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1.
Pediatric Rheumatology Online Journal ; 20(1):112, 2022.
Article in English | MEDLINE | ID: covidwho-2162383

ABSTRACT

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a new syndrome with some clinical manifestations similar to Kawasaki disease (KD), which is difficult to distinguish.

2.
Respiratory Medicine ; : 107084, 2022.
Article in English | ScienceDirect | ID: covidwho-2150520

ABSTRACT

Background Multisystem inflammatory syndrome in adults (MIS-A) is an increasingly recognized complication of Covid-19. We assessed risk factors, clinical characteristics, and outcomes of patients with MIS-A compared with other inflammatory conditions. Methods We analyzed a cohort of patients ≥21 years hospitalized with MIS-A in Quebec, Canada between February 2020 and March 2021. We included comparison groups that share symptomatology or pathophysiology with MIS-A, including Kawasaki disease, toxic shock syndrome, and other Covid-19 complications. We examined characteristics of men and women at admission, and identified preexisting factors associated with MIS-A through odds ratios (OR) and 95% confidence intervals (CI) from adjusted logistic regression models. Results Among 22,251 patients in this study, 52 had MIS-A, 90 Kawasaki disease, 500 toxic shock syndrome, and 21,609 other Covid-19 complications. MIS-A was associated with an elevated risk of respiratory failure compared with Kawasaki disease (OR 7.22, 95% CI 1.26–41.24), toxic shock syndrome (OR 4.41, 95% CI 1.73–11.23), and other Covid-19 complications (OR 3.03, 95% CI 1.67–5.50). Patients with MIS-A had a greater risk of cardiac involvement, renal failure, and mortality. The data pointed towards sex-specific differences in presentation, with more respiratory involvement in women and cardiac involvement in men compared with patients that had other Covid-19 complications. Except for allergic disorders and cancer, prior medical risk factors were not associated with a greater likelihood of MIS-A. Conclusions Patients with MIS-A have an elevated risk of mortality compared with other inflammatory conditions, with women having a predominance of respiratory complications and men cardiovascular complications.

3.
Anais Brasileiros de Dermatologia ; 2022.
Article in English | ScienceDirect | ID: covidwho-2120355

ABSTRACT

Objectives multi-system ınflammatory syndrome in children (MIS-C) is an immune-mediated process that develops after infections like SARS-CoV-2. The authors aimed to reveal the mucocutaneous findings of patients diagnosed with MIS-C at presentation and evaluate the frequency of these mucocutaneous findings and their possible relationship with the severity of the disease. Methods A prospective study was conducted of 43 children admitted to a tertiary hospitals between January 2021 and January 2022 who met Centers for Disease Control and Prevention criteria for MIS-C. Results 43 children (25 [58.1%] male);median age, 7.5 years [range 0.5‒15 years]) met the criteria for MIS-C. The most common symptom was cutaneous rash 81.4%, followed by gastrointestinal symptoms 67.4%, oral mucosal changes 65.1%, and conjunctival hyperemia 58.1%, respectively. The most common mucosal finding was fissured lips at 27.9%, diffuse hyperemia of the oral mucosa at 18.6%, and strawberry tongue at 13.9%. Urticaria (48.8%) was the most common type of cutaneous rash in the present study’s patients. The most common rash initiation sites were the trunk (32.6%) and the palmoplantar region (20.9%), respectively. The presence or absence of mucocutaneous findings was not significantly associated with disease severity. Study limitations The number of patients in the this study was small. Conclusions The present study’s prospective analysis detected mucocutaneous symptoms in almost 9 out of 10 patients in children diagnosed with MIS-C. Due to the prospective character of the present research, the authors think that the characteristic features of cutaneous and mucosal lesions the authors obtained will contribute to the literature on the diagnosis and prognosis of MIS-C.

4.
J Nurse Pract ; 2022 Oct 14.
Article in English | MEDLINE | ID: covidwho-2069520

ABSTRACT

This case report describes a young adult patient with post-severe acute respiratory syndrome coronavirus 2 acute viral myocarditis who initially presented to a local urgent care center. The patient decompensated and was transferred to our tertiary, intensive care setting.

5.
Archives of Disease in Childhood ; 107(Supplement 2):A207, 2022.
Article in English | EMBASE | ID: covidwho-2064029

ABSTRACT

Aims Paediatric populations are generally considered to be at a lower risk of mortality from COVID-19 infection compared with adult populations. Regardless, a notable number of deaths from COVID-19 have been reported in paediatric populations. Therefore, the purpose of our work was to conduct a scoping review of the literature to assess the risk factors for COVID-19 mortality among paediatric populations. Methods Our review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). Searches were performed in PubMed, Scopus, medRxiv, and WHO Coronavirus Database. There were no restrictions placed for searches based on date. Papers that were written in English, included at least one paediatric death from COVID-19, and described at least one risk factor for the death and/or clinical presentation of the child(ren) were eligible for inclusion. The paediatric population was defined as children aged 18 years and younger. Results Searches generated a total of 5828 papers and, of those, 75 were eligible for inclusion. There was a pooled total of 876 paediatric deaths. Significant risk factors for paediatric mortality included having co-infection of other pathogens, and at least one comorbidity;the comorbidities most frequently associated with mortality were malignancies, heart conditions, kidney disease, and genetic disorders such as Down Syndrome. The development of Paediatric Multisystem Inflammatory Syndrome (PMIS) was also consistently demonstrated to be a risk factor. Common clinical complications associated with paediatric COVID-19 infection resulting in mortality were sepsis, acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI). Conclusion Our review has highlighted prominent risk factors for mortality from COVID-19 amongst paediatric populations. It is vital to consider the risk factors in order to assist prognostication and clinical decisions for severe paediatric infections of COVID-19. Our findings also highlight the importance of COVID-19 vaccination in paediatric populations.

6.
Archives of Disease in Childhood ; 107(Supplement 2):A203-A204, 2022.
Article in English | EMBASE | ID: covidwho-2064028

ABSTRACT

Aims Multisystem inflammatory syndrome in children (MIS-C) secondary to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has affected not only the older children, adolescents and adults but also infants, more so during the second wave of the global pandemic. Thus, this study was done to describe the profile of infants presenting with multisystem inflammatory syndrome (MIS) with the aim to alert clinicians regarding the need for its early diagnosis and timely management in this vulnerable age group to prevent the morbidity, mortality and long term complications associated with MIS-C. Methods All sequentially admitted infants hospitalized during a period of 6months from,who fulfilled the WHO/CDC/RPCH criteria for MIS-C were included in the study. The data was recorded in a semi-structured pre-tested self-designed proforma regarding the demographic profile, presenting symptoms, clinical signs, laboratory parameters and treatment received. The data was analysed using appropriate statistical tools. Results A total of 19 infants were studied. Of these, 68.3% (13) had an evidence of recent COVID-19 infection. The median age of presentation was 2 months. The male:female ratio was 1.1:1. The most common presenting symptoms were fever (68.4%), gastrointestinal complaints (63.1%) and edema (36.8%) (figure 1). Other predominant signs were shock (78.9%), myocarditis (52.6%) and neurological complaints (26.3%). Incomplete Kawasaki disease was present in 21% patients. Elevated CRP, ferritin, D-Dimer, NT pro BNP and reduced fibrinogen were markers of severe illness. All subjects received IVIG (100%), 31.5% received a second dose of IVIG and 63.1% received pulse intravenous methylprednisolone. (table 1) A total of 5(26.3%) died as a result of the disease process. Conclusion MIS-C in infants is usually under-diagnosed and under-reported due to the considerable overlap between sepsis and MIS-C especially due to the higher incidence of sepsis in developing countries. The spectrum of this illness can be varied and is different from the overt clinical signs seen in older children and adolescents. Thus, these investigations should be done early in the course for optimal therapy with immunomodulators and favourable outcome.. (Figure Presented).

7.
Cardiology in the Young ; 32(Supplement 2):S92-S93, 2022.
Article in English | EMBASE | ID: covidwho-2062132

ABSTRACT

Background and Aim: Multi-system inflammatory syndrome in chil-dren (MIS-C) causes widespread systemic inflammation including a pancarditis in the weeks following a COVID infection. Further coronavirus surges appear inevitable and with vaccination rates lower in young people an understanding of the medium-term car-diac impacts of this condition is important for planning further treatment and understanding the impacts on their health. Method(s): A retrospective single-center study of 67 consecutive patients with MIS-C was performed. Three time points were determined as the point of worst cardiac dysfunction during the acute admission, then at intervals of 6-8 weeks and 6-8 months. Echocardiographic findings were used to evaluate both 2D and 3D measures of cardiac function. Coronary artery measurements were recorded. Corresponding serial ECG findings were evaluated. Result(s): The worst cardiac function arose 6.8 +/- 2.4 days after the onset of fever. The mean M mode-derived FS was 30.9 +/- 8.1% during the acute phase. The mean 3D left ventricle (LV) ejection fraction (EF) was borderline at 50.5 +/- 9.8%. A pancarditis was typ-ically present: 46.3% showed cardiac impairment;31.3% had some pericardial effusion;26.8% had moderate (or worse) valvar regur-gitation and;26.8% had coronary dilatation. Cardiac function returned to normal in all patients by 6-8 weeks (mean 3D LV EF 61.3 +/- 4.4%, plt;0.001 compared to admission). Coronary dila-tation normalized in all but one patient who initially developed large aneurysms at presentation;these continued 6 months later. ECG findings mainly featured T-wave changes resolving at fol-low-up. There were a small number of adverse events: need for ECMO (2), death as an ECMO-related complication (1), suben-docardial infarction (1), LV thrombus formation (1). Conclusion(s): MIS-C causes a pancarditis with decreased cardiac function and almost a quarter of patients showing coronary changes. In most, discharge from long-term follow-up can be con-sidered as full cardiac recovery is expected by 8 weeks. The excep-tion includes patients with medium sized aneurysms or greater or those with more of a Kawasaki disease phenotype as these require on-going surveillance for persistence of coronary changes.

8.
Cardiology in the Young ; 32(Supplement 2):S183, 2022.
Article in English | EMBASE | ID: covidwho-2062120

ABSTRACT

Background and Aim: Multisystem inflammatory syndrome in chil-dren (MIS-C) is a late manifestation of SARS-CoV-2 infection. Cardiac involvement is common and presents as ventricular dys-function, shock, and coronary anomalies. The aim of the study is evaluate the influence of cardiac disfunction on clinical presen-tations and outcomes in a single center. Method(s): A retrospective study on patients diagnosed with MIS-C and referred to Buzzi Children's Hospital in Milan from November 2020 to February 2021. Patients were treated with intravenous immunoglobulins, corticosteroids and anti-throm-botic prophylaxis, in respect to our approved multidisciplinary protocol. According to the admission cardiac left ventricular ejec-tion fraction (LVEF), the patients were divided into group A (LVEF lt;45%) and group B (LVEF >=45%). Result(s): We collected 32 consecutive patients. Group A included 10 patients (9M/1F, aged 13 years [IQR 5-15]), and group B included 22 patients (15M/7M, aged 9 years [IQR 7-13]). At the presentation, significant differences were observed among shock (group A 6/10 vs group B 2/22, plt;0.01), gastrointestinal involvement (9/10 vs 11/22, p = 0.04) and duration of fever (5.3 vs 6.9 days, p = 0.02). All patients in group A required inten-sive care hospitalization (10/10 vs 12/22, p = 0.01). Interestingly, despite good cardiac function, two patients in group B presented with shock, probably due to vasoplegic/distributive cardiocircula-tory impairment secondary to the inflammatory state. Among biochemistry parameters, leukocytes, neutrophils, and CRP were significantly worse in group A (p = 0.001, p = 0.001 and p = 0.008, respectively). Pathological level of troponin T and NTproBNP were detected in all patients in group A and also in 33% and 77% of group B;with statistically significant higher median values in group A (Troponin T 72 [40-243] ng/L vs 22 [8-49] ng/L, p = 0.01;NTproBNP 14825 [11340-17810] ng/L vs 5921 [1114-11243] ng/L, p = 0.01). In group A, mitral regurgitation was more frequent (plt;0.01) and one patient had transient left main coronary dilation (Boston z-score +2.39). At the discharge, cardiac function normalized in all patients. Total length of hospital stay and cardiac recovery time were not statistically different between groups. Conclusion(s): If correctly diagnosed and early treated, all the MIS-C patients completely recovered, regardless of the initial cardiac involvement.

9.
Cardiology in the Young ; 32(Supplement 2):S56, 2022.
Article in English | EMBASE | ID: covidwho-2062115

ABSTRACT

Background and Aim: Kawasaki Disease remains an enigma to the world to this day since first described by Dr. Tomisaku Kawasaki in 1967. In the last half a century there has been wide-spread global research elaborating the clinical aspects and patho-genesis of this disease entity. Multisystem Inflammatory Syndrome post Covid (MISC) is a relatively new disease which was described in literature in mid 2020. The striking resemblance as well as differences in spectrum of cardiac involvement of both the conditions has been elaborated in this study from a tertiary care centre in Eastern India. Method(s): The study was conducted over a period of 3 years from June 2018 to June 2021. Fiftyone patients with Kawasaki disease (including atypical and incomplete cases) and sixty children diag-nosed with MISC were included in the study. Echocardiography details were noted by a single observer. Data regarding the patient particulars, clinical aspects, lab parameters, imaging details and treatment particulars were collected and analysed. Patients were followed up for a minimum period of six months to one year. Result(s): In the Kawasaki group(51), infants(20) presented with multiple (and larger) aneurysms. Older children (gt;5 years) had more of single coronary involvement, (mostly LAD) and also had more atypical presentation(18) associated with infections like Dengue, Staphylococcal infection, Scrub Typhus. There were 4 cases of Kawasaki shock syndrome, all below 5 years. In the MISC group (60), there was also multiple coronary involvement in infants (11). But LV dysfunction was more common in older children and adolesecents (20), of whom 18 (90%) presented with severe dysfunction (LVEFlt;35%). Those with coronary involve-ment had normal function and those with dysfunction had no coronary involvement. Mild to moderate aneurysmal dilation of coronaries was found in children one to five years of age. No giant aneurysm was found in MISC. Overall, LMCA with LAD was the commonest pattern of involvement in both the conditions. Conclusion(s): KD and MISC had similar pattern of coronary involve-ment, but absence of giant aneurysm and significantly severe dys-function in older children in MISC indicates a likely different pathogenesis for myocardial involvement in MISC.

10.
Cardiology in the Young ; 32(Supplement 2):S91, 2022.
Article in English | EMBASE | ID: covidwho-2062103

ABSTRACT

Background and Aim: Multisystem Inflammatory Syndrome in Children (MIS-C) associate with Coronavirus disease-19 is a life-threatening clinical condition in which cardiovascular system is frequently affected. Shock, cardiac arrhythmias, myocarditis, reduced left ventricular ejection fraction (LVEF), pericardial effu-sion, and coronary artery dilatation are amongst the most common cardiac complications. In this study, we aim to assess myocardial status in patient with cardiac involvement in MIS-C. Method(s): Over a 14-month period, we retrospectively collected clinical, biological, echocardiographic data in children who were admitted to our hospital with a diagnosis of MIS-C and cardiac involvement. WHO criteria for clinical case definition of MIS-C were adopted. Elevation in brain-natriuretic-peptide and troponin-I, electrocardiographic abnormalities, echocardio-graphic evidence of pericarditis, myocarditis, reduced LVEF, valvular disease, and coronary artery dilatation were including cri-teria. LV indexed end-diastolic (EDVi), end-systolic (ESVi), stroke volumes were measured with Cardiac Magnetic Resonance (CMR). T2 mapping, Cine-RM and late gadolinium enhance-ment studies were performed. Result(s): 14 children were identified and included in the study, 71% of which were male. Median age at disease onset was 7 years old (IQR 5 to 9 years). All patients underwent cardiological evaluation in the first 48 hours of hospital staying. LVEF was lt;45% in 28.6% and lt;35% in 14.3% of patients. Myocarditis was detected in 78.6%, pericarditis in 28.6%, valvular damage in 35.7%, coronary abnormalities in 42.9%. All patients underwent CMR after on average 4 months (median: 3.87, IQR 2 to 4) from disease onset, after full clinical and biological recovery. ESVi and stroke volumes resulted within normal range in 100%. CMR abnormalities were observed in 21%. Particularly, left ventricular EDVi resulted elevated in 7%, delayed washout in T2 was described in 7%, and increased T2 mapping in 7%. Conclusion(s): Despite complete clinical and biological resolution, increased EDVi, delayed washout in T2 and increased T2 mapping at follow-up CMR in patient with cardiac involvement due to MIS-C may be signs of myocardial remodeling.

11.
Cardiology in the Young ; 32(Supplement 2):S242-S243, 2022.
Article in English | EMBASE | ID: covidwho-2062101

ABSTRACT

Background and Aim: Multi-system inflammatory syndrome in chil-dren (MISC) associated with COVID-19 has been described as a potentially life-threatening disease. In this study, we aimed to evaluate cardiovascular findings in children diagnosed with MISC at initial presentation and follow up. Method(s): Between November 2020 and November 2021, 35 children diagnosed with MISC based on WHO criteria were evaluated in this retrospective study.Cardiac markers, electrocardi-ography and echocardiography were performed in all cases at pre-sentation. Cardiac evaluation were repeated at the mean of 10th week after discharge(range:5 to 33weeks). Result(s): At this period, 633 children had positive PCR test of Covid-19. The freguency of MISC was 5.5% in our cohort. The median age was 9 years at diagnosis. Comorbid diseases were found in 20% cases, but none had preexisting heart disease. All patients had high grade fever and laboratory evidence of hyperin-flammation. Most cases had mild form disease, however 12 patients had been hospitalized in ICU median 6 day. 27 cases (77%) had cardiovascular involvement.Kawasaki-like findings were found in 10 patients and 5 cases were presented with shock(Figure-1) Echocardiography;Left ventricular (LV)systolic dysfunction (EFlt;57%) was detected in 11 cases (31.4%) and coronary artery (CA) dilatation(z scoregt;2)was found in five(14.2%) cases. Pericardial effusion was seen in 12 cases. Electrocardiography: Sinus tachycardia was the most common finding. 2 cases had pro-longed QTc interval and four cases had T wave alterations. Four cases had experienced complex ventricular arrhythmia. Cardiac markers:24 cases had high Pro-BNP level. 18 cases also had high Troponin T levels. Pro-BNP and Troponin T levels were not found to be correlated with LVEF. Only one adolescent boy who had severe cardiac dysfunction died during the acute period. Followup:There were two cases with persistent cardiac symptom, but no case had LV systolic dysfunction. The mean PR intervale was significantly lower than initial measurements. The mean of QT and QTc at follow up were not different from basal measurements.The mean LVEF was significantly higher than the initial levels. The basal CA z scores normalized at followup. Conclusion(s): MISC is characterized predominantly by cardio-vascular system involvement, but the children with MISC have good cardiac outcomes at short term follow up.

12.
Cardiology in the Young ; 32(Supplement 2):S268, 2022.
Article in English | EMBASE | ID: covidwho-2062093

ABSTRACT

Background and Aim: Kawasaki-like (multisystem inflammatory) syndrome associated with SARS-CoV-2 infection is characterized by acute severe systemic vasculitis, often with multi-organ dys-function and cardiac involvement. Although most patients recover, long-term outcomes are poorly studied [Gema de Lama Caro-Paton et al., 2021;Guimaraes D. et et al., 2021;Sharma C. et al., 2021]. Method(s): We analyzed the results of laboratory, clinical, radiologi-cal, ECG and EchoCG data in the dynamic observation of 15 patients (M 9, 1.5-16 yo, m = 7) in 3 months after the suffered MIS-C. Result(s): At the disease onset high refractory fever was observed in all cases, symptoms of Kawasaki disease in 12 (80%) of them, shock with multi-organ dysfunction-in 8 (53.3%), including symptoms of acute heart failure-in 5 (33%), concomitant in two cases with severe left ventricular dilatation with low LV EF. Myocardial damage was seen in 11 patients (73%), pericarditis in 12 (80%), coronary dilatation in two (13%);troponin level increased in 5 (33%), CK-MB-in 5 (33%), BNP-in 3 (25%). After 3 months, there were no signs of myocardial dysfunction and/or cardiomegaly in any patient, troponin and BNP levels normalized in all patients, a moderate increase of CK-MB was seen in 8 (53%), and coronary dilatation persisted in one patient. Arrhythmias were documented at onset in 9 (60%) patients, 3 (20%) after 3 months (p = 0.028). Conclusion(s): preliminary results of follow-up of children after MIS-C demonstrate favorable course in the majority of patients by clinical, laboratory, ECG and echocardiographic data. Further observations are needed to determine the long-term prognosis.

13.
Cardiology in the Young ; 32(Supplement 2):S248, 2022.
Article in English | EMBASE | ID: covidwho-2062092

ABSTRACT

Background and Aim: Coronavirus infection (COVID-19) in paedi-atric population has a generally mild course. In Spain, patients under 15 years old have accounted only for 0,4% of hospital admis-sions and 0,7% of intensive care admissions. However, in May 2020, cases of children with a systemic inflammatory syndrome related to a recent COVID-19 infection were described. In severe forms, left ventricular systolic dysfunction, mitral regurgitation, pericardial effusion and coronary artery dilatation or aneurysms have been described. The aim of this study is to describe the results obtained in cardiopulmonary exercise test (CPET) in previously healthy patients with PIMS. Method(s): Prospective study of PIMS patients who performed CPET. Godfrey ramp protocol recommended by European Society of Cardiology (ESC) was used in all cases. Measured var-iables, expressed by predicted values, were: forced vital capacity (FVC), forced expiratory volume (FEV1), ratio of minute venti-lation to carbon dioxide production (VE/VO2 slope), maximal oxygen consumption (VO2 max), oxygen uptake efficiency slope (OUES), oxygen pulse (O2 pulse) and maximum heart rate (HR). Result(s): Eight patients (75% boys) aged 5-14 years (median 10,5 years) performed CPET reaching a mean peak load of 105,87 W (median 112,5 W and mean load per kg of weight 2,34 W/kg). Only 1 patient (12,5%) presented basal spirometric disturb-ances in context of asthma without chronic treatment. Obtained mean respiratory parameters were: FVC 97,88%, FEV1 92,7%, Tiffeneau 83% and VECO2p 32,47. Oxygen satu-ration before and after CPET was greater than 95% in 100% of patients. In 6 patients (75%) the V02max and oxygen pulse was greater than 80% of predicted value (100% of patients reached at least 40% of V02 max at anaerobic threshold). Obtained mean cardiovascular parameters were: VO2 max 1624mL/min (median 1655 ml/min and V02 per kg of weight 36,9 ml/kg), pulse oxygen 9 ml and OUES 1,92. Conclusion(s): PIMS may cause severe cardiac disturbances justifying cardiological monitoring of these patients. CPET allows to assess functional capacity of these children after the disease. In our serie, most of patients had a good functional capacity (75%). Studies with more patients are needed to make extended conclusions.

14.
Chest ; 162(4):A2217-A2218, 2022.
Article in English | EMBASE | ID: covidwho-2060912

ABSTRACT

SESSION TITLE: Autoimmune Diseases Gone Wild: Rare Cases of Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Post-Covid-19 Multisystem Inflammatory Syndrome (MIS) is a severe hyperinflammatory syndrome associated with either the acute or recovery phase of covid-19 infection affecting multiple organ systems requiring hospitalization. This syndrome has been described in both children (MIS-C) and adults (MIS-A). Several case reports and systematic reviews have reported an association between post-covid-19 MIS-A and several autoimmune diseases. CASE PRESENTATION: We herein report a case of a 27-year-old female with no known chronic medical condition and a non-contributory family history who was diagnosed with post-covid-19 multisystem inflammatory syndrome in adults (MIS-A). She presented with generalized partial thickness erythematous skin ulcerations with tender blistering and painful erosion of her mucus membranes (oral and vaginal mucosa). This was diagnosed as Steven Johnsons syndrome. She was pulsed with intravenous methylprednisone. During this therapy, she progressed to severe acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (fig 1). Bronchoscopy revealed mild pulmonary hemorrhage fig 2a&b). Serological testing heralded a new onset systemic lupus erythematosus in light of positive antinuclear antibodies, anti Ds DNA and anti Smith antibodies. Her course was complicated by significant proteinuria and an active renal cast suggestive of lupus nephritis. This necessitated further treatment for active lupus. She was successfully extubated and discharged home. DISCUSSION: We arrived at the diagnosis of post-covid-19 multisystem inflammatory syndrome in adults (MIS-A) in light of her presenting with fever, hypotension, persistent sinus tachycardia and new onset atrial fibrillation), acute pancreatitis, acute kidney injury, elevation in transaminases, new onset skin rash, elevated inflammatory markers and a recent history of positive SARS-CoV-2 infection. Covid-19 has been reported to induce wide spread vasculitis resulting in MIS-A or MIS-C by triggering type 3 hypersensitivity (1). Also, multiple case reports and systemic reviews have reported a direct association between MIS-A and several autoimmune diseases including SLE, SJS (2). The patient recovered with high dose corticosteroid and supportive therapy indicating her severe ARDS was most likely due associated to SJS, SLE and MIS-A. Clinicians should also keep in mind that SARS-CoV-2 PCR swab may be negative at the time patient presents with symptoms of MIS-A as the infection might have occurred about 4-5weeks prior just as in our patient(3) CONCLUSIONS: We cannot underscore enough the importance of clinicians having a high index of suspicion for this syndrome in patients with acute or recent covid-19 infection, with or without a positive PCR covid-19 test. Early involvement of a multidisciplinary approach and appropriate management is essential to mitigate morbidity and mortality in these patients. Reference #1: Roncati L, Ligabue G, Fabbiani L, Malagoli C, Gallo G, Lusenti B, et al. Type 3 hypersensitivity in COVID-19 vasculitis. Clin Immunol Orlando Fla. 2020 Aug;217:108487. Reference #2: Gracia-Ramos AE, Martin-Nares E, Hernández-Molina G. New Onset of Autoimmune Diseases Following COVID-19 Diagnosis. Cells [Internet]. 2021 Dec 20 [cited 2022 Mar 22];10(12):3592. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700122/ Reference #3: Morris SB. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2022 Mar 22];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6940e1.htm DISCLOSURES: No relevant relationships by Isaac Ikwu No relevant relationships by Anthony Lyonga Ngonge No relevant relationships by Alem Mehari No relevant relationships by Noordeep Panesar no disclosure on file for Vis al Poddar;No relevant relationships by Emnet Yibeltal

15.
Chest ; 162(4):A2203, 2022.
Article in English | EMBASE | ID: covidwho-2060911

ABSTRACT

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatous polyangiitis (GPA), previously known as Wegener's granulomatosis, is a rare syndrome characterized by inflammation of small and medium sized vessels. The clinical presentation can be very heterogenous and differentiation from an infectious disease can be challenging initially. Here, we present a case of a young male presenting with respiratory symptoms during the pandemic, presumed to have coronavirus disease 2019 (COVID-19) though after extensive workup was later diagnosed with GPA. CASE PRESENTATION: A 19-year-old male presented to the emergency department (ED) with complaints of low-grade fever and dry cough for one week. He reported having abdominal pain, fatigue, loss of appetite and polyarthralgia. An outpatient upper gastrointestinal endoscopy revealed gastritis and duodenitis. In the ED, his vitals included a temperature of 101.8°F, blood pressure of 115/65mmHg, heart rate of 99/min, respiratory rate of 18/minute and oxygen saturation of 99% on room air. COVID-19 testing was negative. A computerized tomography of the chest revealed extensive ground glass opacities. He was presumptively diagnosed with COVID-19 and started on dexamethasone therapy along with azithromycin for atypical pneumonia. However multiple tests for SARS-CoV-2 were negative. Another consideration was COVID-19 induced multisystem inflammatory syndrome given the patients young age. Infectious workup included negative testing for human immunodeficiency virus, Legionella, tick borne diseases and mycoplasma. As febrile episodes continued, he developed microcytic anemia, microscopic hematuria, and petechial rash on his ankles. Antinuclear antigen screen was negative, but C-antineutrophil cytoplasmic and anti-proteinase-3 antibodies were positive. Renal biopsy revealed GPA. He was prescribed pulse dose steroids and transitioned to immunotherapy. DISCUSSION: GPA is a challenging diagnosis given multiple system involvement, though early identification and initiation of treatment are important to prevent long term sequalae. In our case, acute onset febrile illness and pulmonary ground glass opacities led to repeated COVID-19 testing potentially delaying the diagnosis. Ultimately, the correct diagnosis was made and confirmed on renal biopsy. We believe our case highlight the importance of keeping a broad differential and considering vasculitis in these situations for prompt diagnosis. CONCLUSIONS: GPA can often mimic respiratory infectious processes, a high index of suspicion is necessary for timely diagnosis. Reference #1: Selvaraj V, Moustafa A, Dapaah-Afriyie K, et alCOVID-19-induced granulomatosis with polyangiitis. BMJ Case Reports CP 2021;14:e242142 Reference #2: Qurratulain, Q., Ahmed, A., & Jones, Q. (2021). Lesson of the month: Severe granulomatosis with polyangiitis (GPA): a diagnostic challenge during the COVID-19 pandemic. Clinical Medicine, 21(1), 79. DISCLOSURES: No relevant relationships by Aamna Khan No relevant relationships by Usama Sadiq No relevant relationships by Rehan Saeed

16.
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;

17.
Chest ; 162(4):A838-A839, 2022.
Article in English | EMBASE | ID: covidwho-2060702

ABSTRACT

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The Sepsis Prediction Model (SPM) is a proprietary decision support tool created by Epic Systems. The basis of the SPM is a Predicting Sepsis Score (PSS) calculated from demographic, comorbidity, vitals, labs, medication, and procedural data. We assessed the diagnostic accuracy and timeliness of the PSS for sepsis as defined by Centers for Disease Control (CDC) Adult Sepsis Event (ASE) criteria. The performance of the PSS was compared to, Systemic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA), and SOFA scores. METHODS: Retrospective review of 62,460 adults admitted to 4 Wake Forest Baptist Health System hospitals from June 1, 2019 through December 31, 2020 with PSS scores calculated every 15 minutes. A sepsis event was defined as receipt of 4 or more days of antimicrobials, blood cultures collected within 48 hours of initial antimicrobial administration, and at least one organ dysfunction. This definition of sepsis was modified to also include Covid-19 infection with organ dysfunction. Time zero was defined as time of first contact for the healthcare encounter. 30-day readmissions, facility transfers, and deaths in the Emergency Department were excluded. RESULTS: The prevalence of sepsis in the sample was 4.5%. The optimal PSS threshold based on Youden’s J statistic was a score of 8 (sensitivity 0.72, specificity 0.74, Youden’s J 0.46). SIRS (sensitivity 0.90, specificity 0.42), qSOFA (sensitivity 0.64, specificity 0.69), and SOFA (sensitivity 0.89, specificity 0.43) had a Youden’s J statistic for sepsis of 0.32, 0.33, and 0.32, respectively. At a PSS score of ≥ 8, median time to score positivity among those who reached that score (28.4% of sample) was 217 minutes (IQR 74-1477 minutes). For SIRS, qSOFA and SOFA, median time to score positivity was 54 minutes (IQR 24-456), 360 minutes (IQR 53-1593) and 107 minutes (IQR 39-474), respectively. CONCLUSIONS: Discrimination of the PSS for detection of sepsis was highest at a threshold score of 8. Overall, the PSS discriminated better than SIRS, qSOFA and SOFA. Positive SIRS and SOFA scores occurred at an earlier time-point than PSS score. The time to positivity appears to limit the tool’s best expected performance to improve time to initial antimicrobial and compliance with the 3-hour sepsis bundle. CLINICAL IMPLICATIONS: Clinical application of the Epic SPM to improve adherence with sepsis treatment goals is constrained by time to positive screen as compared to other screening tools. DISCLOSURES: No relevant relationships by Alain Bertoni No relevant relationships by Kristin Lenoir No relevant relationships by Beverly Levine No relevant relationships by Morgana Mongraw-Chaffin No relevant relationships by Adam Schertz Stock Ownership Interest relationship with Johnson & Johnson Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership interest stock ownership relationship with Gilead Sciences Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership Stock ownership interest relationship with Bristol-Myers Squibb Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership interest Stock Ownership Interest relationship with Pfizer Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership interest Stock Ownership Interest relationship with Doximity Please note: 1 year Added 04/15/2022 by Karl Thomas, value=Ownership interest No relevant relationships by Brian Wells No relevant relationships by Jack White

18.
Chest ; 162(4):A833, 2022.
Article in English | EMBASE | ID: covidwho-2060699

ABSTRACT

SESSION TITLE: COVID-Related Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Multisystem Inflammatory Syndrome in Adult (MIS-A) is a rare hyperinflammatory response occurring 2 to 6 weeks after COVID-19 resembling Kawasaki disease. CASE PRESENTATION: A 23-year-old male presented to the emergency room with fevers, cough, shortness of breath, fatigue and painful rashes all over his body. 3 weeks prior, he was diagnosed with COVID-19 which was managed conservatively at home. He recovered within 3 days. He had received 2 doses of Moderna COVID-19 vaccine 6 months prior. He denied recent drug intake. Vitals were BP 116/78 mmHg, heart rate 164/min, temperature 97.3℉, SpO2 96% on room air. Physical exam revealed macular erythematous rash in his trunk and extremities. Leukocyte count was 4 k/uL, hemoglobin 15.5 g/dL, platelets 99 k/uL, sodium 126 mmol/L, bicarbonate 20 mmol/L, BUN 30 mg/dL, creatinine 2.2 mg/dL, lactate 5.1 mmol/L, ferritin >7500 ng/mL, total bilirubin 7.6 mg/dL, AST 298 U/L, ALT 291 U/L, ALP 106 U/L, procalcitonin 14.71 ng/mL, D-dimer 11.98 FEUug/mL. Troponin-I peaked at 1359 pg/mL. CT angiography of the chest showed clear lung fields without pulmonary embolism. Venous doppler was negative. Echocardiogram showed normal biventricular function and valves. An extensive infectious disease workup was negative. He was suspected to have MIS-A from recent COVID-19. He was started on methylprednisolone 1g/day, intravenous immunoglobulin (IVIG), anakinra and empiric antibiotics. Over the next 2 days, there was progression of rash with sloughing of skin in his trunk, back and extremities with bullae on his legs, and thigh sparing the face (figures). Skin biopsy revealed epidermal necrobiosis with apoptosis consistent with Toxic Epidermal Necrolysis (TEN). On day 3, he had a cardiac arrest from ventricular fibrillation but was successfully resuscitated. Subsequently, he was intubated, and required escalating vasopressor support for shock. On day 5, he also developed non-purulent conjunctivitis. On day 6, he was transferred to a higher center with a burns unit. However, despite aggressive supportive measures he succumbed to refractory shock the following day. DISCUSSION: Our patient fit the criteria for MIS-A outlined by CDC (1) with age ≥21 years, fevers, rash with non-purulent conjunctivitis for primary clinical criteria, hypotension and thrombocytopenia for secondary clinical criteria, several laboratory criteria, negative infectious work-up with a history of recent COVID-19. It is unclear if the COVID-19 vaccine increased his risk of MIS-A. There have been case reports of MIS-A presenting as TEN following COVID-19 and COVID-19 vaccines in the absence of typical triggering drugs. (2,3) MIS-A is treated with high dose steroids, IVIG, tocilizumab and supportive measures. Anakinra was used for our patient because of liver dysfunction. CONCLUSIONS: MIS-A following COVID-19 can also present as life-threatening skin reactions like TEN in the absence of triggering drugs. Reference #1: Retrieved from https://www.cdc.gov/mis/index.html Reference #2: Narang I, Panthagani AP, Lewis M, Chohan B, Ferguson A, Nambi R. COVID-19-induced toxic epidermal necrolysis. Clin Exp Dermatol. 2021;46(5):927-929. Reference #3: Kherlopian A, Zhao C, Ge L, Forward E, Fischer G. A case of toxic epidermal necrolysis after ChAdOx1 nCov-19 (AZD1222) vaccination. Australas J Dermatol. 2022;63(1):e93-e95. DISCLOSURES: No relevant relationships by Fady Jamous No relevant relationships by Swaminathan Perinkulam Sathyanarayanan

19.
Chest ; 162(4):A801, 2022.
Article in English | EMBASE | ID: covidwho-2060692

ABSTRACT

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: ED clinicians play a critical role in the early detection and management of septic shock. Intravenous fluid (IVF) resuscitation is a central component of the recommended treatment for septic shock (SEP-1), but experts have expressed concerns that excessive fluid administration to patients with COVID-19 could lead to poor clinical outcomes due to the development of ARDS like lung physiology. COVID-19 status is often unknown in the first several hours after ED arrival and withholding adequate IVF resuscitation to patients with septic shock is known to be harmful. Our objective was to evaluate whether adult ED patients meeting criteria for septic shock (≥2 SIRS + initial lactate ≥4 or Mean Arterial Pressure (MAP) <65) who receive 30ml/kg of IV fluids in the ED have poor clinical outcomes, if they are later found to have COVID-19, compared to adult ED patients with non-COVID-19 septic shock. METHODS: In this retrospective cohort study we analyzed EHR of adult patients who visited any of 3 EDs within a single academic health system in Rhode Island. We included patients who had a discharge diagnosis of septic shock and presented to the ED between February 15 -September 30, 2020. The exposure was the receipt of 30ml/kg of IVF and outcomes were intensive care unit (ICU) admission, ventilator receipt, and inpatient mortality. We used multivariate logistic regression and adjusted for fluid volume, age, receipt of antibiotics, and Charlson Comorbidity Index. RESULTS: Of 278 patients with septic shock, 39 (14%) were COVID positive. 15 (38%) COVID positive patients received 30ml/kg IVF per SEP-1 bundle compared to 163 (68%) of COVID negative patients. The overall inpatient mortality rate of COVID positive septic shock patients (n=25, 64%) was three times higher as compared to COVID negative septic shock patients (n=51, 21%). Receipt of 30ml/kg IVF in the ED did not increase the odds of ICU admission [AOR 0.46 (0.07-3.26), p = 0.43], receipt of ventilator [AOR 0.40 (0.07-2.28), p=0.30], or inpatient mortality [AOR 0.15 (0.020-1.10), p=0.06] in patients who were COVID positive. However, in COVID negative patients, receipt of 30ml/kg IVF in the ED significantly reduced the odds of ICU admission [AOR 0.50 (0.27-0.93), p=0.029], receipt of ventilator [AOR 0.41 (0.22-0.74), p=0.003] and inpatient mortality [AOR 0.44 (0.22-0.87), p=0.018]. CONCLUSIONS: Optimal and timely fluid resuscitation per the SEP-1 bundle reduces the odds of unfavorable clinical outcomes in patients with septic shock who test negative for COVID-19, while causing no increased odds of harm to patients with COVID-19 and septic shock. Replication of our work in a post-vaccination cohort and during waves with different variants is advisable as the clinical outcomes may vary. CLINICAL IMPLICATIONS: Early fluid resuscitation in patients diagnosed with septic shock in the ED appears to be a safe strategy even in patients that are later diagnosed with COVID-19. DISCLOSURES: No relevant relationships by Natalie Davoodi No relevant relationships by Elizabeth Goldberg No relevant relationships by Richa Nahar

20.
Chest ; 162(4):A357-A358, 2022.
Article in English | EMBASE | ID: covidwho-2060572

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: Multisystem inflammatory syndrome in children (MIS-C) is a systemic condition that causes multi-organ dysfunction accompanied by fever and extremely elevated inflammatory markers. This syndrome been primarily identified in children or adolescents similar to Kawasaki disease. The hallmark of this illness includes life-threatening complications such as shock and cardiac dysfunction. As the cases of COVID-19 continue to increase worldwide, a form of MIS-C can present in adults known as multisystem inflammatory syndrome in adults (MIS-A). We describe a case of MIS-A after exposure to COVID-19. CASE PRESENTATION: A 28-year-old Hispanic male with no medical history presented with 3 days of persistent fever, diarrhea, and fatigue. He was unvaccinated for COVID-19 but had mild disease three months prior, which did not require hospitalization. Vitals were remarkable for tachycardia and constant fever of up to 103.5 F. Labs were notable for leukocytosis of 26.0 k/uL, CRP of 43 mg/dL, and procalcitonin of 90 ng/mL. Computed tomography with intravenous contrast of his chest revealed multifocal nodular and consolidative airspace disease of the right upper and middle lobes with mediastinal and hilar lymphadenopathy. Echocardiogram revealed ejection fraction (EF) of 29% without wall-motion abnormalities. PCR test for COVID-19 was negative and his infectious work-up was unrevealing. His course was further complicated by shock requiring pressors, intubation, and renal replacement therapy. Despite antibiotics, he did not improve. He was started on pulse dose steroids and intravenous immunoglobulin (IVIG), which decreased his CRP to 34 mg/dL and procalcitonin to 51 ng/mL. He was weaned off the ventilator and pressor support with EF recovery to 51%. He was eventually discharged home without further needs. DISCUSSION: While limited data exists, adult patients of all ages with prior SARS-CoV-2 infection can develop MIS-A. Preliminary reports suggest increased incidence among African American, Hispanic, and Asian ethnic groups. Diagnosis includes one primary and two secondary clinical criteria with two supporting laboratory evidence. Primary criteria includes cardiac dysfunction or rash with conjunctivitis. Secondary criteria includes neurological signs, shock, gastrointestinal disease, or thrombocytopenia. Lab markers include elevated CRP, ferritin, IL-6, ESR, or procalcitonin with a positive SARS-Cov-2 PCR, serology, or antigen detection. Treatment consists of steroids, IVIG, and supportive care based on case reports. There are no current evidence-based guidelines. The best preventative measures include COVID-19 vaccination CONCLUSIONS: MIS-A is a rare complication of unvaccinated COVID-19 cases. Diagnostic criteria include one primary and two secondary clinical signs with supporting lab data. Treatment includes steroids, IVIG, and supportive care. Reference #1: Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. The Lancet. 2020;395(10237):1607-1608. doi:10.1016/s0140-6736(20)31094-1 Reference #2: Kunal S, Ish P, Sakthivel P, Malhotra N, Gupta K. The emerging threat of multisystem inflammatory syndrome in adults (mis-A) in COVID-19: A systematic review. Heart & Lung. 2022;54:7-18. doi:10.1016/j.hrtlng.2022.03.007 Reference #3: Morris SB, Schwartz NG, Patel P, et al. Case series of multisystem inflammatory syndrome in adults associated with SARS-COV-2 infection — United Kingdom and United States, March–August 2020. MMWR Morbidity and Mortality Weekly Report. 2020;69(40):1450-1456. doi:10.15585/mmwr.mm6940e1 DISCLOSURES: No relevant relationships by Sadaf Afraz No relevant relationships by Christine Girard No relevant relationships by Jose Rivera No relevant relationships by Ivan Romero-Legro No relevant relationships by Amy Van

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