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1.
Pakistan Paediatric Journal ; 46(2):229-232, 2022.
Article in English | EMBASE | ID: covidwho-1955740

ABSTRACT

Staphylococcal aureus infection in children is a major public health problem globally. It causes a varied spectrum of clinical disease including bacteremia, endocarditis, skin and soft tissue infection, pleuro-pulmaonry and osteo-articular infection. Deep vein thrombosis (DVT) is a known complication of staphylococcal infection. We report a case series which included, 10-year old boy developed DVT, septic pulmonary emboli and Methicillin-resistant Staphylococcal aureus (MRSA) bacteremia following a furuculosis and 13 year old girl with thrombosis of internal and external jugular vein, cavernous sinus with pulmonary emboli and MRA bacteremia. Both patients are previously healthy showed complete recovery after aggressive appropriate antibiotics, anticoagulants and supportive care. The high index of suspicion of DVT in MRSA infection is needed, prompt diagnosis and aggressive appropriate therapies improve the outcomes and minimize the complications.

2.
Pakistan Journal of Medical and Health Sciences ; 16(6):355-356, 2022.
Article in English | EMBASE | ID: covidwho-1939796

ABSTRACT

Objective: To analyze multisystem imaging techniques for diagnosis of Covid-19 viral pathogenesis and pulmonary complications. Study Design: Retrospective study. Place and Duration of Study: Department of Pulmonology, Ghulam Muhammad Mahar Medical College, Sukkur from 1st June 2021 to 31st December 2021. Methodology: Two hundred patients admitted due to Covid-19 positive results were enrolled. Pulmonary consolidations and pneumonia related alterations were observed due to these images. Changes which were related with acute respiratory distress syndrome in complicate Covid-19 cases were also observed. Patients with serious illness were further underwent chest computer topographic imaging scan. Pulmonary-US scan was also performed on the bedside of severe ill Covid-19 patients. In patients with acute respiratory decline and acute dyspnea were also further diagnosed through computed tomography angiography. Results: The mean age of the patients was 41.2±6.5 years. Chest radiograph presented bilateral pneumonia opacities. In a typical progressive pneumonia could be seen through non-contrast enhanced computed tomography imaging in covid-19 patients with glass opacities and bilateral ground glass opacities. In many cases multifocal, patchy as well as distribution findings which were confluent and organizing as pneumonia were also observed. Pulmonary embolism was also identified through computed tomography imaging in Covid-19 patients. Conclusion: Multisystem imaging techniques are significantly important and efficient in diagnosis of various manifestations of Covid-19.

3.
Congenital Heart Disease ; 17(4):399-419, 2022.
Article in English | EMBASE | ID: covidwho-1939710

ABSTRACT

Background: Adult patients with congenital heart disease (ACHD) might be at high risk of Coronavirus disease-2019 (COVID-19). This study aimed to report on a one-year tertiary center experience regards COVID-19 infection in ACHD patients. Methods: This is a one-year (March-2020 to March-2021) tertiary-center retrospective study that enrolled all ACHD patients;COVID-19 positive patients’ medical records, and management were reported. Results: We recorded 542 patients, 205 (37.8%) COVID-19-positive, and 337 (62.2%) COVID-19-negative patients. Palliated single ventricle and Eisenmenger syndrome patients were more vulnerable to COVID-19 infection (P < 0.05*). Cardiovascular COVID-19 complications were arrhythmias in 47 (22.9%) patients, heart failure in 39 (19.0%) patients, cyanosis in 12 (5.9%) patients, stroke/TIA in 5 (2.4%) patients, hypertension and infective endo-carditis in 2 (1.0%) patients for each, pulmonary hypertension and pulmonary embolism in 1 (0.5%) patient for each. 11 (5.4%) patients were managed with home isolation, 147 (71.7%) patients required antibiotics, 32 (15.6%) patients required intensive care unit (ICU), 8 (3.9%) patients required inotropes, 7 (3.4%) patients required mechanical ventilation, and 2 (1.0%) patients required extracorporeal membrane oxygenation (ECMO). Thromboprophylaxis was given to all 46 (22.4%) hospitalized patients. American College of Cardiology/American Heart Association classification revealed that complex lesions, and FC-C/D categories were more likely to develop severe/critical symptoms, that required mechanical ventilation and ECMO (P < 0.05*). Mortality was reported in 3 (0.6%) patients with no difference between groups (P = 0.872). 193 (35.6%) patients were vaccinated. Conclusions: COVID-19 infection in ACHD patients require individualized risk stratification and management. Eisenmenger syndrome, single ventricle palliation, complex lesions, and FC-C/D patients were more vulnerable to severe/critical symptoms that required ICU admission, mechanical ventilation, and ECMO. The vaccine was mostly tolerable.

4.
Journal of Hypertension ; 40:e180, 2022.
Article in English | EMBASE | ID: covidwho-1937743

ABSTRACT

Objective: The relationship between COVID-19 and blood pressure (BP) has raised great concern since the discovery of Angiotensin Convertase Enzyme 2 (ACE 2) - mediated mechanism of action for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2). Hypertension (HTN) itself proved to be a risk factor for more severe Coronavirus Disease 19 (COVID -19). However less studies focus on the trend of blood BP for patients with COVID-19 during the initial phase of disease. Design and method: We present the case of a 71 years old woman with grade 2 HTN previously controlled with diuretic and betablocker therapy that came to our hospital with dyspnea, cough and debilitating fatigue progressively worsened in the last 10 days. The patient also related the first episode of syncope in her life the night before the presentation. Results: The clinical evaluation revealed a conscious, euvolemic, with polypnea and a peripheral saturation in oxygen of 86%, corrected to 95% with 9 liters oxygen/ minute via simple face mask and a BP of 110/70 mmHg with a ventricular rate of 45 beats per minute in supine position. The assessment of BP values while standing showed a value of 78/60 mmHg after 1 minute and 58/40 mmHg after 3 minutes, while the ventricular rate increased overall to 65 beats per minute. ECG was remarkable only for mild bradycardia and computed tomography pulmonary angiogram excluded pulmonary embolism. The patient was admitted with severe COVID-19 accompanied by severe orthostatic hypotension and bradycardia. Continuous telemonitoring showed only mild bradycardia. Under standard COVID 19 treatment, after 10 days, her symptoms had resolved with no residual orthostatic hypotension or bradycardia. Conclusions: In conclusion this case reflects the life-threatening dysautonomia caused by SARS-COV 2 infection. More concern should be placed on this type of fragile patients, taking into account both the macroscopic implications of being confined to bed for a long period of time and the microscopic butterfly effect caused by the binding of the virus on the widespread ACE 2 in the lungs, heart, kidneys and digestive tract.

5.
Journal of Hypertension ; 40:e178, 2022.
Article in English | EMBASE | ID: covidwho-1937735

ABSTRACT

Objective: To assess clinical and pathomorphological features of kidney damage in patients with arterial hypertension (AH) who died of the new coronavirus infection COVID-19. Design and method: A complex analysis of 268 kidney autopsies was carried out, including the study of macro- and microscopic changes reflected in the protocols of pathological and anatomical autopsies and identified during the histological examination. In 224 patients (83.6%) with AH, the diagnosis was confirmed by isolating the SARS-CoV-2 RNA using the polymerase chain reaction;in 44 (16.4%) - through computed tomography of the lungs. The causes of deaths were the following: in 31 patients (11.6%) acute myocardial infarction;in 40 (14.9%) cerebrovascular accident;in 11 (4.1%) pulmonary embolism;222 patients (83%) had acute respiratory distress syndrome. The analysis included 130 men aged 36 to 92 (72.6 years old on average) and 138 women aged 40 to 106 (77.1 years old on average). Results: In the kidneys we detected ischemic changes caused by disturbances in the microvasculature. These are stases, sludges, erythrocyte and fibrin thrombi predominantly in the medulla. In the glomeruli diapedesis hemorrhages, mesangial cells proliferation, basement membrane thickening and fibrinoid necrosis of the capillary wall were observed. In the epithelium of the convoluted tubules, a granular, hyaline-drop dystrophy and a necrosis as the extreme degree of the damage were noted. In the kidneys, a pronounced lymphoid and leukocyte infiltration was detected. These changes were accompanied by inflammation and renal failure symptoms. In particular, the level of C-reactive protein was 140.6 ± 7.42 mg/l;blood ferritin 1258.0 ± 110.1 mcg/l;blood leukocytes 15.0 ± 0.67 10

6.
Journal of Hypertension ; 40:e168-e169, 2022.
Article in English | EMBASE | ID: covidwho-1937706

ABSTRACT

Objective: The case report presents two patients with COVID-19 history. The first patient, treated with enoxaparin, was diagnosed with pulmonary embolism, and later developed heparin-induced thrombocytopenia. The second patient with history of chronic pulmonary thromboembolism and multiple comorbidities, treated with rivaroxaban and acetylsalicylic acid, reported haemorrhagic events. The objective of this case report is to highlight possible complications of anticoagulant treatment and the role of accurate and rapid response of clinicians in COVID-19 patients. Design and method: Case report of two patients with COVID-19 - related thrombotic complications treated respectively with low molecular weight heparin and rivaroxaban. Observation of the treatment process revealed complications in both cases, demanding change of medications within the same group of drugs. Results: Development of thrombotic episodes was noticed and treated in time. Both patients developed complications of treatment. Modifications of anticoagulation drugs (low molecular weight heparin replaced with fondaparinux and rivaroxaban with apixaban respectively) were provided with positive outcomes. Conclusions: SARS-CoV-2 infection is associated with a high risk of thrombotic events whereas anticoagulant treatment can also lead to various complications. The necessity of watchful observation of coagulation parameters in patients with COVID-19, but also potential complications of any anticoagulant treatment is crucial for the positive long-term outcomes.

7.
European Stroke Journal ; 7(1 SUPPL):137, 2022.
Article in English | EMBASE | ID: covidwho-1928083

ABSTRACT

Background: Despite spontaneous recovery, 60% of stroke patients have residual impairment. Thawed allogenic adipose-derived mesenchymal stem cells (ADSCs) were used in cell therapy studies with promising results. However, fresh allogenic ADSCs, obtained after a short (oneweek) culture from a frozen cell stock, have a better viability and functionality. We assessed feasibility and safety of intravenous (IV) injection of fresh ADSCs in subacute ischemic stroke. Methods: RESSTORE 1a is a first-in-human, open, dose-escalation toxicity 3+3 trial. Four doses of ADSCs were assessed: 1, 1.5, 2 or 3 million/ kg injected <10 days after stroke onset. Dose-limiting toxicity (DLT) events were predefined: recurrent stroke, myocardial infarction, pulmonary embolism, life-threatening event within one week after treatment. Results: 17 patients were included (mean age +/-SD = 57 +/-18 years;inclusion NIHSS = 14.5 +/-3.5). As 2 patients were not treated (non conformity of ADSC culture and technical problem during infusion), 2 additional patients were included. A DLT event (recurrent minor stroke) occurred in the 2-million/kg group. Among the 15 treated patients, 3 patients received 1, 1.5 or 3 million ADSCs /kg, and 6 patients 2 million ADSCs /kg. A lung carcinoma was diagnosed in an active smoker (1.5 year after treatment) and a patient died after Covid-19 pneumopathy (1 year after treatment). No dose effect on safety was noted. Conclusions: IV injection of fresh allogenic ADSC seems safe in subacute stroke. A multicenter randomized trial is planned.

8.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927825

ABSTRACT

Introduction: Antifibrotic drugs, including nintedanib and pirfenidone, are approved for the treatment of idiopathic pulmonary fibrosis (IPF). Pirfenidone blocks the synthesis of TGF-beta and does appear to increase the risk of CV or bleeding events. Nintedanib is a Vascular Endothelial Growth Factor Receptors (VEGFR) inhibitor and may increase the risk of bleeding. Bleeding events were reported in 10% of patients in clinical trials (despite excluding patients at risk of bleeding including those on con-current anticoagulation (AC) or antiplatelet (AP) therapy. Consequently, nintedanib is relatively contraindicated for patients with IPF on anticoagulation or antiplatelet therapy. However, results from real-life data demonstrate that 17.8% of our patients with IPF are on anticoagulation or antiplatelet therapy. The overall incident of bleeding events in those patients taking either or with nintedanib is similar to that reported for Nintedanib alone. We describe two patients with antifibrotic and anticoagulation therapy to highlight how to manage these patients. Case 1. A 67-year-old female with history of acute pulmonary embolism secondary to COVID-19 on anticoagulation therapy presents for workup of acute respiratory distress syndrome or suspected exacerbation of underlying IPF-usual interstitial pneumonia. Patient treated as IPF with pirfenidione. Case 2. A 69-year-old man with a history of atrial fibrillation on anticoagulation therapy presents for follow-up of progressive fibrosing interstitial lung disease secondary to hypersensitivity pneumonitis. Nintedanib initiated for progressive fibrosing lung disease. Discussion: Concomitant use of anticoagulation and/or antiplatelet therapy with antifibrotics doesn't increase bleeding risk. Conclusion. Anticoagulation and/or antiplatelet therapy should not be a reason to withhold antifibrotic therapy in patients with IPF.

9.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927820

ABSTRACT

Introduction: Primary tracheal tumors are rare with an incidence of 0.2/100,000 persons, accounting for 0.6% of all pulmonary tumors. Only 10-20% of these tumors are benign with the most common being recurrent respiratory papillomatosis. Other benign tracheobronchial tumors include hamartoma, fibroma, lipoma and hemangioma among others. Due to the slow growing nature of these tumors, patients may present with progressive exertional dyspnea, cough and recurrent pneumonia, though rarely these tumors are identified incidentally in asymptomatic patients. This case describes a patient with an who underwent successful resection with flexible bronchoscopy and snare electrocautery. Case Report: A 66-year-old male with a history of former tobacco use was admitted to the medical intensive care unit (ICU) in 11/2020 with COVID-19 pneumonia, and incidentally found to have a tracheal tumor noted on CT imaging. His ICU course was complicated by submassive pulmonary embolism, pneumothorax requiring chest tube, and acute hypoxemic respiratory failure requiring heated high-flow nasal cannula. He was successfully discharged to home after 4 weeks and evaluated in the ambulatory clinic for follow-up 2 months later. Review of his imaging from an outside facility demonstrated a 1-cm polypoid lesion arising from the right tracheal wall (Figure 1A). Pulmonary function testing demonstrated a moderate restrictive defect with normal flow-volume loops. He was referred to interventional pulmonology for further evaluation and management. Flexible bronchoscopy revealed a 50% partially obstructing polypoid mass 6-cm distal to the vocal cords (Figure 1B). The mass was excised using snare electrocautery with subsequent cryotherapy for destruction of abnormal tissue at the base of the lesion and argon plasma coagulation for hemostasis. Pathology revealed tracheal lipoma. Repeat flexible bronchoscopy 12 weeks later revealed no evidence of recurrence at the site of the previously resected tracheal lipoma (Figure 1C). Discussion: Among benign tracheobronchial tumors, lipoma is an extremely rare diagnosis representing only 3-9% of cases. Airway lipomas very rarely involve the trachea and are infrequently found incidentally in asymptomatic patients. Epidemiological risk factors are thought to include male gender, obesity, middle age, and smoking. Flexible tracheobronchoscopy remains the gold standard for diagnosis, also allowing for excisional treatment with electrocautery, cryotherapy, or laser therapy. Given the rare incidence of these tumors, follow-up evaluation is recommended, though to-date there are no reports of local recurrence after bronchoscopic treatment. This case highlights the importance for diagnostic evaluation of incidental tracheobronchial tumors given the rare incidence of benign diagnoses.

10.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927819

ABSTRACT

Post-intubation tracheal stenosis (PiTS) is a complication that occurs in 10-22% of patients after prolonged intubation or tracheostomy. Predisposing factors include localized infection, soft tissue trauma, granulation at the site of stoma, hypotension, tracheal cartilage damage, and metabolic disorders. Despite advances in the design of endotracheal tubes and cuffs, PiTS continues to remain an undesired consequence that warrants increased attention, especially in the COVID pandemic, which has led to increased number of tracheostomies and intubations. Consequently, prompt diagnosis and management is imperative to improve patient survival and quality of life. Herein, we present a 52-year-old male with history of tracheostomy in the setting of prolonged intubation from intraparenchymal hemorrhage with subsequent decannulation who was admitted for the management of pulmonary embolism. His course was complicated by encephalopathy and acute hypercapnic respiratory failure requiring intubation. In the intensive care unit, the patient was extubated after improvement in his respiratory and mental status, however developed shortness of breath and the feeling of impending doom a few hours after extubation. Chest radiograph was obtained and suggested tracheal stenosis (Image-1A). Given this finding, follow-up urgent chest computed tomography demonstrated severe lateral collapse of the subglottic space with critical tracheal stenosis (Image-1B). There was >90% cross sectional area reduction at the site of greatest stenosis (Image-1C). The measured area at the site of greatest stenosis was noted at 0.32 cm2 (average tracheal area is 2.8-3.4 cm2). His tracheal stenosis was suspected to be secondary to his history of tracheostomy. Given these findings, patient was reintubated for airway protection and urgently underwent rigid bronchoscopy. Initially, argon plasma coagulation was used in between stenotic areas, however there was minimal improvement in the airway, requiring a silicone 18 x 14 x 14 cm Y-stent to be placed. Since stent placement, patient has required frequent bronchoscopies to assist with mucus and secretion clearing. The remainder of his hospital course was benign. PiTS is an infrequent yet important complication that clinicians must consider in individuals with a history of prolonged intubation who have sudden difficulty breathing postextubation. Prompt recognition is required to manage these patients effectively. Factors considered in the management include location, length, and the severity of the stenosis. Therefore, if 1) critical stenosis is suspected, 2) the facility is capable of resection and reconstruction, and 3) the patient has minimal comorbidities, surgery should be considered. Otherwise, bronchoscopy with stent placement can be performed.

11.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927728

ABSTRACT

Introduction Immune thrombocytopenia (ITP) is an acquired thrombocytopenia due to autoantibodies. Eltrombopag is a thrombopoietin receptor agonist (TPO-RA) used as a second-line agent in the setting of persistent or chronic ITP. Potential severe adverse effects include hepatotoxicity, thromboembolism, and increased risk of myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Upper respiratory infections and pharyngitis have also been described, but to our knowledge, no known cases of eltrombopag-induced pneumonitis have been reported to date. Case Presentation We present a 68-year-old male with a history of recent onset ITP, stage IV mantle cell lymphoma (in remission), and Pneumocystis pneumonia who was initiated on eltrombopag 11 days prior to admission for ITP refractory to corticosteroid therapy. Three weeks prior to admission, the patient underwent a bone marrow biopsy without evidence of monoclonal B cells or immunophenotypically abnormal T cell populations. Following initiation of eltrombopag, the patient had progressive dyspnea on exertion associated with subjective fevers and chills requiring hospitalization. Oxygen saturation was 88% on room air with exam notable for coarse crackles to the bilateral lung bases. CT angiogram of the chest revealed bilateral pulmonary emphysema, ground glass opacities, and bilateral bronchiectasis most pronounced in the lower lobes (Figure 1). No pulmonary embolism or mediastinal adenopathy was identified. Cytomegalovirus DNA, aspergillus antigen, and COVID-19 NAAT testing were negative. A respiratory viral panel was positive for Rhinovirus. Bronchoalveolar lavage (BAL) and right middle lobe lung parenchymal biopsy were subsequently performed. Pathology demonstrated focal intra-alveolar organization and fibroblast plugs, interstitial fibrosis, pneumocyte hyperplasia, and mixed (predominantly chronic) inflammatory infiltrate (Figure 2a & 2b). BAL was negative for malignant cells. Pneumocystis jirovecii DNA was detected, but < 250 copies/mL were identified and thus was thought to be less likely contributing to the disease process.Given the suspicion for eltrombopag-induced pneumonitis, the patient was initiated on high-dose corticosteroid therapy with a slow taper over the span of several weeks. Following initiation of corticosteroids, the patient was noted to have gradual improvement in his respiratory status. The patient was ultimately discharged on room air 1 month later due to other hematologic complications necessitating a prolonged hospital stay. Discussion The exact mechanism of eltrombopag-induced pneumonitis is unclear, although we postulate that it is related to an exaggerated immune response involving T-cell homeostasis resulting in alveolarcapillary permeability, inflammation, and fibrosis. Suspicion for eltrombopag-induced pneumonitis should prompt initiation of early corticosteroid therapy to prevent acute and chronic complications of pneumonitis. (Figure Presented).

12.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927724

ABSTRACT

Introduction: Methamphetamine can cause toxic lung parenchymal injury irrespective of frequency of use. It is important for physicians to be aware of methamphetamine associated lung injury as a differential diagnosis of acute respiratory distress in the era of COVID pandemic. Here we discussed a case of methamphetamine induced pneumonitis and its management. Case description: A 35-year-old female with history of pulmonary coccidiomycosis s/p treatment 15 years ago, ex-smoker (quit 8 years ago), unvaccinated for COVID-19 presented with two weeks of progressively worsening shortness of breath, fever, chills, generalized body aches, sore throat with hoarseness of voice, nonproductive cough, wheezing and midsternal chest pain. On presentation, vitals were significant for hypoxia with SpO2 84% requiring 2L of nasal canula, sinus tachycardia to 109, tachypneic in 30s. Physical exam showed stridor and bilateral diffuse expiratory wheezing. Stridor improved with racemic epinephrine and dexamethasone 10mg IV. CBC, CMP, Procalcitonin, BNP, COVID-19 and Respiratory PCR were negative, while coccidioidomycosis antibody was positive. UDS was positive for methamphetamine. Chest X-ray showed features of atypical pneumonitis. CT Chest showed similar findings and was negative for pulmonary embolism. She was managed symptomatically with albuterol inhaler. Respiratory symptoms improved during hospitalization without any further interventions. Discussion: According to National Survey on Drug Use and Health in 2018, 1.6million people (age >26years) used methamphetamine in one year which is 0.5% more than 2016-2017. Crystalline methamphetamine is a widely used inhaled stimulant with few reported cases of acute respiratory distress syndrome, eosinophilic pneumonia, pneumonitis, and diffuse alveolar hemorrhage. Even though mechanism of injury is unclear in human beings, toxicity was studied in animals. Chronic methamphetamine use causes thickened alveolar walls and reduced alveolar sacs by oxidative stress and by increased free radial formation. Patients often present with non-specific symptoms including cough, short of breath, sore throat or chest pain. The temporal relation of symptomatology with methamphetamine use and exclusion of infectious and other pulmonary etiology based on labs and radiological findings is crucial in establishing the diagnosis. Early diagnosis, symptomatic treatment and cessation of substance use are core management. Conclusion: We discussed a case of methamphetamine induced pneumonitis, who presented with upper and lower respiratory symptoms that resolved dramatically with the early diagnosis and supportive care. We recommend to consider methamphetamine induced lung injury as a differential diagnosis in patients with risk factor of illicit drug use, especially in the era of COVID-19 pandemic for early diagnosis and appropriate management. (Figure Presented).

13.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927719

ABSTRACT

We present a case with significant diagnostic and therapeutic challenges;a 57 year old female with history of bi-ventricular failure status post Left Ventricular Assisted Device (LVAD) in 2020 and Rheumatoid Arthritis (RA) who presented with Shortness of breath and refractory hypoxemia, Computerized tomography(CT) showed dense ground glass opacity and superimposed traction bronchiectasis which was not present in a prior CT. The management included high FiO2 therapy High flow nasal cannula (HFNC), initial heart failure measures with diuresis and antibiotics treatment were attempted, the clinical and radiological diagnosis of acute exacerbation (AE) of connective tissue disease associated interstitial lung disease (CTD-ILD) with progressive fibrosing phenotype was made, The decision of therapeutic pulse corticosteroids with Rituximab was based on the degree of severity of acute exacerbation, following treatment, the course of the disease was reversed with complete oxygen weaning with impressive clinical and radiological response. The case is considered puzzling from multiple aspects, first the complex comorbidities, LVAD placement made heart failure the main differential diagnosis (DD), the absence of interstitial infiltrate in the old CT made the initial diagnosis of AE of ILD less likely, other DD as Covid-19 pneumonia, pulmonary embolism, bacterial pneumonia were worked up. Another major dilemma was the optimal management of the life threatening hypoxemia in the setting of new CT findings. Connective tissue disease associated ILD is a diffuse parenchymal lung disease characterized by both inflammation and fibrosis. The progressive fibrosing phenotype carries poor prognosis, even worse is the prognosis of AE that characterized by marked deterioration and alveolar abnormalities with high mortality. There is extremely limited data of optimal treatment of AE and lack of blinded randomized controlled trials. Management is mainly supportive care, oxygen therapy is considered the cornerstone, otherwise no formal therapeutic strategy. The potential reported therapies included corticosteroids, immunosuppressant, anticoagulants, antibodies targeted therapy with no conclusive evidence. Although corticosteroids were described based on anecdotal evidence but recently published case series described novel combination of treating AE with combination of pulse steroid, Rituximab and plasma exchange resulting in promising outcome. In our case we followed the regimen of pulse steroids in combination with Rituximab which lead to satisfactory results in short interval. The rational of steroids use for its potent anti-inflammatory properties and since AE is linked to autoimmune antibody-driven inflammation, treatment with Rituximab causes Bcell depletion, the impressive clinical outcome of our patient signals a promising therapeutic potentials in treating fatal AE. (Figure Presented).

14.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927701

ABSTRACT

INTRODUCTION: E-cigarette or vaping associated lung injury (EVALI) is an uncommon complication of e-cigarettes or vaping. 96% of these cases require hospitalization. The condition is especially associated with tetrahydrocannabinol (THC) products, frequent use, and is found primarily in young adults. “Dabbing” refers to the process of heating THC containing oils or waxes with butane solvents to vaporize cannabinoids for inhalation. CASE REPORT: An obese 20-year-old college male with a history of prematurity and anxiety presented with cough, dyspnea, nausea, vomiting and diarrhea that began 3 days prior. He reported smoking marijuana, but denied vaping. Multiple PCR tests for SARS-CoV-2 were negative. Initial chest radiograph demonstrated multifocal pneumonia. He was hypoxic on presentation requiring two liters of oxygen via nasal cannula. Broad spectrum antibiotics for pneumonia and steroids were initiated. Oxygen requirements rapidly increased and humidified high flow oxygen was instituted and escalated to 60 liters per minute and 90 % FiO2. He remained hypoxic, prompting intubation 48 hours from presentation. His ventilatory settings were steadily escalated to a positive end expiratory pressure of 15 cm H2O with 100% FiO2. Despite this, the patient had oxygenation saturations as low as 57% requiring transition to venovenous extracorporeal membrane oxygenation (VV-ECMO). Computed tomography angiography ruled out pulmonary embolism but redemonstrated extensive alveolar and interstitial infiltrates bilaterally. Bronchoscopy with alveolar lavage was performed with negative cultures and cytology. Blood cultures were also negative and antibiotic therapy was stopped. Extensive laboratory investigation for autoimmune vasculitis was performed and found to be negative. Discussion with family revealed that the patient regularly inhaled concentrated THC wax with butane as a solvent. Treatment continued with high dose intravenous steroids and supportive care. The patient received a total of 5 days of ventilator support after which he was extubated, and an additional 5 days of VV-ECMO. At discharge, the patient required 2 liters of continuous oxygen at rest and 4 liters with activity. He was otherwise asymptomatic and at his baseline level of function. He was discharged on daily steroids with taper and close outpatient follow up. DISCUSSION: While the majority of hospitalized patients with EVALI require intubation, the necessity of VV-ECMO utilization represents a rare severe presentation. Dabbing remains a rare cause of acute respiratory distress syndrome and EVALI, however, dabbing is emerging as a trend among young adults and represents an under-investigated cause of severe inhalational lung injury.

15.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925572

ABSTRACT

Objective: We aim to report clinical characteristics of an extremely rare case of myelitis with Guillain-Barré syndrome (GBS) and cerebellar ataxia (CA) after COVID-19 infection. Background: There have been many reports about neurological complications following the world pandemic of COVID-19. We found about 100 GBS, 50 myelitis, and 10 CA cases after COVID-19 infection. To best our knowledge, this is the first report of myelitis with GBS and CA accompanied by multiple autoantibodies. Design/Methods: NA Results: A 60-year-old man with fever and cough was diagnosed with mild COVID-19 infection. Fourteen days later from the onset, he developed gait disturbance and fell frequently. On hospitalization, he exhibited fever, hypoxemia, mild consciousness disturbance, flaccid paraplegia, mild numbness and severe deep sensory disturbance in the lower limbs, bladder and bowel disturbance, mild muscle weakness in the fingers, myoclonus in the extremities, and CA. The PCR of COVID-19 was negative. Blood investigations showed elevated inflammatory markers with dehydration, rhabdomyolysis, and hypercoagulation. Cerebrospinal fluid (CSF) analysis presented mild pleocytosis and elevated protein without anti-COVID-19 antibodies. Contrast-enhanced CT showed massive pulmonary embolisms and deep venous thromboses. Brain SPECT showed cerebellar hypoperfusion despite no abnormalities in brain MRI. Spine MRI revealed longitudinal hyperintense lesions mainly in the dorsal white matter, compatible with myelitis. Additional investigations of autoantibodies realized anti-GM3, TPI, GluR, and NMDAR IgG antibodies in serum, and anti-GluR and NMDAR IgG antibodies with increased granzyme B in CSF. Treatments of corticosteroid and intravenous immunoglobulin resulted in complete recovery to consciousness disturbance, muscle weakness of fingers, myoclonus, and CA, while paraparesis with deep sensory and bladder and bowel disturbance remained. Conclusions: We highlight the possibility of the coexistence of several post-infectious autoimmune neurological complications in patients of COVID-19. It is important to search autoantibodies carefully corresponding to clinical manifestations for appropriate treatments and understanding of pathophysiology.

16.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925300

ABSTRACT

Objective: To report a case of antibody-positive neuromyelitis optica (NMO) after COVID-19 vaccination. Background: Neuromyelitis optica spectrum disorder is a rare demyelinating disorder of the central nervous system characterized by longitudinally extensive transverse myelitis (LETM) and severe, sometimes bilateral optic neuritis. The majority of cases have serologic or CSF antibody for aquaporin-4 (AQP4). Design/Methods: Case report Results: A 19 year old woman with no prior medical history presented with two days of progressive, severe weakness and sensory changes first in the arms, then legs. On the morning of presentation, she woke with urinary incontinence. She had received COVID-19 vaccination (Moderna) fifteen days preceding her onset of symptoms. Examination revealed sinus tachycardia, MRC grade 3-4/5 power in the arms, 0/5 in the legs with approximately T4 sensory level. Cervical spine MRI revealed T2 prolongation in the spinal cord extending from the cervicomedullary junction to the conus medullaris. CSF revealed neutrophilic pleocytosis with increased IgG synthesis rate and positive CSF AQP4 antibody;serum AQP4 and MOG antibodies were negative. Bilateral, saddle pulmonary emboli were discovered shortly after admission. Her NMO was treated with high-dose intravenous methylprednisolone, plasmapheresis, and rituximab. Conclusions: This case describes a severe, new presentation of antibody-positive neuromyelitis optica following vaccination against COVID-19.

17.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925218

ABSTRACT

Objective: To report a rarely isolated central retinal artery occlusion (CRAO) following Coronavirus disease 2019 (COVID-19) Vaccine Moderna (mRNA-1273). Background: COVID-19 caused by severe acute respiratory syndrome coronavirus was firstly reported in Dec 2019 and became pandemic as of Mar 2020. Fortunately, novel rapidly developed COVID-19 vaccines are capable of lessening the pandemic effectively. As billions of people vaccinated, however, COVID-19 vaccine-induced thrombosis (VIT) are gradually emerging. Design/Methods: A previously healthy 70-year-old man presented with acute painless visual loss of the right eye five days after the first dose of Moderna vaccine. On examination of the right eye, visual acuity (VA) was counting finger at 15 cm. Fundoscopy revealed a diffuse whitened retina with cherry-red spot. Optical coherence tomography (OCT) showed hyperreflectivity. Screening tests for platelet and D-Dimer levels were unremarkable. CRAO was treated with clopidogrel and hyperbaric oxygen therapy. The serum level of anti-platelet factor-4 (PF4) antibody was 73.34 ng/ml (ref, 0-49.99 ng/ml).Two months later, VA was counting finger at 10 cm3 and OCT revealed hyperreflectivity and mild inner retina atrophy Results: COVID-19 vaccine-induced thrombosis and thrombocytopenia (VITT) based on the victims receiving AstraZeneca and Johnson & Johnson vaccines is through autoimmune antibody against PF4. VITT is typically manifested within 6-24 days post-vaccination;thrombotic sites are in the cerebral sinus, portal vein, splanchnic vein, and pulmonary emboli;as well as thrombocytopenia and increased level of D-Dimer. Our patient had isolated CRAO five days post-Moderna vaccination but normal platelet count and D-Dimer level. Moreover, VIT with isolated CRAO was not published on PubMed. Conclusions: VIT could occur in the unusual site such as CRAO in our case. Normal platelet and D-Dimer levels might not be sensitive tools to exclude VIT. Suspected patient with thrombotic event after COVID-19 vaccines should have anti-PF4 antibody test to assure an effective treatment.

18.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925196

ABSTRACT

Objective: NA Background: COVID-19 infection has been associated with a state of hypercoagulability. The hypercoagulability typically presents as a Deep Venous thrombus or Pulmonary Embolism but rarely can manifest as CVST even after recovery from the original COVID-19 infection. Case Report: 27-year-old Caucasian female who had a COVID-19 infection 2 weeks prior, presented with 4 days of persistent headaches associated with nausea and vomiting. Patient also had episodes of rightward gaze without loss of awareness. No prior history of seizures. NIHStrokeScale was 0. CT head showed a hyper density within the sylvian fissure and the sulci of the right temporal and right lateral frontal lobes suggestive of subarachnoid hemorrhage(SAH);CTA head showed cerebral venous sinus thrombosis(CVST) involving straight sinus, most of vein of Gale, right transverse and right sigmoid sinuses that was also seen on MR venogram. MRI brain showed illdefined edema in a distribution concerning for venous infarct due to CVST. CTA chest also showed multiple bilateral pulmonary emboli. EEG showed focal slowing in the right hemisphere and no epileptiform discharges. Patient was started on heparin and transitioned to Dabigatran on discharge. Past medical history was remarkable for Wolf-Parkinson-White syndrome (s/p ablation), obesity and depression. Patient has no personal or family history of hypercoagulability or malignancy. Patient reported birth control use which she stopped 3 weeks prior to this presentation. Patient stopped cigarette smoking 5 years ago. Patient has a healthy 2.5-year-old son and has no history of miscarriages. Patient was not vaccinated for COVID. Results: NA Conclusions: This is a case of CVST without major classical predisposing factors for CVST however patient had recent COVID-19 infection which should be considered as a potential risk factor for CVST. Considering MR venogram of the head in patients presenting with persistent post-COVID headaches can help identify this potential life threating condition in a timely manner.

19.
Journal of Paediatrics and Child Health ; 58(SUPPL 2):123, 2022.
Article in English | EMBASE | ID: covidwho-1916249

ABSTRACT

Background Infective endocarditis (IE) during pregnancy is rare and is associated with high maternal and fetal morbidity and mortality. We report the case of a 30-year-old patient with IE who was incidentally found to be 24 weeks pregnant during the COVID outbreak. We also reviewed the relevant literature. Case An active intravenous drug user presented with a 2-week history of constitutional symptoms (myalgias, fever) and lower back pain during the COVID outbreak. Initial investigations revealed bilateral consolidations on chest X-ray. After she tested negative for COVID-19, CT chest showed septic pulmonary emboli and grew MSSA on blood cultures. An echocardiogram revealed a large (1.6 × 1.0 cm) mass attached to the tricuspid valve suggestive of IE with severe tricuspid regurgitation. She was also incidentally found to be 24 weeks pregnant (G1P0) and positive for syphilis. Viable intrauterine pregnancy was confirmed at 25 weeks on an ultrasound. She was treated with 5-weeks course of IV flucloxacillin, however a repeat echocardiogram demonstrated an increase in vegetation size (> 3 cm). As her vegetation size had increased, a surgical opinion for IE was sought. Cardiac operation under cardiopulmonary bypass in a pregnant woman is associated with high maternal and fetal morbidity and mortality. She was managed conservatively with oral antibiotics, regular echocardiographic and obstetrics reviews and delivered a healthy baby at 37 weeks following induction of labour. Conclusions: The review of literature confirms that if IE in pregnancy is diagnosed early, an uncomplicated outcome is possible with a multidisciplinary team approach.

20.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i819-i820, 2022.
Article in English | EMBASE | ID: covidwho-1915816

ABSTRACT

BACKGROUND AND AIMS: Voclosporin, a novel calcineurin inhibitor, was approved in the USA in January 2021 for the treatment of adult patients with active lupus nephritis in combination with background immunosuppressive therapy. Voclosporin has a favorable metabolic profile and a consistent dose-concentration relationship, eliminating the need for therapeutic drug monitoring. Previously reported results from the Phase 2 AURA-LV and Phase 3 AURORA 1 studies showed that the addition of voclosporin to mycophenolate mofetil (MMF) and low-dose steroids in patients with lupus nephritis significantly increased rates of complete renal response at 48 weeks (AURA-LV) and 52 weeks (AURORA 1). Here we report the results of the completed continuation study, AURORA 2, which assessed the long-term safety and tolerability of voclosporin compared with placebo in patients with lupus nephritis receiving treatment for an additional 24 months following completion of the AURORA 1 study. METHOD: Key inclusion criteria for the parent AURORA 1 study included a diagnosis of biopsy-proven active lupus nephritis (Class III, IV, or V ± III/IV), proteinuria ≥ 1.5 mg/mg (≥2 mg/mg for Class V) and estimated glomerular filtration rate (eGFR) ≥45 mL/min/1.73 m2. Patients who completed AURORA 1 were eligible to enroll in AURORA 2 and continued with the same blinded treatment of voclosporin (23.7 mg BID) or placebo in combination with MMF (target dose 2 g/day) and lowdose oral steroids. Safety and tolerability were evaluated by monitoring adverse events and laboratory assessments including eGFR;changes in urine protein creatinine ratio (UPCR) were also assessed. RESULTS: In total, 116 patients in the voclosporin arm and 100 patients in the control arm enrolled in AURORA 2, with 92 (79.3%) and 73 (73.0%) patients in each respective arm completing treatment to the end of AURORA 2. There were no new or unexpected safety signals detected in patients who continued on treatment with voclosporin compared to control-treated patients. Rates of serious adverse events in the voclosporin (19.0%) and control arms (24.0%) were similar, with eight serious adverse events of infection in each arm. Estimated glomerular filtration rate remained stable through the end of AURORA 2 (Figure 1). The slopes of the least-squares (LS) mean change in corrected eGFR from AURORA 2 baseline to end of study were -0.2 [95% confidence interval (CI) -3.0 to 2.7' in the voclosporin arm and -5.4 (95% CI -8.4 to -2.3) in the control arm. There were no deaths in the voclosporin arm during AURORA 2;four deaths were reported in the control arm due to pulmonary embolism (n = 1) and coronavirus infection (n = 3). The LS mean reductions in UPCR observed in AURORA 1 were maintained in AURORA 2 with no increase in UPCR noted at the follow-up visit 4 weeks after study drug discontinuation (Figure 2). CONCLUSION: Voclosporin was well-tolerated over three years of treatment with a similar safety profile to control and no unexpected safety signals detected. Further, the significant and meaningful reductions in proteinuria initially achieved in AURORA 1 were maintained throughout AURORA 2. These data provide evidence of a long-term treatment benefit of voclosporin in patients with lupus nephritis. (Figure Presented).

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