TP47. TP047 COVID AND ARDS CASE REPORTS最新文献

{"title":"A Rare Case of Hemorrhagic Cholecystitis in a Patient with Severe Coronavirus Disease 19 (COVID-19)","authors":"P. J. Kramer, S. Sediqe, O. Giddings","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2452","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2452","url":null,"abstract":"Hemorrhagic cholecystitis is a rare end-stage manifestation of acalculous cholecystitis that is associated with high mortality. The hematological sequelae of coronavirus disease 19 (COVID-19) are complex and are associated with increased incidence of both thromboembolic and hemorrhagic events. Our patient is a 69-yearold male with hypertension and gout who was admitted to the medical intensive care unit with severe COVID-19 pneumonia and lactic acidosis. The patient was treated with a therapeutic low-intensity heparin infusion per institutional COVID-19 anticoagulation protocol based on elevated D-dimer (15,217 ng/mL). Computed tomography (CT) of the abdomen and pelvis on hospital day 1 and day 4 were negative for acute pathology. On hospital day 9, the patient developed shock and acute blood loss, and repeat CT of the abdomen showed new hemorrhagic cholecystitis. Heparin infusion was stopped, and acute care surgery consultants recommended against emergent surgery given the patient's hemodynamic instability. The patient was stabilized with blood product resuscitation and antibiotics. Laparoscopy prior to discharge showed heavy intra-abdominal adhesions with friable tissue, and the cholecystectomy attempt was aborted. He was discharged and was seen in clinic for follow-up, where he reported no abdominal pain and good functional status. Systemic coagulation dysfunction related to COVID-19 presents significant challenges to clinicians balancing the competing risks of acute thrombosis and bleeding. Hemorrhagic cholecystitis is a very uncommon complication of gallbladder disease, and reports linked to active COVID-19 are even more scarce. The gallbladder contains a particularly high expression of angiotensin I converting enzyme 2 (ACE2). This pattern is known to be vital for the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter cells, but direct end-organ damage from the virus outside of the respiratory system remains an active area of research. Our patient did not have radiographic gallbladder disease present on admission, but decompensated as a result of hemorrhage early in his COVID-19 course. Here, we present an unusual manifestation of a rare disease, with spontaneous hemorrhagic cholecystitis occurring a patient with severe COVID-19.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"153 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":"121264430","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":"Hypophosphatemic Rhabdomyolysis with Moderate Diabetic Ketoacidosis in a COVID-19 Patient Needing Continous Renal Replacement Therapy","authors":"A. Azeem, H. Salat, L. Haragsim","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2470","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2470","url":null,"abstract":"Introduction: Phosphate is a critical anion in maintaining cellular functions. Notably, most important use of phosphate is for ATP production. Thus, a reduction of phosphate levels is detrimental to every organ system. In this case, we describe a patient who presented with rhabdomyolysis caused by hypophosphatemia, which was worsened due to his DKA. Case: A 67 year old male with past medical history of hypertension, type 2 diabetes mellitus, gout, and prostate cancer diagnosed 1 year before presentation presented to the emergency department for complaints of 1 week of weakness, acutely manifested by the patient falling and being found unresponsive on the bathroom floor. He never lost a pulse and was transferred to a facility where he was found to have COVID-19 and labs concerning for diabetic ketoacidosis. He was then intubated for airway protection and transferred to a higher level of care facility. Upon admission into hospital, patient was found to be in septic shock with hypotension, febrile at 38.9°C and leukocytosis up to 15,000, and was started on broad spectrum antibiotics, an insulin drip, and fluid resuscitation. What was notable was his phosphorous level was below 1mg/dL, and rhabdomyolysis manifested with a CK level of around 40,000, and acute renal failure with oliguria and a creatinine of 5.45mg/dl. He also had a pH of 7.27, and a bicarb of 12. He was eventually started on CRRT due to need for dialysis while being hypotensive on pressors. He was kept in the ICU for 9 days where he was treated for multiple organ system failures including shock liver, NSTEMI, multiple ischemic strokes, and kidney failure. Eventually, the patient's family decided to pursue comfort care and stop all lifesaving measures on day 9 and the patient passed away that evening. Discussion: We discuss a rare case in which a patient with DM2 developed DKA, and as a result developed hypophosphatemia, thus causing rhabdomyolysis that required CRRT in a COVID-19 positive patient. Hypophosphatemic rhabdomyolysis induced by DKA is a rare complication not often seen, which makes the management difficult. Hypophosphatemia is usually managed with oral and IV replacement therapy. However, when treating the DKA, the insulin administered also causes the phosphate to move intracellular, thus further reducing serum concentration of phosphate. Our case highlights the difficulty with dealing with a rare complication of hypophosphatemia such as rhabdomyolysis and efforts used to manage such a patient.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"43 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":"129406668","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 Case of COVID19 Followed by PCP Pneumonia in an Immunocompromised Host","authors":"L. Ramdhanie, K. Gafoor, S. Chauhan, K. Cervellione","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2465","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2465","url":null,"abstract":"Here we present a case of a middle-aged female with extensive past cardiac history, on methotrexate, who presented with respiratory failure. The case illustrates the complicated diagnostic struggles that clinicians have encountered during the pandemic and provokes the possibility of COVID19 as a potential risk factor for PCP pneumonia. A 62-year-old female presented to a New York City Hospital in July 2020 with hypoxic respiratory failure. She had a past medical history of coronary artery disease s/p stent and CABG, rheumatoid arthritis on methotrexate, hypertension, hyperlipidemia, diabetes mellitus, and chronic kidney disease. She was s/p a two month course of antibiotics for sternal wound infection. At presentation, her SpO2 was 75% on room air. She endorsed worsening shortness of breath for 3 weeks. Admission labs were significant for GFR=20, elevated LFTs 2-3xULN, CRP=19.2, troponin=0.5, BNP=45,000 and ANC=1.1. Chest x-ray demonstrated perihilar infiltrates sparing the left upper lobe. She was placed on bipap. COVID19 nasal swab was negative, antibodies were positive. She was intially treated for CHF exaccerbation. During the course of admission, she developed worsening hypoxemia requiring intubation and shock requiring vasopressors. She underwent bronchoscopy with BAL, which revealed lymphocyte count of 42% suspicious for methotrexate toxicity. Steroids were initiated for the treatment of both potential COVID19 and methotrexate toxicity. She developed progressive white out leading to pneumothoraces requiring chest tube insertion. The patient expired. Culture from BAL eventually grew PCP. This patient's case was extremely challenging and introduces thought-provoking questions regarding cooccurrence of PCP and COVID19. There have been a few case reports of PCP coinfection with COVID19. These infections can have significant overlap in terms of the initial imaging and symptoms (bilateral ground glass opacities associated with progressive hypoxemia over weeks). Bronchoscopy is useful for confirming PCP amidst this diagnostic challenge. There has been speculation that lymphopenia associated with COVID19 may result in susceptibility to PCP. PCP infections have commonly been associated with lymphopenia (low CD4) in HIV patients. Most viral infections can predispose patients to fungal and bacterial super-infection. This case raises the question of whether PCP prophylaxis may be considered in patients with COVID19 and other risk factors for development of PCP, such as immunosuppression.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"2014 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":"127569487","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 Cryptococcosis in the 2019 Novel Coronavirus, When the Coinfection Affects the Mortality","authors":"Mostafa M Abohelwa, G. D. Rio-Pertuz, K. Parmar, C. Morataya, S. Siddique, S. Duangkham, K. Nugent","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2461","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2461","url":null,"abstract":"Introduction: The 2019 Novel Coronavirus (COVID-19) is currently causing a pandemic all over the world. Many patients suffer from respiratory syndromes, including acute respiratory distress syndrome (ARDS). Coinfection with fungi is rare in these fragile patients but does increase the mortality risk in them. We present a case of COVID-19 who presented with shortness of breath and was found to have associated pulmonary cryptococcosis.Case presentation: A 78-year-old woman with hypertension and diabetes mellitus was transferred to our hospital with an upper GI bleed. Initially, she presented to another hospital after she was tested positive for COVID-19 and subsequently admitted due to shortness of breath. She was transferred to our critical care unit for a higher level of care after reporting melena and having a hemoglobin drop. She was in respiratory distress when admitted and was intubated. A culture from a deep tracheal aspirate grew Cryptococcus neoformans on admission. Cryptococcal antigen in her blood was negative. The patient was started on fluconazole. More history from her family indicated that she was immunocompetent with no chronic corticosteroid therapy or HIV. Lumbar puncture was done and showed an opening pressure of 34 cm H2O with 25 RBCs/mm3 and 5 WBCs/mm3, but it was performed after she received fluconazole for several days. The patient died with ARDS. Discussion: Cryptococcosis is a potentially life-threatening fungal infection usually caused by inhalation of C. neoformans or C. gatti spores. Severe cryptococcal disease occurs in immunocompromised patients but can also occur in immunocompetent adults. The association between fungal infection and COVID-19 has been reported with Aspergillus species. Yet, few reports are available about coinfection with Cryptococcus species and COVID-19. Considering that COVID-19 causes ARDS, coinfection with Cryptococcus species almost certainly increases inflammation in the lung and the risk for poor outcomes. Since corticosteroids are a necessary treatment in COVID-19 with respiratory symptoms and hypoxemia, initiating them in patients with cryptococcal infection should be closely monitored for the possibility of dissemination. Clinicians should obtain cultures for Cryptococcus species from blood and the central nervous system in COVID-19 patients with pulmonary cryptococcosis and balance the need for corticosteroids with the risk of cryptococcal dissemination.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"31 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":"125194049","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 Rare Case of Viral Pancreatitis as a Result of COVID19 Complicated with Acute Onset Diabetes Mellitus and Severe Diabetic Ketoacidosis","authors":"M. Aldiabat, M. Mubashir, M. Alkhadour, V. P. Gutierrez, V. S. Chemarthi","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2446","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2446","url":null,"abstract":"Introduction:COVID-19 have been associated with various systemic manifestations, among which is gastrointestinal manifestations. Pancreatic injury is a rare finding in the course of the disease, therefore we present a case of case of 46 years old female who developed viral pancreatitis secondary to COVID-19, complicated with new onset diabetes mellitus (DM) and severe diabetic ketoacidosis (DKA), an association that was never reported before in literature.Case presentation:We present a 46 years old female with no past medical history who presented to hospital with respiratory distress and altered mental status. Patient presentation complicated with cardiopulmonary arrest, requiring intubation and CPR. Examination revealed tachycardia (105/min), hypotension (82/45) and hypothermia (32.3), obesity (BMI 38), bilateral rhonchi, soft abdomen with negative Collens and Grey-turner signs. Laboratory testing was remarkable for leukocytosis with neutrophilic predominance (17.5 x10(3)/mcL), hyperkalemia (6.6 mmol/L), elevated lipase levels (4248U/L), high-anion gab metabolic acidosis (anion gab 35, arterial pH <7.000), lactatemia, ketosis, negative alcohol screen. CXR showed bilateral dense alveolar infiltrate with peripheral distribution. CT abdomen (Figure-1) showed swelling of the pancreatic tail and fluid at the anterior pararenal space on the left side suggestive of acute pancreatitis. Ultrasound scan was negative for gallbladder stones. CT brain obtained to investigate cause of altered mental status, and was remarkable for 2.5mm intraparenchymal hemorrhage of the right cerebellar hemisphere. Patient was admitted to MICU for management of ARDS secondary to SARS-CoV-19, acute pancreatitis secondary to SARS-CoV-19, severe DKA, intraparenchymal hemorrhage and post cardiac arrest management. Patient expired after 3 days MICU course as result of multi-organ failure. Discussion: Viral pancreatitis is mainly associated with Mumps, Measles, Coxacki, EBV and Hepatitis A virus [2]. In our case, there were no clinical suspicions or laboratory evidence to attribute patient condition for the before-mentioned viruses. The association of both conditions and the absence of other causes of AP support the theory of COVID19-induced pancreatitis in this scenario. AP as a presenting scenario of COVID19 have been rarely reported before [4]. SARS-CoV is known to be associated with development of acute type 1 diabetes milletus, secondary to islets damage in the exocrine and endocrine tissues of the pancreas which express ACE2, this can explains the acute presentation of hyperglycemia and severe diabetic ketoacidosis in our patient who had no past medical history of diabetes. Such phenomena were never reported to be associated with SARS-CoV-2 in literature prior to this report.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"21 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":"131426929","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":"COVID AnTicks: Not All Infiltrates Are COVID Related","authors":"N. Abdelwahab, T. Schmidt, N. Ingraham, D. M. MacDonald, C. Bruen","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2450","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2450","url":null,"abstract":"Introduction: Anaplasma phagocytophilum causes human granulocytic anaplasmosis (HGA). We present a case of ARDS due to HGA, highlighting the importance of maintaining a broad differential and thorough history taking even in the midst of a pandemic. Case: A 43 year-old man with a history of alcohol and tobacco use presented in late November 2020 in the midst of a regional COVID-19 surge with two weeks of progressive shortness of breath, chest pain, fevers, and altered mental status. Admission labs were notable for hepatocellular injury, thrombocytopenia, leukopenia with absolute lymphopenia, and elevated creatinine. The patient's hypoxemia progressed to the point of requiring mechanical ventilation despite broad spectrum antibiotics. SARS-CoV-2 PCR x3, blood, viral, and fungal cultures were negative. Patient's PaO2/FiO2 ratio of <200, extensive bilateral infiltrates, and low suspicion for heart failure was consistent with ARDS (Figure). Given continued hypoxia, the patient underwent the prone positioning protocol. A peripheral smear was obtained for thrombocytopenia/leukopenia and demonstrated inclusions within the neutrophils consistent with Anaplasma. Upon further history taking, the spouse confirmed that the patient had recently found several ticks on his body after returning from a hunting trip in northern Minnesota. Anaplasma was confirmed with PCR testing. The rarity of ARDS due to anaplasmosis limits insight into therapeutic options aside from antibiotics. However, in addition to receiving doxycycline, the patient was started on dexamethasone, which has demonstrated possible symptomatic benefit through small case studies. The dosage of Dexamethasone administered ranged from 4-20 mg, totaling 5 doses. The patient improved and was discharged home. Discussion: Human granulocytic anaplasmosis is caused by Anaplasma phagocytophilum. Ticks are the main vectors for this zoonotic disease, specifically the Ixodes tick. Like other tick-borne infections, it presents most commonly as a febrile illness. Our patient had several classic manifestations including leukopenia, thrombocytopenia, and elevated transaminases. Pulmonary symptoms are infrequently described aside from some reports of interstitial pneumonia and, rarely, ARDS. Doxycycline is the gold standard treatment for HGA. A few case reports have demonstrated clinical improvement with the addition of steroids when ARDS was present. Our patient saw improvement with the combination of corticosteroids, doxycycline, and ARDS evidencebased practices (i.e. pronation and low tidal volume ventilation). Similar management should be considered in other patients presenting with severe ARDS caused by HGA. Finally, although an atypical season for ticks, this case highlights the importance of a thorough social history and broad differentials, especially in patients presenting with severe illness.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"60 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":"132488680","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":"Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Respiratory Distress Syndrome in COVID-19","authors":"G. I. Judd, R. W. Starcher, D. Hotchkin","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2430","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2430","url":null,"abstract":"Introduction: Wooden chest syndrome (WCS) is a rare and often fatal reaction to fentanyl where airways and chest wall musculature become rigid through α1-noradrenergic activation and cholinergic modulation causing ineffective ventilation.1-4 This dose-independent response is more easily diagnosed in non-ventilated patients either in the operating room or who overdose recreationally.2,4,5 In ventilated patients with acute respiratory distress syndrome (ARDS) it can be difficult to distinguish from poor lung compliance. We describe a case of a previously healthy male with COVID-19 on mechanical ventilation who developed WCS.Case: A 47-year-old previously healthy male was admitted for COVID-19 pneumonia requiring high-flow nasal cannula. On hospital day 11, he was intubated and placed on lung protective ventilation for moderate ARDS (PaO2/FiO2 192). On ventilator day (VD) 2 a fentanyl infusion was started. After 36 hours, hypoxemia improved but plateau pressures were consistently <30 cm H2O necessitating a decrease to 4 cc/kg after minimizing dead space within the ventilator circuit. A trial of airway pressure release ventilation worsened hypercarbia and bronchoscopy did not reveal mucous plugging, airway collapse, or purulent secretions. Worsening lung compliance (PPlat 50 on 4 cc/kg) without change in oxygenation raised suspicion for WCS, so fentanyl was discontinued. Within one hour, plateau pressures nadired at 16 and the ventilator was changed to pressure support. The patient was successfully extubated on VD 10.Discussion: Differentiating low lung compliance in classical ARDS from disproportionately compliant hypoxemia in COVID-19-induced ARDS is an ongoing point of research in the thoracic community.6-9 The novelty of this paradigm allows potential to overlook less common, if not rare, complications such as fentanyl-induced WCS. Our patient's poor compliance despite relatively quick improvement in oxygenation countered available evidence on COVID-19 lung physiology, prompting suspicion for an alternative explanation for his poor ventilation. With descriptions of WCS limited to case reports we found that onset and severity of initial signs (contraction of the chest wall, diaphragm, and abdominal and laryngeal muscles2) can be masked in mechanically ventilated patients. Inadequate ventilation can be interpreted as manifestations of high airway and alveolar pressure making it difficult to differentiate it from classical ARDS and ultimately increasing ventilator use duration. To our knowledge, this is the first report of WCS in a patient with COVID-19 associated ARDS. It demonstrates that when mechanically ventilated COVID-19 patients receiving fentanyl have poor lung compliance and oxygenation improves disproportionately faster than ventilation, WCS should be considered.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"145 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":"114378110","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":"What About the First Public Health Crisis of 2019? EVALI in the Time of COVID","authors":"R. Clarke, T. Saba, H. Flori","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2445","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2445","url":null,"abstract":"Introduction: E-cigarette or Vaping Product Use Associated Lung Injury (EVALI) and Coronavirus Disease 2019 (COVID-19) are both relatively new disease processes which can cause acute respiratory failure. This report describes the case of a 17-year-old male with a history of vaping cannabis during the first wave of the COVID-19 pandemic in Michigan. Report: A previously healthy 17-year-old male presented with cough, shortness of breath, chest pain, fever, and hypoxia requiring 40L high flow nasal cannula (HFNC) and 100% FiO2 to maintain oxyhemoglobin saturations of 88%. He showed no tachypnea or retractions, mimicking the “happy hypoxia” reported in COVID-19 patients. His physical exam demonstrated inspiratory crackles and migratory diminished breath sounds. Chest x-ray showed mild peri-bronchial thickening, subtle right perihilar opacities, and hyperexpansion. Bloodwork showed a procalcitonin of 10 nanograms/milliliter, ESR of 10 millimeters/hour, and CRP of 3.5 milligrams/deciliter. Three prior SARS-CoV2 tests were negative, but given clinical suspicion, the patient was treated as a Patient Under Investigation (PUI) for COVID-19 for 48 hours and re-tested. Care was aligned with institutional COVID-19 guidelines to minimize aerosol-generating procedures;diagnostic bronchoscopy, positive pressure ventilation, and transport for chest CT were discouraged, especially as our patient was awake, interactive, and with gradually improving trajectory. Infection prevention guidelines prohibited our patient's parents from leaving his room for a private interview, but friends alerted them to a history of vaping cannabis, which our patient corroborated. He was transitioned towards supportive care for EVALIinduced bronchoconstriction and improved with beta agonists, systemic steroids, and HFNC. After his fourth negative SARS CoV2 test, the patient underwent a high-resolution chest CT, which showed diffuse ground-glass opacities with subpleural sparing. He was discharged after four days with Pediatric Pulmonology follow up. He was counseled against further e-cigarette or cigarette use. Discussion: This case illustrates challenges in the diagnosis of EVALI during the COVID-19 pandemic, particularly among adolescents. Both conditions present with acute respiratory failure absent another source. Both can have significant hypoxia, elevated inflammatory markers, and an ARDS phenotype. Both demonstrate ground-glass opacities on CT scan. Importantly, here are differences in the workup, management, and public health implications of EVALI and COVID-19. Both are reportable to the Department of Public Health and warrant intervention: Anti-vaping campaigns and restriction on access for EVALI, infection control and immunization programs for COVID-19. As the world endeavors to contain the COVID-19 pandemic through surveillance, treatment, and immunization, we also hope to regain momentum against EVALI.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"173 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":"121782850","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":"ST-Elevation Myocardial Infarction in COVID-19: Redefining Anticoagulation Guidelines - Is Full Dose Anticoagulation Indicated in High Risk Patients to Prevent Thrombotic Coronary Artery Disease?","authors":"G. Sidhu, J. Kizhakkepat, K. Padmanabhan","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2476","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2476","url":null,"abstract":"Introduction - Coronavirus disease 2019 (COVID 19) has direct and indirect effects on cardiovascular system which may be due to myocardial injury from hemodynamic derangement or hypoxemia, inflammatory myocarditis, stress cardiomyopathy, microvascular dysfunction /thrombosis due to hypercoagulability, or cytokine storm causing destabilization of coronary artery plaques. The vascular impact will be greater in patients who have preexisting CAD. Here, we report a patient with COVID 19 disease with significant coronary artery disease (CAD) who developed acute STEMI in spite of prophylactic dose anticoagulation. Case Description - A 67 year old male with significant CAD s/p CABG X 5 and PCI with 18 stents, DM II, HTN presented with dyspnea, fever and non productive cough. He tested positive for Covid19 and found to have bilateral infiltrates on chest X ray and elevated inflammatory markers. Patient was hypoxic requiring 80 % High-flow nasal oxygen supplementation. His D dimer levels on admission was normal around 250 and his serial D dimer were in range of 250-310, with no evidence of venous thromboembolism on ultrasound of lower extremities. He was started on prophylactic anticoagulation with enoxaparin. On Day 9, patient was found to have apical and anterior STEMI. Cardiac catheterization demonstrated significant thrombus burden with occluded left internal mammary artery to left anterior descending, occluded sephanous vein graft, occluded left anterior descending artery, occluded right coronary artery and left main with 90% occlusion. Percutaneous coronary intervention was deemed futile and not attempted in presence of mixed, refractory shock and profound respiratory failure. Patient died shortly thereafter. Discussion - Our patient developed severe acute coronary artery thrombosis in spite of prophylactic enoxaparin. The American Society of Hematology and CHEST guidelines suggests using prophylactic-intensity over intermediate or therapeutic anticoagulation in patients with COVID19 who do not have suspected or confirmed venous thromboembolism (VTE). Our case highlights the fact that in COVID 19 affected patients with significant CAD, therapeutic anticoagulation should be seriously considered in spite of absence of randomized evidence and a normal D dimer doesn't necessarily preclude this risk.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"16 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":"121938289","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":"EVALI Masquerading as COVID-19: A Case Report","authors":"C. Seneviratne, P. Tewari, N. Hernandez, B. Koltz, F. Safi","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2437","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2437","url":null,"abstract":"Introduction: The CDC first defined e-cigarette or vaping product use-associated lung injury (EVALI) as the presence of pulmonary infiltrates on plain film chest radiograph or ground glass opacities on chest CT in September 2019. However since the COVID-19 pandemic, the same radiological appearance have become synonymous with COVID-19 pneumonia. We present a case of a patient who was mistakenly presumed to have COVID-19 and was later found to be a case of EVALI. Case Presentation: 33 year old obese Caucasian male with 15 pack year smoking history and no past medical history presented with one month of worsening exertional dyspnea associated with cough, sore throat, subjective chills, and diaphoresis. He was admitted to the COVID-19 unit due to hypoxemia requiring 3 L/min of oxygen and chest CT scan with contrast showing bilateral ground glass opacities with mosaic attenuation. COVID-19 reverse transcriptase RNA PCR test was negative twice. Labs showed leukocytosis of 12,700 with 74.4% neutrophils and 15.7% lymphocytes, normal procalcitonin of 0.09 ng/mL, and normal BNP of 83 pg/mL. Pulmonary was consulted and after detailed history was obtained, the patient reported vaping nicotine three weeks prior to admission. Respiratory viral panel, including influenza A and B, urine legionella and pneumococcal antigens were all negative. He underwent inpatient flexible fiberoptic bronchoscopy with right upper lobe bronchoalveolar lavage (BAL) and right upper lobe transbronchial biopsy. BAL cell count showed 89% alveolar macrophages including numerous lipid laden macrophages and 6% eosinophils with transbronchial biopsy showing benign respiratory epithelium with unremarkable alveolated lung parenchyma. Diagnosis of EVALI was made, and patient clinically improved after starting on prednisone. He was discharged on steroid taper and will be followed in the pulmonary clinic with repeat CT imaging to check for resolution. Discussion: With the emergence of COVID-19 pandemic there is a bias in diagnosing all ground glass opacities on CT chest in the setting of hypoxemia as COVID-19 pneumonia. However, as per CDC guidelines, our patient met the criteria for EVALI with recent history of vaping within 90 days, typical radiological findings, and infectious causes ruled out. This diagnosis was made more robust by the findings of lipid laden macrophages on BAL. Our case emphasizes the importance of preventing anchoring bias during this COVID-19 pandemic by taking time to obtain a more thorough history and including other causes of lung injury, such as, EVALI in our differential diagnoses.","PeriodicalId":181364,"journal":{"name":"TP47. TP047 COVID AND ARDS CASE REPORTS","volume":"4 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":"124955067","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}