or more cytopenias with an incidence of 0.8-3.7%.Here we present a case of COVID-19 pneumonia complicated by the development of ES. CASE PRESENTATION: A 75-year-old female with the past medical history of 50 pack-year smoking, recent asymptomatic COVID-19 Pneumonia 2 week ago came to the emergency room (ER) with shortness of breath. Her vitals and physical exam were unremarkable. Labs were significant for leukocytosis of 11.66 and D-dimer of 3.32. CT pulmonary angiogram showed bilateral pulmonary embolism along with a COVID-19 pattern of pneumonia. She was started on heparin drip and was eventually discharged on Warfarin with Prednisone taper. After 3 weeks, she presented to the ER with worsening shortness of breath. She was found to have platelet count of 4k and Hb of 6.6 gm%(compared to 370k and 13.1 gm% on last discharge) and was started on transfusions which could not be completed due to development of mid-transfusion fever. She received Dexamethasone and IVIG. All forms of active bleeding were ruled out by bronchoscopy, CT scans and EGD. Flow cytometry was negative for ADAMTS13 ruling out thrombotic thrombocytopenic purpura. Bone marrow biopsy was unremarkable. She was positive for IgG warm agglutinin hemolytic anemia. She was discharged on long-term Prednisone taper. In the clinic she was given intermittent IVIG and Romiplostim to improve her counts. Due to multiple failed attempts to wean her off steroids, she was started on Rituximab with an excellent response of platelets increment to 450k and Hb to 8.5 gm%. Rituximab will be given for a total of 8 weeks. DISCUSSION: ES is considered to be caused by immune system dysregulation. ES in COVID-19 is a diagnostic dilemma as the thrombocytopenia is usually misdiagnosed as COVID-19 sequelae and leads to delay in diagnosis. The treatment of ES is usually with steroids 1 mg/kg/day but they only provide short term improvement. Rituximab, plasma exchange, IVIG, and splenectomy are second-line treatments for relapsing/refractory ES. Our patient had an acceptable response to steroids but it was transient,demonstrating the limited role of steroids in the long term and was eventually treated successfully with Rituximab. A review of limited published cases of ES caused by COVID-19 suggests that diagnosis, treatments, and prognosis are usually individualized according to patient characteristics, presenting symptoms, physician preference, and disease complications. CONCLUSIONS: ES is a very rare syndrome although it requires prompt treatment. It is important to be mindful about immunological causes when a COVID-19 patient presents with cytopenia, as delay in treatment can cause poor outcomes. Reference #1: Turgutkaya A, Bolaman AZ, Yavaşoğlu Í. COVID-19-associated Evans syndrome: A case report and review of the literature. Transfus Apher Sci. 2021 Dec 7:103339. doi: 10.1016/j.transci.2021.103339. Epub ahead of print. PMID: 34896007;PMCID: PMC8655821. DISCLOSURES: No relevant relationships by Nitesh Jain No relevant relationships by Kashyap Kela No relevant relationships by Princy Shah No relevant relationships by namita sharma No relevant relationships by AMIT SHARMA

12.
Chest ; 162(4):A616-A617, 2022.
Article in English | EMBASE | ID: covidwho-2060648

ABSTRACT

SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman

13.
Chest ; 162(4):A121-A122, 2022.
Article in English | EMBASE | ID: covidwho-2060540

ABSTRACT

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multisystem inflammatory syndrome in adults (MIS-A) is a hyperinflammatory condition characterized by fever, elevated inflammatory markers, and multi-organ dysfunction, including severe cardiac illness, neurological and gastrointestinal symptoms, mucocutaneous involvement, and thrombocytopenia usually 2-5 weeks after COVID-19 infection (1). There are currently no guidelines for the management of this novel syndrome. CASE PRESENTATION: A 20-year-old obese male presented for 3 days of fatigue, fever, dyspnea, diarrhea, and worsening encephalopathy. He tested positive for COVID-19 3 weeks prior and experienced 4 days of mild symptoms. He had received 2 doses of Moderna mRNA vaccine 9 months prior. On presentation, he had a GCS of 3. He was febrile, hypotensive, tachycardic, not hypoxic, and found to have non-purulent conjunctivitis but no rash. He was intubated for airway protection and started on norepinephrine (NE) shortly after arrival. Labs revealed positive COVID-19 PCR, lactate of 5.6 mmol/L, elevated hs-troponin which peaked at 11,300 ng/L, D-Dimer 12,574 ng/ml, ferritin >16,500 ng/ml, CRP 224 mg/L, platelet count 18 x109/L. EKG showed sinus tachycardia without ST changes. CT chest/abdomen/pelvis was unremarkable. The patient was given broad-spectrum antibiotics and admitted to ICU. An echocardiogram (echo) showed global hypokinesis with an ejection fraction of 10-15%. Right heart catheterization found a wedge pressure of 23 mmHg, and a cardiac index of 1.4 L/min/m2. NE was weaned, and dobutamine and bumetanide drips were started. Infectious disease was consulted and diagnosed the patient with MIS-A. Treatment was started with methylprednisolone 2mg/kg/day and IVIG (2 g/kg x2 days). 48 hours later, dobutamine was able to be discontinued and follow-up echo showed normalization of biventricular systolic function. Steroids were continued for 7 days before tapering off. The patient’s presenting symptoms, platelets, and inflammatory markers rapidly improved, and he was ultimately able to be discharged home. DISCUSSION: MIS-A is a rare but serious extrapulmonary sequela of COVID-19 which can cause critical illness including cardiogenic shock. The long-term consequences of MIS-A are not known, but fortunately, as demonstrated by our case, severe cardiac dysfunction can be effectively reversed with timely diagnosis and initiation of immunosuppressive treatment. This recovery was achieved without immunomodulators (eg tocilizumab) which have been used in other MIS-A cases (2). MIS-A should be considered in patients with severe cardiac dysfunction and evidence of systemic inflammation even with no known history of COVID as this can develop after mild or even asymptomatic COVID-19 infections. CONCLUSIONS: Immunosuppressive therapies can rapidly reverse severe multiorgan dysfunction in MIS-A. Still, further study is needed to identify at-risk patients and create definitive treatment guidelines. Reference #1: Vogel TP, Top KA, Karatzios C, et al. Multisystem inflammatory syndrome in children and adults (MIS-C/A): Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2021;39(22):3037-3049. doi:10.1016/j.vaccine.2021.01.054 Reference #2: Patel P, DeCuir J, Abrams J, Campbell AP, Godfred-Cato S, Belay ED. Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults: A Systematic Review. JAMA Netw Open. 2021;4(9):e2126456. doi:10.1001/jamanetworkopen.2021.26456 DISCLOSURES: No relevant relationships by Christopher Allison no disclosure on file for Sandeep Arepally;No relevant relationships by Amad Chohan No relevant relationships by Albert Manudhane No relevant relationships by Griffin Reed

14.
Chest ; 162(4):A19-A20, 2022.
Article in English | EMBASE | ID: covidwho-2060533

ABSTRACT

SESSION TITLE: Autoimmune Disorders: Both Primary and Secondary SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: SARS-CoV-2 has demonstrated an impact on the lungs, leads to hypercoagulable states, and has caused immune-mediated reactions. Myasthenia Gravis (MG) represents a neuromuscular junction autoimmune disorder, with only a few case reports associated with new-onset MG following COVID-19 vaccination. Very rarely, MG has been reported in coexistence with Primary Sjogren's Syndrome (PSS). Here we present a case of new-onset MG in a patient with a positive COVID-19 a nasopharyngeal RT-PCR swab test, who received 3 doses of the Moderna COVID-19 vaccine with the latest dose 2 weeks prior to presentation and demonstrated positive PSS antibodies (Abs). CASE PRESENTATION: A 67-year-old male with no known past medical history presented with complaints of progressive weakness for 2 weeks, which began as diffuse malaise, and progressed to upper and lower extremity weakness with associated neck weakness, and dysphagia. Physical exam was remarkable for bilateral ptosis and difficulty ambulating. The patient was admitted to the ICU for suspected new-onset neuromuscular junction disorder and for close monitoring of his respiratory function. COVID-19 PCR was positive. MG and autoimmune disease workup was sent along with COVID-19 antibody testing. Chest X-Ray, CT head, and CT thorax were unremarkable. The patient was started on Pyridostigmine and IVIG, with low dose prednisone initiated on day 3 of admission. On the fifth day, symptoms improved significantly. Antibodies (Ab) against Acetylcholine (Ach) receptors were elevated and the diagnosis of MG was made. PSS Abs were also detected. Lyme, HIV, RPR, thyroid, and B12 levels were within the normal range which may mimic NMJ dysfunction. DISCUSSION: MG represents an autoimmune disorder due to autoantibodies against nicotinic AChR at the neuromuscular junction;however, these Abs can also target non-AChR muscle-specific receptor tyrosine kinase (MUSK). The exact mechanism of the autoimmune response with MG is not fully understood;however, there have been associations found with thymus gland hyperplasia and neoplasm when anti-AChR Abs are involved. Genetic predisposition is also likely to play a role. Viral and bacterial infections are established triggers for a myasthenic crisis in patients with pre-existing MG;however, there is yet to be a clear consensus regarding infections causing MG in otherwise healthy patients. As our pt did receive the COVID-19 vaccine, we have to consider an autoimmune reaction secondary to his administration. CONCLUSIONS: COVID-19 vaccines have demonstrated autoimmune responses such as myocarditis and myasthenic crisis in individuals. There have also been documented cases of MG in symptomatic COVID-19 infections. Given these findings, this patient may have experienced an environmental insult on top of a genetic predisposition and may warrant further investigation in patients with similar presentations. Reference #1: Sriwastava S, Tandon M, Kataria S, Daimee M, Sultan S. New onset of ocular myasthenia gravis in a patient with COVID-19: a novel case report and literature review. J Neurol. 2021 Aug;268(8):2690-2696. doi: 10.1007/s00415-020-10263-1. Epub 2020 Oct 12. PMID: 33047223;PMCID: PMC7549728. Reference #2: Chavez A, Pougnier C. A Case of COVID-19 Vaccine Associated New Diagnosis Myasthenia Gravis. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211051933. doi: 10.1177/21501327211051933. PMID: 34709075;PMCID: PMC8559213. Reference #3: Witberg G, Barda N, Hoss S, Richter I, Wiessman M, Aviv Y, Grinberg T, Auster O, Dagan N, Balicer RD, Kornowski R. Myocarditis after Covid-19 Vaccination in a Large Health Care Organization. N Engl J Med. 2021 Dec 2;385(23):2132-2139. doi: 10.1056/NEJMoa2110737. Epub 2021 Oct 6. PMID: 34614329;PMCID: PMC8531986. DISCLOSURES: No relevant relationships by Brooke Kania No relevant relationships by Anas Mahmoud No relevant relationships by Ahmed Salem No relevant elationships by Jessimar Sanchez No relevant relationships by Shivanck Upadhyay No relevant relationships by Deniz Yucel

15.
Swiss Medical Weekly ; 152(Supplement 261):24S, 2022.
Article in English | EMBASE | ID: covidwho-2057851

ABSTRACT

We present the case of a 63 years old male patient known for type 2 diabetes and sleep apnoea. He was admitted as inpatient for a nontraumatic severe and disabling left hip pain. The pain started progressively one month ago. The medical history was otherwise irrelevant, with no general symptoms nor other symptoms suggestive of an inflammatory disease. To mention a history of an asymptomatic SARS-COV2 infection, diagnosed by a naso-pharyngial PCR, approximately 10 days before the onset of the pain. On physical examination, the patient was afebrile. The palpation of the inguinal region was tender on palpation with marked limitation of the hip range of motion. The spine and other peripheral joints were painless without inflammatory sign. Moreover, there was no skin lesion nor inguinal lymph nods enlargement. Due to the importance of pain with marked functional limitation, the patient is hospitalized for investigations and pain-management. On blood sample there was a mild increase of inflammatory markers (CRP 25mg/l, VS 20mm/h) with normal cell count. Standard X-rays of the pelvis and hip were normal. The MRI of the hip showed a mild coxo-femoral arthritis with marked inflammation of the surrounding musculature. An arthrocentesis was performed and 2ml of serous fluid was aspirated. There were no crystals. The cellularity could not be tested due to small amounts of fluid. The synovial culture showed a polymicrobious growth compatible with contamination. In summary, we were facing a patient with an acute and very painful hip monoarthritis. There was no history of gastrointestinal or urinary tract infection, the search for C. trachomatis and N. gonorrhoea in urines was negative. An extensive serologic testing (HIV, HBV, HCV, HBV, HCV, HIV, Lyme, Syphilis, Coxiella, Bartonella, Brucella & Quantiferon) and the search for T. whipplei were negative as well. There was no HLA-B27 and rheumatoid factor, ACPA, ANA, ANCA and specific antibodies related to polymyositis were negative. The chest-abdomen-pelvis scan showed no sign of neoplasia. To rule out a vasculitis we proceeded to a PET-CT, which showed no sign of vasculitis or myositis. Considering the timing of the onset of the symptoms and the absence of any other diagnosis, the patient was diagnosed with reactive arthritis caused by SARS-COV2. The patient was treated with Diclofenac 150 mg/day and opioids. The clinical evaluation one month after discharge showed a spontaneous significant improvement.

16.
Journal of Neuromuscular Diseases ; 9:S187-S188, 2022.
Article in English | EMBASE | ID: covidwho-2043402

ABSTRACT

Specific clinical, electrophysiological and serological features are used to recognise a phenotype fitting the atypical chronic inflammatory demyelinating (CIDP) variant spectrum. We report a 28-year-old male patient, without any significant history apart from a recent asymptomatic COVID-19 infection, presenting at first with bilateral facial nerve palsy, subsequently -three months later- developing an subacute onset symmetric sensory ataxia and arefl exia, and thirdly experiencing diffuse rapidly progressive motor deficits. Additional investigations suggested an autoimmune polyneuropathy: Liquor analysis showed cytoalbuminologic dissociation. Cerebrospinal fluid protein elevation was remarkable: 631 mg/dL. Nerve conduction studies showed prominent distal latencies prolongation and dispersion of the potentials, meeting the electrodiagnostic criteria of the European Federation of Neurological Societies/Peripheral Nerve Society for CIDP (2021). Full spine magnetic resonance imaging depicted pathological thickening and enhancement of the roots of the cauda equina as seen in radiculitis. There was no or poor response to conventional treatment, i.e. immunoglobulins (IVIG), corticosteroids and even plasmapheresis. Muscle weakness deteriorated. Presence of serum IgG4 anti- contactin-1 (CNTN1) antibodies was found by ELISA identifi- cation and titration, and the patient improved substantially after rituximab treatment. While contributing to the expanding confidence in nodal and paranodal antibodies as valuable biomarkers in clinical practice, our case entails several peculiarities: 1/ SARS-CoV2 positivity as a possible trigger of this auto-immune polyneuropathy 2/ A considerably younger age of onset than in the patients already described (range 33-76 years). 3/ The clinical course progressed in an atypical manner even for atypical CIDP: Initial presentation with bilateral asymmetric facial palsy, followed by sensory ataxia, which prompted the initial diagnosis of Miller-Fisher syndrome, and later development of severe motor impairment. 4/ Proteinorachy was so pronounced that we considered neuroborreliosis as a potential associated disorder. Borrelia seroconversion occurred after the first IVIG-treatment, and could be false positive. However, the patient was treated with intravenous ceftriaxone, which had no effect on the clinic. 5/ Antibodies against CNTN1 were undetectable after 2 months of rituximab. Emphasising the both diagnostic and therapeutic importance of recognising a phenotype compatible with atypical CIDP, an underrecognized and consequently undertreated disease where early diagnosis and prevention of axonal damage is crucial in.

17.
Pharmaceutical Journal ; 308(7959), 2022.
Article in English | EMBASE | ID: covidwho-2043176
18.
Annals of Oncology ; 33:S958, 2022.
Article in English | EMBASE | ID: covidwho-2041540

ABSTRACT

Background: Surufatinib (a small-molecule inhibitor of VEGFR1-3, FGFR1, and CSF-1R) has exhibited encouraging antitumor activity for the treatment of advanced neuroendocrine tumors (including NEN and NEC) in multiple registration studies. Here, we report the preliminary results of advanced neuroendocrine tumors of an ongoing, multicenter, real-world study of surufatinib + MDT (ChiCTR2100049999). Challenges in tumor clinical trials management in the face of the COVID-19 resurgence period in Shanghai. Methods: In this multicenter, single-arm real-world study, adults (18-80) with advanced neuroendocrine tumors (including NEN and NEC) were eligible and received surufatinib (300mg orally, QD) with MDT(multidisciplinary collaborative diagnosis and treatment). The primary endpoint was progression-free survival (PFS) per RECIST 1.1. We minimized the interruptions caused by the pandemic using telemedicine platforms for all patients. This included online consultations, follow-up drug distributions, and health management services. Results: Twenty-three pts were enrolled, with 20 NEN and 3 NEC. At the data cutoff date (April 10, 2022), 15 pts had at least one post-baseline tumor assessment;of them, the confirmed ORR (95%CI) was 20% (4.3-48.1), and DCR (95%CI) was 93.33% (68.1-99.8). Median PFS (mPFS) (95%CI): 10.640 mo (3.796-17.484);median OS: not reached and median duration of follow up was 6.870 mo (6.797-6.943). A pNET patient (NO. 010007) was interrupted by asymptomatic COVID-19 infection 9 mo after enrollment. There are no interruptions caused by COVID-19 for other patients. An NEC patient treated with single agent had a 5.85 mo PFS, evaluated as NE, in whom target lesion resected after baseline. In overall pts (n=23), most commonly (≥3 pts) with hemorrhage, anemia, hypertension, proteinuria, and abdominal pain. Three pts had TRAEs that led to treatment discontinuation. Conclusions: Surufatinib + MDT exhibited promising efficacy and manageable toxicity in pts with advanced neuroendocrine tumors. Now and in the future, it is necessary to design regulatory changes in telehealth adoption for clinical trial design in the pandemic era. Clinical trial identification: ChiCTR2100049999. Legal entity responsible for the study: The authors. Funding: Hutchison MediPharma Limited. Disclosure: All authors have declared no conflicts of interest.

19.
Transplantation ; 106(8):85-86, 2022.
Article in English | EMBASE | ID: covidwho-2040801

ABSTRACT

Background: Traditionally, patients were kept intubated for 48 hours in the postoperative period. Living donor liver transplantation poses a different set of challenges. Most of the predictors mentioned in the literature were, low MELD, low BMI, and with stable comorbidities etc. for early extubation following living donor liver transplantation. We assessed the feasibility of fast tracking and early extubation in our patients, who were not fitting in those mentioned predictors in the literature. Methods: We present a case series of 6 patients who were fast tracked and extubated early, following living donor liver transplantation, out of 22 patients over the last 6 months. Results: All these patients were aged more than 45 yrs, with an average age of 55.8 yrs, average MELD score of 20.8, Child status C, some of our patients had cardio pulmonary comorbidities. patient 2, was COPD, post asymptomatic COVID, with CoRad score3 on HRCT, patient 5, was class 3 obese with no OSA, patient 6, had Hypertension, CAD- triple vessel disease, post CABG 7 yrs back, The intraoperative metabolic parameters like base excess and Lactates were showing good correction and all of them had very minimal inotropic support at the time of extubation, with Norepinephrine < 0.05mcg/kg/minutes. There was no post reperfusion hemodynamic instability or PRS in our patients, the average GRWR in our patients was 0.94, the mean anhepatic period, warm ischemia and cold ischemia times were pretty low. None of them had any significant postoperative complications. Conclusions: We propose, we can safely fast track and extubate early, following living donor liver transplantation with high MELD scores, and stable comorbidities. Further, large studies are needed to look for the feasibility of expanding the criteria for early extubation.

20.
Journal of the American Academy of Dermatology ; 87(3):AB135, 2022.
Article in English | EMBASE | ID: covidwho-2031389

ABSTRACT

Introduction: PURE is an international registry of adult patients with moderate-to-severe psoriasis treated with secukinumab (Cohort 1) vs other approved therapies (Cohort 2). The SARS-CoV-2 (COVID-19) pandemic necessitated adaptations in the collection of data enabling continued, successful monitoring of patients in the registry. This presents an overview of these changes and their impact on the PURE registry. Materials and methods: This ongoing registry enrolled 2362 adult patients with moderate to severe psoriasis (1:1 ratio;secukinumab: other treatments) from 81 community and hospital sites. As a noninterventional study, PURE registry allowed for flexibility in the visit schedule and type of visit (remote visits vs face-to-face) per routine practice. This enabled monitoring of patient outcomes during the pandemic at sites where appropriate resources and capabilities were available to perform virtual visits (video teleconferencing, or through phone calls with photographs). The video conference/photographs should have ensured that the investigator was able to assess the disease activity and its extent. The eCRF was modified to record the type of visit (Remote or On-site) and COVID-19 related adverse events (AE). This included diagnostic testing, symptoms, and concomitant medications. Clear definitions for suspected/confirmed and symptomatic/asymptomatic COVID-19 diagnoses, and the associated data entry instructions with clear illustrative examples were provided. COVID-19 related outcomes are being reported separately at this congress. Conclusions: Adaptations to PURE registry successfully enabled continued follow-up of psoriasis patients through the COVID-19 pandemic. The COVID-19 AE data provides us with the opportunity to explore the impact of the pandemic on patients with psoriasis treated with secukinumab.

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