ABSTRACT
Case;40 y/o male. Clinical course;The patient was transferred to our university hospital because of DOE and severe headache. He had been well and had no history of hypertension or obesity. He had experienced the COVID-19 vaccine injection two week before this visit. After the injection he had been experienced high fever and general fatigue as well as 7 kg of weight loss. On examnation, it was found that he had severe hypertension (190/110 mmHg) and hypertensive optic fundi. On chest X-ray, cardiomegaly and bilateral lung infiltrations was evident and biochemical data indicated renal dysfunction (serum creatinine 2.35 mg/dl), high levels of plasma renin activity (39.1 ng/ml/hour normal;0.6-3.9) and aldosterone concentration (176 pg/ml normal;4.0-82.1), and inflammatory changes (CRP = 23 mg/dl). We also found that increased levels of LDH and decreased levels of hemoglobin which indicated hemolytic anemia and thrombotic microangiopathy. After the control of high blood pressure by intravenous administration of Calcium channel blockades, We performed renal biopsy, which had a finding of diffuse findings of onion skin lesion and global glomerular sclerosis compatible with the diagnosis of malignant hypertension. Any secondary etiologies including renal artery disease or collagen disease had not been identified. Seven days after the admission, we started hemodialysis for this patient because of the renal failure was not resolved. We also had startred ACE inhibitors. We stopped the diuretics and minimized the ultrafiltration. Twenty-five days after the admission the patients was withdrawn from dialysis with the urine volume around 2000 ml/day and the serum creatinine concentration 5.29 mg/dl. He was discharged without any aid of dialysis and with small number of anti-hypertensives. Four months after the discharge, his serum creatinine concentration was 3.36 mg/dl and his blood pressure was 139/85 mmHg with the ACE inhibitor and calcium channel blockades. Conclusions;The case suggested that the malignant hypertension might be triggered by COVID-19 vaccine injection, which is of clinical importance.
ABSTRACT
Purpose: Lung transplant is the last resort for COVID-19 refractory ARDS. Dual organ transplant is seen as a relative contraindication at many institutions. We describe a case of simultaneous Lung-Kidney transplant (SLK) in a patient with COVID-19 ARDS. Method(s): A 24-year-old patient with no PMH presented to an outside hospital with a week of shortness of breath, cough, and fever. Despite treatment with Remdesivir and dexamethasone, the patient developed hypoxemic respiratory failure with acute renal injury requiring ICU care and intubation, V-V ECMO, and dialysis. Additionally, Intravenous and inhaled Aviptadil were given under emergency use authorization. While oxygenation improved, the patient could not be weaned off ECMO. With a LAS score of 90.29, the patient underwent an SLK transplant on HD 53, requiring standard induction and maintenance immunosuppression therapy. The patient was treated post-operatively for PGD as well as for subclinical AMR. After successful inpatient rehabilitation, the patient was discharged home after four months and had a one-month follow-up on room air and normal creatinine clearance. Result(s): Patients with pre-existing renal dysfunction who have undergone lung transplants have a significantly higher one- and three-year mortality than patients with normal GFR. The patient's survival after SLK was similar to isolated lung transplants at one and five years, according to an analysis of the UNOS/OPTN database. Still, dual organ transplant in the COVID-19 ARDS population is considered a contraindication at many centers, given these patients' critical illness and frailty. However, the frailty in this population is reversible due to the rapid onset of disease in an otherwise previously healthy younger population with minimal comorbidities. Thus, multiorgan transplantation should be considered in such a patient population. Our patient received Aviptadil as part of an EIND to stabilize patients and improve oxygenation while waiting on the transplant list. Conclusion(s): We propose that SLK transplantation should be considered for carefully selected patients with COVID-19 ARDS.
ABSTRACT
SESSION TITLE: COVID-Related Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP) is a rare medical emergency with mortality rates reported to be as high as 90% if untreated. We report a case of severe TTP in an immunocompetent patient diagnosed with COVID 19 infection. CASE PRESENTATION: A 34-year-old morbidly obese female not vaccinated for COVID presented to PCP 2 weeks prior with complaints of fatigue. CBC showed Hb 12.2, platelet count 108 (baseline > 200), and covid resulted positive. The patient was reluctant for further workup at the time. After 2 weeks she felt short of breath prompting ICU admission for high flow oxygen with blood work showing hemoglobin of 8.8, platelet count of 11, Reticulocyte count 3.9%, LDH 763, fibrinogen 639, schistocytes on peripheral smear, MCV < 90, INR<1.5, Creatinine 1 giving her a PLASMIC Score of 7. For concerns of TTP, she was urgently started on plasmapheresis, prednisone 1 mg/kg, and remdesivir for COVID. ADAMTS13 was sent prior to the initiation of plasmapheresis resulted at 5% indicating severe deficiency and a high risk of relapse. She underwent 3 cycles of plasma exchange and was also started on Caplacizumab. Rituximab was not started in the setting of active COVID infection and negative COVID IgG. Repeat ADAMTS13 level at 2-week interval increased to 43%. The patient was discharged on steroids and completed 1 month of Caplacizumab. On outpatient follow up the patient was asymptomatic but repeat ADAMTS13 declined to 16%. COVID IgG now resulted positive, and she was started on Rituximab. Ultimately patient was treated with 4 months of steroids and 4 doses of weekly Rituximab with the final two ADAMTS 13 levels normalized above 100. DISCUSSION: TTP is caused by decreased activity of the plasma metalloproteinase ADAMTS 13, the key enzyme involved in the cleavage of ultra-large von Willebrand Factor (vWF) multimers into smaller less procoagulant multimers. It is reported that COVID-19 infection is associated with almost a five-fold increase in vWF levels which the body's ADAMTS-13 enzyme activity cannot adequately regulate, resulting in an excess of unchecked ultra-large vWF, diffuse microthrombi, and systemic ischemia. The presentation of this disease is often characterized by the pentad of fever, thrombocytopenia, hemolytic anemia, renal dysfunction, and neurologic dysfunction. However, the full pentad is often not present in many patients Plasma exchange and immunosuppression are the mainstays of treatment for TTP. A high index of suspicion is required for a timely diagnosis. Early diagnosis is crucial as without treatment TTP is associated with a high mortality rate. CONCLUSIONS: Health care providers should be aware of this life-threatening complication of COVID-19 so that prompt and appropriate interventions can be undertaken if it is suspected or confirmed. Rituximab should be delayed until the acute COVID-19 infection has cleared, and neutralizing antibodies have been produced. Reference #1: Hindilerden F, Yonal-Hindilerden I, Akar E, Kart-Yasar K. Covid-19 associated autoimmune thrombotic thrombocytopenic purpura: Report of a case. Thromb Res. 2020;195:136-138. doi:10.1016/j.thromres.2020.07.005 DISCLOSURES: No relevant relationships by Hanish Jain No relevant relationships by Dragos Manta No relevant relationships by Parth Sampat No relevant relationships by Garima Singh No relevant relationships by Simant Thapa
ABSTRACT
SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Daptomycin is an antibiotic that exerts its bactericidal effect by disrupting multiple aspects of bacterial cell membrane function. It has notable adverse effects including myopathy, rhabdomyolysis, eosinophilic pneumonitis, and anaphylactic hypersensitivity reactions. CASE PRESENTATION: A 46-year-old male with a history of type 2 diabetes presented with a 1-week history of dyspnea and productive cough. 2 weeks prior, he was started on vancomycin for MRSA osteomyelitis of the right foot, but was switched to daptomycin due to vancomycin induced nephrotoxicity. On presentation he was afebrile, tachycardic 100, hypertensive 183/109, tachypneic to 26, hypoxemic 84% on room air, which improved to 94% on nasal cannula. Chest exam noted coarse breath sounds in all fields and pitting edema of lower extremities were present. Labs showed leukocytosis of 15.2/L, Na of 132 mmol/L, and creatinine 3.20mg/dL (normal 1 month prior). COVID-19 testing was negative. Chest X-ray noted new bilateral asymmetric opacifications. Daptomycin was discontinued on day 1 of admission, he was started on IV diuretics and ceftaroline. Further study noted peripheral eosinophilia. Computed tomography of the chest showed bilateral centrally predominant ground-glass infiltrates with air bronchograms and subcarinal and paratracheal lymphadenopathy. On day 4, he underwent bronchoscopy with bronchoalveolar lavage. Cytology noted 4% eosinophil with 43% lymphocytes. Eventually, oxygen requirements and kidney function returned to baseline. He was discharged on ceftaroline for osteomyelitis DISCUSSION: Daptomycin-induced acute eosinophilic pneumonitis (AEP) often results in respiratory failure in the setting of exposure to doses of daptomycin >6mg/kg/day. It is characterized by the infiltration of pulmonary parenchyma with eosinophils and is often associated with peripheral eosinophilia. AEP has been associated with certain chemicals, non-steroidal anti-inflammatory agents, and antibiotics including daptomycin. Renal dysfunction is associated with an increased risk for developing AEP. The mechanism for daptomycin-induced lung injury is unknown but is believed to be related to daptomycin binding to pulmonary surfactant culminating in epithelial injury. Diagnostic criteria include recent daptomycin exposure, fever, dyspnea with hypoxemic respiratory failure, new infiltrates on chest radiography, BAL with > 25% eosinophils, and clinical improvement following daptomycin discontinuation. Our patient met four out of six criteria;we believe that BAL results were due to discontinuing daptomycin days before the procedure was performed. Sometimes stopping daptomycin is enough for recovery, however, steroids may be beneficial and were used in some of the cases reported in the literature CONCLUSIONS: Clinicians should consider AEP in a patient on Daptomycin presenting with respiratory failure, as timely discontinuation favors a good prognosis Reference #1: Uppal P, LaPlante KL, Gaitanis MM, Jankowich MD, Ward KE. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control. 2016;5:55. Published 2016 Dec 12. doi:10.1186/s13756-016-0158-8 Reference #2: Kumar S, Acosta-Sanchez I, Rajagopalan N. Daptomycin-induced Acute Eosinophilic Pneumonia. Cureus. 2018;10(6):e2899. Published 2018 Jun 30. doi:10.7759/cureus.2899 Reference #3: Bartal C, Sagy I, Barski L. Drug-induced eosinophilic pneumonia: A review of 196 case reports. Medicine (Baltimore). 2018;97(4):e9688. doi:10.1097/MD.0000000000009688 DISCLOSURES: No relevant relationships by Chika Winifred Akabusi No relevant relationships by Shazia Choudry No relevant relationships by Hector Ojeda-Martinez No relevant relationships by Mario Torres
ABSTRACT
Extracorporeal membrane oxygenation (ECMO) has been used within the SARS-Cov-2 (COVID-19) pandemic to support patients with severe COVID-19 related acute hypoxemic respiratory failure that is refractory to lung-protective mechanical ventilation. The decision to offer and support patients with ECMO therapy comes from selection criteria which is more likely to demonstrate a positive outcome. However, providers may be faced with challenges regarding discontinuation of therapy when recovery appears unlikely. The in-hospital mortality rate for COVID-19 ECMO patients as reported by ELSO's registry is 47%. This retrospective single-institution study sought to determine the effect of the development of renal dysfunction on mortality rates for COVID-19 ECMO patients. In a cohort of 53 patients, 22 of these patients (41.5%) experienced mortality while receiving ECMO therapy, with a total of 26 (49.1%) experiencing mortality during ECMO therapy or within 90 days after ECMO decannulation. Correlating the outcome of mortality with the stages of severity of AKI as defined by KDIGO guidelines, this study demonstrated a significantly lower percentage of study participants in the No AKI group experienced mortality (12.5%;n=2) relative to all other categories of renal dysfunction, X2(4)=4.96, p<.05. Additionally, bivariate analysis indicated that a significantly higher percentage of study participants who required CRRT experienced mortality (77.8%;n=14) relative to all other categories of renal dysfunction, X2(1)=9.00, p<.01. This demonstrates patients requiring CRRT while on ECMO therapy for ARDS related to COVID-19 are 6.71 times more likely to experience mortality relative to those in other categories.
ABSTRACT
Objective: This study aims to demonstrate the impact of "SARS-CoV-2" infection on renal function in patients who have undergone hemodialysis in the past. Methodology: Telomerase Reverse Polymerase Chain Reaction in Real Time (RT-Real time PCR) To verify "SARS CoV-2" infection, RT-PCR was used, moreover pre and post urea and creatinine tests were confirmed by COBAS INTEGRA 400 plus analyzer was automated qualitative assays rapidly detected Creatinine, urea, and diabetes Mellitus levels. Result(s): The mean of pre-creatinine levels was 7.3336. The post-creatinine levels (11.8276) significantly increased after "SARS-CoV-2" infection with a P-value of 0.001. The mean of pre-urea levels was 163.6724. The post-urea levels (213.706897) significantly increased after "SARS-CoV-2" infection with a P-value of 0.001. Conclusion(s): SARS-CoV-2 infection in patients with pre-existing hemodialysis leads to increasing kidney dysfunction with or without comorbidities (diabetes mellitus and hypertension). Moreover, the old patients with pre-existing hemodialysis are found to be at higher risk of renal dysfunction during "SARS-CoV-2" infection than the younger groups. Copyright © 2022, Bahrain Medical Bulletin. All rights reserved.
ABSTRACT
The COVID-19 pandemic remains a worldwide challenge. Despite extreme study efforts globally, effective treatment and vaccine options have eluded the investigators. Therefore, this study aimed to investigate knowledge, attitudes, and practices (KAP) towards COVID–19 among hemodialysis nurses in Ma, Governorate hospitals- Jordan. An exploratory research design (cross-sectional study design) has been utilized to achieve the aim of the current study. The study was conducted in the dialysis unit at Ma, a governmental hospital- in Jordan. Data were collected by using a self-administered structured questionnaire. Nearly half (47.5%) of nurses were male, ranging from 30 to 40 years old. More than half of them (62.5%) were married and graduated from nursing college;their years of experience were more than 5 years. The vast majority of participants reported that they have adequate knowledge and good practice about how to deal with COVID-19. The majority of participants have a favorable attitude regarding COVID -19 outbreaks. A positive correlation was found between nurses’ knowledge and attitudes toward COVID19 according to their years of experience. The study found that most nurses have good knowledge and practice levels and favorable attitudes toward COVID 19 infection. Educational programs about COVID 19 should be provided to nurses in different departments and units in the hospital.
ABSTRACT
The role of infectious agents derived antigens including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been recognized as a trigger for development of autoimmune mediated disorders following natural infection or immunization. However, there is a scarcity of reports of occurrence of autoimmune associated kidney disorders or flare ups following exposure to a SARS-CoV-2 vaccine. A 65-year-old female presented to a nephrology clinic for evaluation of worsening renal dysfunction. The patient is well known to have systemic sarcoidosis under complete remission on low dose prednisone and likely membranous nephropathy (no previous kidney biopsy) with mildly elevated phospholipase A2 receptor (PLA2R) antibodies. Her membranous nephropathy was in partial remission on angiotensin receptor blockage, with urine to protein creatinine ratio (UPCR) of 1.5 g/g . Five months after receiving the single dose SARS-CoV-2 vaccine (Johnson & Johnson®), she started having a flare up of her systemic sarcoidosis with worsening joint, skin and respiratory symptoms. Blood chemistry revealed worsening renal dysfunction with elevated creatinine up to 1.7 mg/dL from her baseline of 1.0 mg/dL. UPCR was also elevated at 3.4 g/g. Urine sediment revealed no red blood cells or casts, only several calcium oxalate dihydrate crystals. A kidney biopsy was performed and showed a combination of membranous nephropathy (PLA2R positive) along with granulomatous interstitial nephritis with well-formed epithelioid granulomas characteristic of sarcoidosis. She was started on high dose prednisone and her renal function improved to 1.2 mg/dL, UPCR decreased to 1.8 g/g and serum PLA2R antibodies became undetectable. She is still being monitored. After many years of renal sarcoidosis and membranous nephropathy remission, the relapse of renal disease after receiving the SARS-CoV-2 vaccine (Johnson & Johnson®) suggests the association between receiving the vaccine and the recurrence of renal sarcoidosis and membranous nephropathy.
ABSTRACT
Background and aims: The global pandemic has inevitably diverted resources away from management of chronic diseases, including cirrhosis, where up to 40% of patients are readmitted with new cirrhosis decompensation events. Whilst there is increasing knowledge on COVID-19 infection in liver cirrhosis, little is described on the impact of the pandemic on decompensated cirrhosis admissions and outcomes, which was the aim of this study. Method: A single-centre, retrospective study, evaluated decompensated cirrhosis admissions to a tertiary London hepatology and transplantation centre, from October 2018 to February 2021. Patients were included if they had an admission with cirrhosis decompensation defined as new onset jaundice or ascites, infection, encephalopathy, portal hypertensive bleeding or renal dysfunction. Admissions were excluded if they lasted <24 hours,were elective or occurred post liver-transplant. Results: Therewere 351 admissions in the pre-COVID period (October 2018 to February 2020) and 240 admissions during the COVID period (March 2020 to February 2021), with an average of 20.4 admissions per month throughout. Patients transferred in from secondary centres had consistently higher severity scores during the COVID period (UKELD 58 versus 54;p = 0.007, MELD Na 22 versus 18;p = 0.006, AD score 55.0 versus 51.0;p = 0.055). The proportion of ITU admissions pre versus during-COVID stayed constant (22.9% versus 19.2%), but there was a trend towards increased ICU admissions with acute-on-chronic liver failure (ACLF) (73.9% versus 63.8% prepandemic). Of those admitted to the intensive care without ACLF, there was a significant increase in EF-CLIF acute decompensation (AD) scores during the COVID period (58 versus 48, p = 0.009). In addition, there was a trend towards increased hospital re-admission rates during the COVID period (29.5% versus 21.5%, p = 0.067). When censored at 30 days, time to death post discharge was significantly reduced during the COVID period (p < 0.05) with a median time to death of 35 days compared to 62 days pre-COVID.(Figure Presented)Conclusion: This study provides a unique perspective on the impact that the global pandemic had on the clinical course and characteristics of decompensated cirrhosis admissions. The findings of increased early mortality and re-admissions, and higher AD scores, indicating increased disease morbidity, highlight the need to maintain resourcing on providing high-level hepatology care. Given that COVID-19 will likely be a chronic issue, alternative care pathways such as remote monitoring may need adoption to facilitate continuity of care post-discharge and to reduce readmission rates and morbidity in the future
ABSTRACT
CASE: 54-year-old female presented with 1 week of generalized weakness, headache, congestion, cough with dark- colored phlegm, and several days of decreased smell and taste. She was unvaccinated and had positive sick contacts. Patient tested positive for Covid and found to have severe thrombocytopenia with platelets of 5K/uL, very rare schistocytes on smear, and no other notable abnormalities. She received platelet transfusion and was treated for presumed immune thrombocytopenia with IVIG and dexamethasone. The patient had no petechiae, bleeding, or other symptoms concerning for secondary TMA, notably TTP. The platelet count was 93 K/uL by day 5 and she was discharged home. Later that day her ADAMTS13 test resulted at <2% and the ADAMTS13 antibody was elevated. The patient was asked to return to the hospital for monitoring of TTP symptoms. She reported improvement in her weakness. Her thrombocytopenia and oxygen saturation remained normal. Bilateral lower extremity ultrasound showed no lower extremity VTE. On the day of discharge, 10 days after her original thrombocytopenia identified, she had a platelet count of 373 K/uL and repeated ADAMTS13 of 14.8%. IMPACT/DISCUSSION: ADAMTS13 is known as von Willebrand factor (VWF) protease as it cleaves prothrombotic and highly adhesive to platelets ultra-large multimers of VWF into smaller multimers, thus modulating VWF activity and regulating the adhesive function. A severe deficiency of ADAMTS13 characterizes TTP, a rare but potentially fatal disorder associated with thrombosis due to accumulation of prothrombotic ultra-large VWF multimers. There are literature reports of TTP and TTP-like syndromes in Covid-19. It is speculated that in COVID-19, the excess of VWF released in response to endothelial activation likely exhausts the available reserves of ADAMTS13, which may then propagate formation of microthrombi in different organs. We report an extreme thrombocytopenia, marked decrease of ADAMTS 13 and elevated ADAMTS13 antibodies, which would be confirmative evidence of TTP should our patient have clinical features of it. Our patient did not have fever, neurologic abnormalities, renal dysfunction, or active hemolysis. She was followed in outpatient clinic after the discharge. The platelet count recovered and ADAMTS 13 trended up without need for plasmapheresis. Our case is a good example of a fortunate outcome without any complications despite threatening presenting criteria. CONCLUSION: Covid-19 associated endothelial stimulation and damage could mimic a life-threatening disorder without expected fatal complications. On the other hand, it can ultimately lead to the most severe form of thrombotic microangiopathy, TTP, for which the mortality rate is close to 90%. It is hard to know which outcome to expect in different circumstances. Therefore, it is crucial for physicians to promptly recognize clinical picture of TTP as treatment is lifesaving.
ABSTRACT
Background: Water retention leading to worsening congestion is a common reason for heart failure (HF) hospitalisation. Increases in aldosterone, due to increased secretion (driven by angiotensin and hyperkalaemia) and reduced degradation (due to hepatic dysfunction), contribute to congestion. Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in advanced HF. However, use of MRA is often limited by hyperkalaemia, renal dysfunction and hypotension. Hyperkalaemia can be corrected by potassium binding agents. Methods: An open-label, randomised, multi-centre (up to 100 UK sites) trial investigating the use of a potassium binding agent, patiromer, to facilitate higher doses of MRA for HF with worsening congestion requiring treatment with ≥80mg/day of furosemide (or equivalent). Patients are first entered on an unconsented screening-log (approved by the UK Health Research Authority) and then asked to consent to a registry (no exclusion criteria). If they agree, and are eligible (systolic blood pressure ≥90mmHg, eGFR ≥30mL/min/1.73 m2, no other terminal disease, no active infection or myocardial ischaemia), they are invited to participate in a randomised trial. Patients who consent for the trial enter a run-in phase of ≤35 days, when they receive ≤100mg/day of spironolactone. If serum potassium rises to >5.0mmol/L, the patient is randomised either to receive an MRA at guideline recommended doses or to have spironolactone increased ≤200mg/day, using patiromer to manage hyperkalaemia, providing eGFR remains ≥30mL/min and the patient does not become hypotensive. The primary outcome of the first phase of the trial (n = 400) is severity of congestion at 60-days but patients will be followed The RELIEHF Registry & Randomised Trial long-term for morbidity and mortality. An adaptive trial design allows recruitment to be increased up to 2.000 patients. Results: The conduct of the trial has been disrupted by COVID. As of January 2022, from 10 sites, >300 patients (40% women;median age 76 (65-83) years have been screened, >100 (37% women;median age 72 (62-80) years) have consented for the registry and >25 for the randomised trial. Of patients screened, about 50% were asked for registry-consent, of whom one third refused. The main reason for not asking was that the care-team considered it inappropriate due to patient frailty and/or cognitive dysfunction. Most patients who consented for the registry agreed, in principle, to participate in a randomised trial. Most patients have tolerated 100mg of spironolactone during the run-in period. Conclusions: For a high proportion of patients admitted to hospital with worsening HF, research staff do not deem it appropriate to approach them to ask for research consent. Most patients with HF who were asked to participate in research were willing to do so and to participate in a randomised trial, although a substantial proportion were not eligible for this trial. Of those who were, the majority tolerated spironolactone at a dose of 100mg/day.
ABSTRACT
Objectives: The aim of the study was to evaluate the adverse drug reactions (ADR) following Remdesivir therapy in patients of COVID-19. Methods: All patients more than 18 years of age of any gender, diagnosed with COVID-19 infection receiving remdesivir therapy and fulfilling the selection criteria were included in the study after informed consent. They were monitored for ADRs till end of treatment and analyzed for characteristics of the ADRs: Causality, severity, and preventability. Results: Out of 80 patients (mean age of 49.27±16.22 years) enrolled, 51 (63.75%) developed 84 ADRs. Most common ADRs included increased aspartate transaminases, (20.23%), increased bilirubin (19.04%), increased alanine transaminases (13.09%), increased creatinine (11.90%), and increased blood urea (9.52%). Causality assessment using WHO-UMC scale showed, 85.71% possible, 13.09% probable, and 1% certain causal association of the ADRs with remdesivir. A total 75% ADRs were mild in severity and 45% patients recovered from the event at the end of treatment. Conclusion: Hepatic and Renal dysfunctions are observed with remdesivir in COVID-19 patients. Intensive monitoring of ADRs with newer drugs with EUA such as remdesivir is warranted to ensure safer use in patients.
ABSTRACT
Since the spread of the novel coronavirus infection, most researchers have noted a low proportion of sick children in general pediatric cohort compared to adults, who had a mild disease course and rare complications. The most frequent clinical manifestations of the disease are respiratory and, some less frequently diarrheal syndromes. The disease has predominantly mild or asymptomatic course. The risk of adverse outcomes in children, similar to adults, clearly correlate with the presence of background chronic pathology. The need for respiratory support prevails in children with a severe premorbid burden. Here, a clinical case of ongoing novel coronavirus infection in adolescent patient comorbid with chronic kidney pathology is described. In adolescence, the patient was diagnosed with mesangioproliferative glomerulonephritis (IgA-nephropathy), and further registered at the dispensary receiving a combination therapy with angiotensin converting enzyme inhibitors and disaggregation drugs. The epidemiological history contained no established contacts with infectious patients. The clinical manifestations of COVID-19 in the patient are represented by catarrhal and diarrheal syndromes, transient renal dysfunction in the acute period of the disease. The onset of coronavirus infection was clinically characterized by symptoms of damaged gastrointestinal tract and was considered as acute gastroenteritis of infectious etiology. Empirically prescribed antibacterial therapy in combination with antiplatelet agents and symptomatic drugs had no effect. The diagnosis of the novel coronavirus infection was verified only on day 4 of hospitalization, clinical and laboratory signs of lung damage emerged. The inflammatory process developed in the patient lungs was secondary to the main pathology. The severity of the patient’s condition was determined by the presence of respiratory and renal insufficiency. Lung damage with minimal severity complaints and clinical data had a bimodal pattern and required respiratory support. A comprehensive approach to treatment, including respiratory, antiviral, enterosorption, anticoagulation, anti-inflammatory, antihypertensive, hepatoprotective, symptomatic therapy with change in antibacterial drugs allowed to achieve positive dynamics. On day 12 of the illness, the patient required no respiratory support. The presence of symptoms of gastrointestinal tract damage in COVID-19 necessitates the mandatory inclusion of PCR assay for SARS-CoV-2 into diagnostic protocol in patients with diarrheal syndrome to perform etiological disease interpretation.
ABSTRACT
Objective: Severe Maternal Morbidity (SMM) can be considered a marker of both maternity care and maternal mortality. The aim of this study was to review SMM in 2021 within the National Maternity Hospital (NMH), a tertiary level unit in Dublin, Ireland, with more than 9,000 births per year. Design: The study was a retrospective cohort study of women who experienced SMM in the NMH, Dublin in 2021. Methods: SMM was defined using the criteria established by the National Perinatal Epidemiology Centre (NPEC) in University College Cork. There are 17 reportable morbidities including Major Obstetric Haemorrhage (MOH), Eclampsia, Peripartum Hysterectomy, Anaesthetic complications etc. Data was prospectively recorded from a variety of sources including HDU, Pathology, Placenta Accreta Team, Maternal Medicine Team, Microbiology, Haematology, Anaesthesiology, Labour Ward. Data was included from Jan 1st 2021 to December 31st of the same year. Results: Using the NPEC criteria, 41 women experience at least one SMM during this time, of which four had more than one SMM. As with previous audits and in parallel with National and International data, the most common SMM was MOH with 18 cases. Five women underwent a Peripartum Hysterectomy. Seven women had Renal/Liver Dysfunction, mostly as a result of Pre-eclampsia. Of note, given the context of the COVID pandemic, there were no patients with septic shock due to a COVID infection. There was one late maternal death due to metastatic carcinoma diagnosed during pregnancy. Conclusion: This study highlights the importance of ongoing training for new and established staff members in obstetric emergencies, such as MOH. It also demonstrates importance of audit in the clinical setting, where ongoing reviews highlight issues of importance.
ABSTRACT
Objective: The objective of the study was to estimate how the proinflammatory and prothrombotic imbalances correlates with cardiovascular and renal events at hypertensive patients (pts) after Covid-19. Design and method: 40 hypertensive pts, (mean age 58.5 ± 9.6 years, 52.5% males)=group 1 and 40 hypertensive pts recovered after Covid-19, matched for age and sex (mean age 60.4 ± 10.8 years, 55% males)=group 2. Inflammation profile was estimated by serum measurement of C reactive protein (CRP), ferritin (F), interleukin 6 (IL6) and fibrinogen (Fb). Prothrombotic profile was determined by serum measurement of D-Dimer (DD). All pts were evaluated during one year, in order to detect the following complications: unstable angina (UA), non-STsegment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), renal dysfunction (RD): microalbuminuria, proteinuria, chronic kidney disease. Results: In group 1, UA was significantly associated with higher level of CRP (2.25 ± 0.65 mg/L vs 7.32 ± 1.18 mg/L, p = 0.04). In the same group, RD was found in a higher proportion at pts with increased CRP (2.10 ± 0.56 mg/L vs 8.11 ± 1.21 mg/L, p = 0.02). In group 2, UA was also significantly associated with higher level of CRP (3.44 ± 0.62 mg/L vs 9.68 ± 1.15 mg/L, p = 0.03) and with greater proportion of DD (0.35 ± 0.08 mcg/ml vs 1.53 ± 0.12 mcg/ml, p = 0.01). NSTEMI was found in a higher proportion at pts with increased DD (0.42 ± 0.07 mcg/ml vs 1.87 ± 0.15 mcg/ml, p = 0.01). In the same group, RD was significantly more frequent at pts with higher level of IL6 (4.55 ± 0.92 pg/ml vs 8.32 ± 0.85 pg/ml, p = 0.04) and with greater level of F (76 ± 15 ng/ml vs 635 ± 26 ng/ml, p = 0.01). Conclusions: Proinflammatory status seems to predict a worse midterm outcome (one year) concerning cardiovascular and renal events at hypertensive pts, especially after Covid-19. Moreover, proinflammatory and prothrombotic imbalances appears to have more powerful midterm prognostic value for incidence of acute coronary syndromes without ST-segment elevation and for incidence of RD at hypertensive pts recovered after Covid-19.
ABSTRACT
Introduction: Daptomycin is an antibiotic approved by FDA in 2003 with an excellent coverage for Gram positive cocci including methicillin resistant Staph. Aureus and vancomycin resistant Enterococci.Acute Eosinophilic Pneumonia(AEP) is a rare but potentially fatal complication of daptomycin is characterized by febrile illness, Hypoxemia,Diffuse Bilateral pulmonary infiltrates and BAL with >25% eosinophils. Case Report: 79 Y/O M with the CKD stage 4 and hypertension presented to the hospital with fever, dry cough and worsening shortness of breath after a recent hospital admission for MRSA bacteremia.Patient was admitted 1 week before presentation for symptoms of pyelonephritis and was found to have MRSA bacteremia for which he was discharged on IV daptomycin for 6 weeks. On admission,patient was febrile with hypoxic to 81%. Labs did show leukocytosis with mild peripheral eosinophilia.PCR for respiratory viruses including covid was negative.Chest X ray was done, which was consistent with multifocal Pneumonia which was followed by Chest CT scan which demonstrated new bilateral dense ground-glass and consolidative opacities.Given concerns for aspiration pneumonia, fungal infections or eosinophilic pneumonitis,pulmonology was consulted for possible bronchoscopy.Bronchoscopy with BAL was done the next day.BAL revealed a WBC of 260/μL with 45% eosinophilic predominance. Given the bronchoscopy results,his symptoms were attributed to Daptomycin related eosinophilic pneumonia.Patient was started on 40mg oral prednisone for a total of 4 weeks with rapid taper.Over the hospital course, his symptoms completely resolved. Discussion: The prosed mechanism involves presentation of drug or drug-hapten combination by the macrophages to the T helper cell results in interleukin-5 release which along with macrophage released eotaxin, results in eosinophilic migration to lungs.The criteria for to diagnose AEP due to daptomycin consist of 4 components which includes febrile illness,hypoxemia,diffuse bilateral pulmonary infiltrates and BAL with >25% eosinophils.Peripheral eosinophilia may not be present in all cases. It is also possible that daptomycin, a renally excreted drug, persists in the lungs of patients with renal dysfunction as seen in our patient and as such may lead to higher incidence of daptomycin induced AEP.In most cases, a short course of steroids(2-3 weeks)is sufficient for complete resolution of symptoms. Conclusion: Daptomycin induced AEP is increasingly seen in patients with high doses of drug and underlying renal dysfunction,and not related to therapy duration as it can occur as early as day 3 of treatment and as late as week 6 of treatment course. Bronchoscopy with BAL should be considered in all cases suspected. (Figure Presented).
ABSTRACT
BACKGROUND AND AIMS: During COVID-19, the renal impairment is the most frequent after lung impairment and is associated of poor prognosis particularly in the intensive care unit (ICU). In this work, we aim to assess the incidence of acute kidney injury (AKI) in COVID-19-related acute respiratory distress syndrome (ARDS) patients, the existence of an early renal dysfunction and its prognosis, and its specificity compared with patients with non-COVID ARDS. METHOD: This a prospective and multicentric study led in four ICUs. Patients of 18 years and older in ICU with invasive mechanical ventilation for ARDS were enrolled. Precise evaluation of renal dysfunction markers, including urinary protein electrophoresis, was performed within 24 h after the onset of mechanical ventilation. RESULTS: From March 2020 to September 2021, 131 patients in ICU for ARDS were enrolled, 98 COVID-19 ARDS and 33 ARDS from other causes. There was more tubular profile in COVID-19 patients (68% versus 24%;P = .001) and a more mixed, tubular and glomerular profile in non-COVID-19 patients (29% versus 14%;P = .001). COVID-19 patients displayed an important tubular proteinuria, tended to display more AKI (49% versus 31%;P = .07), and had a longer duration of mechanical ventilation (18 versus 10 days;P = .002) and longer ICU length of stay (23 versus 15 days;P = .013). In COVID-19 patients, tubular proteinuria was associated with poor renal prognosis with a significant association with the onset of KDIGO ≥ 2 AKI. CONCLUSION: COVID-19 ARDS patients had a specific renal impairment with tubular dysfunction, which appeared to be of poor prognosis on kidney and disease evolution.
ABSTRACT
BACKGROUND AND AIMS: Replication of the enveloped SARS-COV2 virus can alter lipidomic composition and metabolism of infected cells [1]. These alterations commonly result in a decline in HDL, total cholesterol and LDL, and an increase in triglyceride levels in COVID-19 patients. Furthermore, the 'cytokine storm' subsequent to release of inflammatory cytokines can severely impair lipid homeostasis. Importantly, decreased HDL-cholesterol correlates with severity of COVID-19 infection and represents a significant prognostic factor in predicting poor clinical outcomes [2]. Similarly, it has been observed that COVID-19 patients' recovery is accompanied by a rise in serum HDL levels. Pharmacological intervention that aims to restore ApoA-1 or functional HDL particles may have beneficial roles for clinical outcome of COVID-19 patients and has recently been approved for compassionate use [3]. SARS-CoV 2 spike proteins S1 and S2 can bind free cholesterol and HDL-bound cholesterol, facilitating virus entry by binding the ACE2 co-receptor Scavenger Receptor-BI (SR-BI) [4]. When activated at the trans-membrane level, SR-BI signalling culminates in Ser1173-eNOS phosphorylation with both anti-inflammatory and anti-apoptotic effect. We hypothesized that SARS-COV2 binding promoted SR-BI internalization, so that it could not exert its essential protective function. Therefore, the aim of this study is to evaluate the effects of CER-001, a mimetic HDL, in antagonizing this process. METHOD: Endothelial and tubular (RPTEC) cells were exposed to S1, S2 and S1 + S2 (50-250 nM) with or without CER-001 (CER-001 50-500 ug/mL) and cholesterol (10-50 uM). Apoptosis tests (MTT and AnnV/PI) were performed. Internalization of SR-BI, ACE2 with S1 and activation of eNOS was evaluated by FACS analysis. SR-BI and ACE2 expression were evaluated on kidney biopsies from COVID-19 patients. RESULTS: At concentrations used, the exposition of S1, S2 and S1 + S2 in the presence of CER-001 and cholesterol did not induce apoptosis of endothelial cells and RPTEC. Endothelial and tubular cells stimulated by S1, in presence of cholesterol, showed an increased intracellular level of SR-BI and ACE-2, with significantly reduced eNOS phosphorylation compared to baseline (P < 0.05). The treatment with CER-001 reversed trans-membrane SR-BI levels and eNOS phosphorylation to baseline values. The detection of S1 spike protein by endothelial cells immunohistochemistry revealed an increased level in S1-exposed cells with cholesterol and reduced S1 intracellular positive staining in CER-001-exposed cells (P < 0.05). Interestingly, S1-exposed cells without cholesterol appeared not to be capable of mediating S1 spike protein internalization. Consistent with in vitro results, analysis of renal biopsies from COVID-19 patients with proteinuria showed increased SR-BI and ACE-2 cytoplasmic signals and reduced expression at the apical domain of injured tubules. CONCLUSION: Our data confirmed the key role of lipid profile in SARS-COV2 infection, evaluating the molecular signalling involved in HDL metabolism and inflammatory processes, and could offer new therapeutic strategies for COVID-19 patients. (Figure Presented).
ABSTRACT
BACKGROUND AND AIMS: A Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents with severe pneumonia and fatal systemic complications. Currently, SARS-CoV- 2 vaccines are effective in reducing the risk of onset and severity of the disease. However, autoimmune diseases, including anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), have been reported as rare complications of the COVID-19 vaccine. Although the mechanism of ANCA vasculitis remains unknown, the genetic background, environmental factors and infections are involved in the development of the disease. Genome-wide association studies have identified several AAV-related haplotypes, including the human leukocyte antigen (HLA)-DRB1∗09: 01 allele. Here, we report a case of AAV with a risk HLA allele after SARS-CoV-2 vaccination (Pfizer-BioNTech) and a literature review. METHOD: Case report: A 71-year-old woman visited a clinic complaining of fever (37.0-37.5°C) and malaise, 1 week after receiving second dose of COVID-19 vaccine (Pfizer-BioNTech). Two months after her first dose, her serum creatinine (Cr) level had increased from 0.86 mg/dL to 1.2 mg/dL with high titer of MPO-ANCA (280 IU/mL, normal value <3.5 IU/mL). Urinary microscopy revealed a red blood cell count of 30-49/high power field and a urinary protein-creatinine ratio of 1.06 g/gCr. We diagnosed MPO-AAV with manifestations of renal involvement, general symptoms and the presence of ANCA, as a cause of renal progressive glomerulonephritis. A course of corticosteroids and intravenous cyclophosphamide was initiated. After treatment, her general symptoms and urinary abnormalities disappeared, and renal insufficiency was improved as well. Three months later, the MPO-ANCA titer decreased to 27.4 IU/mL. We examined a human leukocyte antigen (HLA) haplotype and her allele was HLA-DRB1∗09:01, which is a known risk allele of MPO-ANCAassociated vasculitis. RESULTS: Review: Until November 30, 2021, we searched PubMed, including the case report study and seven cases have been reported as De novo AAV after SARS-CoV-2 vaccination. The mean age of patients was 72.5 years (three women and four men). The onset of symptomatic symptoms, such as fever, headache and malaise, ranged from the day after the first dose to 2 weeks after the second dose;consequently, renal dysfunction was detected. In six patients (except for our case), histological findings showed pauci-immune crescentic glomerulonephritis. Most patients received initial induction immunosuppressive therapy, including corticosteroids and cyclophosphamide, followed by maintenance therapy. The renal involvement of six patients improved, but one patient with severe renal dysfunction developed end-stage renal disease. Information on HLA allele was not available in any case. CONCLUSION: This is the first case report of De novo AAV after SARS-CoV-2 vaccination in a patient with AAV susceptible HLA-DRB1∗09:01 allele. (Table Presented).
ABSTRACT
BACKGROUND AND AIMS: The objectives of the present study are to compare the renal impairment between patients with SARS-COV-2 in two different time periods with dominant beta and delta SARS-COV-2 variants, with or without prior chronic kidney disease (CKD). METHOD: The study was performed on 80 patients from Bucharest Emergency University Hospital, Nephrology ward, 40 out of 80 patients were diagnosed with SARS-COV-2, beta variant dominant and 40 were diagnosed with SARS-COV-2 delta variant dominant. All patients were confirmed with SARS-COV-2 infection with positive PCR tests. In order to assess the renal function for the patients with beta and delta variant of SARS-COV-2, the values of urea, creatinine, sodium, potassium, calcium, phosphorus and haemoglobin were observed during their hospitalization. Only 4 out of 40 patients with beta variant (10%) had documented pre-existing CKD. The average period of hospitalization was 14 days, with three exceptions (7.5%) in which due to the advancement of acute respiratory failure patients were transferred to the ICU. Only 3 out of 40 patients with delta variant (7.5%) were diagnosed with acute kidney injury (AKI). Average period of hospitalization was 14 days, with three exceptions (7.5%) in which due to the advancement of acute respiratory failure patients was transferred to the ICU. RESULTS: In 36 out of 40 patients (90%) with beta variant dominant of SARS-COV- 2, the analysis of biological parameters shows a minimal change in their values during hospitalization with normal maintenance of renal function. In two patients (5%), diagnosed with CKD, an average of three to four haemodialysis sessions were performed with the improvement of renal function, while maintaining a minimum nitrogen retention. In two patients with CKD (5%), renal function depreciated, leading to haemodialysis initiation. In 33 out of 40 patients (82.5%) with delta variant dominant of SARS-COV-2, the analysis of biological parameters shows a minimal change in their values during hospitalization with normal maintenance of renal function. In 4 out of 40 patients (10%), the renal function depreciated in context of multiple system organ failure (MSOF), and subsequently they died. During hospitalization, in three patients (7.5%) who were admitted with AKI, the renal disfunction was resolved by the time of their discharge. There were no statistically relevant differences (P > .1) in measured parameters between the two time periods with the different SARS-COV-2 strings. CONCLUSION: According to this statistical analysis, the delta variant does not cause more kidney damage than the beta variant of SARS-COV-2. For the six patients (7.5%) with renal impairment, two from the beta batch (2.5%) and four from the delta batch (5%), the suspicion of renal damage in SARS-COV-2 infection may be raised, but excluding other causes of renal damage is necessary. For the three patients (7.5%) with AKI from the delta batch, the suspicion of renal damage caused by COVID-19 may be raised because there were no other causes for renal impairment.