COVID-19 in pregnant patients with ankylosing spondylitis

Objective: To describe the course of COVID-19 in women with AS during pregnancy and the effect of COVID-19 on AS activity. Material and Methods: 75 pregnant women with confirmed AS (modified New York criteria, 1984) were included for prospective observation. 26 of them were followed during the Covid-19 pandemic (03.2020 -04.2022). The average age of the patients was 33.0 ± 3.9 years, the duration of the disease was 117.0 ± 72 months. The activity according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in the 1st, 2nd and 3rd trimesters of pregnancy was 2.0 ± 1.4;2.0 ± 1.4 and 1.9 ± 1.5, respectively. The Ankylosing Spondylitis Disease Activity Score CRP (ASDAS-CRP) was 1.5 [1.3;2.1];1.8 [1.3;2.5] and 1.7 [1.1;2.0], respectively. The delivery period was 38.7 ± 1.6 weeks. Results: COVID-19 was transferred to 4 pregnant women, 3 of them -at the end of the 1st -beginning of the 2nd trimester, one -at 38 weeks of pregnancy. No women have been vaccinated against COVID-19. In 3 cases, the activity of AS was low, in one -high due to axial manifestations and arthritis. In 3 women, the course of COVID-19 was mild, in one -moderate (febrile temperature for more than 3 days);only 1 woman had a dry cough. One pregnant woman canceled AS therapy (certolizumab pegol, CZP), against which the back pain of the inflammatory rhythm increased. In other cases, AS therapy was not canceled, there was no effect of COVID-19 on AS activity. (Table Presented) Conclusion: According to preliminary data, COVID-19 in pregnant women with AS can be characterized by a mild and moderate course. There was no increase in AS activity during ongoing AS therapy.

Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

More Than Meets the Eye: Orbital Swelling in an Adolescent with Sickle Cell Disease

Periorbital swelling is a clinical presentation with a broad differential and potentially deleterious consequence. Causes range from benign, including allergic reaction, to vision-and life-threatening, including orbital cellulitis and orbital infarction. The recent climate of SARS-CoV-2 has further complicated this differential, as the virus poses broad clinical presentations with new manifestations reported frequently. Rapid identification of the underlying etiology is crucial, as treatment approaches diverge greatly. Here, we report the case of an African American adolescent male with a history of homozygous sickle cell anemia presenting to an inner city hospital with bilateral periorbital swelling amid the coronavirus pandemic. Differentials including orbital cellulitis, COVID-MIS-C, orbital inflammatory syndrome, Hoagland sign, and orbital infarction secondary to sickle cell crisis are contrasted. We contrast our case with 12 case reports of orbital infarction in the setting of sickle cell crisis within the past 10 years, highlighting how these presentations, along with commonly reported findings of orbital infarction, compare with our patient. Copyright © 2022 Tehran University of Medical Sciences.

Sudden death due to diffuse metastatic melanoma - a case report

Undiagnosed metastatic malignancy at autopsy is an uncommon finding in the younger age groups. Melanoma, however, is a common malignancy and early diagnosis is important for long term survival. We present a case of widely disseminated metastatic melanoma in a young Caucasian male, in his forties. He died suddenly and unexpectedly on his way to the hospital for ongoing lower back pain. The deceased had a three-month history of persistent back pain and ongoing purulent discharge from a wound on his arm. There was no history of neoplasia and the deceased had not been physically seen by a doctor due to the COVID-19 pandemic. On internal examination macroscopic tumour deposits were seen diffusely in the skin, muscle, bone, heart, lungs, and other major organs. Microscopic deposits of melanoma were seen in the brain and conduction system of the heart. We review the complications of metastatic melanoma as a cause of death and emphasise the importance of direct clinical care of patients during an ongoing pandemic. Copyright © 2022

Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

A Comprehensive Review on Rising Concern of Transmission Potential of Monkeypox Virus on Healthcare System

Over the past few years, the countries of the world have been afflicted with numerous infectious ailments. As the terror of the COVID-19 disease widespread decreases, nations throughout the world are facing the terror of the epidemic surrounding the pervasiveness of the geographical spread of human monkeypox cases worldwide. Thus, several approaches to decimate the rising spread of the monkeypox virus (MPXV) are warranted. MPXV cases received global attention during the 1970s, emanating from Africa has fully-fledged to be a universal concern with MPXV cases reported in Israel, Singapore, the United Kingdom, and the United States. Monkeypox appears as a zoonotic viral disease that is instigated via the monkeypox virus recognized as the most critical orthopoxviral infection in humans. Transmission of the monkeypox virus to human beings is alleged to occur via direct exposure to infected animals or it can probably be transmitted via consuming infected meat, or blood. The transmission from human to human takes place through the respiratory route (droplets), virus-contaminated material, and direct contact (skin-to-skin or sexual). This disease may be caused several difficulties including, headache, fever, malaise, back pain, rash, and lymphadenopathies. Presently, there is no proven therapy for its treatment, thus monkeypox virus is considered a major threat to global health security. In this review, we discussed the transmission potential of the monkeypox virus on the healthcare system, its epidemiology, mode of transmission, and different diagnostic, preventive, and treatment approaches. Copyright © 2022 Caproslaxy Media. All rights reserved.

Results of a Novel National Emergency Department Chief Complaint Database

Study Objectives: Emergency department (ED) chief complaint data has several potential applications, including quality measurement, syndromic surveillance, operations, research, and education. However, there are no consistent methods to categorize ED chief complaints or evaluate their association with other ED outcomes, which has limited the utility of this type of data. To advance chief complaint data standardization, we report the initial results of a novel national ED chief complaint dataset under development in the Veteran Health Administration (VA). We identified common presenting ED chief complaints, characterized their associations with an ED discharge diagnosis of an emergent condition, and related admission rates. Method(s): This was a retrospective observational study of VA ED visits in FYs 2018-2020. A Natural Language Processing (NLP) program based on cTAKES, an Apache open source project, was applied to the original text of VA ED chief complaints. Results were mapped to Concept Unique Identifiers (CUI) in the Unified Medical Language System (UMLS). Multiple concepts could be identified from a chief complaint text entry. ED discharge diagnoses were defined by ICD-10 codes. Emergent diagnoses were selected based on a previously established list of codes for Emergency Care Sensitive Conditions (ECSCs), which are acute illnesses that require timely, quality emergency care to improve morbidity and mortality. Result(s): A total of 5,898,684 VA ED visits were identified with at least one ED chief complaint and a discharge diagnosis. 59% of visits had 1 chief complaint concept, 26% of visits had 2 concepts, 10% had 3 concepts, 4% had 4 concepts, and 1% had 5 concepts. The 10 most common chief complaints, associated rates of an ECSC discharge diagnosis, and respective admission rates for both ECSC and non-ECSC ED visits are depicted in Table 1. Among the most common chief complaints, dyspnea had a majority of ED visits with an ECSC diagnosis, likely due to the COVID-19 pandemic. Otherwise, rates of ECSC visits varied from 24% (coughing) to 5% (back pain). However, admission rates for ECSC visits ranged from 67% (abdominal pain) to 15% (pharmaceutical preparations). Conclusion(s): To our knowledge, this national ED chief complaint dataset is the largest in the country, and representative of a diverse patient population (ie by age, region, rurality). Initial work has highlighted areas for refinement of this dataset. Further work is ongoing to examine combinations of chief complaints to better predict ECSC diagnosis and admission rate given the variation in initial findings. Additionally, ongoing work to improve context detection and reduce mapping errors is underway, and will improve utility in multiple applications. [Formula presented] No, authors do not have interests to disclose Copyright © 2022

Detection of back pains among office workers using MRI

Staying at home and having a sedentary lifestyle has become a new pattern of life in the world of the Covid-19 pandemic. Office workers were a group of people who had to stay at home during the lockdown and they adopted to this pattern of life. Because of this sedentary pattern of life, the occurrence of back pain became more prevalent in this population. Using MRI as an accurate technique to detection of low back pain was suggested and in this paper we have tried to collect data regarding this new pattern of life style and detection of low back pain among office workers using published papers in Scopus, PubMed, and Web of Science from 2015 till 2020. Copyright © Nova Science Publishers, Inc.

Prevalence of low back pain and osteoporosis in health care workers after the COVID 19 pandemic

Aim: Prevalence of low back pain and osteoporosis in health care workers after the COVID 19 pandemic. Material(s) and Method(s): The present prospective study was conducted among 300 apparently healthy adults who are working as a health care individual in the institute. A questionnaire addressing known risk factors for osteoporosis was made. The severity of the LBP was graded using a visual analogue scale for pain (VAS). The VAS is a reliable scale used to register the intensity of chronic pain where 0 signifies no pain and 10 signifies the worst pain imaginable. Those who had chronic LBP were also questioned on whether the onset of LBP preceded the Covid-19 pandemic, and whether the severity of the LBP had increased during the pandemic. Result(s): Light, moderate, sedentary and vigorous physical activity was revealed in 50.1%, 33.6%, 11.1% and 5.2% of the subjects respectively. >1 hour sun exposure in a day was reported among 15.4% of the subjects.In this study, low back was found among 42.7% of the subjects. Mean BMD level was -0.49+/-2.40. Mean BMD level was lower in subjects having back pain, sedentary/vigorous physical activity and no sun exposure as compared to counterparts. Conclusion(s): The confinement decreed due to the COVID-19 pandemic led to a significant increase in LBPintensity among health care workers. Copyright © 2022 Ubiquity Press. All rights reserved.

Post COVID-19 Vaccination Associated Acquired Neuromyotonia

Objective Acquired neuromyotonia or Isaacs' syndrome is an immune mediated inflammatory disorder characterized by involuntary continuous muscle fiber activity manifesting as twitching and stiffness along with autonomic dysfunctions like hyperhidrosis and/or tachycardia. Here we report a young male who developed acquired neuromyotonia following COVID- 19 vaccination. Background A 20-year-old male presented in our clinic with gradually progressive pain and numbness in bilateral lower limbs, tremors in both hands, shivering while walking, excessive sweating and difficulty in micturition for last 15 days. He also noticed twitching of muscles in calf and thigh muscles along with these symptoms. According to patient, these symptoms started after he took his first dose of COVID-19 vaccination (Covishield- Oxford- AstraZeneca viral vector vaccine) 10 days back. There was no history of fever or backache. He had no chronic illness and was not on any medications. Examination revealed hyperhidrosis, mild proximal muscle weakness in both lower limbs with twitching in muscles suggestive of myokymia. There were quivering and rippling movements of intrinsic muscles of both hands resembling polyminimyoclonus. In view of the above findings, possibility of acquired neuromyotonia possibly following COVID-19 vaccination was kept and further evaluation was done. Design/Methods Routine blood investigations, thyroid function test, anti-thyroid peroxidase antibodies and anti-nuclear antibodies were normal. Cerebrospinal fluid analysis was normal. Anti-VGKC antibodies were detected in serum with strongly positive anti-CASPR and weakly positive anti-LGI1 antibodies confirming diagnosis of acquired neuromyotonia. Results Pulse dose of intravenous methylprednisolone for 5 days was given which resulted in visible improvement in pain, twitching, hyperhidrosis and urinary symptoms. He was continued on oral steroids and complete resolution of his symptoms was noted over a period of 2 months. Conclusions COVID-19 vector vaccine associated acquired neuromyotonia is a rare condition, but its early recognition and treatment is the key for a favorable prognosis.

Pharmacoeconomical Aspects of Self-Medication, a Community Pharmacy Survey in Northern Kerala

Objectives: The main objectives of the study are to identify the socio-economic characteristics of lay persons who engage in self-medication activities, to determine the economic aspects of self-medication, to conduct cost minimization analysis, and to determine the consequences of self-medication. Method(s): A cross-sectional survey was conducted in community pharmacies throughout Northern Kerala for a period of 6 months from April 2021 to September 2021. A total of 300 participants were selected through consecutive sampling. Result(s): 117 people were from upper middle class families based on Kuppuswamy's scale. A majority of participants considered self-medication for economic benefits which confirmed that self-medication is closely related to the financial background of the respondents. The costs saved were measured by calculating the costs associated with hospital visits by them or family in the past 6 months for similar manifestations. During the study, the cost of branded drugs prescribed was determined as 70-1498.78% more than the generic versions. Hence, patients are spending much more on their treatment unaware about other alternative options. 117 participants experienced an adverse drug reaction after taking the medication, and 134 participants responded that their symptoms were not improving and 99 entrants had to visit the hospital who had an economic burden due to delay in detection of the disease. Conclusion(s): Thus, the study concluded that there is a strong relationship between pharmacoeconomics and self-medication behavior. Copyright © 2022 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

New Onset Cmv Disease in Post Renal Transplant Patients in Association with Covid19 Infection - 2 Cases and Brief Review of Literature

BACKGROUND: Several cases of CMV syndrome and invasive CMV infection have been reported following COVID19 infection worldwide during COVID19 pandemic in both immunocompetent and immunosuppressed patients. AIM OF THE STUDY: We intend to discuss more about the interrelationship of COVID19 and CMV infection in renal transplant patients. METHOD(S): We discuss two clinical cases, and we present a brief review of literature. 30-year-old man with end-stage primary lupus nephritis underwent mother-to-son kidney transplantation. Post-transplant surgery the patient was discharged with 1.8 mg/ml baseline creatinine. After 3 months, he was admitted with complaints of fever for 4 days with no derangement of renal function. He tested positive for COVID 19 infection and was managed conservatively. Subsequently within 10 days, he was readmitted with chief complaints of loose stools abdominal pain and back pain with mildly raised creatinine and leukopenia. CMV PCR detected 128500 copies per ml. This patient was treated with injection ganciclovir and GM-CSF injection. Mycophenolate mofetil was withheld in view of CMV infection. However, the patient complained of persistent back pain with gradual decline in graft and renal function. With decreasing urine output, dialysis was initiated. Subsequently, the patient developed altered sensorium and had cardiac arrest. 34-year-old male with end-stage chronic nephritis had undergone cadaveric kidney transplantation. Post-transplant the patient had delayed onset graft function with baseline creatinine of 2 mgdl on the 10th post-operative day. Subsequently, the patient suffered from active antibody-mediated rejection, and the patient was managed with six cycles of plasmapheresis. One month later, the patient was admitted with fever and cough. The patient tested positive for COVID19 infection and was managed conservatively. Simultaneously, the patient developed multiple episodes of hematochezia pain in abdomen and diarrhea. Urine output was maintained with stable creatinine. Stool routine and microscopic examination revealed multiple RBCs few pus cells - however no parasite was detected. CMV PCR was positive with 3000 copies per ml. The patient was initially treated with injection ganciclovir and was switched to oral valganciclovir. The patient remained afebrile general condition improved with no further episodes of hematochezia and gradual decline of creatinine to baseline level. RESULT(S): In both our cases, COVID19 infection were managed conservatively, and CMV infection was treated with stoppage of mycophenolate mofetil and addition of ganciclovir injection and resulted into one positive and one negative clinical outcome. CONCLUSION(S): CMV reactivation after COVID 19 infection in renal transplant patient may be a common phenomenon. Further studies are immediately needed to know whether CMV viremia should be routinely tested in all renal transplant patients in India who get COVID19 infection. Studies are also required to determine if clinical outcomes of CMV disease after COVID19 infection in renal transplant patients are different from CMV disease outcomes in other renal transplant patients who have no history of immediately preceding COVID 19 infection.

Real world experience with cladribine treatment in Slovakia

Background: Data from registration studies indicate that cladribine is effective for the treatment of MS and has a promising safety and tolerability profile. However, careful long-term monitoring is needed. Real world data could provide valuable information about cladribin in routine clinical practice. Objective(s): This paper present a retrospective analysis of the effectiveness and safety of cladribine treatment in two MS Centers in Slovakia. Method(s): We performed a retrospective cohort study of 93 patients with relapsing MS, receiving cladribine treatment since December 2018 to May 2022. One patient was excluded, followup was lost. We collected information about relapses, disability (using EDSS), and MRI activity before and during cladribine treatment. Data about previous immunomodulatory medicaments (IMT) and adverse events associated with cladribine treatment were also found. Result(s): Mean age of group was 44years, 71% were women. Before starting cladribine mean EDSS was 4.4 (+/- 3.1), disease duration was 11.6 (+/- 8.3), 97.8% patients experienced relapses and 25.8% had MRI activity. Before starting cladribine treatment, 33% received 1 IMT, 27% were on 2 IMT, and 33% were on >= 3 IMT. 7 patients were IMT-naiive. Patients were most frequently switched to cladribine from dimetylfumarate and teriflunomide. In Year I cladribine treatment,86% (n = 78) of patients did not experience a relapse, and 79% of patients had no radiological activity, 96% of patients had no increase in EDSS following cladribine treatment. In Year II, 83% (n = 53) of patients did not experience a relapse, 92% of patients had no radiological activity, and 80% of patients had no increase in EDSS following cladribine tablets treatment. In Year III, 93% (n = 30) of patients did not experience a relapse, 88% of patients had no radiological activity, and 96% of patients had no increase in EDSS. None of the patient had grade 4 lymphopenia. Lymphopenia grade 2 was the most frequent (41%). We detected one case of mammal carcinoma and 2 precancerosis (dysplasio cervicis uteri) after Year I. The patients did not continue in treatment. Upper respiratory tract infections, Covid-19, fatigue, back pain and artralgy were most common adverse effects in the group. Conclusion(s): Our study confirmed high long-term efficacy of cladribine in MS patients. Considering relative risk of cancer we strictly require patients to have a periodic preventive medical evaluation.

Acute Spinal Cord Infarction in the Setting of Diabetic Ketoacidosis Status Post COVID-19 Infection: A Case Report

Case Diagnosis: 37-year-old female with nontraumatic spinal cord injury secondary to spinal stroke. Case Description or Program Description: Patient in diabetic ketoacidosis (DKA) 13 days status post COVID-19 infection presented with acute onset back pain, right-sided monoplegia, and neurogenic bladder/ bowel. Workup revealed T-spine MRI with abnormal signal in spinal cord at T8/9 level and T-spine angiogram with partial occlusion of proximal anterior spinal artery (ASA) at T9. Patient had not received any COVID-19 vaccine doses. Setting(s): Acute inpatient rehabilitation hospital Assessment/Results: Patient progressed well with therapy and showed reasonably good return of function for the right lower limb. On admission to acute inpatient rehabilitation, patient required two-person assistance level within the parallel bars to ambulate 6 feet. At time of discharge, patient ambulated 152 feet with a rolling walker at standby assistance level. Patient successfully able to self-catheterize for neurogenic bladder and was started on a bowel program with scheduled suppositories. Discussion (relevance): Spinal cord infarction is a rarely documented complication of both DKA and COVID-19 infection. Multifactorial explanations for this phenomenon include etiology stemming from acute cerebrospinal edema and an increasingly hypercoagulable state. To our knowledge this is the first documented case of acute spinal cord infarction in the post- COVID-19 setting. We hypothesize our patient's spinal infarct may have occurred when her elevated hypercoagulable state following COVID-19 infection was exacerbated by DKA in the presence of proximal ASA occlusion. Conclusion(s): Patients in DKA status post COVID-19 infection experiencing an increased hypercoagulable state may be at risk of acute spinal cord infarction. This phenomenon requires further investigation.

Severe Respiratory Failure from SARS-CoV-2, Complicated with Pneumothorax in a Pregnant Woman: A Case Report

INTRODUCTION: The first data for COVID-19 in pregnancy showed mild-to-moderate forms of the disease while the current data speak of severe forms in these subjects. Here, we present a case of a severe form of COVID-19 in a gemelar pregnant woman complicated with pneumomediastinum and pneumothorax, during her hospital stay, in a late stage of disease. CASE PRESENTATION: A 38-year-old multiparous woman was referred to university hospital at 25 weeks of gemelar pregnancy. On admission, the patient presented with signs of moderate respiratory insufficiency, which after 12 h progressed further to severe ARDS. She tested positive for SARS-CoV-2 on quantitative real-time polymerase chain reaction. Under these conditions, it was decided that the patient undergoes a cesarean section for termination of pregnancy. Remdesivir 200 mg/day and tocilizumab 8 mg/kg were administered, based on national guidelines. The patient’s fever subsided, but her SpO2 remained at 94%, even with a 15 L/min oxygen mask. After 12 days, the patient complains of a severe back pain and her respiratory condition rapidly worsened and reduced saturations up to 80% being under O2 therapy with facial mask with 15 l/min. Chest CT findings confirmed pneumomediastinum and pneumothorax, which deteriorated the patient’s status. Thereafter, tube thoracostomy was performed. There was a clinical and ABG analysis parameter’s improvement. The patient was discharged 34 days after cesarean delivery with a proper general health. CONCLUSION: Our case highlights even more convincingly the fact that, in pregnancy, can be severe to life-threating forms of COVID-19. Pneumothorax and pneumomediastinum are complications that can be encountered even in the late stages of severe forms cases with COVID-19 in pregnancy. Early diagnosis of these complications is essential in adequate management and treatment to avoid fatal outcome.

COVID-19-INDUCED IMMUNOSUPPRESSION LEADING TO SECONDARY INFECTION AS DISSEMINATED COCCIDIOIDOMYCOSIS

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Coccidioidomycosis caused by the fungi C. immitis and C. Posadasii is well known to be endemic to the Southwest United States. Less than 1% of these infections will manifest as extrapulmonary symptoms and multiple sites causing dissemination fungemia [1]. Risk factors for disseminated infection include exogenous immunosuppression, immunodeficiency, pregnancy, and ethnic backgrounds of African and Filipino descent [2]. CASE PRESENTATION: A 39-year-old previously immunocompetent Congolese male with recent onset of recurrent skin abscess, and positive testing for COVID-19 three week prior (not treated with steroids). He presents with shortness of breath, back pain, fevers after recently migrating from the Southwest region to the Midwest. Upon admission imaging with Computed Tomography (CT) revealed extensive pulmonary infiltrates (Fig 1), intra-abdominal abscesses, and magnetic resonance imaging revealing (MRI) osteomyelitis of the thoracic (Fig 2) and lumbar spine (Fig 3). His work of breathing continued to worsen, requiring prompt intubation, and he was initiated on a broad-spectrum antimicrobial regimen, including fluconazole, voriconazole, cefepime and vancomycin. Immunoglobulins, HIV and oxidative burst testing was unremarkable. Cultures from image-guided aspiration of the psoas abscess, incision, and drainages of skin abscess and bronchoalveolar lavage fluid were all positive for coccidioidomycosis, transitioned to amphotericin B. Course complicated with the development of multidrug-resistance pseudomonas aerogenes VAP treated with inhaled tobramycin and meropenem. He developed progressive acute respiratory distress syndrome with refractory hypoxemia. After 3 weeks of antimicrobial and anti-fungal treatment, a decision was made to transfer the patient to a lung transplant center, however, due to ongoing fungemia, he was deemed to be not a candidate for extracorporeal membrane exchange and lung transplantation. About a month into his hospitalization, the family decided to withdraw care. DISCUSSION: Reactivation of latent coccidiomycosis has been largely studied in the immunosuppressed population that includes HIV, hematological malignancies, and diabetes mellitus, however little is known about this fungal infection in the immunosuppressed state in the setting of COVID-19. Thus far only two case reports have been reported of co-infection if COVID-19 and pulmonary coccidioidomycosis [3]. The days of the COVID-19 pandemic might contribute to further delays in diagnosing this fungal infection due to similarities of pulmonary manifestation. CONCLUSIONS: This case demonstrates a COVID-19 infection leading to an immunosuppressed status resulting in disseminated infection from reactivation of latent coccidiomycosis. As a result, physicians must maintain a high level of suspicion for superimposed fungal infections in those with even relative immunosuppression from a recent COVID infection. Reference #1: Odio CD, Marciano BE, Galgiani JN, Holland SM. Risk Factors for Disseminated Coccidioidomycosis, United States. Emerg Infect Dis. 2017;23(2):308-311. doi:10.3201/eid2302.160505 Reference #2: Hector RF, Laniado-Laborin R. Coccidioidomycosis–a fungal disease of the Americas. PLoS Med. 2005;2(1):e2. doi:10.1371/journal.pmed.0020002 Reference #3: Shah AS, Heidari A, Civelli VF, et al. The Coincidence of 2 Epidemics, Coccidioidomycosis and SARS-CoV-2: A Case Report. Journal of Investigative Medicine High Impact Case Reports. January 2020. doi:10.1177/2324709620930540 DISCLOSURES: No relevant relationships by Stephen Doyle No relevant relationships by Connor McCalmon No relevant relationships by John Parent No relevant relationships by Jay Patel No relevant relationships by Angela Peraino No relevant relationships by Keval Ray

Durability of Symptom Relief with Restorative Neurostimulation for Mechanical Chronic Low Back Pain: Three-Year Follow-up Results of the Pivotal Trial: Track 3: Neurostimulation for Back and Leg Pain

Introduction: Mechanical chronic low back pain (CLBP) can be caused by impaired neuromuscular control and degeneration of the multifidus muscles, the most important stabilizers of the lumbar spine. An implantable Restorative Neurostimulation system bilaterally stimulates the medial branches of the L2 dorsal rami to override underlying multifidus inhibition to facilitate motor control restoration. A randomized sham-controlled pivotal trial provided evidence of safety, effectiveness and durability of this therapy (clinicaltrials.gov/show/NCT02577354).[1,2] Here we will report the three-year durability results. Materials / Methods: Eligible patients had activity limiting mechanical CLBP (VAS >=6cm;Oswestry Disability Index (ODI) >=21 points) despite medical management, which included at least pain medications and physical therapy. They had evidence of impaired multifidus motor control (positive prone instability test) and no indication for spine surgery. All patients were implanted with a Restorative Neurostimulation system (ReActiv8, Mainstay Medical, Dublin, Ireland). During the long-term follow-up phase, all participants delivered stimulation for up to 30 minutes twice daily eliciting repetitive, tonic multifidus contractions. Result(s): At baseline (N=204), participants were 47+/-9 years of age, had history of backpain for 14+/-11 years, had an average low back pain VAS of 7.3+/-0.7 cm, ODI of 39+/-10, EQ-5D of 0.585+/-0.174 points and had pain on 97+/-8% of days in the year prior to enrollment. Three-year data are available for 124 participants*. Average VAS improved by 5.0+/-2.4 cm, ODI by 23+/-15 points and EQ-5D by 0.223+/-0.199 (All P<0.0001);78% of participants had a >=50% VAS improvement;69% reported LBP-Resolution (VAS<=2.5 cm);65% had a >=20-point ODI improvement and 86% of participants were "definitely satisfied" with the treatment. Pain intensity and disability are interdependent symptoms and treatment success is determined by composite improvements in ODI and VAS: 84% had a substantial improvement of >=50% in VAS and/or >=20points in ODI, and 59% had these improvements in both VAS and ODI. Of participants using opioids at baseline, 72% had voluntarily discontinued or decreased consumption. Overall safety compares favorably to other neurostimulation systems, and no lead migrations were observed. During the third year of follow-up, 6 participants requested device removal citing resolution of pain. Discussion(s): See conclusions. Conclusion(s): Restorative-Neurostimulation is an effective, durable, and safe treatment for patients with refractory, activity-limiting CLBP secondary to impaired multifidus neuromuscular control. Consistent with the restorative mechanism, improvements accrue progressively over time. *Twenty-five follow-ups pending (Covid-19 restrictions) Learning Objectives: 1. Understand the long term pain outcomes (three year outcomes) of restorative neurostimulation for refractory chronic low back pain. 2. Understand the long term function outcomes (three year outcomes) of restorative neurostimulation for refractory chronic low back pain. 3. Understand the long term safety outcomes (three year outcomes) of restorative neurostimulation for refractory chronic low back pain. Keywords: nociceptive low back pain, multifidus, motor control, Restorative neurostimulation, chronic low back pain Copyright © 2022

SEVERE HYPONATREMIA AS A MANIFESTATION OF A NEUROLOGIC DISORDER ASSOCIATED WITH THE COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: More reports are indicating a temporal association between Bell's palsy and the mRNA vaccine for coronavirus disease 2019 (COVID-19). Therefore, collecting vaccine history is becoming important in post-marketing surveillance to monitor the safety of vaccines in real-world settings. We report the case of concomitant occurrence of Bell's palsy and glossopharyngeal neuralgia leading to severe symptomatic hyponatremia in a previously healthy patient. CASE PRESENTATION: A 60 year-old-female without significant medical history presented to the hospital with odynophagia, and generalized weakness for two weeks. She decreased her oral intake due to stabbing pain in the back of her throat triggered by swallowing. She reported hyperacusis and frequent shooting pain in the left cheek managed with non-steroidal anti-inflammatory drugs. The symptoms occurred several days after the first dose of the mRNA vaccine for COVID-19. She denied previous COVID-19 infection and herpes zoster. Examination revealed dry mucosa, left facial muscle weakness, inability to raise the left eyebrow or lift the labial commissure, effacement of the nasolabial fold, and left-sided frontal wrinkles. Laboratory investigation revealed sodium of 110. Computerized Tomography of the brain revealed negative findings for intracranial abnormalities. Severe symptomatic hyponatremia was managed with hypertonic saline. The neurologist made the diagnosis of Bell's palsy and glossopharyngeal trigeminal neuralgia leading to poor oral intake. We initiated acyclovir, prednisone, and gabapentin. The patient recovered from hyponatremia and experienced improvement of neurological symptoms with initiated medications. DISCUSSION: High morbidity and mortality of patients with COVID-19 accelerated the development and production of the vaccines. During the pandemic, mRNA COVID-19 vaccines reduced asymptomatic and prevented severe symptomatic COVID-19 infection and its complications. Although the benefits and protective effects of the COVID-19 vaccines outweighed the risks associated with them, we have reports of associations between vaccines and certain disorders such as Bell's palsy. Glossopharyngeal neuralgia is defined as sudden severe brief pain in the distribution of the glossopharyngeal nerve. It can be described as transient stabbing pain experienced in the ear, tonsillar fossa, and base of the tongue. Unusual presentation is fear to eat as this can be a precipitating cause of the pain. It overlaps with trigeminal neuralgia and can create a diagnostic dilemma. CONCLUSIONS: In summary, it is unknown what causal relationship exists between the mRNA COVID-19 vaccine and neurological diseases such as Bell's palsy and glossopharyngeal neuralgia. Glossopharyngeal neuralgia is frequently overlooked as a diagnosis. This is a unique case of concomitant glossopharyngeal neuralgia and Bell's palsy that is coincidental with a history of COVID-19 vaccine. Reference #1: El Sahly HM, Baden LR, Essink B, et al. Efficacy of the mRNA-1273 SARS-CoV-2 Vaccine at Completion of Blinded Phase. New England Journal of Medicine. 2021;385(19):1774-1785. doi:10.1056/NEJMoa2113017 Reference #2: Singh PM, Kaur M, Trikha A. An uncommonly common: Is glossopharyngeal neuralgia. Ann Indian Acad Neurol. 2013;16(1):1-8. doi:10.4103/0972-2327.107662 Reference #3: Cellina M, D'Arrigo A, Floridi C, Oliva G, Carrafiello G. Left Bell's palsy following the first dose of mRNA-1273 SARS-CoV-2 vaccine: A case report. Clin Imaging. 2022;82:1-4. doi:10.1016/j.clinimag.2021.10.010 DISCLOSURES: No relevant relationships by Nemanja Draguljevic No relevant relationships by Katherine Hodgin No relevant relationships by Kristina Menchaca No relevant relationships by Catherine Ostos Perez

Septic arthritis caused by Brucella melitensis - An orthopedic chal-lenge (11194)

Introduction The zoonotic infection with Brucella melitensis can be acquired by inges-tion of unpasteurized goat's or sheep's milk. The infection is common in Eastern Mediterranean countries (EMC), but rare in western Europe (6 cases in Switzerland, 2021). When evaluating patients with symptoms of septic arthritis, brucellosis is not the foremost differential diagnosis. How-ever, with the increasing population of people from EMC in western Eu-rope, the incidence may be rising. We present a patient who was initially suspected to suffer from Long-COVID-Syndrome (LCS), which underscores the relevance of this case in a pandemic situation. Methods/Results A 58-year-old male patient was admitted to the emergency department with a painful right knee effusion after a minor trauma. Additionally, he suffered from fatigue, subfebrile temperatures, back pain and myalgias for more than two months. He was suspected to suffer from LCS after a mild COVID-19 three months earlier. The culture of the arthrocentesis (14.400 cells/mul with 61% polynuclear cells) unexpectedly turned positive for B. melitensis. The patient declared that he had been drinking three liters of unpasteurized goat's milk to cure the presumptive LCS. To ensure staff safety, arthroscopic lavage was postponed until brucella-active antibiotics had been administered for at least 24 hours. Surgery was performed under strict infection control measures to avoid generating aerosols. According to Duke, one major (continuous bacteremia over 14 days) and 2 minor criteria (fever, most probably septic embolic gonarthritis) were fulfilled. Therefore, possible endocarditis had to be assumed although transesophageal echocardiography was normal. Antibiotic treatment was escalated to a quadruple regimen (intravenous gentamicin for three weeks;as well as oral doxycycline, trimethoprim/sulfomethoxazole and rifampin for at least 3 months). The clinical recovery - still under treatment - is protracted with slowly improving knee pain and normalizing signs of inflammation. Conclusion Although B. melitensis is a rare pathogen in Switzerland, orthopedic sur-geons, rheumatologists and infectious disease specialists need to be aware of diseases with low incidence and non-specific symptoms espe-cially in times of a global pandemia. A high index of suspicion is needed in patients related to EMC. When brucellosis is confirmed, strict infection control measures to protect staff involved in aerosol generating proce-dures must be adopted.