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1.
Acta Phlebologica ; 23(2):70-75, 2022.
Article in English | EMBASE | ID: covidwho-2067522

ABSTRACT

BACKGROUND: Catheter directed thrombolysis (CDT) proved to be effective treatment in deep venous thrombosis (DVT), However, there is some concerns about the associated bleeding risk. We assessed the safety and efficacy including technical and clinical success in resolution of iliofemoral DVT after one session treatment with penumbra aspiration mechanical thrombectomy catheter as an alternative CDT. METHOD(S): This is a retrospective study that was conducted on patients presented to Aseer Central Hospital and Saudi German Hospital in Saudi Arabia from January 2019 to December 2020 with symptomatic acute iliofemoral DVT. Patients were treated with Indigo continuous aspiration mechanical thrombectomy 8 system (Penumbra Inc, Alameda, CA, USA). Secondary end point was treatment complications, DVT recurrence and postphlebetic syndrome occurrence within 1 year follow-up. RESULT(S): Our study included twenty-three patients with sixteen females (59.6%) and seven males (30.4%) with a median age of 38 years (18-60years). Indication for treatment was primary DVT in seventeen patients (73.9%), recurrent DVT in six patients (26.1%). Provoked DVT was present in fifteen patients (65.2%) with nine of them was tested positive for COVID-19 while non provoked DVT in eight patients (4.8%). Seven patients (30.4%) had underlying May-Thurner Syndrome after thrombus removal and needed stenting for left common iliac vein (CIV) and two patients (8.7%) with recurrent DVT has significant residual Left common iliac vein stenosis that needed stenting. Two patient (8.7%) have thrombosis extending to inferior vena cava. Initial technical success using Penumbra was 82.6%. All patients in whom aspiration thrombectomy was not successful underwent further treatment with CDT which was successful in further three cases with failure in one case making overall technical success was 95.7%. Recurrent iliac occlusion after successful recanalization was seen in two patients (8.7%) at 6 months follow up. One patient (4.3%) developed pulmonary embolism that required full anticoagulation with no further treatment. No patient develops postphlebetic syndrome at 1 year follow-up. CONCLUSION(S): Penumbra aspiration thrombectomy catheter was safe, effective and promising technique in treatment of acute iliofemoral DVT and allowed definitive treatment in one session with no need for the use of thrombolysis in the majority of cases with no risk for bleeding complications, shorter hospital stay, no need for ICU admission and lower cost. COVID infection does not seem to alter the outcome. Copyright © 2022 EDIZIONI MINERVA MEDICA.

2.
NeuroQuantology ; 20(9):5579-5590, 2022.
Article in English | EMBASE | ID: covidwho-2067299

ABSTRACT

The emergence of SARS-CoV-2 has increased mucormycosis cases, which was perceived to be a rare infection caused by belligerent fungi belonging to order Mucorales. It is also called the black fungus and is exhibited as one of the seven variants such as rhino-cerebral, cutaneous, pulmonary, renal, gastrointestinal, disseminated or miscellaneous, leading to the debilitation of systemic wellness often associated with a reduction in functional efficiency and characterized by organ failure due to necrosis necessitating early diagnosis and timely treatment. Hence, to sustain the quality of life during the pandemic, a better understanding of mucormycosis is the need of the hour for efficient management to overcome global crises. This review was carried out on existing literature over three decades involving data in India as well as its global comparison, especially in terms of incidence and prevalence for enabling a scientifically evidence-based comprehensive analysis so that appropriate modalities could be adopted in individuals with immunocompromised conditions to safeguard them from contracting as they are more susceptible to having high-risk exposure. Copyright © 2022, Anka Publishers. All rights reserved.

3.
Pharmaceutical Journal ; 305(7941), 2022.
Article in English | EMBASE | ID: covidwho-2064900

ABSTRACT

Introduction: Monitoring of patients on immunomodulator therapy for inflammatory bowel disease (IBD) and auto-immune hepatitis (AIH) significantly increases clinical workload in gastroenterology outpatient clinics owing to blood test monitoring requirements. Aim(s): This study conducted at Barnsley Hospital NHS Foundation Trust aimed to determine the clinical impact of a pharmacist-led virtual thiopurine clinic on drug monitoring, safety and quality of service in a cohort of IBD and AIH patients. Method(s): Patients attended an initial face-to-face outpatient consultation and were then followed-up via remote telephone consultations, as part of a virtual clinic, at two-week intervals. Patient biochemical data were analysed alongside anonymous postal questionnaires to provide an assessment of the quality of the service over a three-month period between 1 May and 31 July 2014. A second survey was performed in December 2019 to re-assess patient satisfaction. Result(s): 81 patients were assessed;clinical indications for thiopurines were IBD (n=75) and AIH (n=6). Overall, 39.5% (n=32) patients failed to reach the thiopurine therapeutic target (2mg/kg with normal thiopurine methyltransferase) owing to drug intolerance, lack of clinical response or hepatotoxicity. Thioguanine nucleotide analysis was performed in 29.6% (n=24) of patients who failed initial treatment, to allow dose optimisation. Hepatotoxicity developed in 9.9% (n=8) of patients, which required shunting of thiopurine metabolism with allopurinol. Myelosuppression developed in 6.9% (n=21) of the total number of blood tests performed (n=304), leading to discontinuation of thiopurines in two patients. The questionnaire response rate was 51.9% (n=42);92.9% of respondents (n=39) found the virtual clinic to be convenient;and 95.2% (n=40) were satisfied with the service. The follow-up survey included 373 patients with a 35.9% response rate (n=134);88% (n=118) found the service easily or very easily accessible, and 82% (n=109) found it very helpful or extremely helpful. Overall satisfaction was highly rated (average 4.46/5). Conclusion(s): Pharmacist-led virtual thiopurine clinics were shown to be safe and regarded favourably by patients. The clinics identified patients exposed to the risks of myelosuppression, as well as allowing thiopurine dose optimisation during the three-month period from May to July 2014. The followup survey in 2019 showed patients valued telemedicine as an alternative to face-to-face visits. Virtual clinics offer a viable alternative to traditional outpatient-driven thiopurine monitoring, especially during the ongoing COVID-19 pandemic. Copyright © 2020 Pharmaceutical Press. All rights reserved.

4.
American Journal of Transplantation ; 22(Supplement 3):806, 2022.
Article in English | EMBASE | ID: covidwho-2063511

ABSTRACT

Purpose: The Coronavirus Disease 2019 (COVID-19) pandemic prompted widespread vaccination for the immunosuppressed population starting in January 2021 with minimal information on safety outcomes. The purpose of this study is to evaluate the relationship between kidney pathological changes and mRNA-based COVID-19 vaccines in three kidney transplant recipients. Method(s): We conducted a single-center retrospective case review of three kidney transplant recipients with biopsy-proven acute rejection or pathological changes after 2-dose COVID-19 mRNA vaccination. Renal function, maintenance immunosuppressant regimens, and pathology slides at baseline and post-rejection are recorded. Possible factors associated with the development of rejection were analyzed. Result(s): All participants were male, two received related-living donor transplants and one received a deceased donor transplant. The mean age was 44.3 years. Average time from 2nd COVID-19 vaccine to confirmed rejection or pathological changes was 33.7 days. Two patients received mRNA-1273 COVID-19 mRNA vaccine and one received the BNT162b2 COVID-19 mRNA vaccine. All three allograft biopsies demonstrated findings consistent with acute active antibody mediated rejection and thrombotic microangiopathy. One allograft biopsy also demonstrated findings consistent with collapsing focal segmental glomerular sclerosis. As of November 26, 2021, there have been over 26 reports of solid organ rejection or failure to the Vaccine Adverse Event Reporting System (VAERS) for the COVID-19 mRNA vaccines highlighting the need for further investigation. Conclusion(s): Immunization with COVID-19 mRNA vaccine has potential to precipitate clinically significant immune response to renal allografts leading to acute allograft rejection, thrombotic microangiopathy, and collapsing focal segmental glomerular sclerosis.

5.
American Journal of Transplantation ; 22(Supplement 3):929, 2022.
Article in English | EMBASE | ID: covidwho-2063489

ABSTRACT

Purpose: COVID-19 pandemic has had a significant impact on access to routine healthcare in both hospitalized and out-patient settings. This impact was also noted in various aspects of pre and post-transplant care of liver transplant (LT) recipients. The aim of our study was to analyze the direct and indirect impact of COVID-19 on mortality in patients with recent LT. Method(s): We retrospectively analyzed 30-day, 6-month and 1-year mortality data from the UNOS database in adult LT recipients from 3 distinct groups;Pre-COVID (March 11- September 10, 2019: LT and immediate follow-up care before pandemic), Para-COVID (September 11- March10, 2020: LT before pandemic and follow-up care during pandemic), and COVID (March 11- September 10, 2020: LT and follow-up care during pandemic). Result(s): 12,598 LTs were performed during the study period. During COVID period, there was increase in LT for alcoholic liver disease, average MELD score was higher, LT for hepatitis C decreased, use of thymoglobulin induction decreased and waiting time was shorter. During the 30-day period, overall mortality between 3 groups remained same. In the COVID group, mortality from graft failure was higher (7.4 vs 17.9%, p=0.07), rate of infection was lower (14% vs 4.2%, p=0.039), and incidence of graft rejection prior to discharge was higher. During the 6-month follow-up, overall mortality, mortality from malignancy and COVID, and graft failure increased significantly in the COVID group. During the 1-year follow-up period, mortality was highest in COVID group over para-COVID group and lowest in the pre-COVID group. In the COVID group, increased mortality was from graft failure and COVID. Overall mortality in the study cohort directly from COVID was 7.8%, which was highest in the COVID group. Multivariable cox regression for one year mortality showed that risk factors for mortality were COVID period [Hazard Ratio (95%CI) 1.22 (1.02-1.46), p=0.027], older age of recipient, diabetes, portal vein thrombosis, ventilation at the time of transplant, hemodialysis at the time of transplant, re-transplant, and prolonged cold ischemic time. Conclusion(s): COVID-19 significantly impacted LT short term outcomes with increased mortality seen from COVID directly as well as indirectly. During COVID, cautious and lower use of immuno-suppression was likely associated with higher rates of rejection and lower rates of infection. Disruptions in routine post-transplant follow-up likely contributed to increased death from graft failure, malignancy, and poor control of chronic medical conditions like diabetes. (Figure Presented).

6.
American Journal of Transplantation ; 22(Supplement 3):761-762, 2022.
Article in English | EMBASE | ID: covidwho-2063449

ABSTRACT

Purpose: The purpose of this study is to evaluate outcomes of readmission, rejection, graft dysfunction, graft failure, and death in SOT recipients (SOTR) after COVID-19 infection. Method(s): We conducted a retrospective cohort study of SOTR diagnosed with COVID-19 infection before 5/1/2021. COVID-19 disease severity was assigned retrospectively by NIH criteria and grouped into asymptomatic/mild and moderate/ severe/critical infection. Data collected included demographics, clinical features, treatment, and outcomes. Bivariate comparisons to evaluate characteristics associated with outcomes were performed with independent group t-tests for continuous variables and Fisher's exact tests for categorical variables. Result(s): 138 SOTR were diagnosed with COVID-19 at a median of 5 (IQR 3-8) years post-transplant with a mean age of 57+/-12 years at diagnosis. Most were kidney or liver recipients (Table 1);49 (36%) had asymptomatic or mild infection. 29 (21%) of SOTR had moderate, 26 (19%) severe, and 31 (22%) critical infection. Disease severity, treatment with steroids or remdesivir did not correlate with rejection. Most graft failures occurred in SOTR with critical (n=12) disease (Table 2). 102 (74%) SOTR were admitted to the hospital for COVID-19 infection, of which 27 (26%) were readmitted more than 2 months after their index hospitalization. Of the readmissions, 5 were for renal complications, 5 infectious, and 7 pulmonary. Among those hospitalized, 13 (13%) SOTR died during the index admission. Among the 27 SOTR who were readmitted, 3 (11%) SOTR died during readmission. The mean time from initial infection to death was 121+/-176 days. Conclusion(s): In this cohort, disease severity was associated with graft failure. Readmissions were frequent more than 2 months after the index admission. Mortality in those who were readmitted remained high. Rejection was relatively infrequent.

7.
American Journal of Transplantation ; 22(Supplement 3):426-427, 2022.
Article in English | EMBASE | ID: covidwho-2063400

ABSTRACT

Purpose: Due to heterogeneity observed in the kidney transplant population, it has been extremely challenging for traditional methods such as histopathology to predict graft outcomes. In this real-world evidence(RWE) study, we applied machine learning (ML) models to a multi-analyte urinary biomarker assay to predict whether a kidney allograft would experience a rejection episode. Method(s): A cohort of 550 (37.5% biopsy matched) urine samples from patients across 3 renal transplant centers were used to develop a predictive ML model (scaled 0-100) to prognosticate allograft failure. Samples were collected between 1-1539 days post-transplant from allograft recipients with ages ranging from 7-77 years. Of the 206 biopsy matched samples, acute kidney allograft rejection (AR) and no-rejection (NR) phenotypes were confirmed in 136 and 70 respectively. We also evaluated the developed ML model on two additional cohorts of 15 COVID+ transplant recipients and 30 non-transplant healthy population. The ML model incorporates clinico-demographics with 6 urinary biomarkers: Clusterin, total protein, CXCL10, Creatinine, cfDNA and methylated cfDNA. Monte Carlo confidence intervals for the model incorporated biomarker assay and sample variances. Result(s): The novel rejection score was able to discriminate AR from NR efficiently. Score below 32 classified stable allograft, score range of 32 - 55 identified progression of AR, and Score > 55 identified AR with high sensitivity: 92%, and specificity: 89%;AUC: 96% and accuracy: 91%(figure). The associated NPV and PPV of 87% and 93% respectively. In the COVID cohort with 86% clinician assessed rejection, the median score was 51(IQR:30-87). In the non-transplants the median score was 19(IQR:13-26). It was established that presence of COVID was not a confounder in the model. Conclusion(s): The accuracy of the novel rejection score emphasizes the promise of applying ML algorithms as an aid to decision-making in evaluating graft outcomes with high sensitivity and specificity. Moreover, this RWE retrospective analysis demonstrates the efficacy of the urine multi-analyte approach to accurately predict acute rejection in kidney transplant recipients. (Figure Presented).

8.
American Journal of Transplantation ; 22(Supplement 3):558-559, 2022.
Article in English | EMBASE | ID: covidwho-2063373

ABSTRACT

Purpose: Early allograft dysfunction (EAD) is associated with an increased rate of graft failure in liver transplantation (LT), but a mechanism remains unclear. Recent experience with COVID-19 has identified that microvascular clots related to fibrinolysis shutdown [ SD (lack of ability to break down clot)] drives organ failure, which can be treated with tissue plasminogen activator (tPA). It remains unclear how SD interacts with EAD, and if it may be associated with a worse outcome in LT. We hypothesize that fibrinolysis shutdown with EAD would be an unfavorable combination with an increased risk of graft failure compared to patients with EAD without SD. Method(s): Adult liver transplant recipients underwent thrombelastography (TEG) on post-operative day-1 to assess for fibrinolysis shutdown. Fibrinolysis activity was quantified by the amount of clot strength lost from peak clot strength in 30-minutes (LY30) in the presence of tPA (75ng/ml). SD was defined as an LY30 of 0%, indicative or no fibrinolytic activity in the presence of a fibrinolytic activator (median LY30 = 8% in healthy volunteers). EAD was defined on laboratory measurements defined and validated by Olthoff et al. Graft survival analysis was conducted with logistic regression analysis when controlling for recipient severity of liver disease (MELD) and graft quality (donor risk index). Survival time was assessed with Kaplan Meier curve. Result(s): 230 liver transplant patient recipients with a median laboratory MELD of 23 were included in the analysis. Graft failure rate was 13% with a median follow up time of 345 days. EAD occurred in 31%, and SD was present in 45%. The combination of EAD and SD was associated with a 46% graft loss rate which was significantly higher than EAD without SD (8% p<0.001). When controlling for MELD, and donor risk index, EAD (OR 3.3 95%CI 1.3-8.4 p=0.014) and fibrinolysis shutdown (OR 2.9 95%CI 1.1-7.9 p=0.034) were independent predictors of graft failure. Graft survival times were significantly different when patients were stratified by EAD and SD (figure p<0.001). Conclusion(s): The combination of EAD and SD bodes poor prognosis following liver transplantation. The stark difference in survival warrants further investigation if activation of the fibrinolytic system can safely improve graft survival time in LT recipients with EAD without the risk of excessive bleeding. (Figure Presented).

9.
American Journal of Transplantation ; 22(Supplement 3):605-606, 2022.
Article in English | EMBASE | ID: covidwho-2063365

ABSTRACT

Purpose: Solid organ transplant (SOT) recipients admitted for COVID-19 commonly experience immunosuppression reduction and acute allograft dysfunction. Given the number of SOT patients hospitalized for COVID-19, it is critical to understand the natural history of alloimmunity and allograft dysfunction in this population. Method(s): We prospectively enrolled SOT patients admitted with COVID-19 to our institution between January 1, 2020 and June 1, 2021 as well as a non-SOT control cohort. We collected anti-HLA antibody (HLA-Ab) and renal function data. We retrospectively reviewed donor-specific antibody (DSA) assignments in the context of each patient's transplant history and HLA typing. DSA that crossed the 1500 MFI threshold was classified as new DSA, and DSA that increased >1000 MFI was classified as increased DSA. For kidney transplant (KT) patients, we additionally evaluated renal function. The outcome of interest was change in serum creatinine (sCr) from pre-infection baseline to the most recent post-infection value. Baseline sCr was calculated as the median sCr in the year prior to COVID-19. For follow-up, the final sCr at least 60 days from COVID-19 was used. If the patient experienced allograft failure or the final sCr was >5.0 mg/dL, the final sCr was set equal to 5.0 mg/dL. Cumulative incidence of new or increased DSA was modeled with the Kaplan-Meier (KM) method. Group means were compared with one-way ANOVA using Tukey's multiple comparisons test. Result(s): We enrolled 129 hospitalized SOT patients: 82 (64%) with a KT, 27 with a liver transplant, and the remainder with a heart, lung, or pancreas transplant. Of the 86 patients who underwent HLA-Ab testing 10-180 days after COVID-19 diagnosis, 15 developed new or increased DSA (Fig. 1A). We then evaluated the 39 KT patients with HLA-Ab testing, a baseline sCr, and a late sCr measurement. At a median follow-up of 330 days, KT patients with new or increased DSA (in red, Fig. 1B) showed a significantly greater increase in late sCr than both non-SOT patients (in blue) and KT patients without new or increased DSA (in green). Conclusion(s): New or increased DSA following hospitalization for COVID-19 is common in SOT patients, with a KM-estimated incidence of 25% in the six months following COVID-19. In KT patients, this DSA is associated with poorer allograft function. These data suggest a role for more intensive surveillance in SOT patients convalescing from COVID-19. Further studies will be needed to elucidate the contribution of infection, immunosuppression, and other factors.

10.
Neuromodulation ; 25(7 Supplement):S255-S256, 2022.
Article in English | EMBASE | ID: covidwho-2061714

ABSTRACT

Introduction: The advancement of wearable integrated augmented reality (AR) devices has rapidly progressed over recent years. We describe the first use of AR goggles during a revision neuromodulation surgery, which enabled specialist consultant support from remote despite ongoing coronavirus pandemic restrictions. Materials / Methods: This case report describes a revision surgery case in a previously successfully implanted spinal cord stimulator (SCS) patient. The attempt, to revise the existing percutaneous SCS leads failed due to the patient's challenging anatomy, which left the patient without therapy. A further revision via hemi-laminectomy and insertion of a surgical paddle lead was being organised with specialist support due to expected further anatomical challenges. Due to ongoing coronavirus restrictions both in travelling as well as reduced staffing numbers in the operating theatre in particular for visiting staff, the decision was made to use AR goggles to enable an experienced specialist to attend virtually. Result(s): The use of AR googles enabled a specialist colleague to virtually attend the live surgery despite a 200 mile distance. This included being able to see the surgical field on their computer screen as well as all live radiographic imaging displayed on the operating theatre monitors, having live sound, stopping any live images of the surgery to annotate with drawings and writing, speak to the resident surgeon in real time and discuss as if being physically present. Annotated images could be sent back to the lens of the operating surgeon for review as well as live commentary via integrated microphone and speaker in the surgeons AR goggles. The technology enabled remote specialist support and valuable expert input resulting in successful insertion of paddle leads in an anatomically very challenging patient. The patient reported 90% pain reduction after programming of his new paddle leads. Discussion(s): AR technology opens up new exciting avenues in supporting neuromodulation surgeries remotely with expert advice for difficult operations without being locally present. This saves unnecessary travel, reduces the carbon footprint, downtime of the expert in their local institution resulting fewer potential local case cancellations, reduces the risk of spread of infections such as SARS-CoV-2, as well as gives the ability to teach in remote locations. Furthermore, this opens further opportunities for mentoring of novice implanters. Conclusion(s): Augmented reality technology is a new and exciting way of further promoting proctorship and mentoring and might be particularly useful in supporting novice implanters and those who need additional specialist input in selected cases. Supplemental Data: [Formula presented] [Formula presented] [Formula presented] Learning Objectives: 1. Advances in augmented reality technology - raise awareness of available technology and its use 2. Ability to delivery intraoperative live teaching remotely - opening new avenues for teaching opportunities and training in neuromodulation 3. Proctorship - assistance of a specialist without being physically present. Keywords: Augmented Reality, SCS, Teaching, Training, Paddle leads, Surgical paddle leads Copyright © 2022

11.
Chest ; 162(4):A2703-A2704, 2022.
Article in English | EMBASE | ID: covidwho-2060985

ABSTRACT

SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Discontinuing mechanical ventilation is a difficult process and takes time. Some patients succeed while others fail and remain on full ventilator support for a longer period. Extubation failure can result in many complications for the patient and a prolonged stay in the ICU. It's a common practice to have an SAT and SBT protocol in the majority of ICUs. Spontaneous awakening trial (SAT) is a nurse-driven protocol for discontinuation of sedation hypnotic drug to facilitate recovery to her baseline level of consciousness/responsiveness and assessment of intrinsic respiratory drive in the critical care setting. In general SAT protocol is followed and most ICUs are in the morning hours. If the patient needs the initial safety screening for SAT the sedative infusion is interrupted with a goal to awaken the patient or SAS 3-4. If the patient is showing signs of SAT failure with either tachypnea or desaturation or cardiac dysrhythmia or unacceptable ventilator asynchrony that the patient is resumed sedation/analgesia at 50% of the previous dose and bolus as needed dose of sedation is also utilized to achieve stability. A spontaneous breathing trial (SBT) is a protocol for systematic weaning of a patient from a mechanical ventilator in preparation for extubation. Before SBT protocol again safety screening is done and if the patient meets the criteria for SBT protocol, the patient is placed on spontaneous breathing mode that his CPAP of 5 to 8 cm of water for 30 to 120 minutes at the same FiO2. Various tools are utilized to analyze the success of the SBT trials including the RSBI index. Each institution has its own assessment of the average length of ventilator stay and the average length of ICU stay. The majority of hospital does SAT/SBT trials once a day for evaluation and successful liberation from ventilator. This project was done with the assumption that if compliance of SAT/SBT huddle is improved and if it is done twice in a day rather than only once the outcome in terms of length of ventilator stay, length of ICU stay, and rate of successful extubation improves METHODS: This is a prospective quality improvement study done at Einstein Medical Center Philadelphia. This is a 16-bed MICU unit and we implemented twice daily hurdle from August 2021 to April 2022. ( Study Period) This project was happening during the COVID pandemic during which the average length of ICU stay and the average length of ventilator stay was already high due to the natural course of COVID ARDS. The SAT/SBT Huddle involved interaction between our respiratory therapist, ICU fellow, and the nurse involved in the patient care. It had a checklist of SAT SBT protocol which needed a signature (electronic or manual) to consider it completed. This was done twice a day from the period of August 2021 to April 2022 (STUDY PERIOD). This study period was compared to the control period (August 2020 to April 2021). The reason for selecting this control period was to remove outlier and increased length of stay due to the COVID pandemic itself with the assumption that the COVID pandemic was present throughout the study and control period. RESULTS: In the control period- ie August 2020 to April 2021 the average ventilator length of stay is 6.85 days. In the study period from August 2021 to April 2022, the average length of a ventilator was 6.21. There is a clear decrease in ventilator length of stay with the intervention and no other change in the sample size. It should be noted that the COVID pandemic with the third surge was happening in both the control and study period. This is approximately a 10% decrease in length of stay. This is a Pilot study and with better compliance with a huddle, the length of stay will decrease further is our assumption. Here the huddle compliance ranged from 60-65% and out estimate is for better power we need at least 70% or more compliance with huddle CONCLUSIONS: Conclusion- This q ality improvement project aims to improve communication amongst healthcare providers with the ultimate goal of patient safety and decreased length of ventilator stay for every patient in MICU. Clearly, the minimal intervention of documenting each huddle and doing it twice a day had a decrease in ventilator length of stay. The greatest challenge for this compliance project is to have documentation of having a twice-daily hurdle. During this period to improve her compliance we have done various methods that included paper signatures electronic signatures and also QR code signatures. Of this, the maximum Complan success rate was achieved with a QR code signature for the huddle members. CLINICAL IMPLICATIONS: Limitation to the study–due to the COVID pandemic the average length of ventilator stay has increased in all hospitals which are affected by the COVID pandemic. Though the reflection of decreased length of ventilator stay is small this gives a glimpse of how her daily communication between a respiratory therapist, nursing staff, and the physician taking care of the patient makes a difference in the patient's overall length of stay and mortality. DISCLOSURES: No relevant relationships by Raminder Cheema No relevant relationships by Megan Dondarski No relevant relationships by Yasmeen Hassan No relevant relationships by Mahwish Hussain No relevant relationships by Myriam Poindijour No relevant relationships by Arnaldo Rodriguez No relevant relationships by Kumar Sarvottam No relevant relationships by Bhavna Sharma No relevant relationships by Teresa Vizak

12.
Chest ; 162(4):A2588-A2589, 2022.
Article in English | EMBASE | ID: covidwho-2060969

ABSTRACT

SESSION TITLE: Late Breaking Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Mortality from intermediate risk (IR) Pulmonary Embolism (PE) ranges from 1.9% to 14.5% and exceeds 31% in high risk (HR) PE. Catheter based therapies for IR PE offer an alternative to parenteral thrombolysis, and catheter directed embolectomy (CDE) may be associated with a low risk of bleeding. Surgical Pulmonary Embolectomy (SPE) is performed when thrombolysis is contraindicated or advanced therapies for IR, or HR PE have failed. Our aim was to compare the safety and efficacy of CDE versus SPE. METHODS: We performed a retrospective review of 34 consecutive patients with acute PE diagnosed by Chest CT angiography (CTA) admitted to three urban teaching hospitals from 8/2019-12/2021, who received FlowTriever Retrieval/Aspiration suction thrombectomy (CDE), or SPE. RESULTS: 15 patients received SPE, and 19 patients received CDE. Indications for SPE included failed CDE due to cardiac arrest n=1, failed catheter thrombolysis n=1, hemodynamic instability, and CTA evidence of chronic thrombi, or distal thrombi not accessible to CDE. All SPE had high clot burden, and echo evidence of RV failure. All following data are presented as SPE vs CDE. There was no statistically significant difference between both cohorts with respect to;female (%) (47 Vs 58), race, initial systolic BP (126 Vs 122 mmHg), and heart rate (101 Vs 99/min). Mean age was higher for CDE (56.4 Vs 67.6, p< 0.05). SPE patients had higher rate of dyspnea (93% Vs 53%) and longer duration of symptoms. PESI score (105 Vs 131) and PESI class were similar (p> 0.05). SPE patients included 53% IR and 47% HR, and CDE patients included 53% IR and 47% HR. On CTA, saddle PE was seen in SPE group (53% Vs 39%, p = 0.63) and 1 patient from SPE group and 2 patients from CDE group had clot in transit. Mean troponin 0.41 Vs 0.28, BNP 275 Vs 317, and D-dimer 8.5 Vs 16.5 were not significantly different. Procedure time was shorter for CDE (median 243 Vs 93 minutes, p<0.001). Median hospital length of stay (LOS) was similar (7.7 Vs 7 days p= 0.579), but median ICU LOS was shorter in CDE group (128 Vs 46.3 hours p<0.001). Survival rate on discharge was 93.4% Vs 89.5% (SPE Vs CDE). Causes of 30-day post procedure mortality included cardiac arrest due to RV failure and hypotension after CDE (10.5%). There was no 30-day post procedure mortality in the SPE cohorts. One death occurred 60 days post SPE for massive PE, from complications related to severe COVID-19 pneumonia. Major bleeding (need for 2 units PRBC) occurred in 27% Vs 5.3% following SPE Vs CDE. CONCLUSIONS: Acute PE patients who received CDE were older, had a shorter duration of symptoms, less dyspnea, reduced procedure time and shorter ICU stay vs SPE treated patients, but similar length of stay. CLINICAL IMPLICATIONS: CDE and SPE provided satisfactory results and SPE was effective for patients who had worse dyspnea, distal and or more chronic thrombo-emboli. DISCLOSURES: No relevant relationships by Samuel Acquah No relevant relationships by Hafiza Noor Ul Ain Baloch No relevant relationships by Madeline Ehrlich No relevant relationships by Yoshiko Ishisaka No relevant relationships by Omar Lattouf no disclosure on file for Robert Lookstein;No relevant relationships by Janet Shapiro No relevant relationships by David Steiger

13.
Chest ; 162(4):A1805, 2022.
Article in English | EMBASE | ID: covidwho-2060866

ABSTRACT

SESSION TITLE: Variety in Risk Factors and Treatment of VTE SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pulmonary embolism is a very common clinical entity that health care providers face routinely. Recurrent pulmonary embolism while on anti-coagulation therapy happens in about 2 to 4% of patients, but failure of multiple modalities of anti-coagulation is unusual and should prompt a closer evaluation. In this case we present an unusual cause of anti-coagulation failure. CASE PRESENTATION: A 65-year-old male patient diagnosed in 2016 with colon cancer status post hemi-colectomy and followed with CT surveillance. In 2016 he was also diagnosed with pulmonary embolism which was deemed secondary to his malignancy;this was treated with anti-coagulation for a finite duration. On surveillance CT scan in 2019 a new pulmonary embolism was diagnosed, and he was started on Apixaban therapy. In December of 2020 he was diagnosed with COVID19 which was mild to moderate in severity. A CT chest that was done at the time showed progression of the pulmonary embolism, so he was switched to low molecular weight heparin (LMWH). He presented in March of 2021 with hemoptysis and chest pain and another CT scan showed the same left pulmonary artery filling defect despite being on therapeutic LMWH. At this point we suspected an endovascular pathology, and a PET/CT scan was preformed which demonstrated an FGD positive left pulmonary artery endovascular lesion concerning for malignancy. Bronchoscopy and EBUS was done by interventional pulmonary team and biopsies from the left PA artery were taken. Pathology came back highly suspicious for angiosarcoma. The patient received chemotherapy (AIM;Adriamycin, Ifosfamide with MESNA) with an excellent response. DISCUSSION: Pulmonary artery sarcoma is a rare tumor that usually originates from the intimal layer of the pulmonary artery. It can mimic pulmonary embolism in clinical presentation and on imaging studies. In an observational analysis study published in Journal of Thoracic Disease;nearly half of 391 confirmed cases were originally misdiagnosed as pulmonary embolism. The treatment of pulmonary artery sarcoma is typically surgical intervention, although some patients may benefit from the use of chemotherapy. CONCLUSIONS: Pulmonary embolism is by far the most common cause of pulmonary artery filling defect on CT scan, typically treated with anti-coagulation with good outcomes. In the setting of therapy failure other etiologies must be considered. Although difficult to distinguish from PE, knowing the distinguishing clinical and radiologic will aid an accurate diagnosis. Reference #1: Symptoms, Diagnosis, and Therapy of Primary Sarcomas of the Pulmonary Artery. By I. Kruger, A. Borowski, M. Horst, E.R. de Vivie, W. Gross-Fengels. Thorac Cardiovasc Surg. 1990 Apr;38(2):91-5. doi: 10.1055/s-2007-1014001 Reference #2: Primary pulmonary artery sarcoma: a close associate of pulmonary embolism, 20-year observational analysis. Debabrata Bandyopadhyay, 1 Tanmay S. Panchabhai,2 Navkaranbir S. Bajaj,3 Pradnya D. Patil,4 and Matthew C. Bunte5 J Thorac Dis, v.8(9);2016 Sep, PMC5059338 doi: 10.21037/jtd.2016.08.89 Reference #3: Al-Mehisen, Rabah et al. "Primary pulmonary artery sarcoma: A rare and overlooked differential diagnosis of pulmonary embolism. Clues to diagnosis." International journal of surgery case reports vol. 65 (2019): 15-19. doi:10.1016/j.ijscr.2019.10.014 DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Mark Peicher

14.
Chest ; 162(4):A1572, 2022.
Article in English | EMBASE | ID: covidwho-2060842

ABSTRACT

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pulmonary clinicians are all too familiar with the ground-glass and consolidative pulmonary opacities that are the hallmark of COVID-19 pneumonia on imaging. As the pandemic continues, we encounter an ever-growing list of complications of SARS-CoV-2 infection. Pneumatoceles are thin-walled, gas-filled spaces within the lungs that occur in association with pneumonia or chest trauma and typically resolve spontaneously1 but may rupture and cause pneumothorax2. Reports of pneumatoceles due to COVID-19 are uncommon. In this case report, I describe a patient who developed large bilateral pneumatoceles as a complication of COVID-19. CASE PRESENTATION: A 25-year-old male non-smoker with no significant past medical history presented with dyspnea after a lab-confirmed diagnosis of COVID-19 nine days prior. Initial chest radiograph showed multifocal bilateral airspace infiltrates consistent with COVID-19 pneumonia. He was admitted for management of acute hypoxic respiratory failure and treated with dexamethasone, remdesivir, and tocilizumab. He required heated high-flow nasal cannula oxygen up to 60 LPM but did not require CPAP or mechanical ventilation. On hospital day 5 he developed increasing tachypnea and exertional desaturation. CT pulmonary angiogram (CTPA) ruled-out pulmonary embolus but revealed progression of bilateral infiltrates and extensive pneumomediastinum with subcutaneous air in the neck and chest wall, and no clear evidence for pneumothorax. The patient discharged on day 12 with oxygen but returned 2 days later with new onset hemoptysis. CTPA on admission showed new bilateral pneumothoraces and he was transferred to a quaternary hospital for intensive care where bilateral chest tubes were placed. Repeat CT Chest after lung expansion revealed bilateral cystic areas within the lungs initially concerning for necrotizing infection. Bacterial and fungal cultures were negative. Despite resolution of the pneumothoraces and removal of chest tubes, he continued to experience hemoptysis and chest pain. CT Chest demonstrated enlargement of now clearly very large pneumatoceles with air-fluid levels. After conservative management and discharge, a 6-week surveillance CT showed significant decrease in the pneumatoceles but a new moderate-to-large right pneumothorax. Ultimately after 2 more admissions and 90 days since COVID-19 diagnosis, he underwent wedge resection and mechanical pleurodesis for definitive management of secondary pneumothoraces. DISCUSSION: A pneumatocele, especially when large and containing an air-fluid level, may mimic hydropneumothorax, empyema, or pulmonary abscess among other diagnoses. Failure to recognize a pneumatocele and differentiate it from other conditions could lead to inappropriate treatment and cause patient harm3. CONCLUSIONS: It is important to recognize pneumatoceles as a potential complication in the post COVID-19 setting to guide appropriate management. Reference #1: Quigley, M. J., & Fraser, R. S. (1988). Pulmonary pneumatocele: pathology and pathogenesis. AJR. American journal of roentgenology, 150(6), 1275–1277. https://doi.org/10.2214/ajr.150.6.1275 Reference #2: Odackal, J., Milinic, T., Amass, T., Chan, E. D., Hua, J., & Krefft, S. (2021). A 28-Year-Old Man With Chest Pain, Shortness of Breath, and Hemoptysis After Recovery From Coronavirus Disease 2019 Pneumonia. Chest, 159(1), e35–e38. https://doi.org/10.1016/j.chest.2020.07.096 Reference #3: Jamil A, Kasi A. Pneumatocele. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556146/ DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: 2018 to present Added 04/01/2022 by Erin Peterson, value=Honoraria

15.
Chest ; 162(4):A1558, 2022.
Article in English | EMBASE | ID: covidwho-2060840

ABSTRACT

SESSION TITLE: Technological Innovations in Imaging SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 PM - 2:30 PM PURPOSE: Point-of-Care Ultrasound (POCUS) has become an indispensable tool for clinicians evaluating patients with acute illness in hospital settings. Trained clinicians can rapidly detect cardiopulmonary disease with high sensitivity, guiding diagnosis and therapeutic management based on real-time findings. Despite this revolution to bedside care, POCUS has rarely been employed in the ambulatory setting. We aimed to evaluate the role of POCUS in the diagnosis and effect on clinical-decision-making in patients presenting to a pulmonary clinic with respiratory complaints. METHODS: This is a prospective case series of adult patients presenting to a pulmonary clinic in an urban medical center between January and February 2022. POCUS was performed by trained pulmonary faculty and triggered at the discretion of the clinician. Studies triggered by POCUS were followed-up, and a diagnosis if made was recorded. RESULTS: Between January-February 2022, the clinic saw N=53 patients for whom POCUS was triggered for N=10. Reasons included: no prior imaging on record (N=4), physical exam findings (N=5) and/or unclear clinical picture (N=4) after review of history, exam, and the medical record. Average age was 59.5±12.7 years. The chief complaint was dyspnea for all patients. In 4 patients, POCUS revealed diffuse B-lines with irregular pleural line suggestive of ILD. The work-up eventually diagnosed UIP-pattern ILD related to rheumatoid arthritis (N=1), non-specific interstitial pneumonitis (N=1), and sarcoidosis (N=1). Work-up remains pending for 1 patient. POCUS revealed new left ventricular dysfunction in 2 patients: one subclinical post-viral cardiomyopathy following COVID-19 and one ischemic cardiomyopathy from coronary artery disease. POCUS revealed new biventricular failure in one patient, for whom cardiac sarcoidosis is currently being worked-up given a history of anterior uveitis. In 1 patient, POCUS revealed a massive echogenic mass within the right hemithorax, prompting urgent chest x-ray and referral to ER. With a personal history of leiomyosarcoma, this mass was eventually diagnosed as recurrence of cancer. In 1 patient, POCUS diagnosed new pleural effusion, prompting referral for thoracentesis revealing an exudate of unclear etiology. One patient presented with COPD exacerbation, for whom POCUS found a basilar consolidation suggestive of pneumonia, prompting antibiotic therapy. CONCLUSIONS: POCUS can detect in real-time cardiopulmonary disease, and thus may serve as a powerful tool in the diagnosis and clinical-decision-making by trained clinicians encountering patients with respiratory complaints in an ambulatory setting. CLINICAL IMPLICATIONS: Our case series demonstrates the potential utility of POCUS, when triggered appropriately, can allow additional diagnostic studies to be considered earlier, and potentially narrow the time interval between patient presentation and a made diagnosis. DISCLOSURES: No relevant relationships by Gerardo Eman No relevant relationships by Marjan Islam No relevant relationships by Rahul Nair No relevant relationships by Abhishek Sharma No relevant relationships by Shwe Synn No relevant relationships by Tito Zerpa

16.
Chest ; 162(4):A1308, 2022.
Article in English | EMBASE | ID: covidwho-2060802

ABSTRACT

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: Since 2020, SARS-CoV-2 virus has spread rapidly and endlessly throughout the world, being one of the worst pandemics that the world has ever seen. The BNT162b2 mRNA COVID-19 has an efficacy rate around 95% and ability to reduce disease severity, but also associated with numerous adverse reactions. Here we present a case of a Vaccine Induced Pneumonitis following a booster of the BNT162b2 vaccine. CASE PRESENTATION: A 72-year-old female presented to the ED with 3-day history of cough and dyspnea after receiving the booster (3rd dose) Pfizer COVID-19 mRNA vaccine. On the second day following vaccination started to develop a non-productive cough, difficulty breathing, and later in the afternoon had several episodes of nausea, vomiting, and fever. Initial presentation to hospital concerning for community acquired pneumonia, and patient was started on IV fluids and empiric antibiotics. However, after initial treatment respiratory condition worsened drastically concerning for iatrogenic pulmonary edema. Patient received diuretics but still failed to improve respiratory condition. CT chest revealed bil ground-glass opacities. Microbiologic and serologic testing negative, except for positive ANA. As the patient's condition failed to improve still on heated high flow O2, the patient underwent bronchoscopy which revealed diffuse erythematous with copious, thick, whitish mucus plugging airways. BAL cell count showed WBC 204 /cumm with lymphocytic predominance. BAL cultures were only positive for candida albicans in 1/2 pooled samples. Silver stain negative for P. jirovecii. After a negative infectious workup, the patient was started on systemic steroid therapy and her symptoms improved in two days. After five days of treatment, the patient was able to be discharged home with oxygen therapy on 1 L/min along with a steroid taper. DISCUSSION: Although there was likely a component of iatrogenic fluid overload from IV hydration, the patient's clinical condition did not improve even after vigorous diuresis. Patient does not have any significant underlying pulmonary disease, or CT/PFTs in past. Extensive infectious and autoimmune workup has been negative. Based on the GGO distribution, clinical course including symptoms after exposure to COVID-19 booster, and improvement after steroids, BAL cell count with lymphocytic predominance, we consider vaccine-induced interstitial lung disease as the most probable diagnosis. CONCLUSIONS: Our case highlights challenges in managing patients with airspace disease in the era of COVID-19 and vaccination. We would like to share a possible case of vaccination-induced interstitial lung disease. Our conclusion was made after ruling out the most common infectious and noninfectious causes and after having a favorable response to steroids. Reference #1: Influenza vaccine-induced interstitial lung disease. Watanabe et al. European Respiratory Journal Feb 2013, 41 (2) 474-477;DOI: 10.1183/09031936.00146912 Reference #2: COVID-19 vaccine induced interstitial lung disease, Yoshifuji et al, Journal of Infection and Chemotherapy, 2021 Reference #3: COVID-19 mRNA Vaccine-induced Pneumonitis: A Case Report. Internal Medicine, Japanese Society of Internal Medicine. Matsuzaki S et al., Released October 26, 2021 DISCLOSURES: No relevant relationships by Harold Cedeno No relevant relationships by Chengtin Tseng

17.
Chest ; 162(4):A960-A961, 2022.
Article in English | EMBASE | ID: covidwho-2060741

ABSTRACT

SESSION TITLE: Pulmonary Involvement in Critical Care Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Cryptogenic organizing pneumonia (COP), also known as bronchiolitis obliterans organizing pneumonia (BOOP), is one of the idiopathic interstitial lung diseases that affects the alveolar epithelium and surrounding interstitium. Its diagnosis is usually delayed due to similar clinical presentation as other illnesses (e.g. pneumonia) [1]. CASE PRESENTATION: A 65-year-old male presented with rapidly progressive respiratory failure. Computed tomography (CT) of chest showed multifocal ground glass opacities. He had suboptimal response to antibiotics and had to be intubated on day 9 due to worsening respiratory failure. Bronchoscopy with bronchoalveolar lavage was performed, cytology of which revealed severe acute inflammation and mononuclear infiltration. Decision was made to perform open lung biopsy which showed polypoid plugs of organizing fibroblasts and myofibroblasts in the distal airways and alveoli with focal hyaline membrane and alveolar damage, consistent with acute onset fulminant COP. As expected, the patient responded fairly well to high-dose corticosteroids and was extubated on day 9 of intubation. DISCUSSION: Even though it is very rare, COP should be kept in differentials especially when initial interventions fail (as in our patient). There is no single laboratory study or intervention to diagnose this condition. Hence it is imperative to rule out other causes of similar presentation like pneumonia (using cultures, urine antigen testing, and viral polymerase chain reaction tests). The clinical picture is combined with supportive evidence like elevated erythrocyte sedimentation rate, leukocytosis, imaging findings, and bronchoscopic and histopathology evaluation [2]. Once diagnosed, it is important to rule out any associated CTD, for it can change management and prevent additional complications. The majority of patients with COP exhibit rapid response to glucocorticoid treatment. For fulminant disease, intravenous glucocorticoids (e.g. methylprednisolone 125-250 mg every six hours) should be initiated based on the clinical experience and case reports [3]. CONCLUSIONS: Diagnoses of interstitial lung diseases should be pursued in a systemic fashion from more common to less common. However, anchoring to common diagnoses should be avoided to negate delay in diagnoses and allow timely management. If initial workup is unrevealing, bronchoscopy and open lung biopsies should be performed while the patient is stable enough to undergo the interventions to avoid antibiotic resistance, morbidity and mortality associated with rapidly progressive noninfectious illnesses like fulminant COP. Reference #1: Drakopanagiotakis F, Polychronopoulos V, Judson MA. Organizing pneumonia. The American journal of the medical sciences. 2008 Jan 1;335(1):34-9. Reference #2: Cordier JF. Cryptogenic organising pneumonia. European Respiratory Journal. 2006 Aug 1;28(2):422-46. Reference #3: Nizami IY, Kissner DG, Visscher DW, Dubaybo BA. Idiopathic bronchiolitis obliterans with organizing pneumonia: an acute and life-threatening syndrome. Chest. 1995 Jul 1;108(1):271-7 DISCLOSURES: No relevant relationships by Fareeha Abid No relevant relationships by Vipin Garg No relevant relationships by Qirat Jawed No relevant relationships by Asnia Latif No relevant relationships by Ahmed Mowafy No relevant relationships by Muniba Naqi No relevant relationships by Muhammad Atif Masood Noori No relevant relationships by Hasham Saeed

18.
Chest ; 162(4):A906, 2022.
Article in English | EMBASE | ID: covidwho-2060723

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: Hemophagocytic Lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome caused by severe, dysregulated hypercytokinemia. This can be associated with genetic defects or immunologic triggers such as infection, malignancy or autoimmune disorder. The clinical picture consists of multi-organ failure including fever, hepatosplenomegaly, cytopenia,hypertriglyceridemia, hemophagocytosis, high ferritin and IL-2 levels, neurological and liver dysfunction. We present a case of a patient with HLH in the setting of Herpes Simplex Virus (HSV) and SARS-CoV-2 co-infection. CASE PRESENTATION: A 39-year-old male presented to the ER with dyspnea and was found to have COVID-19 pneumonia. He had worsening hypoxemia and was admitted to ICU. He rapidly developed multi-system organ failure (MSOF)including severe hepatitis with AST 13,950 U/L and ALT 10,000 U/L, pancytopenia (Hb 12.9 g/dL, WBC 1.7 K/uL, platelet 15,000 K/uL), acute kidney injury (Cr 6.61 mg/dL), and severe ARDS requiring mechanical ventilation. Abdominal ultrasonography showed splenomegaly. Blood HSV1 DNA PCR was positive with liver biopsy revealing viral inclusions consistent with HSV hepatitis. He had elevated ferritin > 100,000 ug/L and LDH > 2500 U/L. Bone marrow biopsy demonstrated hemophagocytosis and trilineage hematopoiesis. He met 6 of 8 diagnostic criteria for HLH per the HLH-2004 protocol. He received dexamethasone. Risks and benefits of HLH-specific therapy were considered in the setting of liver dysfunction and the decision was made to withhold etoposide and administer anakinra. He died of refractory septic shock and disseminated intravascular coagulopathy. DISCUSSION: Diagnosis of HLH can be challenging due to its rarity and the clinical picture may be initially attributed to sepsis in the presence of infection, as in our patient who had COVID-19 infection and HSV hepatitis. However, a ferritin level >10,000 ng/mL is 90% sensitive and 96 % specific for HLH, with very minimal overlap with sepsis, infections, and liver failure. Additionally, infection is a known trigger of HLH. Despite high mortality without therapy, survival can be significantly increased with HLH-specific therapy, such as etoposide. Treatment with etoposide in the setting of severe liver disease can raise concern because it is metabolized by the liver but it is an essential component of optimal therapy and can be considered in patients with hepatic dysfunction with dose reduction. CONCLUSIONS: Our case highlights the importance of maintaining a high index of suspicion for HLH in critically ill patients with MSOF and liver failure, despite an apparent infectious etiology. This may allow timely diagnosis, early referral to a specialist center and consideration of HLH-specific therapy such as etoposide despite liver dysfunction, to prevent high morbidity and mortality in this potentially fatal disease. Reference #1: Filipovich AH. Hemophagocytic lymphohistiocytosis (HLH) and related disorders. Hematology Am Soc Hematol Educ Program 2009;:127. DISCLOSURES: No relevant relationships by Abdul Khan No relevant relationships by Nehan Sher No relevant relationships by yuttiwat vorakunthada

19.
Chest ; 162(4):A836, 2022.
Article in English | EMBASE | ID: covidwho-2060701

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: Coronavirus disease 2019 (COVID-19) can manifest as a severe immunologic syndrome known as hemophagocytic lymphohistiocytosis (HLH). HLH is a hyper-inflammatory state with a lethal mortality rate, especially when discovered late in the disease process. The optimal timely approach to diagnosis and treatment of secondary HLH in COVID-19 is unclear, however, risk stratification with Hscore using biomarkers can be useful to increase confidence in an HLH diagnosis. CASE PRESENTATION: A 36-year-old morbidly obese male with a history of well controlled mild intermittent asthma presented to the hospital complaining of a one week history of dyspnea and cough after failing outpatient COVID-19 treatment. Upon arrival, he was hypoxic on room air and was placed on non-invasive ventilation. He unfortunately decompensated further and was transferred to the intensive care unit where he was intubated for severe hypoxia and increased work of breathing. His course was complicated by superimposed bacterial pneumonia, vasopressor dependent septic shock, and anuric acute kidney injury requiring continuous renal replacement therapy. He remained profoundly hypoxic despite rescue therapy with multiple sessions of prone ventilation. On hospital day seventeen his platelets declined acutely and a serotonin release assay confirmed heparin-induced thrombocytopenia. His clinical status remained tenuous into the third week of admission. Notably, he developed persistent fever with associated bicytopenia and elevated lactate dehydrogenase, D-dimer, fibrinogen, triglycerides, and aspartate aminotransferase. His calculated Hscore was 189. Hematology recommended initiating HLH therapy with daily dexamethasone and etoposide, however the latter was held due to the patient's rapid hemodynamic decline. The patient succumbed to illness after a twenty-day hospitalization. His HLH was confirmed with a positive postmortem soluble-IL-2-receptor test. DISCUSSION: Proposals of routine HLH screening in critically ill patients are endorsed to promote early detection of this morbid condition. Calculating Hscore using vital signs, imaging, laboratory tests, and patient history can guide suspicion of diagnosis, since HLH-specific markers are often not feasible. Hscores more than 169 correspond to 93% sensitivity and 86% specificity in HLH diagnosis. Immunosuppression is standard therapy with hematology guidance due to the complex pathophysiology and limited research. CONCLUSIONS: This case emphasizes the importance of understanding the relationship between COVID-19 and secondary HLH. A timely diagnosis is vital in order to attempt to effectively treat a syndrome that carries a 65% mortality rate. Reference #1: Dimopoulos G, Mast Q. de, Markou N, et al. Favorable Anakinra responses in severe COVID-19 patients with secondary hemophagocytic lymphohistiocytosis. Cell Host Microbe 2020;doi: 10.1016/j.chom.2020.05.007. PubMed PMID: 32411313. Reference #2: Bauchmuller K, Manson JJ, Tattersall R, et al. Haemophagocytic lymphohistiocytosis in adult critical care. J Intensive Care Soc 2020;21:256–68. Reference #3: Schnaubelt, Sebastian MDa,∗;Tihanyi, Daniel MDb;Strassl, Robert MDc;Schmidt, Ralf MDc;Anders, Sonja MDb;Laggner, Anton N. MDa;Agis, Hermine MDd;Domanovits, Hans MDa Hemophagocytic lymphohistiocytosis in COVID-19, Medicine: March 26, 2021 - Volume 100 - Issue 12 - p e25170 doi: 10.1097/MD.0000000000025170 DISCLOSURES: No relevant relationships by Kristina Catania No relevant relationships by Katie Kennedy No relevant relationships by Josef Kinderwater No relevant relationships by MaryKate Kratzer no disclosure submitted for Ogugua Obi;

20.
Chest ; 162(4):A810-A811, 2022.
Article in English | EMBASE | ID: covidwho-2060694

ABSTRACT

SESSION TITLE: Autoimmune Disorders: Both Primary and Secondary SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Neurologic sequelae of COVID infection appear to be common. The infection may present with neurologic symptoms, unmask neurologic disease, or worsen established disease. Myasthenia gravis (MG) is an autoimmune neuromuscular disease (NMD) that does not appear to be a usual COVID sequela. We present an elderly veteran with COVID pneumonia who struggled to wean from mechanical ventilation (MV) secondary to neuromuscular weakness. He was ultimately diagnosed with seropositive MG. CASE PRESENTATION: A 79 year old male with a history of prior COVID infection complicated by need for mechanical ventilation (MV) complained of progressive cough and shortness of breath. He was admitted for treatment of community-acquired pneumonia. On hospital day 8, he developed respiratory failure, was intubated, and was transferred to the intensive care unit (ICU). He was diagnosed with COVID a second time. After antibiotics and supportive treatment, he successfully completed a spontaneous breathing trial and was extubated. Within 24 hours, he developed hypercapnia, necessitating reintubation. Given his need for repeat intubations, we ordered myositis titers and MG autoantibodies. After a fourth failed extubation, a tracheostomy was placed. On hospital day 32, his acetylcholine receptor binding antibody returned positive at 30.0, suggesting seropositive MG. His MG composite score was 11 (for ptosis and ventilator dependence). For further work-up, a CT chest excluded thymoma;a focused neurological exam was limited by sedation, and inpatient electrodiagnostics were not feasible. He received 5 days of intravenous immune globulin (40 mg), a Prednisone taper, and Rivastigmine 60 mg thrice daily. His symptoms improved and he was transferred to the floor. DISCUSSION: It is well established that coronaviruses exhibit neurotropism. However, it is unclear whether the novel coronavirus SARS-CoV-2 unmasks underlying neurologic illness or creates de novo disease. Critical care physicians are often tasked with making an initial diagnosis of neuromuscular disease (NMD). NMD is a known cause of complicated extubations. When the diaphragm and accessory respiratory muscles fatigue, respiratory decompensation ensues as full MV support is removed. In many cases, underlying illness is unmasked during this process of extubation. In our case, it is unknown whether infectious insult led to molecular mimicry and development of autoantibodies or unmasked latent neuromuscular disease. If the infection did cause his disease, it would be one of the first cases of COVID-associated MG to be published. Our case is a reminder that NMD is a secondary cause of extubation failure and may suggest MG as a cause of MV weaning failure secondary to COVID. CONCLUSIONS: Critical care physicians should be aware of this potential neuromuscular complication of COVID infection as it may complicate MV weaning, increase vent days, and prolong ICU stays. Reference #1: Collantes MEV, Espiritu AI, Sy MCC, Anlacan VMM, Jamora RDG. Neurological manifestations in covid-19 infection: A systematic review and meta-analysis. Can J Neurol Sci. 2021 Jan;48(1):66-76. Doi: 10.1017/cjn.2020.146. Epub 2020 Jul 15. PMID: 32665054. Reference #2: Huber M, Rogozinski S, Puppe W, Framme C, Hoglinger G, Hufendiek K, Wegner F. Postinfectious onset of myasthenia gravis in a COVID-19 patient. Front Neurol. 2020 Oct 6;11:576153. Doi: 10.3389/fneur.2020.576153. eCollection 2020. PMID: 33123081. Reference #3: Muralidhar Reddy Y, B SK, Osman S, Murthy JMK. Temporal association between SARS-CoV-2 and new-onset myasthenia gravis: Is it causal or coincidental? BMJ Case Rep. 2021 Jul 21;14(7):e244146. Doi: 10.1136/bcr-2021-244146. PMID: 34290032. DISCLOSURES: No relevant relationships by Jeffrey Li No relevant relationships by Anupa Nadkarni No relevant relationships by Justin Owens No relevant relationships by Jennifer Perry no disclosure on file for Hayley Sp res;

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