TP47. TP047 COVID AND ARDS CASE REPORTS最新文献

{"title":"Disseminated Intravascular Coagulation (DIC) as a Predecessor of Thromboinflammation and Multiorgan Organ Failure in a Patient with Coronavirus Disease 2019 (COVID-19), A Case Report","authors":"M. Hayrabedian, R. Sreedhar","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2458","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2458","url":null,"abstract":"Introduction: Individuals with COVID-19 may have complex coagulation abnormalities in consistence with hypercoagulability. This manifests as high plasma level of certain coagulation factors, particularly fibrinogen. DIC, on the other hand, is characterized by consumption of these factors. We present a case of COVID-19 respiratory failure at which a DIC phase was followed by thromboinflammation and organ failure. Case Presentation: A 51-year-old male presented with 3-day duration of fever and dyspnea. He had laboratoryconfirmed COVID-19 infection a day prior to his presentation. He displayed significant hypoxia and respiratory distress which led to mechanical ventilation at 48 hours post presentation. His laboratory evaluation showed a platelet count of 45 x 1000/ mm3, International Normalized Ratio (INR) of 3.2, activated Partial Thromboplastin Time of 39 seconds, Fibrinogen of 30 mg/dl, D-Dimer of <4 mcg/ml and Fibrin Split Products of 320 unigram/ml. Peripheral blood smear showed schistocytes and ultrasound of the lower extremities showed bilateral deep venous thrombosis. Thrombotic thrombocytopenic purpura (TTP) and Disseminated Intravascular Coagulation (DIC) were considered. Serum Disintegrin And Metalloprotease with a ThromboSpondin type 1 motif, member 13 (ADAMTS-13) level was ordered, plasmapheresis trial initiated and IV argatroban drip started. Platelet count normalized with 48 hours. ADAMTS-13 level was inconsistent with TTP. On the sixth day of admission, serum fibrinogen level increased to 457 mg/dl which coexisted with worsening ventilatory requirements. A similar pattern of increasing serum D-Dimer level, ferritin and creatinine was observed together with the development of shock and multiorgan failure syndrome. Patient eventually succumbed to his critical illness on the 28th day of admission. Discussion: Endothelial injury [1] and hypercoagulable status [2] cause COVID Coagulopathy. DIC is predominately a consumptive disorder associated with bleeding, COVID- associated coagulopathy is associated with increasing thrombosis. In s series that reported on thromboembolic events, none of the patients developed overt DIC[3]. While thromboembolic events in COVID-19 are associated with increased mortality, the clinical significance of this compensated form of DIC is unknown. Conclusion:Critically ill patients with COVID-19 may display “compensated” DIC. Whether this is a separate entity or lies within a large spectrum of different coagulation abnormalities is unknown. The clinical significance of it is unknown wither. Randomized clinical trials are needed for further understanding.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"51 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116013031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acquired Tracheoesophageal Fistula in a Pregnant Patient with Coronavirus Disease 2019 (COVID 19) Pneumonia on Prolonged Invasive Ventilation","authors":"P.M.G.M. Cuaño, Jun Pilapil, R. Larrazabal, K.V.C. Bismark, R. Villalobos","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2451","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2451","url":null,"abstract":"Introduction.An acquired tracheoesophageal fistula (TEF), an abnormal communication between the trachea and esophagus, is most often caused by malignancies in adults. Occasionally, it may arise from benign causes, such as endoscopic intervention, trauma, and prolonged intubation. Case Presentation. A 24-year old previously healthy pregnant female was diagnosed with COVID-19 pneumonia and was intubated. Due to non-reassuring fetal status, an emergency cesarean section was performed at the 36th week of gestation;the baby tested negative for COVID-19 and was separated. Throughout her illness, the patient was treated for recurrent bouts of pneumonia, coupled with findings of pneumothorax and pneumomediastinum- all of which were attributed to pulmonary fibrosis from Acute Respiratory Distress Syndrome (ARDS). A chest and neck CT scan (figure 1), however, confirmed the presence of a tracheoesophageal fistula (TEF), along with a hyperinflated endotracheal (ET) cuff. A temporizing procedure, involving tracheostomy with an extended length tracheal tube, was performed. The long-term plan was to surgically correct the TEF after nutritional upbuilding and liberation from the ventilator, however the patient succumbed to her infections. Discussion.The findings of a communication between the trachea and the esophagus tie all of these events together: the pneumothorax and pneumomediastinum, as well as the recurrent bouts of pneumonia from recurrent aspiration through the fistula. Despite its rarity (0.3-3%), tracheoesophageal fistulas are a very real possibility in patients who require prolonged invasive ventilation. A retrospective study by Fiacchino et al. noted a significant increase in full thickness tracheal lesions in patients with COVID-19 pneumonia, which may be caused by several factors: the presence of an overinflated endotracheal (ET) cuff, prolonged steroid use, hypoxic injury, as well as possible direct injury of the tracheal mucosa from the Coronavirus itself [1]. This case highlights the importance of keeping a high index of suspicion for tracheal injury in patients who experience prolonged periods of intubation. It also underlies the high morbidity and mortality rate associated with TEF, albeit being a rare disease. Lastly, it highlights yet another possible long-term complication of COVID-19. Reference:[1]Fiacchini G, Tricò D, Ribechini A, et al. Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19. JAMA Otolaryngol Head Neck Surg. Published online November 19, 2020. doi:10.1001/jamaoto.2020.4148 .","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"36 3 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116536854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pneumomediastinum as a Complication in Covid-19 Patients with Lung Protective Mechanical Ventilation - A Case Series","authors":"H. J. Graaff, A. N. Tacx, E. Visse, P. van Velzen","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2467","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2467","url":null,"abstract":"Introduction Novel coronavirus 2019 (COVID-19) can cause severe pneumonia requiring endotracheal intubation in 20-25% of all hospitalized patients. High peak pressures, driving pressures and plateau pressures as well as large tidal volumes are known risk factors for ventilator induced lung injury (VILI). Reported mortality rate of pneumomediastinum in COVID-19 is 60%. Therefore, target pressures are a peak pressure and plateau pressure below 30 cmH2O, tidal volumes below 6ml/kg ideal body weight (IBW) and driving pressure below 15 cmH2O. Cases We report two male COVID-19 patients, aged 64 and 65 years, who developed a pneumomediastinum while undergoing mechanical ventilation with lung protective strategies. Medical histories included obesity, hypertension, type 2 diabetes mellitus and were unremarkable for pulmonary disease. Both were hospitalized with respiratory insufficiency. COVID-19 was confirmed by a positive polymerase chain reaction test and CT-scan findings. Within three days, all patients were admitted to the intensive care unit (ICU) and mechanically ventilated in prone position 16-20 hours/day with lung protective strategies and in accordance with the lower positive end expiratory pressure (PEEP) higher FiO2 strategy. Peak pressures ranged 13-33 cmH2O, driving pressure (DP) ranged 10-15 cmH2O, PEEP 5-12 cmH2O, plateau pressure 14-24 cmH2O with tidal volumes 4-7 ml/kg (4-6 ml/kg while on pressure-controlled ventilation). After 7-10 days CT-scans were repeated because of progressive hypoxemia. In both patients CT-scan showed pneumomediastinum with pneumothorax requiring chest tube insertion in one patient and pneumopericardium in one patient (figure 1). Ventilator settings were lowered while allowing permissive hypercapnia to pH 7.20. Pneumomediastinum resorbed in both patients. During follow up, one patient died of progressive lung disease one month after hospitalization and one patient died from pulmonary hemorrhage one month after ICU-admission. Discussion A recent autopsy series in COVID-19 patients showed that alveolar epithelial damage causes loss of lung compliance. Decreased lung compliance combined with high plateau and peak pressures might predispose to VILI, however our case series shows two patients with pneumomediastinum while on lung protective mechanical ventilation. We hypothesize that alveolar epithelial damage predisposes to VILI rather than mechanical ventilation itself. This was confirmed in reports of COVID-19 patients with pneumomediastinum in the absence of mechanical ventilation. Therefore, the recently described mortality rate of 60% is a sign of severe pulmonary disease rather than a result of pneumomediastinum itself. Furthermore, our case series suggests that developing pneumomediastinum while on lung protective mechanical ventilation in COVID-19 patients predisposes to a high mortality rate.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128442840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acute Pancreatitis from Triglyceridemia with Concominant Diabetic Ketoacidosis: A Complication of COVID-19 Infection","authors":"V. T. Gonuguntla, S. Shajahan, H. Waseem","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2449","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2449","url":null,"abstract":"Introduction: COVID-19 pneumonia is a viral infection that has been shown to affect numerous organ systems causing diagnostic and treatment dilemmas. Previous literature shows that 17% of patients with COVID-19 were found to have acute pancreatitis without any additional risk factors. However, the role of hypertriglyceridemia has not yet been examined. We present a case of acute pancreatitis secondary to triglyceridemia in the setting of COVID-19 infection. Case Report: A 31 year old man with morbid obesity (body mass index of 41.5 kg/m2) and no other past medical history presented with abdominal pain at the periumbilical region radiating to the back associated with nausea and vomiting for five days. He also complained of polyuria and polydipsia for one week. He denied any history of diabetes mellitus (DM), high triglycerides, alcohol use, and gallstones. He also denied any family history of hyperlipidemia. Of note, the patient's wife was sick with COVID-19 3 weeks prior and he tested negative at that time. His vitals were remarkable for sinus tachycardia of 140/minute. Labs were notable for positive PCR for COVID-19 pneumonia, lipase of 520, elevated triglycerides of 7265, and evidence of pancreatitis on computed tomography (CT) scan of abdomen and pelvis. His arterial blood gas was significant for a pH of 7.191 and lactate of 1.9. His chemistry revealed a glucose of 377, anion gap of 26, and a bicarbonate of 8, consistent with a diagnosis of diabetic ketoacidosis (DKA). He was admitted to intensive care unit (ICU) for management of acute pancreatitis and DKA. He was managed with intravenous (IV) insulin drip, Atorvastatin, Niacin, Gemfibrozil and isotonic IV fluids. Following a 10 day ICU course he had complete resolution of DKA and hypertriglyceridemia and was subsequently transferred to the medical floor. Discussion:The proposed mechanism of acute pancreatitis in COVID-19 infection is the entry of the virus via angiotensin II receptor that causes damage to pancreatic cells. This results in decreased insulin production leading to increased peripheral lipolysis and hypertriglyceridemia. The breakdown of triglycerides then often results in DKA. In the case of our patient it is possible that COVID-19 infection is a coincidence but the timing of symptoms, lack of prior history of triglyceridemia, and lack of family history makes COVID 19 the most likely cause. Therefore, in COVID-19 patients with abdominal pain, acute pancreatitis should be considered.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"88 20 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130770046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Young Adult with Covid-19 Associated Multisystem Inflammatory Syndrome","authors":"K. Ejaz, N. Patel, J. Ramos, A. Sharma","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2468","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2468","url":null,"abstract":"Background: Coronavirus Disease 2019 (COVID-19) is an evolving entity with a myriad of clinical presentations and complications. Most cases of COVID-19 associated multisystem inflammatory syndrome (MIS) have been reported in children with little data in adults. Here we present a case of MIS in a 19-year-old African American adult. Case Presentation: The patient is a previously healthy 19-year-old African American female who presented with 5 days of nausea, vomiting, diarrhea, fever, chills, headache, and malaise. She was diagnosed with COVID- 19 24 days before presentation and remained asymptomatic since testing positive. On presentation, the patient's vitals were significant for a fever of 102.2 F, blood pressure of 97/56, and heart rate of 123. Laboratory workup showed elevated creatinine, and inflammatory markers including procalcitonin, lactate dehydrogenase, ferritin, Creactive protein, and, D-dimer. A multidisciplinary approach comprising of critical care, cardiology, rheumatology, and infectious disease was undertaken. The initial hospital course was complicated by hypotension requiring pressor support, and an episode of supraventricular tachycardia which resolved with adenosine. Additionally, the patient had a brief episode of paroxysmal atrial fibrillation, which self resolved. Initial transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 30% with left wall hypokinesis. The patient was successfully treated with 1 dose of intravenous immunoglobulin (IVIG), and Solu-Medrol 1 g daily for three days. The patient was monitored with serial troponins, B-natriuretic peptide, and inflammatory markers. Acute kidney injury present on admission resolved within two days. A follow-up TTE obtained three days later showed a significant improvement in EF to 45%. The patient's symptoms resolved within three days of treatment. Discussion: MIS should be considered in adults presenting with atypical gastrointestinal, cardiac, and musculoskeletal symptoms with elevated inflammatory markers in the setting of a recent diagnosis of COVID-19. Cardiac manifestations such as arrhythmias and wall motion abnormalities should be expected. Unlike MIS in children who display features of Kawasaki disease, adults often lack these overlapping features. Inflammatory markers including procalcitonin, lactate dehydrogenase, C-reactive protein, and ferritin can be used to monitor treatment response as they trend down with appropriate management. Intravenous steroids and IVIG can be effective in managing this clinical entity by improving cardiac parameters such as EF, although long term prognosis remains to be analyzed. Despite limited data, it is reasonable to postulate that MIS may be caused by Covid-19 associated cytokine storm and severe inflammatory response that entails multisystem dysfunction even in individuals without underlying medical conditions.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132672406","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) as a Bridge to Lung Transplantation Following Severe Covid-19 Infection","authors":"P. A. Sarhene, M. Dawson, A. Kirkner, N. Lunardi","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2439","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2439","url":null,"abstract":"Introduction The Coronavirus Disease 2019 (COVID-19) has proven to be the most infectious and deadly respiratory virus since the 1918 H1N1 influenza A pandemic. According to the World Health Organization (WHO), COVID-19 has caused over 62 million infections and more than 1.4 million deaths worldwide in the first year of the pandemic. This case report depicts the clinical course of a patient with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, requiring VV-ECMO and bilateral orthotopic lung transplantation (BOLT). Case Description R.R. was a 57-year-old triathlete with history of smoking 20 years ago, anxiety, and depression. He initially presented to an outside hospital (OSH) with symptoms of fever and dyspnea and was admitted to the intensive care unit (ICU) due to increasing oxygen requirements on BiPAP seven days later. Notably, two subsequent COVID tests resulted negative. On hospital day (HOD) 28, he necessitated urgent cannulation for VV-ECMO and was transferred to our institution for further management. R.R.'s ICU course was characterized by a progressive decline of respiratory function. Chest computed tomography (CT) revealed severe bullous emphysema and interstitial fibrosis. The patient developed right ventricular (RV) failure warranting treatment with inhaled nitric oxide and diuresis. Given the overall clinical status, he underwent expedited work-up and listing for lung transplantation. On HOD 32 he required intubation for worsening hypoxemia despite ECMO support with flows of 4.5 L/min, sweep of 4 L/min and circuit FiO2 of 100% with maximum lung protective ventilator support. Notably, a repeat COVID test was positive. Several days later, he underwent a tracheostomy. He continued to experience refractory hypoxia and hypercarbia, necessitating deep sedation, paralysis, and ECMO sweep of 14 L/min on the night preceding his BOLT. Post-operative course was largely unremarkable. His tracheostomy was decannulated on HOD 52 and he was discharged to rehab on HOD 59. The patient spent 17 days in rehab and was discharged home. Discussion In this case, an active triathlete without significant comorbidities developed severe pulmonary fibrosis leading to end stage lung disease from COVID-19. The vast majority of patients infected with COVID-19 have mild to moderate disease. However, patients with severe disease requiring mechanical ventilation have a mortality rate of up to 20-25%. The proportion of patients who require ECMO and lung transplantation is small. This case illustrates the merit of urgent evaluation for ECMO candidacy and consideration of lung transplantation for selected individuals in this small cohort of patients.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125717351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lung Recovery After Long Venovenous Extracorporeal Membrane Oxygenation Support for COVID-19 Acute Respiratory Failure: A Case Report","authors":"C. Merley, L. Galloway, A. Zaaqoq","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2438","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2438","url":null,"abstract":"Introduction: Venovenous (VV) Extracorporeal Membrane Oxygenation (ECMO) is an effective rescue therapy for coronavirus disease 2019 (COVID-19)- acute respiratory failure. However, the optimal duration of ECMO support and time to lung recovery remain unknown. Description: A 48-year-old Hispanic male without significant past medical history was transferred to a tertiary care high-volume ECMO center on mechanical ventilation after 11 days of progressive shortness of breath due to COVID-19 pneumonia. He was transferred heavily sedated, paralyzed, in the prone position, and with lung protective mechanical ventilation settings of 6cc/kg of ideal body weight, tidal volume of 350cc, positive end-expiratory pressure of 14 cm H2O, respiratory rate of 30 breaths per minute, and FiO2 of 100%. His driving and plateau pressures were 13 and 27 cm H2O, respectively. Three days after intubation, his PO2/FiO2 ratio repeatedly dropped below 80 and he was placed on Vf -Vj ECMO for severe acute respiratory distress syndrome (ARDS). During his ICU course, the patient received adjunctive therapies, including Remdesivir and Dexamethasone. He was extremely encephalopathic, resulting in a failed trial of extubation and requiring tracheostomy placement 14 days after intubation. His ECMO run was complicated by oxygenator failure and emergent exchange of ECMO circuit despite anticoagulation with bivalirudin. His course was complicated by superimposed Enterobacter pneumonia and he was treated with antibiotics. After 38 days of VV ECMO support, he showed improvement in compliance and gas exchange, indicating lung recovery. The patient was weaned successfully from ECMO and remained on mechanical ventilation for almost 30 days after decannulation. The ICU team carried out aggressive physical therapy, the patient was weaned off mechanical ventilation, his tracheostomy was decannulated, and he was discharged on 2L O2. CT at the time of discharge showed “improved aeration of both lungs” with residual lung fibrosis and bronchiectasis (Figure 1). Discussion: ARDS remains the most common indication for long-term ECMO support, which is frequently complicated by severe deconditioning, secondary infection, and vascular complications. In a stratified analysis of 127 patients who received ECMO support for respiratory failure, patient survival was 52% after being on ECMO for more than 20 days.1 Despite multiple complications, including superimposed infection and oxygenator failure, our patient showed recovery from his ARDS. He was eventually extubated and discharged from the hospital, indicating ECMO as an effective treatment for COVID-19 pneumonia. VV ECMO support for COVID-19 pneumonia should be considered for all eligible patients as infection rates and continue to rise.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"61 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123811792","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Corticosteroid Therapy in Post-COVID-19 Pulmonary Fibrosis","authors":"E. Lam, N. Sayedy, F. Anjum, J. Akella, Javed Iqbal","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2429","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2429","url":null,"abstract":"Introduction:Pulmonary fibrosis (PF) is characterized by excessive deposition of extracellular matrix components and destruction of the pulmonary parenchyma. Studies have shown severe Coronavirus Disease 2019 (COVID-19) can lead to PF with residual lung function abnormalities and fibrotic remodeling. As of today, there is no consensus on treatment for PF caused by COVID-19. We are reporting a case series of three post-COVID-19 PF patients treated with tapering prednisone. Case Series:Patient 1 is 52-year-old male presented to the clinic after a 3-month hospital course of COVID-19 requiring hyperbaric hood. He was discharged with 2L of home oxygen. The patient saturated at 95% at rest but desaturated to 70% on exertion. Chest X-ray (CXR) and CT thorax showed diffuse ground glass opacity with pulmonary fibrosis and scarring. Tapering prednisone from 40mg over 1 month was initiated. Follow-up visit after one month confirmed reduce home oxygen requirement. CXR also revealed mild improvement in interstitial infiltrates. Patient 2 is a 56-year-old male hospitalized 2 months ago for COVID-19 where he required non-rebreather mask for oxygen supply. In the office, he complained of shortness of breath on exertion. CXR showed diffuse bilateral airspace opacities and thickened interstitial lung markings. Pulmonary function test (PFT) revealed moderate restrictive pattern with reduced lung volumes. He was sent home with a course of tapering prednisone over 1 month and weekly office follow up. His symptoms improved. Repeat CXR showed improving bilateral diffuse reticular markings. Repeat PFT improved to mild restrictive lung pattern. Patient 3 is a 70-year-old male hospitalized for 1 moth for COVID-19 requiring face mask with recent discharge on 4L home oxygen. After 2 weeks of hospital discharge, the patient still required 2L of oxygen at home. CXR showed streaky lung opacities predominantly in the left lower lung field. The patient was started on tapering prednisone. At 2-month follow-up, he admitted clinical improvement of symptoms and was able to titrate off home oxygen at rest. Repeat CXR also showed improvement of streaky opacity in the left mid/lower lung. Discussion:No evidence-based treatment is available for post-COVID-19 PF. Corticosteroid is used for treatment of acute exacerbation of other forms of PF by decreasing inflammation in the lungs, and therefore may improve symptoms of post-COVID-19 PF. Our patients received 1-month course of tapering prednisone treatment showed mild clinical improvement with no major adverse effect. Further clinical trials should address the utility and risks of corticosteroid in post-COVID-19 PF.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"56 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115655001","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fatal Pulmonary Hemorrhage: Cirrhosis and COVID19","authors":"A. Haag, S. Sangli","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2464","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2464","url":null,"abstract":"Background: The clinical impact and therapeutic implications of COVID-19 infection in a patient with pre-existing liver disease is unknown. We present a case of a middle-aged female with underlying non-alcoholic steatohepatitis associated cirrhosis who suffered a fatal pulmonary hemorrhage associated with COVID-19 infection. While the management of COVID-19 is evolving with regards to therapeutic anticoagulation requirements in critically ill patients, the impact of a pre-existing liver disease and its therapeutic implications when associated with COVID-19 is yet to be thoroughly elucidated. Case Report: Our patient is a 47 year old female with a past medical history of hypertension, hypothyroidism, fibromyalgia, non-decompensated NASH cirrhosis Child-Pugh Class C, gastric bypass surgery who developed progressive shortness of breath secondary to a COVID-19 pneumonia requiring hospitalization. She then developed acute hypoxic respiratory failure that required mechanical ventilation for over two weeks. Dexamethasone and Convalescent plasma were given for treatment of COVID-19. Unfortunately, her respiratory status during her ICU stay, declined requiring interventions including neuromuscular blockers and proning for refractory hypoxemia. She concurrently developed acute kidney injury requiring continuous renal replacement therapy. Her hospital course was also complicated by septic shock requiring vasopressors secondary to candidemia, and she was initiated on antifungal therapy with fluconazole. During ongoing CRRT therapy, we encountered recurrent clotting events and with the presumed COVID related hypercoagulability, patient was initiated on anticoagulation with systemic unfractionated heparin protocol. On day 17, her respiratory status and shock had resolved. However, her clinical status deteriorated quickly with recurrent shock of presumed sepsis, requiring initiation of broad spectrum antibiotics including vancomycin and piperacillin-tazobactam. Over the course of these 24 hours, patient suffered a fatal pulmonary hemorrhage despite massive transfusion protocol and reversal with protamine sulfate. Conclusion: We presented a cirrhotic patient who died of massive pulmonary hemorrhage associated with COVID-19 infection. There is overall paucity in the literature and in our understanding of management of COVID-19 associated with liver disease. While the literature reports a higher incidence of venous thromboembolic disease in COVID-19 patients, there are several challenges encountered with initiation of anticoagulation in a cirrhotic patient with concurrent coagulopathy. There are however anecdotal reports of favorable outcomes reported in these patients with use of anticoagulation possibly secondary to their antifibrotic properties. Future studies are required to clarify the role of safe and effective anticoagulation, criteria to make this decision, and perhaps even the choice of anticoagulation in patients with underlying liver disease.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"40 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121738568","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pulmonary and Pancreatic Aspergillosis Infection in the Setting of Immunosuppression from Granulomatosis with Polyangiitis Treatment and Concomitant SARS-CoV-2 Infection","authors":"A. Chang, J. A. Lee, H. Nabeel, P. Richman","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2436","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2436","url":null,"abstract":"Introduction Typical orofacial manifestations of granulomatosis with polyangiitis (GPA) include rhinitis and sinusitis, but salivary gland involvement is rare. Treatment of GPA increases risk of opportunistic infections. In light of the recent SARS-CoV-2 pandemic, this places this population in a particularly vulnerable position. Here we describe a case of suppurative parotitis as the presenting sign of GPA, treated with prednisone and cyclophosphamide, subsequently complicated by SARS-CoV-2 infection, disseminated MRSA infection, and invasive pulmonary aspergillosis (IPA) with aspergillosis of the pancreas. Presentation A 71-year-old male with COPD was admitted to hospital for progressive facial pain with left parotid gland swelling despite outpatient antibiotics. Basic laboratory workup was unremarkable. He developed hemoptysis, and CT chest revealed a new left upper lobe (LUL) cavitary lesion with bilateral nodules. Diagnostic bronchoscopy showed thickened, nodular mucosa in the LUL with luminal narrowing. Endobronchial biopsy showed inflammation with necrosis but no malignancy;culture showed no microorganisms. Parotid gland pus grew normal oral flora. CT-guided core biopsy of the LUL lesion showed fibrotic and necrotic tissue with inflammation and multi-nucleated giant cells, again without tumor cells. Initial autoimmune workup revealed ANA positivity, but he elected for discharge to outpatient autoimmune workup. Four weeks later he was admitted to another hospital with acute renal failure where testing revealed hypocomplementemia, elevated c-ANCA and anti-PR-3 antibodies. Renal biopsy demonstrated focal necrotizing and diffuse crescentic glomerulonephritis. A diagnosis of GPA was made and treatment with prednisone and cyclophosphamide was initiated. After three months of this regimen, he was re-admitted to our facility for SARSCoV- 2 infection. Hospital course was complicated by MRSA endocarditis and presumed fungal pneumonia. Despite aggressive treatment of both, he developed septic shock and ultimately expired. Autopsy revealed invasive aspergillus in the lungs and necrotizing pancreatitis from aspergillus. Discussion Salivary gland involvement is a rare manifestation of GPA and documented infrequently in case reports. The presence of parotitis in a patient with hemoptysis and negative malignant or infectious workup should prompt the consideration of GPA. Importantly, IPA associated with SARS-CoV-2 infection in immunocompetent patients has been frequently documented in the literature, and immunosuppressed individuals such as this patient are surely at increased risk. The rare, incidental finding of aspergillus invading the pancreas on autopsy was likely related to his immunocompromised state. Given the high mortality rate, there should be a low threshold to treat for presumed IPA in patients with SARS-CoV-2 infection for which secondary infection is suspected.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129929753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}