Neurologic Manifestations of COVID-19

Coronavirus disease (COVID-19) caused by a new coronavirus, SARS-CoV-2, has become a serious health problem throughout the world. Although COVID-19 primarily presents as an acute respiratory tract infection, many neurological findings have also been described in patients. Neurological findings are classified into three groups as central, peripheral nervous system and musculoskeletal system. The most common central nervous system symptom is headache. Encephalitis, encephalopathy, seizures, acute ischemic stroke are also seen. The most common symptoms in the peripheral nervous system are loss of smell and taste. Myalgia, myositis and rhabdomyolysis also can be seen in musculoskeletal system involvement. Awareness of the neurological symptoms by physicians will be beneficial in early diagnosis and treatment of the disease.

Neurologic Manifestations of COVID-19.

Coronavirus disease (COVID-19) caused by a new coronavirus, SARS-CoV-2, has become a serious health problem throughout the world. Although COVID-19 primarily presents as an acute respiratory tract infection, many neurological findings have also been described in patients. Neurological findings are classified into three groups as central, peripheral nervous system and musculoskeletal system. The most common central nervous system symptom is headache. Encephalitis, encephalopathy, seizures, acute ischemic stroke are also seen. The most common symptoms in the peripheral nervous system are loss of smell and taste. Myalgia, myositis and rhabdomyolysis also can be seen in musculoskeletal system involvement. Awareness of the neurological symptoms by physicians will be beneficial in early diagnosis and treatment of the disease. Copyright © 2022 Ankara Pediatric Hematology Oncology Training and Research Hospital. All rights reserved.

Post-COVID Multisystem Inflammatory Syndrome-Adult (MIS-A) Presenting with Rhabdomyolysis and AKI.

Multisystem inflammatory syndrome is a rarely reported post-COVID (coronavirus disease) phenomenon in adults. Our understanding of the multisystem inflammatory syndrome- adult (MIS-A) is based on multiple case reports that have demonstrated heterogeneous clinical presentations and treatment options. Rhabdomyolysis is an unusual presentation of MIS-A. We report the case of a 61-year-old man who presented with rhabdomyolysis with acute kidney injury (AKI), acute inflammatory demyelinating polyneuropathy (AIDP), myocarditis, disseminated intravascular coagulation, and minimal respiratory symptoms. The patient was found to have post-COVID inflammatory syndrome and recovered with supportive treatment and intravenous immunoglobulin (2 g/kg over 5 days). COVID-19 (coronavirus disease 2019) antibody positivity played a significant role in making the diagnosis of MIS-A and in providing prompt treatment.

Acute kidney injury due to myoglobin cast nephropathy in the setting of coronavirus disease 2019-mediated rhabdomyolysis: a case report.

BACKGROUND: We present this case of coronavirus disease 2019-associated acute kidney injury with rhabdomyolysis-with noteworthy renal biopsy findings demonstrating myoglobin cast nephropathy-to add to the limited literature on coronavirus disease 2019-related acute kidney injury and rhabdomyolysis. CASE PRESENTATION: A 67-year-old Caucasian man presented to our hospital with 3 weeks of malaise and decreased oral intake and several days of abnormal taste, poor appetite, decrease urine output, gastrointestinal symptoms, and myalgias, and was ultimately diagnosed with coronavirus disease 2019. His hospital course was complicated by acute kidney injury and, upon workup of his renal failure, was diagnosed with myoglobin cast nephropathy due to coronavirus disease 2019-mediated rhabdomyolysis. Ultimately, his renal function improved following hydration back to his baseline 6 weeks after his initial diagnosis of coronavirus disease 2019. CONCLUSIONS: Given our limited knowledge of manifestations of coronavirus disease 2019, it is important to have a more in-depth understanding of the spectrum of disease of coronavirus disease 2019, which can affect various organ systems, including the kidney, and the manifestations of end-organ damage associated with it. We present this case to highlight a rarely reported finding of myoglobin cast nephropathy due to coronavirus disease 2019-mediated rhabdomyolysis.

Rhabdomyolysis Associated with Recent SARS-COV-2 Infection in a Patient with Carnitine Palmitoyltransferase II Deficiency.

Carnitine palmitoyltransferase II deficiency (CPT II) is an autosomal recessive inherited disorder of long-chain fatty acid oxidation in the mitochondrial matrix, resulting in an inability to utilize fat for energy in cells. The most frequent myopathic form occurs in young adults and is associated with recurrent episodes of exercise-induced rhabdomyolysis. The myopathic form is caused by the Ser113Leu mutation of the CPT II gene. Rarely, massive rhabdomyolysis could be complicated by acute kidney injury (AKI), cardiomyopathy, and respiratory insufficiency. We present a case of an 18-year old male with myalgia, muscular weakness, and dark-colored urine after prolonged exercise and a recent mildSARS-CoV-2infection. Massive rhabdomyolysis was diagnosed with markedly increased serum concentrations of myoglobin and creatine kinase, with normal kidney function. The patient experienced two similar episodes in the years 2017 and 2018, with rhabdomyolysis and AKI treated with hemodialysis. After excluding autoimmune and infectious diseases as causes of recurrent rhabdomyolysis, the patient was genetically tested and Ser113Leu mutation of the CPT II gene was confirmed. When a patient presents with myalgia and dark-colored urine triggered by minor physical activities, genetic testing for possible CPT II deficiency should be initiated. TheSARS-CoV-2infection could be a factor that triggers the occurrence of rhabdomyolysis and aggravates the severity of the attack in patients with CPT II deficiency.

A case of Legionnaires' disease with severe rhabdomyolysis misdiagnosed as COVID-19.

Background: COVID-19 case numbers have begun to rise with the recently reported Omicron variant. In the last two years, COVID-19 is the first diagnosis that comes to mind when a patient is admitted with respiratory symptoms and pulmonary ground-glass opacities. However, other causes should be kept in mind as well. Here we present a case of Legionnaires' disease misdiagnosed as COVID-19. Case presentation: A 48-year-old male was admitted with complaints of dry cough and dyspnea. Chest computed-tomography revealed bilateral ground-glass opacities; therefore, a preliminary diagnosis of COVID-19 was made. However, two consecutive COVID PCR tests were negative and the patient deteriorated rapidly. As severe rhabdomyolysis and acute renal failure were present, Legionnaires' disease was suspected. Urine antigen test for Legionella and Legionella pneumophila PCR turned out to be positive. The patient responded dramatically to intravenous levofloxacin and was discharged successfully. Discussion: Legionnaires' disease and COVID-19 may present with similar signs and symptoms. They also share common risk factors and radiological findings. Conclusions: Shared clinical and radiological features between COVID-19 and other causes of acute respiratory failure pose a challenge in diagnosis. Other causes such as Legionnaires' disease must be kept in mind and appropriate diagnostic tests should be performed accordingly.

COVID-19 Still Surprising Us-A Rare Movement Disorder Induced by Infection.

BACKGROUND: Many neurological manifestations are part of COVID-19 infections, including movement disorders, but a clinical picture closely resembling stiff-person syndrome has not yet been described. CASE PRESENTATION: We report a case of a stiff-person-like syndrome in the context of COVID-19 infection. A 79-year-old woman, with no prior history of diseases, presented global reversible stiffness associated with SARS-CoV-2 infection. We aim to shed light on several particularities regarding this clinical picture and its evolution in close relationship with the infectious disease progression, with full regression of symptoms and signs once the infectious process ceased. The impairment of speech and motility caused the wrong diagnosis of stroke in the Emergency Room. In addition, we would also like to emphasize the concomitant rhabdomyolysis, closely linked to the grade of muscle rigidity. CONCLUSIONS: We would like to raise awareness regarding this clinical setting and its association with SARS-COV-2 infection, to aid in its future recognition and management. To our knowledge, this is the first case of a stiff-person-like syndrome to be described in association with COVID-19 infection.

Severe rhabdomyolysis secondary to COVID-19 mRNA vaccine in a teenager.

BACKGROUND: Rhabdomyolysis, the breakdown of skeletal muscles following an insult or injury, has been established as a possible complication of SARS-CoV-2 infection. Despite being highly effective in preventing COVID-19-related morbidity and mortality, several cases of COVID-19 mRNA vaccination-induced rhabdomyolysis have been identified. We provide the second description of a pediatric case of severe rhabdomyolysis presenting after COVID-19 mRNA vaccination. CASE: DIAGNOSIS/TREATMENT: A 16-year-old male reported to the emergency department with a 2-day history of bilateral upper extremity myalgias and dark urine 2 days after his first dose of COVID-19 vaccine (Pfizer-BioNtech). The initial blood work showed an elevated creatinine kinase (CK) of 141,300 units/L and a normal creatinine of 69 umol/L. The urinalysis was suggestive of myoglobinuria, with the microscopy revealing blood but no red blood cells. Rhabdomyolysis was diagnosed, and the patient was admitted for intravenous hydration, alkalinization of urine, and monitoring of kidney function. CK levels declined with supportive care, while his kidney function remained normal, and no electrolyte abnormalities developed. The patient was discharged 5 days after admission as his symptoms resolved. CONCLUSION: While vaccination is the safest and most effective way to prevent morbidity from COVID-19, clinicians should be aware that rhabdomyolysis could be a rare but treatable adverse event of COVID-19 mRNA vaccination. With early recognition and diagnosis and supportive management, rhabdomyolysis has an excellent prognosis.

Rhabdomyolysis after COVID-19 Comirnaty Vaccination: A Case Report.

Rhabdomyolysis is an acute disruption in skeletal muscle integrity, leading to the rapid release of 4 muscle contents into the bloodstream, such as creatine kinase (CK). It can have various causes, including infections. Throughout the pandemic, multiple cases of rhabdomyolysis following COVID-19 infections have been reported. However, rhabdomyolysis subsequent to COVID-19 vaccinations appears to be relatively rare. Here, we report such a case after a second COVID-19 Comirnaty (BioNTech/Pfizer) vaccination. Our patient developed rhabdomyolysis 1 day after the second Comirnaty vaccination with high creatine kinase (CK) levels, generalized weakness, and kidney failure. CK levels and muscle weakness resolved after treatment with intravenous fluids, but unfortunately, he remained hemodialysis dependent after discharge. To our knowledge, this is one of the first case reports describing a patient with rhabdomyolysis after a Comirnaty vaccination. However, as millions of people have received the Comirnaty vaccine, it is unclear whether the rhabdomyolysis in our patient is a rare side effect or an unrelated, coincidental event. Large observational studies are needed to elucidate the causality between the Comirnaty vaccination and rhabdomyolysis. Awareness is warranted in patients with myalgia and muscle weakness shortly after COVID-19 vaccination, in order to initiate treatment early and prevent life-threatening complications.

An Unusual Presentation of Rhabdomyolysis and Acute Kidney Injury after Physical Activity: A Case Report.

Exercise-induced rhabdomyolysis refers to the breakdown of striated muscle, which releases intracellular elements into the bloodstream due to heavy physical activity. In rare instances, this condition may be the first clinical manifestation of sickle cell trait (SCT). We report on a 31-year-old woman with post-infectious fatigue who, after suffering mild COVID-19 symptoms 3 weeks prior, presented with intense muscle pain in the ankles, dyspnea, and choluria hours after strenuous physical exercise during a practical test. She sought emergent care the next day, where serum creatinine was measured at 2.4 mg/dL (baseline 1.0 mg/dL) and creatine phosphokinase at 118,000 U/L. She was previously healthy, without regular use of any medication, and habitually sedentary except in training, with no personal or family history of blood or muscle diseases. She was admitted without hemodialysis and discharged after 2 weeks. At 3 months, she had normalization of creatine phosphokinase and creatinine. As an outpatient, other tests were requested. Hemoglobin (Hb) electrophoresis revealed HbA1 of 57.8%, HbA2 of 3.1%, HbF of 0.3%, and HbS of 38.8%, which were compatible with SCT. Evaluation for SCT should be considered in cases of exercise-induced rhabdomyolysis, especially in young, healthy patients.

Rhabdomyolysis after COVID-19 Infection: A Case Report and Review of the Literature.

Rhabdomyolysis is a condition in which muscle breaks down potentially leading to renal dysfunction, and often occurs secondary to a precipitating factor. Viral or bacterial infections are common precipitants for initiating rhabdomyolysis. Recently, healthcare systems across the world have been challenged by a pandemic of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causing 'coronavirus disease 2019' (COVID-19) disease. SARS-CoV-2 infection is recognized to cause respiratory and cardiovascular compromise, thromboembolic events, and acute kidney injury (AKI); however, it is not known whether it can precipitate rhabdomyolysis, with only a limited number of cases of SARS-CoV-2 infection preceding rhabdomyolysis reported to date. Here, we report the case of a 64-year-old woman who developed rhabdomyolysis shortly after SARS-CoV-2 infection and COVID-19. She initially presented with muscular pain, a creatine kinase level of 119,301 IU/L, and a mild rise in her creatinine level to 92 µmol/L, but successfully recovered with intravenous fluid support. We also review the literature to summarise previously reported cases of rhabdomyolysis precipitated by SARS-CoV-2, highlighting the need to consider this diagnosis in patients presenting with SARS-CoV-2 and myalgia.

DAPTOMYCIN-INDUCED EOSINOPHILIC PNEUMONITIS

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

MALIGNANT HYPERTHERMIA AND COVID-19: IS THERE A CORRELATION?

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Malignant hyperthermia (MH) is a hypermetabolic crisis where an increase in carbon dioxide is seen despite an increased minute ventilation with a proposed mechanism as a disturbance in calcium homeostasis. Commonly seen in volatile anesthetic agents and depolarizing neuromuscular blockers, rarely with nondepolarizing agents. There has been one reported case of cisatracurium-induced MH in the setting of ARDS. There have been two cases reported of nondepolarizing neuromuscular agents causing MH in the setting of COVID-19. CASE PRESENTATION: A 34-year-old man with severe COVID-19 complicated by ARDS on ventilator day 16, due to refractory fevers, ventilatory dyssynchrony, high minute ventilation and auto-PEEP phenomena, the decision was made to attempt neuromuscular paralysis. After one dose of cisatracurium, the patient became hyperthermic and end-tidal carbon-dioxide increased from 58-98 with inability to oxygenate. The patient developed high peak pressures, bedside ultrasound revealed no evidence of pneumothorax also confirmed with chest x-ray. The patient then received a dose of dantrolene with end-tidal improving to 60 and tachycardia also resolved. A creatinine kinase level drawn was elevated at 571. DISCUSSION: A proposed mechanism of MH is calcium release from sarcoplasmic reticulum, a mutation in skeletal muscle ryanodine receptor calcium release channels that can release IL-6 when activated leading to excessive muscular contraction. Proinflammatory cytokine IL-6, dantrolene may block IL-6 release which results in its therapeutic effect in the treatment of MH. IL-6 has been used to predict deterioration from COVID-19. Dantrolene in this sense has been proposed as a potential therapeutic agent against COVID-19, inhibiting intracellular calcium influx thus preventing the pathological feedback of viral entry into cells via endocytosis, as this is a calcium dependent process. Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of MH, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. CONCLUSIONS: Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of malignant hyperthermia, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. Reference #1: Sathyanarayanan SP, Hamza M, Hamid K, Groskreutz D. Cisatracurium-Associated Malignant Hyperthermia During Severe Sars-CoV-2 Infection. Am J Ther. 2021 Aug 10;28(5):e590-e591. doi: 10.1097/MJT.0000000000001437. PMID: 34387563;PMCID: PMC8415506. Reference #2: Chiba N, Matsuzaki M, Mawatari T, Mizuochi M, Sakurai A, Kinoshita K. Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report. Eur J Med Res. 2021 Feb 8;26(1):18. doi: 10.1186/s40001-021-00489-8. PMID: 33557936;PMCID: PMC7868892. Reference #3: Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, Zhang P, Liu X, Gao G, Liu F, Jiang Y, Cheng X, Zhu C, Xia Y. Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors. Emerg Microbes Infect. 2020 Dec;9(1):1123-1130. doi: 10.1080/22221751.2020.1770129. PMID: 32475230;PMCID: PMC7473317. DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Timothy DAmico no disclosure on file for Sarah Margolskee;No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore

RHABDOMYOLYSIS AS A VARIANT OF COVID-19 MYOSITIS

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

WHEN ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) IS JUST THE BEGINNING: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) FROM COVID-19 INFECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur

Pattern of admission and outcome of patients admitted to dedicated trauma intensive care unit (ticu), emergency department, teaching hospital, north-eastern malaysia

Background: The role of dedicated Trauma ICU (TICU) in Emergency Department is vital in the chain of trauma care to ensure rehabilitation and sustainable critical care for a better survival outcome. This study is conducted to find out demographic patterns and predictors that can affect the outcomes of trauma patients.Methods: A retrospective review of all patients admitted to TICU, Hospital Universiti Sains Malaysia (HUSM) was carried out from January 1st, 2016 till December 31st, 2018. Data were collected from TICU admission and discharge registers and were analyse using SPSS version 23.0. Results: A total of 108 trauma patients were included in this study. All cases were exclusively blunt trauma (99.1%) and mainly attributed by road traffic injuries (92.6%). In terms of trauma clinical scoring, 25%(p= 0.001) presented with GCS score < 4, 46.9% (p=0.001) with RTS score <5.5 and 15.6% (p=0.012) with APACHE II score > 28had demonstrated prolonged ICU stay (> 7 days). Meanwhile 62.5% (p= 0.000) with GCS < 4, 75% (p= 0.000) with RTS < 5.5 and 75% (p= 0.000) with APACHE II > 28 were died in TICU. Besides that, those who had prolonged ICU stay (> 7 days) were 8.5 times higher odds to get sepsis (adj OR= 8.532;95% CI: 2.710, 26.863;p= 0.000) and 7 times higher odds to get acute kidney injury (AKI) (adj OR= 7.131;95% CI: 1.464, 34.733;p= 0.015). Meanwhile, patient who received blood transfusion led to 5 folds higher odds ofassociation with rhabdomyolysis (adj OR= 4.968;95% CI: 1.821, 13.549;p= 0.002).Conclusion: In the midst of pandemic COVID-19 it is important for ED physician to early identify and prioritise high risk trauma patient based on predictors and allows for targeted monitoring and intervention that may improve their outcome and also optimise resources accordingly.

Rhabdomyolysis and Acute Myopathies

The clinical syndrome of rhabdomyolysis is based on the 'classical' triad of myalgia, weakness and pigmenturia. For this lecture it will be defined as an acute such clinical syndrome with markedly elevated serum CK. The common general triggers of rhabdomyolysis are: Exertion, heat & fever, fasting and dehydration, drugs and anesthesia and muscle trauma. The causes of rhabdomyolysis are divided to two general groups: Genetic (metabolic myopathies and dystrophies) and acquired. The main complications of rhabdomyolysis are acute kidney failure and electrolyte imbalance. There is no consensus on treatment guidelines but the main therapeutic modes are high fluid load (if renal status allows) and alkalization of urine. Initial observations on rhabdomyolysis and COVID-19 will be discussed. The lecture will present the issues with clinical cases and their dilemmas to enhance the relevance between the theory and clinical practice.

Rhabdomyolysis in Pediatric Patients with SARS-CoV-2 Infection.

BACKGROUND: Rhabdomyolysis is a rare but severe complication in adult patients with Coronavirus disease 2019 (COVID-19), which can result in acute kidney injury and death; however, it is rarely reported in pediatric patients. METHODS: In this study, we retrospectively reviewed the clinical features and outcomes of rhabdomyolysis in pediatric patients aged 0-18 years with COVID-19 who were hospitalized at Taipei Tzu Chi Hospital, an epicenter of COVID-19 in northern Taiwan. RESULTS: We treated eight patients with rhabdomyolysis during the omicron variant-Severe acute respiratory syndrome coronavirus 2 (omicron variant-SARS-CoV-2) community outbreak and none during the alpha variant endemic. These eight patients shared stereotypical presentations, including the presence of bilateral calf pain after defervescence. The creatinine kinase (CK) levels were between 1346 and 6937 U/L on admission, and clinical course was uneventful after aggressive saline hydration. CONCLUSION: Rhabdomyolysis is not a rare complication in pediatric patients with the omicron-SARS-CoV-2 infection, and reassurance of a good prognosis is important to alleviate family anxiety.