Asymptomatic Presentation Research Articles

Clinical Presentation in Children With Coeliac Disease in Central Europe

During the past decades, there has been a shift in the clinical presentation of coeliac disease (CD) to nonclassical, oligosymptomatic, and asymptomatic forms. We assessed clinical presentation of CD in children and adolescents in Central Europe. Paediatric gastroenterologists in 5 countries retrospectively reported data of their patients diagnosed with CD. Clinical presentation was analyzed and the differences among very young (<3 years) and older children and adolescents were studied. Data from 653 children and adolescents (median age 7 years 2 months; 63.9% girls) from Croatia, Germany, Hungary, Italy, and Slovenia were available for the analysis. One fifth (N = 134) of all children were asymptomatic. In symptomatic children, the most common leading symptom was abdominal pain (33.3%), followed by growth retardation (13.7%) and diarrhoea (13.3%). The majority of symptomatic children (47.6%; N = 247) were polysymptomatic. Abdominal pain was the most common symptom in polysymptomatic (66.4%) as well as in monosymptomatic children (29.7%). Comparing clinical presentation of CD in very young children (younger than 3 years) with older children (3 years or older), we found that symptoms and signs of malabsorption were significantly more common in younger (P < 0.001), whereas abdominal pain and asymptomatic presentation were more common in older children and adolescents (both P < 0.001). In children with CD, abdominal pain has become the most common symptom. However, in younger children, symptoms of malabsorption are still seen frequently. This raises a question about the underlying mechanism of observed change in clinical presentation in favour of nonclassical presentation and asymptomatic disease at certain age.

Outcomes after transfemoral carotid artery stenting stratified by preprocedural symptom status

ObjectiveThe available data on outcomes after transfemoral carotid artery stenting (TFCAS) originate from the early experience with TFCAS. Although most previous studies stratified outcomes according to a symptomatic or asymptomatic presentation, they often did not specify the degree of presenting neurologic injury. We previously reported that the outcomes after carotid endarterectomy differed according to neurologic injury severity, the contemporary perioperative outcomes of TFCAS stratified by the specific presenting symptom status are unknown. MethodsPatients with data in the Vascular Quality Initiative database who had undergone TFCAS from 2016 to 2020 were included. We stratified patients according to their preprocedural symptom status as asymptomatic, formerly symptomatic (last symptoms >180 days before the procedure), or recently symptomatic (symptoms <180 days before the procedure). The symptoms included stroke, hemispheric transient ischemic attack (TIA), and ocular TIA. We compared the occurrence of in-hospital stroke or death (stroke/death) among the asymptomatic, formerly symptomatic, and specific subtypes of recently symptomatic patients. Multivariable logistic regression models were constructed to adjust for the baseline differences among the groups. ResultsOf the 9807 included patients, 2650 (27%) had had recent stroke, 842 (9%), recent hemispheric TIA, and 360 (4%), recent ocular TIA. In addition, 795 patients (8%) were formerly symptomatic and 5160 (53%) were asymptomatic. The patients with recent stroke had a perioperative stroke/death rate of 5.5%, higher than that of patients with recent hemispheric TIA (2.4%; P < .001) or recent ocular TIA (2.8%; P = .03) and asymptomatic patients (1.4%; P < .001). The stroke/death rate was greater for patients with recent ocular TIA than for asymptomatic patients (2.8% vs 1.4%; P = .04). Formerly symptomatic patients had higher stroke/death rates compared with asymptomatic patients (3.5% vs 1.4%; P < .001). On multivariable-adjusted analysis, recent stroke was associated with higher stroke/death compared with recent hemispheric TIA (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.6-4.3; P < .001) and asymptomatic status (OR, 4.1; 95% CI, 3.0-5.6; P < .001) and demonstrated a trend toward higher stroke/death compared with recent ocular TIA (OR, 2.0; 95% CI, 1.0-3.9; P = .06). Furthermore, asymptomatic status was associated with lower stroke/death compared with formerly symptomatic status (OR, 0.4; 95% CI, 0.2-0.6; P < .001). ConclusionsFor patients undergoing TFCAS, recent stroke was associated with greater odds of in-hospital stroke/death after TFCAS compared with recent hemispheric TIA. Also, formerly symptomatic status was associated with greater odds of stroke/death compared with asymptomatic status. These findings support further symptom stratification by the degree of the presenting neurologic injury in the preoperative risk assessment.

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

English

English

Female Adnexal Tumour of Wolffian Origin Masquerading as a Broad Ligament Fibroid: A Rare Case Report

Female adnexal tumour of Wolffian origin (FATWO), a rare neoplasm arising from the female adnexa, is typically benign in nature, although recurrences and metastasis have been reported infrequently. First identified and reported in the early 1970s, less than 100 cases have been reported thus far. We present a case of a 16-year-old girl with a left adnexal tumour of Wolffian origin who presented with excessive bleeding during mensuration. With no overt clinical signs, ultrasound revealed a left ovarian neoplasm which was confirmed by CT scan as a solid enhancing lesion in the left adnexa measuring 6.2 x 5 x 4.5 cm. A broad ligament mass was excised, and cytology of peritoneal fluid wash revealed no malignancy. Histomorphological examination and immunohistochemistry confirmed the diagnosis of FATWO. The postoperative course was uneventful; however, the patient was lost to follow-up. Due to the rarity of occurrence, asymptomatic presentation, its variable location, and its morphological diversity, the diagnosis of FATWO may present a challenge especially when the tumour arises in an ovarian location.

Serological follow-up of SARS-CoV-2 asymptomatic subjects

SARS-CoV-2 symptoms are non-specific and can range from asymptomatic presentation to severe pneumonia. Asymptomatic subjects carrying SARS-CoV-2 often remain undiagnosed and it is still debated whether they develop immunoglobulins (Ig) and how long they persist. The aim of this study was to investigate the development and persistence of antibodies against SARS-CoV-2 in asymptomatic subjects infected by the virus. This follow-up study was performed on the 31 asymptomatic subjects who presented a positive nasal swab or serology against SARS-CoV-2 (Ig against Spike-RBD) in the first part of the UNICORN study (March 2020) aimed at attesting previous or current contacts with the virus in the personnel of the University of Milan. Eight weeks after the first Ig measure, these subjects were invited to donate a second blood sample for testing serum antibodies (IgM, IgG and total antibodies) and to fill-in a structured questionnaire. About 80% of asymptomatic subjects did not present circulating immunoglobulins against SARS-CoV-2 after 8 weeks from a positive nasal swab against the virus. Moreover, in more than 40% of these subjects, no Ig against SARS-CoV-2 were detected at any time. Finally, about two third of subjects with immunoglobulins at baseline did not present IgG against SARS-CoV-2 after 8 weeks. The majority of subjects who developed an asymptomatic SARS-CoV-2 infection do not present antibodies against the RBD-spike protein after 8 weeks of follow-up. These data should be taken into account for the interpretation of the serological evidences on SARS-CoV-2 that are emerging nowadays.

Leiomyosarcoma of Urinary Bladder, A Review of Two Cases

Abstract Introduction/Objective Leiomyosarcomas of the urinary bladder are rare smooth muscle tumor, and constitute 1% of all bladder malignancies. Although rare, leiomyosarcoma is a clinically significant disease, presenting as a high-grade advanced malignancy with associated substantial morbidity and mortality, if not treated early. The diagnosis can be delayed because of the asymptomatic presentation until the tumor reaches an advanced stage. Methods We present two cases of leiomyosarcoma of the urinary bladder. First case: a 63 years old female with a history of cervical carcinoma treated with radiation, 25 years ago, followed by uncomplicated clinical course, until recent development of vesicovaginal fistula. During her work up with cystoscopy, a large bladder mass was identified. Second case: a 71 years old female with a history of treated breast cancer, who presented with recurrent history of cystitis and hematuria. Cystoscopy revealed a nodular mass in the right posterior bladder wall. Results Microscopically, both lesions were highly cellular with infiltrative, interlacing fascicles of spindle cells and associated mitosis, cellular atypia and necrosis. Immunohistochemistry revealed positive expression of muscle- specific actin, desmin, and caldesmon; with negative expression of ALK-1, EMA, Cytokeratins and GATA3, in both the cases. Other spindle cell lesions including, leiomyoma, inflammatory myofibroblastic tumor and sarcomatoid carcinoma were included in the differential diagnosis, and ruled out by morphology and immunohistochemistry. Conclusion Our cases highlight the importance of awareness of the occurrence of leiomyosarcomas, a rare manifestation in bladder. Although rare, but they present with a poor outcome. The differential diagnosis of spindle cell lesions is extensive, including close benign and malignant mimics, the treatment of all being very different. Immediate radical cystectomy has been associated with longer survival rates for leiomyosarcoma. Leiomyosarcoma, being aggressive, with associated high recurrence rate and metastatic potential, an early correct diagnosis would aid in the institution of proper management.

Neonatal and Children's Immune System and COVID-19: Biased Immune Tolerance versus Resistance Strategy.

The recent outbreak of COVID-19 has emerged as a major global health concern. Although susceptible to infection, recent evidence indicates mostly asymptomatic or mild presentation of the disease in infants, children, and adolescents. Similar observations were made for acute respiratory infections caused by other coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). These observations suggest that the immune system behaves differently in children than adults. Recent developments in the field demonstrated fundamental differences in the neonatal immune system as compared with adults, whereby infants respond to microorganisms through biased immune tolerance rather than resistance strategies. Similarly, more frequent/recent vaccinations in children and younger populations may result in trained immunity. Therefore, the physiological abundance of certain immunosuppressive cells, a tightly regulated immune system, and/or exposure to attenuated vaccines may enhance trained immunity to limit excessive immune reaction to COVID-19 in the young.

Incidence of major adverse cardiac events following non-cardiac surgery.

Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood. We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months. One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery. https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

Immunocompromised Seroprevalence and Course of Illness of SARS-CoV-2 in One Pediatric Quaternary Care Center.

BackgroundThe burden of coronavirus disease 2019 (COVID-19) is poorly understood in pediatric patients due to frequent asymptomatic and mild presentations. Additionally, the disease prevalence in pediatric immunocompromised patients remains unknown.MethodsThis cross-sectional study tested convenience samples from pediatric patients who had clinically indicated lab work collected and an immunocompromising condition, including oncologic diagnoses, solid organ transplant (SOT), bone marrow transplant, primary immunodeficiency, and rheumatologic conditions or inflammatory bowel disease on systemic immunosuppression, for the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).ResultsWe tested sera from 485 children and observed SARS-CoV-2 seroprevalence of 1.0% (Confidence Interval [CI] 95%: 0.3%–2.4%). Two patients were positive by nasopharyngeal (NP) swab Reverse transcriptase polymerase chain reaction (RT-PCR), but only 1 seroconverted. Patients with oncologic diagnoses or SOT were most likely to be tested for COVID-19 when presenting with respiratory illness as compared with other groups. ConclusionsSeroprevalence of antibodies to SARS-CoV-2 in immunocompromised children was similar to that of an immunocompetent pediatric population (0.6%, CI 95%: 0.3%–1.1%), suggesting an adequate antibody response. However, none of the patients who tested positive for antibodies or via NP RT-PCR had more than a mild illness course and 2 patients did not have any reported illness, suggesting that SARS-CoV-2 may not cause a worse clinical outcome in immunosuppressed children, in contrast to immunocompromised adults.

Prevalence of Odontogenic Tumours in a Dental Hospital in Southern India

Odontogenic Tumours (OTs) pose as a heterogenous group of lesions exhibiting diverse clinical behaviourand histopathological types which can range from hamartomatous lesions to malignancies. Although a largenumber of studies have been done to record the epidemiology of odontogenic tumours, there is a paucityof information where its prevalence is concerned in South Indian cities. Thus, the aim of our study is tohighlight the prevalence of various types of odontogenic tumours in a predominantly South Indian hospitalset up so as to improve clinical understanding and handling of patients with said tumours. A retrospectivecross-sectional study was conducted after reviewing and analysing the data from patient records over the lastfive years. Patients with histopathologically established odontogenic tumours were selected without any agerestriction. The data was collected and descriptive statistics were performed. The findings of our study hintedat a benign odontogenic prevalence with a male predilection (68.6%). The posterior region of the mandiblewas the most commonly involved site (60%) and ameloblastomas followed by odontomas and adenomatoidodontogenic tumours were the most prevalent odontogenic tumours in our hospital set up. An asymptomatictrend with multilocular radiolucencies was evidently observed. Through the results of our study, we hopeto elucidate the prevalence of odontogenic tumours in the South Indian population. In essence our findingssuggest a male predilection in the posterior region of the mandible and that Ameloblastomas and Odontomasare the most common odontogenic tumours. Due to the large number of asymptomatic presentations, properdiagnosis and management is key. Thus, further studies need to be done to overcome the limitations of ourstudy and to confirm our findings.

Alerta epidemiológica para enfrentar el COVID 19: revisión de un caso en la comunidad de Sanbuenaventura – Latacunga

Introducción: Actualmente la humanidad está enfrentando una enfermedad joven denominada COVID 19, la salud mundial está amenazada por el contagio y la muerte, su forma de presentación asintomática es una condición agravante, poniendo de relieve la necesidad de aunar las fuerzas en la ciencia, investigación y la epidemiología.&#x0D; Objetivo: Describir un caso clínico de una paciente de 31 años de edad, enfermera de profesión, a fin de actualizar conocimientos sobre Covid 19&#x0D; Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico relacionado con el Covid 19.&#x0D; Resultados: Se realiza visita domiciliaria al paciente por ser contacto en su lugar de trabajo de un paciente diagnosticado con la COVID 19, se le realizó la prueba de Reacción en Cadena de Polimerasa en tiempo real (RT - PCR) resultando positivo. Presentando por dos días un cuadro clínico inicial caracterizado por cefalea y fiebre (38,7O C), sin otros síntomas.&#x0D; Conclusiones: Los hallazgos microbiológicos permitieron confirmar el diagnóstico de COVID 19, cuyos resultados sirvieron de alerta, para realizar acciones epidemiológicas efectivas y contener la transmisión de la enfermedad en la comunidad.

Corrigendum to “Asymptomatic presentation of a congenital malformation of the portal vein with portosystemic shunt” [Radiol Case Rep 15 (2020) 2009-2014

[This corrects the article DOI: 10.1016/j.radcr.2020.07.076.].

Frequency of Symptoms and Asymptomatic SARS-CoV-2 Infection in Louisiana, USA

Background: While many surveillance studies of seroprevalence to SARS-CoV-2 rely on remnant blood samples obtained as medical waste, representative, prospective collection allows for analysis of a representative cross-section of symptomatic and asymptomatic presentation of infection in the community. Louisiana, and particularly New Orleans, were hard-hit in the early phase of the pandemic, and an ongoing outbreak was occurring in Baton Rouge throughout July.Methods: A representative, cross-sectional sample of subjects from two cities in Louisiana were sent to testing sites to complete a verbal consent, survey, nasopharyngeal swab, and blood draw. Swabs were tested for active viral shedding (PCR) and blood was tested for immunoglobulin G (IgG) specific to SARS-CoV-2.Findings: Anosmia was extremely predictive for a positive test (40·6% of those with anosmia tested positive, OR: 13·6; CI 10·1, 18·3) and 47·3% of the sample experienced no symptoms at all. A lower quantity of virus was noted during the contagious phase of infection in asymptomatic compared to symptomatic individuals. Symptom presentation clustered into three groups; low/no symptoms (0·4±0·9 symptoms on average), highly symptomatic (7·5±1·9) or moderately symptomatic (4·0±1·5). The probability of reporting symptoms changed with age; those under age 60 had a >50% probability of reporting symptoms while those 60 years and older had Interpretation: Anosmia should be used as a screening criterion to differentiate from other illnesses, and, given the high ratio of asymptomatic individuals, mask mandates should be enforced. Asymptomatic individuals should be tested with cause.Funding: This study was funded by ReNOLA, Ochsner Health, the Baton Rouge Area Foundation, Louisiana COVID-19 Health Equity Task Force, and The Humana Foundation, the Blue Cross and Blue Shield of Louisiana Foundation, Healthy Blue, the Huey and Angelina Wilson Foundation, and the Irene W. and C.B. Pennington Foundation.Declaration of Interests: The authors have no other conflicts of interest to report.Ethics Approval Statement: This study was approved by the Ochsner Clinic Foundation Institutional Review Board #2020·163.

SARCOID-LIKE REACTION TO IMMUNOTHERAPY MIMICS PROGRESSIVE MALIGNANCY ON IMAGING

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Recurrence or progression of thoracic malignancies can often be mimicked by numerous processes discovered on imaging including infection and inflammation. There is increasing evidence that immunotherapy can be associated with a sarcoid-like reaction causing enlarged, PET-avid lymph nodes that can resemble recurrence or progression of malignancy.1,2 We present a case in which progression of mesothelioma was suspected based on surveillance imaging, however, pathology was consistent with a sarcoid-like reaction in the setting of recent immunotherapy. CASE PRESENTATION: A 75-year-old female former smoker with a history of asbestos exposure subsequently diagnosed with epithelioid mesothelioma presents for evaluation of recurrence of her mesothelioma. She was initially diagnosed in 2018 when she presented with cough, pleuritic chest pain, weight loss and a pleural effusion. Diagnosis was made by thoracentesis and CT-guided biopsy of a left lower lobe nodule. Her initial stage was T2N0. She was treated with neoadjuvant Atezolizumab, Pemetrexed Disodium, Cisplatin followed by surgery (left pleurectomy, decortication, mediastinal lymph node dissection, and wedge resections for peripheral pleural nodules) and postoperative adjuvant Atezolizumab. Six months later, PET CT showed enlarged hypermetabolic mediastinal lymph nodes, a perifissural nodule, enlarging pleural nodules, and increased pleural thickening, suspicious for disease progression. The patient was asymptomatic and evaluated with bronchoscopy and endobronchial ultrasound with transbronchial needle aspiration of multiple mediastinal lymph nodes. Pathology revealed granulomatous inflammation. Given her asymptomatic presentation, enlarged and PET avid mediastinal lymphadenopathy and recent immunotherapy exposure, she was diagnosed with a sarcoid-like reaction as a cause for her mediastinal lymphadenopathy. Adenopathy later resolved after withdrawal of immunotherapy. DISCUSSION: We present a case in which a sarcoid-like reaction to immunotherapy mimics metastatic progression of mesothelioma. In this case, tissue biopsy indicated a lower disease stage compared to imaging and allowed for local rather than systemic treatment options. CONCLUSIONS: Recognition of sarcoid-like reactions is important during surveillance and restaging of malignancy in patients undergoing treatment with immunotherapy. This case illustrates the importance of direct tissue sampling in diagnosing mimickers of thoracic malignancies. Reference #1: Nishino M, Sholl LM, Awad MM, Hatabu H, Armand P, Hodi FS. Sarcoid-Like Granulomatosis of the Lung Related to Immune-Checkpoint Inhibitors: Distinct Clinical and Imaging Features of a Unique Immune-Related Adverse Event. Cancer Immunol Res. 2018;6(6):630-635. Reference #2: Tetzlaff MT, Nelson KC, Diab A, et al. Granulomatous/sarcoid-like lesions associated with checkpoint inhibitors: a marker of therapy response in a subset of melanoma patients. J Immunother Cancer. 2018;6(1):14. DISCLOSURES: stockholder relationship with Merck Please note: $20001 - $100000 Added 03/09/2020 by Adam Fox, source=Web Response, value=Ownership interest stockholder relationship with MMM Please note: $20001 - $100000 Added 03/09/2020 by Adam Fox, source=Web Response, value=Ownership interest No relevant relationships by Courtney Linkous, source=Web Response No relevant relationships by Gerard Silvestri, source=Web Response

S3574 Duodenal Diverticula: An Unusual Cause of Dyspepsia

INTRODUCTION: Duodenal diverticula are a rare entity. They frequently remain undiagnosed owing to their asymptomatic presentation. Here we report a case of a middle-aged female who presented to us with episodic abdominal pain and her endoscopy revealed multiple diverticula in the duodenum. CASE DESCRIPTION/METHODS: A 45-year-old woman presented to the clinic with complaints of 3 months history of episodic upper abdominal discomfort and vomiting. These episodes were worsened after a heavy meal and sometimes when she lies down immediately after a meal. She denies any heartburn. Her appetite had decreased during the past 3 months and she reported a 3 kg weight loss during this period. Her examination was normal. Initial laboratory investigations (including amylase and lipase levels) were normal. Her stool for H. Pylori was negative. An endoscopy was performed which showed hyperemic mucosa in the gastric antrum and multiple duodenal diverticula (Figure 1). Biopsy from the antrum and diverticula showed non-specific inflammation. She was started on high dose proton pump inhibitors, prokinetics, and was advised to take multiple small meals instead of two large meals. She was advised to get regular followup as well. DISCUSSION: Duodenal diverticula can be classified as extramural or intramural with the latter commonly attributed to a developmental abnormality. They are mostly asymptomatic but can present with abdominal discomfort, nausea, and bloating. The complications, although rare, can include perforation, diverticulitis, and other pathologies arising due to mechanical compression. The diagnosis can be made on endoscopy and barium studies, with most of them discovered as incidental findings. Treatment is mainly conservative. Surgery is reserved for complications and symptoms refractory to medical treatment.Figure 1.: Endoscopy showing multiple diverticula in the duodenum.

Intraperitoneal rupture of liver hydatid cyst, a Post sleeve gastrectomy unusual presentation: a case report

Background The asymptomatic clinical presentation of hydatid cysts is the usual picture of presentations, and the cysts are incidentally discovered during radiological examination for other reasons. However, some patients develop symptoms and complications depending on cyst size, location, and the relationships between the cysts and the neighboring structures. Most dangerous complications consist of perforation of the cysts into the adjacent structures like a biliary tree, major vessels, hollow viscera, and peritoneal cavity. Herein, we aimed in this case report to describe the laparoscopic assessment and treatment of a case with an unusual presentation of intraperitoneal rupture of hepatic hydatid cyst after weight loss (post-sleeve gastrectomy) accompanied with review article. Case summary A female patient aged 44 was presented to our hospital with abdominal pain, diarrhea, and hypotension. The perforated cyst was located in the liver. Cyst rupture developed spontaneously. Enzyme-linked immunosorbent assay IgG result was negative. The patient received urgent resuscitation immediately and albendazole treatment was started 2 days before laparoscopic surgical intervention. No recurrence during postoperative follow-up (4 months). Conclusion Intraperitoneal perforation is a rare and severe life-threatening complication of hydatid cysts that can happen after significant weight loss. It is very crucial to treat the patients with appropriate emergent surgical management (including laparoscopy) as rapidly as possible after judicious medical treatment for allergic reactions.

SILENT TYPE A AORTIC DISSECTION DUE TO SUSPECTED AORTIC AMYLOID

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Stanford type A dissection of the proximal aorta is considered a surgical emergency due to high early mortality (1). The weakening of the aortic wall along with elevated shear stress may predispose to an aortic dissection. Concurrently, systemic amyloidosis tends to deposit in the vasa-vasorum, which leads to the frailty of the aortic vascular layers. Here we present an unusual case in which an asymptomatic type A aortic dissection was diagnosed due to suspected aortic amyloidosis. CASE PRESENTATION: A 73 year old woman with a history of uncontrolled hypertension (HTN) and diabetes mellitus presented for elective cardiac magnetic resonance imaging (MRI) due to suspected cardiac amyloidosis after testing positive for hereditary ATTR amyloid gene mutation. Her family history was significant for amyloid cardiomyopathy in two siblings. She had no exertional symptoms, and physical exam was only notable for a soft systolic ejection murmur at the left sternal border. Her electrocardiogram showed normal sinus rhythm with normal intervals. MRI unexpectedly noted a type A aortic dissection arising at the level of the sinotubular junction extending up the ascending aorta and down to the level of the iliac bifurcation with no evidence of myocardial amyloid deposition. She remained clinically asymptomatic but was transferred to the cardiac intensive care unit for initiation of intravenous antihypertensive therapy. Cardiac surgery was consulted and performed an urgent ascending hemi-arch replacement. Aortic tissue pathology was negative for amyloid protein. Subsequent outpatient follow-up showed stable aortic repair with chronic type B aortic dissection, and she continued to remain asymptomatic. DISCUSSION: It has been observed that 6.4% of aortic dissections are clinically subtle in presentation resulting in an increased mortality (2). Although MRI & pathologic analysis did not demonstrate amyloidosis, microvascular intramural amyloid deposition in the aorta remains possible. In this case, chronic uncontrolled HTN with age related degeneration of the aortic wall were likely the primary underlying factors. CONCLUSIONS: This case illustrates an unusual clinically silent presentation of a catastrophic illness. Although the management of silent Type A dissection typically require early surgical intervention, to improve survival, late asymptomatic presentations have been observed (3) Reference #1: Mehta RH, Suzuki T, Hagan PG, Bossone E, Gilon D, Llovet A, et al. Predicting Death in Patients With Acute Type A Aortic Dissection. Circulation. 2002 Jan 15;105(2):200–6. Reference #2: Park SW, Hutchison S, Mehta RH, Isselbacher EM, Cooper JV, Fang J, et al. Association of Painless Acute Aortic Dissection With Increased Mortality. Mayo Clin Proc. 2004 Oct 1;79(10):1252–7. Reference #3: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014 Nov 1;35(41):2873–926. DISCLOSURES: No relevant relationships by Benjamin Kenigsberg, source=Web Response Removed 06/24/2020 by Benjamin Kenigsberg, source=Web Response No relevant relationships by Omar Yacob, source=Web Response

Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center

Background: Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs through the development of institutional guidelines and real-time prospective audit and feedback (PAAF) on provider management may have a significant impact on the overuse of antimicrobials. Objective: Our study evaluated the effectiveness of a UTI focused disease state stewardship intervention by assessing institutional guideline adherence before and after implementation. Methods: This retrospective quasi-experimental study was conducted at a tertiary-care academic medical center. Patients &gt;18 years of age receiving antimicrobials for a UTI were included. A previously performed retrospective review of UTI management from September-November 2017 was used as the baseline. The UTI management guideline was implemented in July 2018, and service lines were educated. A PAAF initiative began in June 2019, whereby the antimicrobial stewardship team performed daily reviews of patients receiving antimicrobials for UTIs. Data was collected on their management, and providers were contacted in real time with recommendations based on the institutional guideline. Patients reviewed June–October 2019 were included in the postimplementation analysis. Patients were excluded if they were pregnant, underwent a urological procedure with risk of mucosal bleeding, or were an outside hospital transfer already on UTI therapy. The primary outcome of this study was to evaluate guideline adherence before and after the implementation of PAAF for the management of UTIs. Results: In total, 198 patients in the preintervention group and 246 in the PAAF group were included. The emergency department was the primary ordering service of urinalyses (60.1% vs 66.1%; P = .2287) in both periods and altered mental status as the main indication for testing (35.2% vs 31.3%; P = .5465). Treatment of asymptomatic bacteriuria and pyuria decreased significantly between the 2 periods: 74.8% versus 36.2% (P = .0001). Appropriate ordering of urinalyses (33.8% vs 68.3%; P = .0001) and urine cultures (29.3% vs 61.0%; P = .0001) also improved in the PAAF group. Recommendations made during PAAF included therapy discontinuation (66.7%), antimicrobial therapy change (15.5%), or duration modification (15.5%), and 59.5% of first interventions were accepted. Overall guideline compliance significantly improved from 13.1% in the preintervention period to 26.1% in the PAAF period (P = .0011). Conclusions: A UTI disease state intervention was associated with significant reductions in the treatment of asymptomatic presentations as well as an improvement in overall guideline adherence. We believe that this approach represents a powerful stewardship strategy for decreasing unnecessary antimicrobial usage.Funding: NoneDisclosures: None

A Fatal Case of Suicide Fruit Ingestion in Singapore by Cerbera Cardiac Glycoside Intoxication: Case Report and Review of Literature

Case Presentation: We present a case of Cerbera fruit ingestion which highlight the knowledge gap in unusual glycoside poisoning. Despite the patient’s asymptomatic presentation, life threatening clinical features such as hyperkalaemia, hypotension and arrhythmia occurred later. Treatments instituted were activated charcoal (AC), atropine, hyperkalaemia management, Digoxin Fab and intravenous lipid emulsion (ILE). Advanced Cardiac Life Support (ACLS) was instituted with automated chest compression device. The patient died despite prolonged of resuscitation effort. Cerbera glycoside toxicity warrants serious consideration in view of rare presentation and unpredictable nature of toxicology. Discussion: We highlight the prevalence of Cerbera species in Asia-Pacific and present the similarities of cardiac glycosides pharmacology. Early recognition of ingestion and cardiac monitoring are particularly important. In this case, we highlight the diagnostic and prognostic challenge as patient deteriorated despite normal serum digoxin level. As the evidence of Cerbera glycoside poisoning treatment options is lacking, we take this opportunity to examine treatment options assuming similar pharmacology among cardiac glycoside family. We argue for a case for use of Digoxin Fab which is the prevailing treatment for glycoside poisoning. Multi-dose-activated charcoal (MDAC) and ILE are postulated to have physiological basis given current evidence. Electrical and pharmacology treatment for arrhythmia were explored as there is limited evidence. We propose ECMO should always be considered for cardiac toxicity in anticipation of treatment failure as the novel therapy has shown great promise. Conclusion: Cerbera glycoside poisoning should be treated with utmost caution as the fruit is easily accessible and highly toxic. Close cardiac monitoring is a must due to high mortality risk. Digoxin Fab should be instituted as guided by toxicologist. Patients should be transferred to ECMO centre for observation in all cases due to the unpredictable nature of toxin. Further investigation of treatment is awaited.