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1.
Journal of the American Society of Nephrology ; 33:681, 2022.
Article in English | EMBASE | ID: covidwho-2125995

ABSTRACT

Background: A minimal-resource (MR) pre-screening model has been developed in UK data for people with type 2 diabetes (T2DM) with no previous diagnosis of chronic kidney disease (CKD). It identifies those at higher risk of having reduced kidney function (eGFR < 60ml/min/1.73m2) using readily available non-clinical inputs. The model was developed to support prioritization of CKD screening resource, particularly where resources are limited. The model has previously been validated in global study data and whilst strong performance was observed, the data were limited in volume and collected prior to 2018. The goal of this study is to test the performance of the model in up-to-date data, reflective of the application setting. Method(s): The model was applied to the observational iCaReMe registry data covering 21 countries in 7 regions globally from 2018. We evaluated the global and regional positive predictive values (PPV) at thresholds that ensured a sensitivity of at least 80%. We compared the PPV of the MR model against current practice (i.e. "screen all", testing the entire T2DM population). Result(s): 5618 patients with a valid eGFR measurement were included. The MR model resulted in a PPV of 28.0% [95% CI: 26.5% -29.6%] with a sensitivity of 82.4% [95% CI: 80.2% -84.7%] -a relative improvement of 44.8% compared with the screen all approach (PPV 19.3% [95% CI: 18.3% -20.4%]). Regional variation in performance was observed (Figure 1, PPV range of 23.8% -34.9%), but the improvement remained significant in regions with sufficient sample size. Conclusion(s): The MR model can be used globally to identify people with T2DM that are likely to have kidney function impairment, but should be adapted to regional populations. The model can be used to conduct targeted screening where resources are limited. Prioritized screening of high-risk individuals could help to address the backlog in routine care provision due to the COVID-19 pandemic.

2.
Diabetologie und Stoffwechsel ; 17(5):340-341, 2022.
Article in German | EMBASE | ID: covidwho-2115285
3.
NeuroQuantology ; 20(9):4327-4336, 2022.
Article in English | EMBASE | ID: covidwho-2067290

ABSTRACT

Background: Due to the increase in life expectancy and population growth over 65 years, cognitive impairment (CI) is gradually increasing. Because of many changes in the human brain that occur with aging, cognitive decline usually worsens with age. The number of neurons, dendrites, synapses, receptors, glial components, and critical neurotransmitters (norepinephrine, dopamine, acetylcholine) diminishes every year after age 50 (by 0.1–0.2 percent). As a result, the brain's volume, metabolism, and perfusion decrease, and an average age-related cognitive decline emerge. Objective: This review will elucidate the underlying factors mediating the interaction of COVID-19, diabetes, and mental health, which may provide essential clues for tailored intervention for this vulnerable population. Result: As per the World Alzheimer Report, 46.8 million individuals worldwide suffered from dementia in 2015, a figure that's still expected to quadruple every 20 years. During the COVID-19 epidemic, researchers and practitioners are becoming increasingly concerned about the emergence of neurological symptoms, particularly the development of cognitive impairment. Learning, memory, flexible thinking, concentration, and executive function are all cognitive functions. Examples of executive functions include understanding a specific problem, solving problems, judging, halting, or modifying old behaviors, and initiating new ones. When patients are required to complete complex tasks, such as changing their insulin dose, predicting the effects of physical exercise on blood glucose, or even diagnosing and treating appropriate hypoglycemia, all these behavioral reactions are critical. Conclusion: Cognitive problems impair a patient's capacity to carry out several treatment measures, such as adhering to a medical regimen and recognizing signs of deterioration, all of which compromise the patient's treatment compliance. The current review focuses on the state of cognitive functioning in patients with metabolic syndrome and diabetes mellitus at the time of diagnosis and following COVID-19.

4.
Open Access Macedonian Journal of Medical Sciences ; 10:1593-1598, 2022.
Article in English | EMBASE | ID: covidwho-2066708

ABSTRACT

AIM: The aim was to assess the impact of the COVID-19 outbreak on the healthcare of Type 2 Diabetes patients and identify the factors that correlated. METHODS: A cross-sectional study was carried out from November 2020 to February 2021. The study enrolled 400 adults with Type 2 diabetes aged 40–65 years with at least one other chronic illness who received primary care health services in Vlore, Albania. A short questionnaire based on the literature, considering the situation of the COVID-19 pandemic, was used for data collection. The administration of the questionnaire was carried out by trained nurses. All participants give their written informed consent before administering the questionnaire. Pearson’s two-tailed correlations and linear regression were used to test the correlations. RESULTS: Among 400 patients with Type 2 Diabetes in the study, 53.0% were female and 47.0% were men. Most of the participants were married (n = 303) with a high level of edcation (54.3%). Treatment was mainly with oral medications (58.0%). Based on the body mass index (BMI), 63.0% of the participants were overweight. Employment status (p = 003), the type of treatment, oral medication versus insulin (p = 001), BMI (p = 001), and living alone (p = 008) were the most correlated factors. CONCLUSIONS: The care of Type 2 Diabetic patients due to the COVID-19 pandemic is closely associated with social determinants of health and the resources of health-care settings. The need to address innovative approaches to care, including self-care, social support, and e-health, is recommended.

5.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P170, 2022.
Article in English | EMBASE | ID: covidwho-2064425

ABSTRACT

Introduction: Keloids of the head and neck can result in significant disfigurement and psychological stress. Here we report a novel case of keloid formation at a well-healed postauricular incision presenting after a year of daily ear loop mask use and discuss unique considerations for management. Method(s): This is a retrospective case review of a 35-year-old African American man with Klinefelter syndrome, type 2 diabetes mellitus, and a history of hypertrophic scar formation who presented to otology clinic in 2015 with chronic left otitis media and cholesteatoma. He underwent left tympanoplasty and mastoidectomy in 2016 through a postauricular incision 1 cm posterior to retroauricular sulcus in a standard fashion. In 2018, the patient was noted to have a hypertrophic scar without extension beyond the borders of the incision that was stable until 2021. Result(s): In 2021, the patient was noted to develop a 12A 7-cm postauricular keloid in the setting of mechanical irritation from his mask worn throughout the COVID-19 pandemic. Given the disfiguring cosmesis and resulting challenges securing an ear loop mask, he elected to undergo complete excision of the postauricular keloid with tension-free primary closure of the wound, intralesional corticosteroid injection (triamcinolone acetonide 40 mg/mL), and pressure dressing. The patient was counseled on options for mask wearing to avoid contact with the postauricular incision. Conclusion(s): When designing postauricular incisions in patients prone to hypertrophic scar or keloid formation, the point of postauricular contact of ear loop masks is a novel consideration to minimize risk of future pressure-related injury. Counseling on alternative face masks that tie behind the head or anchoring ear loops to buttons sewn onto a hat or headband are other preventative pressures.

6.
Journal of Cardiopulmonary Rehabilitation and Prevention ; 42(4):E53-E54, 2022.
Article in English | EMBASE | ID: covidwho-2063029

ABSTRACT

Background: The Diabetes College Brazil Study (NCT03914924) is a pioneer randomized clinical trial designed to promote behavioral changes in adults living with prediabetes and diabetes. Method(s): A single-center randomized pilot study involving a 12-week exercise intervention aiming the participants accumulate at least 150 min of aerobic exercise and two sessions of resistance exercise per week with a 6-month follow-up after the intervention. The follow-up objective was to support the participants in maintaining the health benefits arising from the intervention through monthly structured phone calls. Physical activity (PA) level (seven days using a pedometer), exercise self-efficacy (Bandura's Exercise Self-Efficacy Scale), and quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey) were assessed at pre, post-intervention (PI), and post-follow-up (PF). Variables measured in the PI and PF were compared by unpaired t-test. The aerobic exercise time in minutes/week was collected during monthly phone calls and compared by ANOVA. The weekly frequency of resistance exercise sessions was also collected and analyzed by absolute frequencies. The association between the interest variables was analyzed using the Pearson correlation test. Result(s): Of 21 participants who were assessed at PF, 12 answered all phone calls along with follow-up (75% male, 57.4 +/- 10.7 years, 8.3% prediabetes, 41.6% Type 1 diabetes, and 50% Type 2 diabetes) and were included in this study. There was no significant difference between the values obtained in the PI and PF for PA level (41947+/-28868 vs. 49915+/-33054 total steps/week, 5992+/-4124 vs. 7131+/-4722 average steps/day;P=0.09), exercise self-efficacy (65.6+/-13.1 vs. 71.8+/-22.3;P=0.31), physical health (82.7+/-22,84.1 vs. 81.4+/-20.5;P=0.64) and mental health (65.9+/-40.7 vs. 70,5+/-38,4;P=0.70) components of quality of life, revealing maintenance of the exercise intervention benefits after six months. Most participants aerobically exercised above 150 min/week in moderate-intensity during the follow-up, with no change in average exercise time over the six months (225.0+/-154.8, 197.0+/-133.9, 235.0+/-143.9, 142.0+/-102.6, 174.0+/-177.5 minutes/week;P=0.12). The proportion of participants who maintained resistance exercise were 41%, 58%, 66%, 50%, and 50%, and the average weekly frequency was more than three times a week during the follow-up. The average minutes of aerobic exercise/week during the follow-up was moderately correlated with total steps/week (r=0.59, P=0.06) and with mental (r=0.49, P=0.12) and physical (r=0.49, P=0.12) health components of quality of life, and strongly correlated with exercise self-efficacy (r=0.63, P=0.04). Conclusion(s): Participants maintained the health benefits of the intervention at the six-month follow-up, despite the social restrictions due to the COVID-19 pandemic.

7.
Chest ; 162(4):A1854-A1855, 2022.
Article in English | EMBASE | ID: covidwho-2060873

ABSTRACT

SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: This report describes the case of a patient presenting with pneumothorax and Severe Acute Respiratory Syndrome (SARS) Coronavirus-2 (SARS-cov-2) infection leading to Coronavirus Disease 2019 (COVID-19) pneumonia, with worsening presentation, later found to have underlying Pleuroparenchymal Fibroelastosis (PPFE). CASE PRESENTATION: A 68 year old male with a past medical history of hypertension and type 2 diabetes presented to his primary care clinic with shortness of breath. He underwent a Chest X-Ray as an outpatient which revealed a moderate right-sided pneumothorax (PTX), and he was sent to the Emergency Department by his primary care provider. He was found to be COVID positive on initial workup, also requiring supplemental oxygen. Other routine laboratory tests did not reveal any significant abnormalities. His shortness of breath worsened and on repeat X-rays his pneumothorax increased in size therefore a chest tube was placed by Cardiothoracic Surgery. Computerized Tomography of the chest revealed moderate right pneumothorax, bilateral diffuse ground glass opacities and pulmonary micronodules [Figure 1]. The patient had mild initial improvement and the chest tube was removed but he had recurrence of the PTX and he underwent urgent Video Assisted Thoracoscopic Surgery (VATS), with right upper lobe wedge resection and talc pleurodesis. A biopsy of the resected lung revealed a benign lung with fibroelastotic scarring, diffusely involving subpleural tissue and prominently extending into and entrapping areas of underlying alveolated tissue, with no inflammation, granulomas or pneumonia noted. Workup for tuberculosis, autoimmune disorders, HIV was negative. He eventually was discharged home with close pulmonology and cardiothoracic surgery follow ups, planned for disease surveillance and malignancy workup. DISCUSSION: PPFE is a rare entity, and classified amongst rare causes of idiopathic interstitial pneumonias (IIP) [1]. It is characterized by upper lobe fibrosis, supleural and parenchymal scarring. It can occur at any age, and the usual presentation is of pneumothorax in a thin male, with a shortened anteroposterior diameter of the chest. Radiographic findings typically include subpleural nodular or reticular opacities in the upper lobes, usually sparing the middle and lower lobes. Pathology reveals increased elastic tissue and dense collagen fibers, along with subpleural fibrosis [2]. Pulmonary function testing reveals a restrictive pattern with reduced diffusion capacity and it is usually resistant to steroids [3]. CONCLUSIONS: PPFE is an uncommon cause of insidious, slowly progressive fibrotic lung disease often limited to the upper lobes. It should be suspected in any person presenting with recurrent pneumothorax or blebs without other known inciting causes. Lung biopsy helps establish the diagnosis. Patients with this condition need close pulmonology follow up to assess progression. Reference #1: Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, Ryerson CJ, Ryu JH, Selman M, Wells AU, Behr J, Bouros D, Brown KK, Colby TV, Collard HR, Cordeiro CR, Cottin V, Crestani B, Drent M, Dudden RF, Egan J, Flaherty K, Hogaboam C, Inoue Y, Johkoh T, Kim DS, Kitaichi M, Loyd J, Martinez FJ, Myers J, Protzko S, Raghu G, Richeldi L, Sverzellati N, Swigris J, Valeyre D;ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013 Sep 15;188(6):733-48. doi: 10.1164/rccm.201308-1483ST. PMID: 24032382;PMCID: PMC5803655. Reference #2: Frankel SK, Cool CD, Lynch DA, Brown KK. Idiopathic pleuroparenchymal fibroelastosis: description of a novel clinicopathologic entity. Chest. 2004 Dec;126(6):2007-13. doi: 10.1378/chest.126.6.2007. PMID: 1559 706. Reference #3: Watanabe K. Pleuroparenchymal Fibroelastosis: Its Clinical Characteristics. Curr Respir Med Rev. 2013 Jun;9(4):299-237. doi: 10.2174/1573398X0904140129125307. PMID: 24578677;PMCID: PMC3933942. DISCLOSURES: No relevant relationships by FNU Amisha No relevant relationships by Perminder Gulani No relevant relationships by Hyomin Lim No relevant relationships by paras malik No relevant relationships by Divya Reddy

8.
Chest ; 162(4):A1773, 2022.
Article in English | EMBASE | ID: covidwho-2060858

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

9.
Chest ; 162(4):A1009, 2022.
Article in English | EMBASE | ID: covidwho-2060750

ABSTRACT

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: PAP is a rare entity that can occur secondary to infection, malignancy, or trauma. Mucormycosis in the setting of Covid-19 pneumonia has been increasingly recognized but PAP has only recently been reported in this setting. CASE PRESENTATION: A 44 year-old man with type 2 diabetes, non-ischemic cardiomyopathy, hypothyroidism, and ulcerative colitis presented with dyspnea and cough in July 2021. He was diagnosed with Covid-19 pneumonia and initially treated with molnupiravir. Eight days later he presented to the emergency room with worsening dyspnea, hypoxemia and diabetic ketoacidosis. He required 3L of oxygen and was intubated for airway protection. CT chest revealed mild bilateral patchy opacities and dexamethasone was started. Unfortunately, persistent fevers and worsening respiratory status ensued and repeat chest CT on hospital day (HD) 8 showed a new large left upper lobe (LUL) cavitary lesion. Cultures ultimately grew Rhizopus microsporus and he was started on amphotericin then isavuconazole after acute kidney injury developed. Dexamethasone was discontinued and interval imaging after ten days showed dramatic growth of the cavitary lesion (9 x 6 x 3 cm) with new extension through the chest wall, infiltrating the intercostal spaces and pectoralis muscle. Due to ventilator dependency a tracheostomy was performed on HD 24. Despite anti-fungal therapy the cavitary lesion persisted, with evidence of osseous destruction of the third and fourth ribs, as well as new fluid collections within the cavity and hilar extension. On HD 46 he was transferred to our institution for Thoracic Surgery and Interventional Radiology (IR) evaluations. Percutaneous drain placement followed by pneumonectomy vs. staged cavernostomy was considered;however, on HD 50, the patient suddenly developed massive hemoptysis. CTA of the chest showed a 1.6 x 1.5 cm PAP with active hemorrhage from the LUL anterior segmental artery with dispersion into the cavity. Urgent coil and glue embolization was successfully performed by IR. Ultimately, thoracic surgical intervention was deemed too high risk and thus he was medically managed with a regimen of isavuconazole, amphotericin, and terbinafine. Hemoptysis did not recur and he was eventually discharged from the hospital and liberated from both mechanical ventilation and tracheostomy. Chest CT 6 months from the initial diagnosis has shown stable to mildly decreased size of the cavitary lesion. DISCUSSION: This is the first case to our knowledge of PAP as a complication of Covid-19 and Mucor superinfection in the United States. Five cases of this combination have been recently reported in other countries. Risk factors for Mucor infection after Covid appear to be uncontrolled diabetes, DKA, and steroid administration. CONCLUSIONS: A high index of suspicion should be maintained in patients with these risk factors, as PAP can present as massive hemoptysis and is often fatal. Reference #1: Hoenigl M, Seidel D, Carvalho A, et al. The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries [ 2022 Jan 25]. Lancet Microbe. 2022;10.1016/S2666-5247(21)00237-8. doi:10.1016/S2666-5247(21)00237-8 Reference #2: Pruthi H, Muthu V, Bhujade H, et al. Pulmonary Artery Pseudoaneurysm in COVID-19-Associated Pulmonary Mucormycosis: Case Series and Systematic Review of the Literature. Mycopathologia. 2022;187(1):31-37. doi:10.1007/s11046-021-00610-9 Reference #3: Coffey MJ, Fantone J 3rd, Stirling MC, Lynch JP 3rd. Pseudoaneurysm of pulmonary artery in mucormycosis. Radiographic characteristics and management. Am Rev Respir Dis. 1992;145(6):1487-1490. doi:10.1164/ajrccm/145.6.1487 DISCLOSURES: No relevant relationships by Kevin Patel No relevant relationships by Clifford Sung

10.
Chest ; 162(4):A951, 2022.
Article in English | EMBASE | ID: covidwho-2060739

ABSTRACT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multisystem inflammatory syndrome in adults (MIS-A) is a rare but clinically significant complication of COVID-19 infection characterized by severe illness with extrapulmonary organ dysfunction, markedly elevated inflammatory markers in the absence of severe respiratory illness or other obvious source of infection (1). We present a case of a 37-year-old male, with negative infectious evaluation and marked clinical improvement after administration of IVIG. CASE PRESENTATION: We present a 37-year-old black male with a past medical history of type 2 diabetes who was admitted to the hospital with shock and organ failure;prior to his presentation, he was diagnosed with COVID-19 pneumonia requiring outpatient therapy. On presentation, he was tachycardic, febrile, hypotensive with significant renal failure and lactic acidosis;inflammatory markers were elevated (CRP 640, ESR 108). Imaging was significant for mediastinal and hilar lymphadenopathy, with clear parenchyma (Figure 1). Broad coverage antibiotics, vasopressors, and stress dose steroids were initiated. Infectious evaluation was unrevealing with negative blood, urine, and sputum cultures;Echocardiogram revealed LVEF of 40% with mild RV dysfunction. His renal failure worsened, requiring CRRT. Vasculitis evaluation with ANA, ANCA, MPO, PR3, GBM, HIV, C3-C4 and cryoglobulins returned normal. Eventually, the patient was weaned from vasopressor support on hospital day four. Trials of weaning steroids resulted in recurrence of fevers and increasing vasopressor support. Given continued fevers without obvious infection there were concerns for MIS-A occurring shortly after COVID-19 infection. Antibiotics were discontinued and he received 2g/kg of IVIG with marked clinical improvement and was rapidly weaned from vasopressor support. We initiated methylprednisolone 1 mg/kg twice daily with steroid taper. He had improvement in inflammatory markers after IVIG and high dose steroids (CRP-6.7, ESR-49 prior to discharge). DISCUSSION: MIS-A is a rare disease that occurs after COVID-19 infection, with few reported cases in literature. Presentation is variable, but symptoms include high fever, dyspnea, lethargy, myalgias, and a diffuse maculopapular rash. Notably, hypoxia is not a prominent feature, a significant distinction from classic COVID-19 infection. Patel et al noted a predominance in young adults, males, and non-Hispanic black or Hispanic persons (2). The proposed mechanism stems from dysregulated immune response, with abnormal interferon production which drives macrophage activation and organ damage (3). There are no treatment guidelines available, and treatment of MIS-A is extrapolated from MIS-C and includes immunomodulatory therapies with IV IG, IL-1 receptor antagonist, and methylprednisolone. CONCLUSIONS: Prompt recognition of MIS-A critical given its potential for significant multi-organ dysfunction. Reference #1: Centers for Disease Control and Prevention. Multisystem Inflammatory Syndrome in Adults (MIS-A) Case Definition Information for Healthcare Providers. Available at Multisystem Inflammatory Syndrome in Adults (MIS-A) Case Definition Information for Healthcare Providers (cdc.gov). Accessed 3/19/2022 Reference #2: Patel, P., Decuir, J., Abrams, J., Campbell, A. P., Godfred-Cato, S., & Belay, E. D. (2021). Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults: A Systematic Review. In JAMA Network Open (Vol. 4, Issue 9). https://doi.org/10.1001/jamanetworkopen.2021.26456 Reference #3: Weatherhead, J. E., Clark, E., Vogel, T. P., Atmar, R. L., & Kulkarni, P. A. (2020). Inflammatory syndromes associated with SARS-cov-2 infection: Dysregulation of the immune response across the age spectrum. Journal of Clinical Investigation, 130(12). https://doi.org/10.1172/JCI145301 DISCLOSURES: No relevant relationships by Mohammed Al-Charakh No relevant relationships by John Pare t no disclosure on file for Maximiliano Tamae Kakazu;

11.
Chest ; 162(4):A918, 2022.
Article in English | EMBASE | ID: covidwho-2060728

ABSTRACT

SESSION TITLE: Critical Renal and Endocrine Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: About 7% of acute pancreatitis (AP) cases are caused by hypertriglyceridemia (HTG). In such cases bowel rest, IV fluids, symptomatic therapy, and triglyceride (TG) lowering interventions are initiated. Plasmapheresis is one of the treatment options, but it has specific indications. We present a case of severe hypertriglyceridemia-induced pancreatitis that required plasmapheresis. CASE PRESENTATION: A 30 y/o man with type 2 diabetes, hyperlipidemia, multiple previous admissions for HTG-AP, presented with severe abdominal pain, nausea, and vomiting x 1 day. On admission, he was tachycardic, hypotensive, afebrile, SpO2 > 96% on RA. Labs: Glu 491 mg/dL, TG > 1000 mg/dL, Cholesterol 509 mg/dL, Lipase 987 U/L, Cr/BUN 2.4 mg/dL /20 mg/dL, VBG pH 7.25/PCO2 36.2 mmHg/PO2 19.4 mmHg/Ca 0.8/lactate 5.6;WBC 13.07 K/cm;COVID PCR positive. CXR: diffuse patchy opacities. CTAP with contrast was deferred because of AKI. He was admitted to the ICU and started on insulin drip with no improvement over 24hrs. He was still acidotic, Ca persistently low, TG still >1000, and kidney function worsened. Plasmapheresis was initiated. After one session his TG lowered to 700. He was restarted on insulin drip and in the next 24hr TG decreased to < 500 and metabolic acidosis resolved. Once AKI resolved, CT abdomen/pelvis with contrast confirmed acute pancreatitis, with focal hypodensities within the uncinate process and the proximal body, concerning infarcts as well as large phlegmon surrounding the pancreas, but no evidence of necrotizing or hemorrhagic pancreatitis. His hospital course was complicated with sepsis and DVT, which resolved with therapy. He was discharged home with TG lowering agents, Apixaban, and his previous T2DM regimen. DISCUSSION: Plasmapheresis is indicated in patients with severe HTG (>1000- 2000 mg/dl), severe HTG-AP, and when standard treatment options are inadequate. It lowers the lipid levels and removes proinflammatory markers and cytokines stopping further inflammation and damage to the pancreas and other organs faster compared to conservative therapy. Most patients need only one session which lowers TG level by 50-80%, as seen in our patient. CONCLUSIONS: Plasmapheresis should be considered in cases of HTGP with worrisome features such as lactic acidosis, hypocalcemia, worsening inflammation, and multi organ failure. Reference #1: Rajat Garg, Tarun Rustagi, "Management of Hypertriglyceridemia Induced Acute Pancreatitis", BioMed Research International, vol. 2018, Article ID 4721357, 12 pages, 2018. https://doi.org/10.1155/2018/4721357 Reference #2: Pothoulakis I, Paragomi P, Tuft M, Lahooti A, Archibugi L, Capurso G, Papachristou GI. Association of Serum Triglyceride Levels with Severity in Acute Pancreatitis: Results from an International, Multicenter Cohort Study. Digestion. 2021;102(5):809-813. doi: 10.1159/000512682. Epub 2021 Jan 21. PMID: 33477149. Reference #3: Gavva C, Sarode R, Agrawal D, Burner J. Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach. Transfus Apher Sci. 2016 Feb;54(1):99-102. doi: 10.1016/j.transci.2016.02.001. Epub 2016 Feb 20. PMID: 26947356. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Vaishali Geedigunta No relevant relationships by Zinobia Khan No relevant relationships by Jelena Stojsavljevic

12.
Chest ; 162(4):A858, 2022.
Article in English | EMBASE | ID: covidwho-2060710

ABSTRACT

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Up to 17% of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been shown to develop pancreatic lesions (1). We present 2 cases of coronavirus disease 2019 (COVID-19) patients that presented with pancreatic lesions. CASE PRESENTATION: Case1 A 47-year-old lady with a history of type 2 diabetes mellitus present to the emergency department (ED) with complaints of flu-like symptoms for ten days. She tested positive for COVID-19 by rapid PCR. Computed tomography (CT) scan without contrast on admission shows an incidental finding of a pancreatic mass (see Figure 1). Abdominal CT with contrast shows a large, multiloculated cystic mass in the pancreatic tail (see Figure 2). Laboratory examination depicted lipase: 27 U/L, CA19-9: 72 U/mL, CEA: 6.5 ng/mL, CA125: 24 U/mL, erythrocyte sedimentation rate (ESR):2 mm/h, Total Bilirubin: 0.6 mg/dl, Direct Bilirubin: 0.1 mg/dl. Following treatment, the patient recovered fully and is discharged from the hospital 10 days later with home oxygen therapy. Case2 An 81-year old Caucasian lady presented to the outpatient clinic with complaints of fecal incontinence. She tested positive for COVID-19, four months before her visit. CT scan of the abdomen with oral contrast revealed multiple hypodense masses on the pancreas measuring 0.3cm in diameter (see Figure 3). Laboratory tests reveal CA19-9: 57 U/mL, CA125: 8 U/mL, CEA: 1.9 ng/mL, erythrocyte sedimentation rate (ESR):11 mm/h, C-reactive protein: 0.7 mg/L, Total Bilirubin: 1.5 mg/dl, Direct Bilirubin: 1.3 mg/dl. Following outpatient treatment and follow-up, the patient's symptoms were relieved. DISCUSSION: Pancreatic lesions in COVID-19 patients can be caused directly by the cytopathic effects of the viral infection, or indirectly by systemic responses to inflammation or respiratory failure. Several studies have shown that ACE2 is the functional receptor used by SARS-CoV-2 to gain access to target cells (2) and ACE-2 receptors are expressed in significant amounts in the pancreas (3). In the first case, an incidental finding of a multi-cystic pancreatic mass on admission was reported. There was no pancreatic ductal dilation on the CT scan, which may indicate a direct injury caused by cytopathic effects of the virus rather than inflammation resulting in exocrine secretions forming cysts. In the second case, multiple masses on the pancreas were found after recovering from COVID-19. These lesions could be remnants of a previous pancreatic injury during the acute phase of the infection. CONCLUSIONS: COVID-19 infection may trigger pancreatic injury in some patients. Reference #1: Yong, Shin Jie. Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments. Infectious diseases. 2021 Oct;53(10): 737–754. Reference #2: Ma C, Cong Y, Zhang H. COVID-19, and the Digestive System. Vol. 115, American Journal of Gastroenterology. Wolters Kluwer Health;2020. p. 1003–6. Reference #3: Liu F, Long X, Zhang B, Zhang W, Chen X, Zhang Z. ACE2 Expression in Pancreatic Damage After SAERS-CoV-2 Infection. Gastroenterology. 2020 Aug 1;18(9): 2128 – 2130.e2. DISCLOSURES: No relevant relationships by Ailine Canete Cruz No relevant relationships by Claudia Ramirez No relevant relationships by Joseph Varon No relevant relationships by Mohamed Ziad

13.
Chest ; 162(4):A712-A713, 2022.
Article in English | EMBASE | ID: covidwho-2060673

ABSTRACT

SESSION TITLE: Pulmonary Involvement in Critical Care Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Hemophagocytic Lymphohistiocytosis (HLH) is a condition in which the body's natural ability to end an immune or inflammatory response is defective1. COVID-19 also presents with severe inflammation, and like HLH, leads to significantly elevated ferritin2. We present a case that was initially thought to be COVID-19, but the patient was diagnosed with HLH in the setting of S. aureus endocarditis. CASE PRESENTATION: A 62-year-old male with a history of atrial fibrillation, mechanical mitral valve on warfarin, type II diabetes, chronic obstructive pulmonary disease, and recently diagnosed COVID-19 presented to the hospital with progressive dyspnea. In the emergency department, he was found to be hypoxemic and in atrial fibrillation with rapid ventricular response. He had a fever of 39.3°C and his initial laboratory workup revealed hemoglobin of 11.9 g/dL, leukocytes of 5,700, platelets of 83,000, AST 35 U/L, ALT 34 U/L, CRP of 31.89 mg/dL, and ferritin of 1994 ug/L. The patient was admitted and started on dexamethasone 6 mg daily. The following day, the patient's blood work revealed a significant worsening of AST and ALT to 7280 U/L and 3319 U/L, respectively. D-dimer increased to 11861 ng/mL (DDU) and ferritin to 36,470 ug/L. On the third day of admission, his clinical status declined acutely as he became significantly bradycardic, progressing to a cardiac arrest after which he required cardiopulmonary resuscitation, intubation, and was transferred to the intensive care unit. A CT scan obtained revealed hepatomegaly of 22 cm and blood cultures were positive for S. aureus requiring vancomycin treatment. The patient was kept on dexamethasone due to concerns for HLH. Ferritin continued to worsen, reaching 50,749 ug/L. His sCD25 came back positive. Unfortunately, the patient expired on his fifth day of hospitalization after discussing with his family their goals for his care and switching his care to comfort only. DISCUSSION: HLH is a challenging condition since diagnosis is difficult and mortality is high. There are a few methods used to diagnose HLH. Usually, 5 of 8 criteria must be met, which was achieved with this patient. However, often the patient only fulfills 4 of 8 since many criteria are difficult to obtain such as bone marrow biopsy, sCD25, and CXCL9. A useful tool is the H-calculator3. Our patient scored a 180 indicating a 50-75% likelihood of HLH. Assessing the likelihood of disease is important since sCD25 and CXCL9 take time and if the patient is clinically deteriorating treatment should not be delayed. CONCLUSIONS: HLH is catastrophic and rare. Physicians should always have it as a differential diagnosis in patients with severe inflammatory states and elevated ferritins to avoid anchoring bias. If suspicion is high based on clinical evaluation and scores, treatment should not be delayed. Reference #1: Filipovich A, McClain K, Grom A. Histiocytic disorders: recent insights into pathophysiology and practical guidelines. Biol Blood Marrow Transplant. 2010;16(1 Suppl):S82-S89. doi:10.1016/j.bbmt.2009.11.014 Reference #2: Cheng L, Li H, Li L, et al. Ferritin in the coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis. J Clin Lab Anal. 2020;34(10):e23618. doi:10.1002/jcla.23618 Reference #3: Fardet L, Galicier L, Lambotte O, et al. Development and validation of the HScore, a score for the diagnosis of reactive hemophagocytic syndrome. Arthritis Rheumatol. 2014;66(9):2613-2620. doi:10.1002/art.38690 DISCLOSURES: No relevant relationships by Areeka Memon No relevant relationships by Carissa Monterroso No relevant relationships by Carson Oprysko No relevant relationships by Eduardo Padrao No relevant relationships by Mouna Penmetsa

14.
Chest ; 162(4):A642, 2022.
Article in English | EMBASE | ID: covidwho-2060656

ABSTRACT

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Since the start of the COVID-19 pandemic, COVID-19 Associated Pulmonary Aspergillosis (CAPA) has been on the rise. This superinfection, if not properly identified and treated, has shown to increase mortality up to 67% in COVID-19 patients. We are presenting a late presentation of CAPA after 4-month of COVID-19 infection and treated successfully. CASE PRESENTATION: A 57-year-old female patient with past medical history type 2 diabetes mellitus, hypertension and cardiomyopathy in addition to COVID-19 pneumonia treated for months ago with azithromycin, Bamlanivimab/Etesevimab, and Dexamethasone who presents to the hospital with massive hemoptysis and shortness of breath requiring intubation and mechanical ventilation. There was no reported history of recent travel, smoking, alcohol, or illicit drug use. Physical exam showed diminished lung sounds at the right lower lobe. Her labs showed mild leukocytosis, lactic acidosis and negative COVID-19 PCR. CT scan showed dense consolidation on right lower lobe consistent with lobar pneumonia and centrilobular ground glass opacities in the right upper lobe. Bronchoscopy showed complete obstruction of right bronchus intermedius and minimal blood clots in LLL. BAL respiratory culture, fungal smear, acid fast bacilli were non-diagnostic and negative for malignancy. Patient continued to have hemoptysis and bronchoscopy was repeated with negative cytology and cultures. The patient continued to have hemoptysis and she was transferred to tertiary center were bronchoscopy was repeated and confirmed right bronchus intermedius stenosis, blood clots, and suspicious right mainstem nodules with mucosal lesion. Biopsy results from bronchoscopy came back positive for the morphologic features of Aspergillus species. The patient was started on voriconazole with significant improvement in her symptoms. DISCUSSION: The recent literature of COVID-19 suggest association between COVID infection and invasive pulmonary Aspergillosis. COVID-19 virus causes damage in the airway epithelium and enable aspergillus to invade the pulmonary tract leading to serious infections with Aspergillus. It has also been known that Aspergillus infections are associated with diabetes mellitus and immune suppression which can be precipitated by steroid use and other treatments for COVID-19 infection like IL-6 inhibitors. Here in our patient with help of tissue biopsy we diagnosed CAPA, started treatment early and treated successfully. CONCLUSIONS: CAPA can be difficult to diagnose and needs high index of suspicion in the appropriate clinical scenario when dealing with post COVID respiratory complaints like hemoptysis. Bronchoalveolar lavage alone without tissue biopsy might miss the diagnosis in the context of invasive aspergillosis like the scenario we observed in our case. Doing tissue biopsy through bronchoscopy might add more clinical benefit when Aspergillus infections are suspected. Reference #1: Chih-Cheng Lai, Weng-Liang Yu, COVID-19 associated with pulmonary aspergillosis: A literature review, https://doi.org/10.1016/j.jmii.2020.09.004 DISCLOSURES: No relevant relationships by Haytham Adada No relevant relationships by Mahmoud Amarna No relevant relationships by Rishika Bajaj No relevant relationships by Camelia Chirculescu No relevant relationships by Sonia Dogra No relevant relationships by Azad Patel

15.
Chest ; 162(4):A612-A613, 2022.
Article in English | EMBASE | ID: covidwho-2060647

ABSTRACT

SESSION TITLE: TB and TB-Involved Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary Aspergillus infection has a wide array of manifestations. Chronic Pulmonary Aspergillosis is an uncommon progressive respiratory disease, with the Subacute Invasive Pulmonary Aspergillosis form, one of the most challenging to manage. Typically it presents with rapidly progressive infection (of less than 3 months) in mild to moderately immunocompromised patients with underlying structural lung disease. We herein report the case of a 69-year old female with post-tuberculous cavity with disease progression, in approximately 6 weeks, associated with Aspergillus infection. CASE PRESENTATION: Patient is a 69-year old African American female, never smoker, with known history of Type 2 Diabetes Mellitus and previously treated mycobacterium tuberculosis with residual small right upper lobe cavity (measuring approximately 35 x 40 mm). She was being followed in our outpatient thoracic oncology clinic with serial imaging for surveillance, CT Chest initially every 3 - 6 months then annually thereafter with PET scan as clinically indicated. The cavity remained relatively unchanged for approximately 5 years. In October 2021, her CT Chest had revealed a stable cavity, even despite SARS-CoV-2 Pneumonia infection the previous year. The following month she was admitted to an outside hospital for hyperglycemia with notable significant increase in size of the right upper lobe cavity to 69 x 72 mm with surrounding nodularity. She completed a course of antibiotics and was seen in our clinic 3 months post discharge with a repeat CT Chest which now revealed a mass like area of consolidation with large area of lucency and superimposed fungus ball (now measuring 80 mm x 70mm). She underwent Electromagnetic Navigational Bronchoscopy with transbronchial biopsy and right upper lobe bronchoalveolar lavage. BAL culture identified Aspergillus niger, with no other pathogens (including acid fast bacilli isolated) or malignant cells observed. Biopsy revealed marked mixed inflammation and fungal hyphae. Patient is currently undergoing long-term oral antifungal therapy with plan for close surgical follow-up. DISCUSSION: The diagnosis of Chronic Pulmonary Aspergillosis requires a combination of clinical, radiological and histopathological characteristics present for atleast 3 months for diagnosis. This includes the presence of one or more cavities on thoracic imaging, evidence of aspergillus infection or an immunological response to aspergillus as well as excluding alternative diagnoses. Advances in diagnostic tools have improved early diagnosis and subsequent management as noted in our case. Surgical resection is recommended for simple aspergilloma, however rapidly progressive disease processes are recommended to be managed as invasive aspergillosis. CONCLUSIONS: Post-tuberculosis chronic pulmonary aspergillosis is an emerging disease with significant associated morbidity and likely health burden. Reference #1: Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management David W. Denning, Jacques Cadranel, Catherine Beigelman-Aubry, Florence Ader, Arunaloke Chakrabarti, Stijn Blot, Andrew J. Ullmann, George Dimopoulos, Christoph Lange European Respiratory Journal Jan 2016, 47 (1) 45-68;DOI: 10.1183/13993003.00583-2015 Reference #2: Bongomin F. Post-tuberculosis chronic pulmonary aspergillosis: An emerging public health concern. PLoS Pathog. 2020;16(8):e1008742. Published 2020 Aug 20. doi:10.1371/journal.ppat.1008742 DISCLOSURES: No relevant relationships by Omotooke Babalola No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Sulaiman Tijani

16.
Chest ; 162(4):A365, 2022.
Article in English | EMBASE | ID: covidwho-2060575

ABSTRACT

SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION: A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam: faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs: CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 1:40, dsDNA 1:640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR: opacification of the left lung up to midfield. CT chest: moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon: negative. Thoracentesis: 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura: necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity: pan-sensitive M. tuberculosis. Sputum: negative for TB. She was discharged on RIPE treatment for reactivation of TB. DISCUSSION: The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high. CONCLUSIONS: Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1: Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus: case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2):563-568. Reference #2: Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3: Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8):1211-7. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic

17.
Chest ; 162(4):A310, 2022.
Article in English | EMBASE | ID: covidwho-2060559

ABSTRACT

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: As the coronavirus pandemic continues to burden the global health care system, strong associations have emerged with hypercoagulability. Recent reports of Covid-19 support both venous and arterial thromboembolism, thus coagulopathy emerging as one of the most severe sequelae of the disease, which has also been associated with poorer outcomes. CASE PRESENTATION: A 71-year-old female with a past medical history of hypertension, type 2 diabetes, and obesity presented with progressively worsening shortness of breath and cough. She was found to be hypoxic to 80% on arrival and tested positive for COVID-19. She was subsequently intubated and admitted to the ICU. Her D-dimer was noted to be 9.04mcg/mLFEU (0-0.55mcg/mLFEU), ferritin 256ng/mL(10-291ng/mL), LDH 707 U/L(130-270U/L), CRP 138mg/L (< 10mg/L). She was treated with a ten-day course of dexamethasone and a five-day course of Remdesivir. On Day 7, purple discoloration was noted in the second to fifth digits of the left hand, concerning acute ischemia. Left upper extremity ultrasound revealed intraluminal heterogeneous echogenicity likely occlusive ulnar arterial thrombus with no flow to mid or distal segment and normal flow in the radial artery into a complete palmar arch. This was seen to be classical for micro-embolic phenomenon attributable to the hypercoagulable state associated with Covid-19 infection. Treatment with Heparin drip was initiated along with the local application of nitro paste. The patient was subsequently discharged home but re-presented a month later for gastrointestinal bleeding. At this admission, her left second digit was noted to express purulent drainage. Imaging confirmed osteomyelitis in the second through fifth digits and was referred to a tertiary center for definitive treatment. DISCUSSION: Covid-19 has been shown to provoke catastrophic inflammatory responses by triggering a dysfunctional cascade of thrombosis in the pulmonary vasculature leading to both micro and macroangiopathic manifestations. The quick progression of ischemia to digital gangrene, despite collateral circulation and early intervention, indicates severe microangiopathy. CONCLUSIONS: Thus physicians must always have a high index of suspicion for thromboembolic complications in patients with Covid-19. The development of severe complications despite prompt anticoagulation highlights the need for alternative or newer therapies like targeted immunotherapy that would effectively manage these complications of SARS-CoV-2. Reference #1: Digital Gangrene as a Sign of Catastrophic Coronavirus Disease 2019-related Microangiopathy Jessica S. Wang, MD,* Helena B. Pasieka, MD, MS,† Vesna Petronic-Rosic, MD, MSc, MBA,† Banafsheh Sharif-Askary, MD,* and Karen Kim Evans, MDcorresponding author Reference #2: Galván Casas C, Català A, Carretero Hernández G, Rodríguez-Jiménez P, Fernández-Nieto D, Rodríguez-Villa Lario A, Navarro Fernández I, Ruiz-Villaverde R, Falkenhain-López D, Llamas Velasco M, García-Gavín J, Baniandrés O, González-Cruz C, Morillas-Lahuerta V, Cubiró X, Figueras Nart I, Selda-Enriquez G, Romaní J, Fustà-Novell X, Melian-Olivera A, Roncero Riesco M, Burgos-Blasco P, Sola Ortigosa J, Feito Rodriguez M, García-Doval. Classifications of the cutaneous manifestations of Covid-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. 2020 Jul;183(1):71-77. doi: 10.1111/bjd.19163. Epub 2020 Jun 10. Reference #3: Mouhamed Yazan Abou-Ismail 1, Akiva Diamond 2, Sargam Kapoor 3, Yasmin Arafah 2, Lalitha Nayak 4.The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management Thromb Res. 2020 Oct;194:101-115. doi: 10.1016/j.thromres.2020.06.029. Epub 2020 Jun 20. DISCLOSURES: No relevant relationships by Navyamani Kagita No relevant relationships by ABHIGNA KULKARNI No relevant relationships by Rajesh Thirumaran

18.
Investigative Ophthalmology and Visual Science ; 63(7):1008-F0255, 2022.
Article in English | EMBASE | ID: covidwho-2058447

ABSTRACT

Purpose : In the COVID-19 era, tele-retinal technologies are rising to the forefront of contactless ophthalmic care. Point-of-care Optical Coherence Tomography (OCT) and fundus photography remotely analyzed by an off-site retina specialist (tele-R) must be validated for screening retinal disorders. This study assesses the feasibility of tele-R as a screening tool for diabetic retinopathy (DR) in an outpatient clinical setting. Methods : A retrospective study was conducted on 16 patients (32 eyes, 28 with DR, and 4 controls) presenting to the retina clinic (RC) of an urban academic medical center. Automated OCT-B and 45 fundus photographs of the posterior pole were taken using a Topcon Maestro 3D OCT-1 unit, and 3D topographical maps of the macula were generated. Images were transmitted to a remote retina specialist (blinded to patient history and demographics) who assessed severity of DR and diabetic macular edema (DME). Primary outcomes included grading of DR and DME with fundus and OCT-B images, respectively, using the International Clinical Diabetic Retinopathy classification scale. The secondary outcome was identifying the severity grade of DME using the 3D macular map. Concordance was tested between diagnoses obtained from tele-R assessment and in-person examination by the retina specialist (gold standard) using Cohen's Kappa statistic (κ). Eyes that could not be assessed were removed from analysis. Results : 30 of 32 eyes with sufficient data for analysis were included. The average age was 57.9 (±11.2) years. 37% of patients were male, 69% were Hispanic, and 94% had Type 2 diabetes. The κ±standard error (SE) for DR severity was 0.738±0.099 (p<0.001), for DME severity was 0.588±0.122 (p<0.001), and for presence of DME was 0.727±0.122 (p<0.001). The retina specialist was able to grade the DME severity in only 10/14 (71%) eyes using the 3D macular map alone, but in 93% (13/14) eyes with OCT-B images. Conclusions : Tele-R is a reliable modality for diagnosis of DR severity;there was substantial agreement on identifying DR severity using tele-R vs in-person examination. There was substantial agreement in discerning DME using tele-R vs in-person while only moderate agreement on determining the severity of DME, which suggests that tele-R may useful in identifying presence of DME but not determining the severity of edema.

19.
Swiss Medical Weekly ; 152(Supplement 261):24S, 2022.
Article in English | EMBASE | ID: covidwho-2057851

ABSTRACT

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

20.
Medical Letter on Drugs and Therapeutics ; 64(1654):105-112b, 2022.
Article in English | EMBASE | ID: covidwho-2057513

ABSTRACT

The FDA has approved tirzepatide (Mounjaro - Lilly), a peptide hormone with activity at both glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors, to improve glycemic control in adults with type 2 diabetes. Tirzepatide, which is injected subcutaneously once weekly, is the fi rst dual GIP/GLP-1 receptor agonist to become available in the US. Selective GIP receptor agonists are not available in the US;GLP-1 receptor agonists have been available for years. Copyright © 2022, Medical Letter Inc.. All rights reserved.

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