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Upon initial discovery in late 2019, severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, has managed to spread across the planet. A plethora of symptoms affecting multiple organ systems have been described, with the most common being nonspecific upper respiratory symptoms: cough, dyspnea, and wheezing. However, the cardiovascular system is also at risk following COVID-19 infection. Numerous cardiovascular complications have been reported by physicians globally, in particular cardiac tamponade Physicians must hold a high index of suspicion in identifying and treating patients with cardiac tamponade who may have contracted the novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2 and cardiac tamponade, highlighting their clinical course progression and the implications it may have for the severity of both illnesses. The paper will also review published case reports of cardiac tamponade, clinical presentation, and treatment of this complication, as well as the disease as a whole. © 2022 Elsevier Inc.
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Background: The present radiological COVID literature is mainly confined to the CT findings. Using High Resolution Computed tomography (HRCT) as a regular 1st line investigation put a large burden on radiology department and constitute a huge challenge for the infection control in CT suite. Materials and Methods: A prospective study of 700 consecutive COVID positive cases who underwent Chest Xray (CXR) and HRCT thorax were included in the study. Many of these CXR were repeated and followed up over a duration of time to see the progression of disease. Results: 392/700 (56%) were found to be negative for radiological thoracic involvement. 147/700 (21%) COVID positive patients showed lung consolidations, 115/700 (16.5%) presented with GGO, 40/700 (5.7%) with nodules and 42/700 (6%) with reticular–nodular opacities. 150/700 patients (21.4 %) had mild findings with total RALE severity score of 1-2. More extensive involvement was seen in 104/700 (14.8 %) and 43/700 (6.2%) patients, who had severity scores of 3-4 and 5-6 respectively. 11/700 patients had a severity score of >6 on their baseline CXR. Those with severity score of 5 or more than 5 (54/700, 7.7%) required aggressive treatment with mean duration of stay of 14 days, many of them died also (23/54, 42.5%). Conclusion: In cases of high clinical suspicion for COVID-19, a positive CXR may obviate the need for CT. Additionally, CXR utilization for early disease detection and followup may also play a vital role in areas around the world with limited access to CT and RT-PCR test.
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Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.
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Objective: To analyze the diagnostic accuracy of lung ultrasonography (LUS) and high-resolution computed tomography (HRCT), to detect COVID-19. Materials and Methods: This study recruited all patients admitted to the emergency medicine unit, due to a suspected COVID-19 infection, during the first wave of the COVID-19 pandemic. These patients also who underwent a standardized LUS examination and a chest HRCT. The signs detected by both LUS and HRCT were reported, as well as the sensitivity, specificity, positive predictive value, and negative predictive value for LUS and HRCT. Results: This cohort included 159 patients, 101 (63%) were diagnosed with COVID-19. COVID-19 patients showed more often confluent subpleural consolidations and parenchymal consolidations in lower lung regions of LUS. They also had "ground glass” opacities and "crazy paving” on HRCT, while pleural effusion and pulmonary consolidations were more common in non-COVID-19 patients. LUS had a sensitivity of 0.97 (95% CI 0.92–0.99) and a specificity of 0.24 (95% CI 0.07–0.5) for COVID-19 lung infections. HRCT abnormalities resulted in a 0.98 sensitivity (95% CI 0.92–0.99) and 0.1 specificity (95% CI 0.04–0.23) for COVID-19 lung infections. Conclusion: In this cohort, LUS proved to be a noninvasive, diagnostic tool with high sensitivity for lung abnormalities that were likewise detected by HRCT. Furthermore, LUS, despite its lower specificity, has a high sensitivity for COVID-19, which could prove to be as effective as HRCT in excluding a COVID-19 lung infection.
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Introduction and Objective: Idiopathic inflammatory myopathies(IIMs) is a group of autoimmune disease characterized by muscular and extra-muscular manifestation. IIMs with anti-MDA5 antibody positivity carries poor prognosis due to rapid progressive interstitial lung disease (RP-ILD). We report clinical course of patients cared in our centre. Method(s): Patients medical record were reviewed for data collection. Result(s): Four patients with MDA5 antibody positive IIMs following up in our clinic (Table 1). None has reported Covid infection. Two has respiratory disease responded to induction therapy. One still undergoing titration of immunosuppressant. One female patient presented unwell with pleural effusion and acute pneumonitis. Patient later developed rapid progression of interstitial lung inflammation with refractory supraventricular tachycardia. IVIG was initiated, however she succumbed to adult respiratory distress syndrome (ARDS) due to pneumonia. Plasma exchange was not carried out due to source limitation at that time of period. Conclusion(s): Prevalence of anti MDA-5 positive is 30%-50% in Asians patients with IIMs particularly the east. However, it is likely under-reported in Malaysia due to lack of understanding of the pattern of disease in our multiracial population as well as lack of myositis serology tests availability especially in government hospitals. Research and registry should be instituted to allow better study of this disease in our population, to better the treatment and reduce morbidity and mortality due to rapid progressing interstitial lung disease. (Table Presented).
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Case Report: Respiratory distress is one of the most common complaints evaluated by pediatric providers in the office and emergency department setting. While primary cardiopulmonary processes represent the majority of cases of respiratory distress, pleural effusions of extravascular origin remain a rare but important differential. In this case, we present a previously healthy adolescent female who presented to our institution with respiratory distress and was subsequently found to have a pancreatic pleural effusion in the setting of a pancreaticopleural fistula. A 13 year old female with no chronic past medical history presented to the emergency department for three weeks of progressively worsening shortness of breath. History was notable for SARS-CoV-2 infection 6 months prior and intermittent night sweats and fevers for previous 4 weeks. She denied trauma, abdominal pain, nausea, vomiting, diarrhea, or anorexia. Her exam was notable for tachycardia, tachypnea, tripod positioning and absent breath sounds on her left. Chest computed tomography (CT) revealed left pleural effusion of entire left hemithorax with midline shift in addition to right sided pulmonary thromboembolism, small right sided pleural effusion and venous thromboses of the left internal jugular, subclavian, and proximal innominate veins. A left thoracentesis was performed, and patient was admitted to the PICU on a heparin infusion with subsequent left chest tube placement. Follow-up CT imaging revealed bilateral renal infarcts, iliac vein thrombosis, and a pancreatic fluid collection extending into the mediastinum with pancreatic ductal dilation. Magnetic resonance cholangiopancreatography further characterized the pancreatic lesion as a cystic tract traversing from the inferior mediastinum into the retroperitoneum and replacing the majority of the pancreatic gland suggesting a pancreaticopleural fistula as the source of a pancreatic pleural effusion. Serum amylase was 256 U/L and serum lipase was 575 U/L. Pleural fluid amylase was 1702 U/L and pleural fluid lipase was >2400 U/L, exceeding detection limit of this institution's lab. An extensive diagnostic work-up included infectious, hematologic, oncologic, autoimmune and rheumatologic etiologies and was largely unremarkable. Given concern for pancreaticopleural fistula, patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) which was diagnostic for pancreatic divisum. A pancreatic duct stent was placed with normalization of serumpancreatic enzymes prior to discharge and resolution of pleural effusion at one month post ERCP Although an initial episode of acute pancreatitis usually resolves with supportive care, this case is a reminder that pancreatitis can present with local and systemic complications including pulmonary effusion or venous thromboses and keeping a high index of suspicionfor it is crucial toavoid delaying diagnosis and care. Copyright © 2023 Southern Society for Clinical Investigation.
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Introduction Lactococcus garvieae, a zoonotic pathogen, may rarely infect humans through the consumption of fish. Documented manifestations of L. garvieae infection in humans include infective endocarditis, prosthetic joint infections, liver abscesses, peritoneal dialysis-associated peritonitis, osteomyelitis, meningitis, infective spondylodiscitis, acalculous cholecystitis, and urinary tract infection. Case report An 87-year-old female was hospitalized for coffee-ground emesis secondary to acute gastritis after eating cooked fish. One week after her discharge, she developed new-onset confusion and was returned to the hospital. Chest computed tomography revealed total consolidation of the left lung and a multiloculated left pleural effusion. The patient required intubation and direct admission to the intensive care unit. Pleural fluid and blood cultures grew L. garvieae, which was susceptible to ceftriaxone, penicillin, and vancomycin. Despite intensive antibiotic therapy and supportive care for thirteen days, the patient remained in irreversibl e shock, and the family opted for comfort care. Conclusions Heretofore unreported, this case demonstrates that L. garvieae can cause bronchopneumonia and empyema. Copyright © GERMS 2022.
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Background: Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious sequelae of acute COVID-19 infection affecting children. This study was done over a period of 12 months from December 2020 to November 2021 to describe the clinical presentation, laboratory abnormalities, and outcome of children with MIS-C. Method(s): Seventy-eight children below 12 years of age who satisfied the WHO diagnostic criteria for MIS-C were included in the study. Clinical parameters were recorded at admission. Relevant laboratory investigations, radiological studies, and outcome were documented. Result(s): The most commonly affected age group was 6-12 years with a female predominance. COVID RTPCR was negative in all patients. Most cases presented 2-6 weeks after the onset of acute COVID-19 infection. Lethargy, poor feeding, vomiting, abdominal pain, loose stools, cough, and cold are common symptoms of MIS-C syndrome in children and the common signs were rash, conjunctival congestion, hypotension, tachycardia, tachypnea, and hypoxemia. Gastrointestinal system was the commonly affected followed by the hepatic, renal, and cardiovascular systems. Coronary artery abnormalities were seen in 20% of cases. IVIg was the mainstay of therapy used in 95% of patients. Mortality was 1.3%. Cases responded well to IVIg and steroids. Conclusion(s): Overall, the short-term outcome was favorable with low mortality in our study cohort. One-fifth of children had coronary artery abnormalities during acute phase underscoring the need for long-term follow-up. Copyright © 2022, The Author(s).
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Case Report: Prolonged fever in children is a symptom that is seen in many different diseases, infections, malignancies, and autoimmune conditions. This can, at times, make the correct diagnosis challenging. A previously healthy 10-year-old male was transferred to our institution with one week history of fever, fatigue, abdominal pain, and vomiting. Laboratory studies demonstrated pancytopenia, transaminitis, electrolyte abnormalities, elevated pro-inflammatory markers & D-Dimer, and hypoalbuminemia. COVID-19 IgG was reactive. Due to the severity in presentation the patient was transferred to the ICU with a presumptive diagnosis of MIS-C. Hewas started on IVIG as well as a five-day course of high-dose methylprednisolone per protocol. Aspirin was added, but later discontinued, due to worsening thrombocytopenia. CT imaging with contrast showed small bilateral pleural effusions & periportal edema, mild splenomegaly, and echocardiogram showed diffuse dilation of the left main and left anterior descending arteries. Given the laboratory findings the differential diagnosis was expanded, Ehrlichia caffeensis serology was sent and empiric Doxycycline started. EBV Nuclear Antigen IgG antibody and EBV Viral Capsid Antigen IgM Antibody resulted as positive suggesting recent or reactivated infection. Respiratory viral PCR with COVID-19, Cytomegalovirus and Parvovirus PCR were negative. Despite initial treatment, the patient continued to have persistent fever, severe pancytopenia, and high ferritin up to 24 426 ng/mL, raising suspicion for Haemophagocytic Lymphohistiocytosis (HLH). Soluble interleukin-2 level was elevated & his presentation was then considered to be more consistent with HLH given that he met 6/8 criteria. Screening for primary HLH including CD107a, perforin and granzyme B, SAP, and XIAP resulted in the latter three being normal but CD107a was abnormal. Next generation sequencing for primary criteria was negative. E. Chaffeensis resulted positive: IgM 1:80, IgG 1:256. MIS-C and HLH have overlapping features but differ in some clinical manifestations. Timely recognition and management is paramount as the management differs. This case illustrates the importance of performing a broad search for potential causes, allowing for appropriate and timely treatment. COVID-19 serology alone should not be the basis for diagnosis of MIS-C in a patient with fever and inflammation. This is important as SARS-CoV2 becomes endemic. Infections such as EBV and Ehrlichiosis should be on the differential particularly in endemic areas and during seasons of higher prevalence for the latter, as these have been well documented to cause HLH. Copyright © 2023 Southern Society for Clinical Investigation.
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Aim/Introduction: While COVID-19 infection is associated with the increased risk of pulmonary thromboembolism (PTE), it may also affects the lungs that causes ventilation-perfusion (VQ) patterns other than PTE. Although extensive research has been done to address different anatomical patterns of COVID-19, there is a knowledge gap in terms of VQ lung scintigraphy in these patients. The purpose of this study is to demonstrate these patterns and to show how important it is to use SPECT/CT in addition to planar images to differ these patterns from PTE [1, 2, 3]. Material(s) and Method(s): We collected lung scans performed in 64 patients with history of past/recent COVID-19 infection (in the preceding 1.5 years) who were referred for VQ scintigraphy. The scan was performed using Q-SPECT/Q-planar (26.6%), Q-SPECT/CT (42.2%), VQ-SPECT (14%) and VQ-SPECT/CT (17.2%). Interpretation was based on the EANM criteria. Result(s): Of these patients 10 (15.6%) had positive scan for PTE. Moreover, in 49 (76.6%) of these patients, anatomical abnormalities were observed compatible with COVID-19 infection. The patterns seen were as follows: 1) apparent hot spot due to focal sparing of lung, 2) zones of decreased and increased perfusion, 3) zones of normal and increased perfusion, 4) small sub-segmental defects matching with CT findings, and 5) reverse mismatched defects. Also, a case of loculated pleural effusion in CT with Q abnormalities was observed. Conclusion(s): Lung perfusion abnormalities are common findings in COVID-19 patients. They are usually either due to pulmonary embolism, parenchymal infiltrates, or other causes of mosaic attenuation related to, but not specific of the pathophysiology of COVID-19 infection. The value of VQ SPECT/CT imaging to detect and differentiate the various types of Q abnormalities was noticeable.
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Case Report: Protein losing enteropathy (PLE) occurs when proteins leak from the gastrointestinal (GI) system more rapidly than they are produced. Inflammation of the GI tract facilitates increased membrane permeability of gastric mucosa, leading to excess protein leakage. 1 PLE in children has been associated with CMV, rotavirus, COVID-19, HIV, C. difficile, and autoimmune diseases like Crohn's Disease. 2-6 Norovirus is a known cause of PLE in immunocompromised pediatric patients. 7-8 However, to our knowledge, there are no case reports about PLE precipitated by norovirus in immunocompetent pediatric patients. The purpose of this case report is to present a case of PLE precipitated by a norovirus infection in a 4- year-old previously healthy child. While the above gastrointestinal viruses have been proposed as precipitators for this disease, PLE precipitated by norovirus infection has not been well described. This case also highlights the importance of early diagnosis and management to avoid complications. Method(s): Our patient initially presented with two days of abdominal pain, diarrhea, emesis, reduced urine output, and swelling of the lower extremities. He was exposed to several sick family members-his sister had upper respiratory symptoms and his grandmother had gastrointestinal symptoms. Physical exam was notable for diminished breath sounds in the right lower lobe, abdominal distension with diffuse tenderness and dullness to percussion, significant scrotal and penile edema, and bilateral lower extremity pitting edema. Laboratory results revealed leukocytosis, hypoalbuminemia, hyponatremia, elevated aspartate aminotransferase (AST), and elevated serum alpha-1-antitrypsin, as well as low Immunoglobulins G and M. CD3 and CD4 levels were low reflecting cellular immune dysregulation seen in patients with PLE. IgA and Tissue Transglutaminase (TTF) were within normal limits. Ebstein Barr Virus and cytomegalovirus IgM antibodies were negative. COVID IgG was negative as well. His Polymerase chain reaction (PCR) gastrointestinal panel was positive for norovirus. A chest X-ray showed a large right pleural effusion. Abdominal CT revealed large ascites slightly more predominant in the upper abdomen, mesenteric lymphadenitis, and bilateral pleural effusions. Echocardiogram showed small anterior and apical pericardial effusions. Result(s): Based on the patient's elevated serum alpha-1 antitrypsin levels, hypoalbuminemia, low levels of immunoglobulins and lymphocytes, and clinical manifestations of ascites, bilateral pleural effusions, pericardial effusion, and dependent edema, along with a positive PCR for norovirus, the diagnosis of PLE secondary to Norovirus was made. Conclusion(s): This case demonstrates the importance of recognizing viruses like Norovirus as potential causes of PLE to avoid a delay in diagnosis and initiation of therapy, and to avoid unnecessary additional testing. Copyright © 2023 Southern Society for Clinical Investigation.
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Aim/Introduction: While COVID-19 infection is associated with the increased risk of pulmonary thromboembolism (PTE), it may also affects the lungs that causes ventilation-perfusion (VQ) patterns other than PTE. Although extensive research has been done to address different anatomical patterns of COVID-19, there is a knowledge gap in terms of VQ lung scintigraphy in these patients. The purpose of this study is to demonstrate these patterns and to show how important it is to use SPECT/CT in addition to planar images to differ these patterns from PTE [1, 2, 3]. Material(s) and Method(s): We collected lung scans performed in 64 patients with history of past/recent COVID-19 infection (in the preceding 1.5 years) who were referred for VQ scintigraphy. The scan was performed using Q-SPECT/Q-planar (26.6%), Q-SPECT/CT (42.2%), VQ-SPECT (14%) and VQ-SPECT/CT (17.2%). Interpretation was based on the EANM criteria. Result(s): Of these patients 10 (15.6%) had positive scan for PTE. Moreover, in 49 (76.6%) of these patients, anatomical abnormalities were observed compatible with COVID-19 infection. The patterns seen were as follows: 1) apparent hot spot due to focal sparing of lung, 2) zones of decreased and increased perfusion, 3) zones of normal and increased perfusion, 4) small sub-segmental defects matching with CT findings, and 5) reverse mismatched defects. Also, a case of loculated pleural effusion in CT with Q abnormalities was observed. Conclusion(s): Lung perfusion abnormalities are common findings in COVID-19 patients. They are usually either due to pulmonary embolism, parenchymal infiltrates, or other causes of mosaic attenuation related to, but not specific of the pathophysiology of COVID-19 infection. The value of VQ SPECT/CT imaging to detect and differentiate the various types of Q abnormalities was noticeable.
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Background: The COVID-19 first surfaced when cluster of pneumonia patients arose in Wuhan, Hubei Province, China. Although the current gold standard for COVID-19 diagnosis is reverse transcriptase-polymerase chain reaction (RT-PCR), chest x-ray (CXR) and computed tomography (CT) play a vital role in sickness diagnosis due to their limited sensitivity and availability. Aim: To evaluate retrospectively the role of CXR, the main radiological findings in it and its diagnostic accuracy in COVID-19 pneumonia. Methods: This is a cross sectional study involving 264 PCR positive COVID-19 patients with their clinical-epidemiological findings admitted at Ziauddin Hospital from May-July 2020. CXRs were taken as digital radiographs in our emergency department's isolation wards using the same portable X-ray device, according to local norms. CXRs were taken in two directions: antero-posterior (AP) and postero-anterior (PA). The hospitals' database had all of the images. To determine the number of radiological findings, multiple radiologists on duty completed an independent and retrospective examination of each CXR. In the event of disagreement, a mutual agreement was reached. SPSS version 20 was used for statistical analysis. Results: We were able to find 264 patients who met our criteria. With a mean age of 56.4214.89, the majority of individuals were determined to be males 189(71.6%) and females 75(28.4%). (Range of 16 to 87 years). 127 patients (48.1%) had severe illness symptoms and were admitted to the ICU, while the remaining 102(38.6%) had mild to moderate disease 35(13.3%). Diffuse (29.2%) and middle and lower co-existing distribution (25.8%) whereas just lower lobe (13.3%) were the most common predominance in severity. Peripheral involvement was also seen in (8.7%) cases. Conclusion: Both lungs are equally affected with the disease having the consolidation and opacifications while the effusion is the major complication in the severe cases. Diffuse involvement of the lung lobes is seen in the study followed by the middle and lower lobe involvement.
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Methicillin-resistant Staphylococcus aureus (MRSA) infections are a primary health concern. They are commonly differentiated as hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, based on their epidemiology, susceptibility findings, and molecular typing patterns. Therefore, appropriate contact precautions and isolation measures should be implemented. CA-MRSA mostly causes skin and soft-tissue infections, but the probability and incidence of it causing sepsis and invasive infections have increased dramatically in recent years. In this study, we report a case of CA-MRSA pneumonia with pan-pneumonic effusion in a 59-year-old male diabetic patient with preexisting comorbidities such as diabetic ketoacidosis and non-ST elevated myocardial infarction. The early reporting of the organism's identity and its antimicrobial susceptibility, as well as timely initiation of antibiotic therapy, aided in the successful management and cure of the patient.
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Background and Aim: Whilst most commonly recognised as a res-piratory pathogen, COVID-19 can also result in a variety of extrapulmonary manifestations including myocardial dysfunction and arrhythmia. We report a case of a 15 year old girl with repaired atrioventricular septal defect, presenting with arrhythmia and sud-den severe cardiac failure masked by COVID-19 positivity. Method(s): A 15 year old girl with repaired atrioventricular septal defect and tetralogy of Fallot, under regular follow up with asymp-tomatic moderate to severe atrioventricular valve dysfunction, pre-sented with one month's history of progressive breathlessness to her local hospital. Onset of illness coincided with typical COVID-19 symptoms;her family, attributing her deterioration to this, delayed seeking medical help. She was rapidly referred to our unit. The heart failure severity, which included diffuse dependent oedema, large pleural effusion and severe biventricular dysfunc-tion, could not be attributed to major valve function change. Moreover, deterioration had occurred rapidly without apparent ongoing cause, after extensive diagnostics. Tachyarrhythmia was suspected;initial adenosine challenge via peripheral vein was inconclusive. Diuretics, inotrope and empirical administration of amiodarone provided limited response;the patient was therefore ventilated, enabling further adenosine challenge via central line, which revealed atrial flutter. Shortly after conversion to sinus rhythm and pleural drainage, her biventricular function improved to near normal. Result(s): Redo surgery was undertaken. Firstly, this included mechanical valve replacement of left and right atrioventricular valves and ablation of the isthmus. Secondly, a permanent pace-maker was inserted a few days later. The patient made a quick and uneventful recovery and was discharged on day 10 with good biventricular function on minimal medical therapy and no symptoms. Conclusion(s): Our case highlights delayed presentation as a hidden effect of the COVID-19 pandemic, and that sudden deterioration in stable children with repaired congenital heart disease should prompt the clinician to exclude all reversible causes of de-stabili-sation, and in particular to maintain high suspicion of arrhythmia.
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SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We present two cases of symptomatic post-COVID eosinophilic pneumonia responsive to steroids. CASE PRESENTATION: Case 1: A 73-year-old gentleman with underlying asymptomatic rheumatoid arthritis (RA), was admitted with COVID pneumonia for which he received tocilizumab, remdesivir, and 12 days of dexamethasone. His course was complicated by MRSA pneumonia and bacteremia, so was discharged on IV Vancomycin. Six days post discharge, he redeveloped respiratory distress. Labs showed a WBC 18,000 and proBNP 2828. A chest CT revealed bilateral ground-glass opacities, worsening right upper lung airspace disease and bilateral pleural effusions. Despite receiving Furosemide, Vancomycin, and Ceftazidime, he required high-flow nasal cannula oxygenation (HFNC). Bronchoscopy demonstrated thick right bronchial secretions. BAL fluid revealed 7% eosinophils and grew MRSA. Case 2: A 70-year-old gentleman with extensive smoking history, emphysema, psoriasis, Guillain-Barré syndrome and a recent hospitalization for COVID pneumonia was discharged on a steroid taper. He returned 23 days post discharge in respiratory distress requiring HFNC, 5 days after discontinuing steroids. The chest CT revealed worsening fibrosis and bronchiectasis. Intravenous Levofloxacin and Vancomycin resulted in no clinical improvement. Bronchoscopy showed inflamed bronchi with secretions and BAL analysis revealed 6% eosinophils. For both patients, BAL was negative for fungi and PJP and CTA ruled out PE. Both patients were started on Prednisone with a prolonged taper. They improved clinically with decreased oxygen requirements to 4L nasal cannula and dramatic decrease in subjective dyspnea within 48 hours of starting steroids. DISCUSSION: The differential diagnosis for the clinical deterioration and worsening radiographs in both patients includes bacterial/fungal superinfection, PE, post-COVID-ILD and eosinophilic pneumonia. For the first patient, his RA was inactive. His BAL was positive for MRSA but did not improve until steroids were initiated. Neither of the patients were stable for VATS biopsy. Eosinophilic pneumonia is defined as pulmonary infiltrates with peripheral blood eosinophilia =500/ml, BAL eosinophils > 5% or eosinophilic infiltration on lung biopsy [1]. Both of our patients had >5% BAL eosinophils. Potentially, prolonged COVID-ILD stimulates T-Helper-2 cells, causing the release of IL-4/5/13 with recruitment of eosinophils. Studies report post-COVID-ILD biopsies show organizing pneumonia and fibrosis but have not yet been associated with eosinophilia. In both patients, we observed eosinophilia on BAL. It can be hypothesized that a delayed inflammatory response mediated by eosinophils play a role. CONCLUSIONS: Pulmonary eosinophilic pneumonia is a complication of post-COVID-ILD and can be successfully managed with steroids. Reference #1: De Giacomi F, Vassallo R, Yi ES, Ryu JH. Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management. Am J Respir Crit Care Med. 2018 Mar 15;197(6):728-736. doi: 10.1164/rccm.201710-1967CI. PMID: 29206477. DISCLOSURES: No relevant relationships by farrukh ahmad No relevant relationships by Deborah Markowitz No relevant relationships by Dhiraj Shah No relevant relationships by Garima Singh No relevant relationships by Aakriti Soni
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SESSION TITLE: Variety in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Actinomyces is a Gram-positive anaerobic and micro aerophilic filamentous bacillus that normally colonize the human mouth and digestive and urogenital tracts. They most commonly cause cervical and abdominopelvic infections and rarely pulmonary actinomycosis. CASE PRESENTATION: 67-year-old female with past medical history of recurrent DVT with IVC filter placement, non- ischemic cardiomyopathy, atrial fibrillation, 40 pack year history, recent COVID19 infection, lung nodules & COPD presented with complaint of coughing up blood associated with chest pain for the past 2 days. She had a low-grade fever with stable vitals with preliminary labs showing she was anemic and had reactive leukocytosis. She was recommended to hold oral anticoagulation and follow-up outpatient during when her symptoms worsened. On admission she was started on tranexamic acid nebulization for hemostasis and underwent CTA chest which showed no evidence for pulmonary embolism but commented on a right lower lobe perihilar 12.5 mm mass which has increased in size compared to previous scans. Patient underwent bronchoscopy which showed generalized edema of the tracheobronchial tree with bleeding from superior segment of the right lower lobe bronchus with no visualization of mass. PET scan showed hyper-metabolic lung mass with concerns for malignancy. CT guided biopsy of nodule was done and was not staining for malignant cells, acid fast bacilli with no fungal or bacterial growth. Blood cultures and Karius Digital cultures were also negative. She began expectorating blood clots despite being on treatment and cardiothoracic surgery was consulted. A partial lobectomy with lysis of adhesions of the right lower lobe was done. Specimen sent to pathology showed no evidence for malignancy but instead elicited a contained pulmonary abscess containing filamentous bacteria with parenchymal inflammation with areas of chronic hemorrhagic fibrosing pleuritis and hilar thrombi. She was diagnosed with pulmonary actinomycosis and started on IV 24,000,000 IU penicillin. She underwent a panoramic dental x-ray which was read as suboptimal dentition with multiple missing teeth and did not identify a source. Patient symptoms resolved post lobectomy and since discharged on long course of antibiotics. She continued to have no more episodes of hemoptysis. DISCUSSION: Hemoptysis as a symptom of pulmonary actinomycosis is a rather rare presentation. Actinomycosis causes cavities, nodules, and pleural effusions. It is commonly mistaken for chronic suppurative lung disease and sometimes malignancy. Isolation and identification occur only a minority of cases with a high culture failure rate due to previous antibiotic therapy, inadequate incubation time or culture conditions. CONCLUSIONS: Due to it's variable presentation pulmonary actinomyces has a large overlap with other diseases but must be considered in the differential of unexplained hemoptysis. Reference #1: Hemoptysis secondary to actinomycosis: A rare presentation. PMID: 24778485 PMCID: PMC3999682 DOI: 10.4103/0970-2113.129864 DISCLOSURES: No relevant relationships by Victoria Famuyide No relevant relationships by rukhsaar khanam
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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: Myalgias are one of the most common manifestations of a COVID infection. Myositis is much less reported with the spectrum of presentation ranging from asymptomatic elevation of creatinine kinase (CK) to rhabdomyolysis. Further understanding is required to formulate evidence based protocols for management and prognostication. CASE PRESENTATION: A 25-year-old male smoker, unvaccinated for COVID presented to the hospital with fever, weakness and myalgias and tested positive for COVID. Examination showed mild tenderness in the proximal muscles of the lower extremities. Labs were significant for metabolic acidosis, hypocalcemia, hyperkalemia, acute kidney injury, AST 6178, ALT 1340, CK > 36000 and CPK > 60000 and gross hematuria. Electrolyte abnormalities were corrected and he received aggressive hydration with intravenous fluids containing bicarbonate. Oxygen requirements increased and he received dexamethasone and Baricitinib for COVID. His creatinine continued to increase despite downtrending transaminases and CK. Ultrasound liver was normal. He developed bilateral pleural effusions and mild ascites suspected secondary to volume overload in the setting of acute renal failure. Hemodialysis was initiated and he received a total of 6 sessions of hemodialysis over the next week. Creatinine, BUN and GFR significantly improved. AntiJo1 Ab ordered to rule out polymyositis was negative. Transaminitis and raised CK levels downtrended alongside the COVID inflammatory markers and oxygen requirements as the patient was weaned to room air. DISCUSSION: The spectrum of COVID myositis reported thus far covers asymptomatic elevation of muscle enzymes, myasthenia, paraspinal myositis, dermatomyositis and rhabdomyolysis (1). The pathophysiology of COVID myositis has been hypothesized to be through ACE2 receptor mediated viral entry into muscle fibers leading to activation of innate and adaptive immunity. Other proposed mechanisms include the release of inflammatory cytokines and molecular mimicry with cross reaction of the antiviral antibodies. Myositis was most reported most commonly among males aged 33–87 (1). Symptoms when present include fevers, cough, shortness of breath, myalgias and proximal, lower limb–dominant, acute, and symmetric weakness. Peak CK values as high as 33,000 U/L have been reported (2). In general, patients diagnosed with rhabdomyolysis appear to have negative myositis-specific autoantibodies and higher CK levels than those without, highlighting the need for close monitoring of CK levels. Rhabdomyolysis associated fatality was reported to be as high as 45% (4 of 9 reported) over a short follow-up duration (1). Our case documents a recovery period in days-weeks with hydration and hemodialysis (3). CONCLUSIONS: Areas for exploration include factors predisposing patients to rhabdomyolysis, utility of checking enzyme levels and impact of vaccination on disease severity. Reference #1: Saud A, Naveen R, Aggarwal R, Gupta L. COVID-19 and Myositis: What We Know So Far. Curr Rheumatol Rep. 2021 Jul 3;23(8):63. doi: 10.1007/s11926-021-01023-9. PMID: 34216297;PMCID: PMC8254439. Reference #2: Husain R, Corcuera-Solano I, Dayan E, Jacobi AH, Huang M. Rhabdomyolysis as a manifestation of a severe case of COVID-19: A case report. Radiol Case Rep. 2020 Jul 7;15(9):1633-1637. doi: 10.1016/j.radcr.2020.07.003. PMID: 32690987;PMCID: PMC7340044. Reference #3: Byler J, Harrison R, Fell LL. Rhabdomyolysis Following Recovery from Severe COVID-19: A Case Report. Am J Case Rep. 2021 May 8;22:e931616. doi: 10.12659/AJCR.931616. PMID: 33963170;PMCID: PMC8127859. DISCLOSURES: No relevant relationships by Asim Amjad No relevant relationships by Sarasija Natarajan No relevant relationships by Pius Ochieng No relevant relationships by Yamini Patel
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SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder that can lead to thrombosis, hemolytic anemia and leukemia. Though there are documented relationships between autoimmune hemolytic anemia (AIHA) and COVID-19 infection, this is the first to highlight aa potential association between PNH exacerbations and COVID vaccinations. CASE PRESENTATION: A 38 year-old female with a history of chronic paroxysmal nocturnal hemoglobinuria (PNH) currently on maintenance ravculizumab therapy presented with 3 days of generalized fatigue, chills, and worsening scleral icterus. She reports being unable to move out of the bed with concomitant somnolence. Of note, she received her second dose of the Moderna COVID-19 vaccine 2 days prior to symptom onset and not had any similar symptoms prior to this episode. Patient was hemodynamically stable on admission and afebrile. Physical exam revealed generalized lethargy/weakness and jaundice. Chest x-ray did not demonstrate any evidence of infection or pleural effusions. Initial complete blood count showed a hemoglobin of 5.9 g/dL, compared to her baseline of 9 without any evidence of bleeding. Absolute reticulocyte and bilirubin levels were elevated to 295.2 x 109 and 4.7 mg/dL respectively with a haptoglobin of <20 mg/dL. She received a total of 3 units of packed red-blood cells with subsequent stable hemoglobin levels and did not require emergent use of glucocorticoids or plasma exchange. Her lethargy improved slowly, and within a week, she returned back to her baseline functional status. She was ultimately stable and discharged for follow up with her hematologist without any complications. DISCUSSION: Though the sequelae of COVID-19 infections and associated hematologic diseases have been extensively established, the pathogenesis of COVID-19 vaccinations associated exacerbations remain unclear. Given the timing of the onset of our patient's symptoms, it is highly suggestive that her second COVID-19 vaccination was the inciting factor for her acute hemolytic anemia. It is crucial to be cognizant of the potential hematologic side effects in individuals with rare auto-immune disorders such as PNH and take into consideration the timing of vaccination or booster administrations. CONCLUSIONS: While COVID-19 vaccination benefit most likely outweighs the risks for this specific patient population, our case raises the question about the need for extra precautions in patients with known PNH associated AIHA including the timing of PNH treatment before receiving the vaccination. Reference #1: Algassim AA, Elghazaly AA, Alnahdi AS, Mohammed-Rahim OM, Alanazi AG, Aldhuwayhi NA, Alanazi MM, Almutairi MF, Aldeailej IM, Kamli NA, Aljurf MD. Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection. Annals of Hematology. 2021 Jan;100(1):37-43. DISCLOSURES: No relevant relationships by Suhwoo Bae No relevant relationships by Edward Bae No relevant relationships by Joseph You
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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: Rib fractures are an infrequent consequence of severe cough. In some patients, undetected rib fractures can lead to life-threatening outcomes. We bring to light a case of uncontrolled cough associated with COVID-19 infection resulting in multiple rib fractures that were missed in 2 hospital visits and subsequently diagnosed when the patient presented in acute distress and at high risk of decompensation from a hemothorax and a diaphragmatic hernia that required expedited evaluation, ICU admission, and surgical intervention. CASE PRESENTATION: This is a case of a 73 years old male who presented with shortness of breath and worsening dry cough of 4 weeks duration. He was seen in the ED 3 weeks previously for severe right-sided chest pain that was evaluated by a CT chest that did not reveal any acute findings. He was discharged home on pain medications. He had a repeat admission in 2 days and was diagnosed with acute hypoxic respiratory failure secondary to COVID-19 infection. CT abdomen was done for continued right upper quadrant pain which showed an upper abdominal wall hernia. He was discharged with instructions to follow up with outpatient surgery for hernia repair. In the interim, the patient continued to have excessive dry cough, progressively worsening shortness of breath, and bruising over the right abdominal wall and back. He returned to the ED where he was found to be hypoxic, and hypotensive. Imaging studies revealed a large right pleural effusion, fracture of the right sixth rib and seventh rib, and herniation of the hepatic flexure of the colon into the chest. He was subsequently admitted to the cardiothoracic ICU and underwent flexible bronchoscopy, right VATS, evacuation of hemothorax, complete decortication, and repair of diaphragmatic hernia. DISCUSSION: This case is an unusual presentation of an amalgamation of complications resulting from an unrelenting cough that prompted rapid recognition and swift action. Cough-induced complications are rare but can be life-threatening. Various imaging studies can be pursued to avoid a delay in diagnosis. CONCLUSIONS: Persistent cough is a common complication of COVID-19 infection. A clinician should have a high index of suspicion for rib fractures, diaphragmatic hernia, and hemothorax in a patient with persistent or progressive symptoms. Reference #1: Camarillo-Reyes LA, Marquez-Córdova RI, Surani S, Varon J. Hemothorax induced by severe cough: An unusual presentation. SAGE Open Med Case Rep. 2019;7:2050313X19846043. Published 2019 Apr 26. doi:10.1177/2050313X19846043 Reference #2: Daccache A, Haddad J, Ghanem A, Feghali EJ, El Osta B. Cough-induced rib fracture in a smoker: a case report. J Med Case Rep. 2020;14(1):147. Published 2020 Sep 5. doi:10.1186/s13256-020-02497-4 DISCLOSURES: No relevant relationships by Navya Akula No relevant relationships by Sanjana Chetana Shanmukhappa No relevant relationships by Muhammad Ahmed Malik No relevant relationships by Aqsa Malik No relevant relationships by Fahd Shaukat