Days Of Chilling Research Articles

Mitigating quality deterioration in chilled pork by combining cinnamaldehyde nanoemulsions and a high-voltage electrostatic field

Cinnamaldehyde nanoemulsion (CNE) was obtained through ultrasonication, using Tween 80 as an emulsifier. The CNE was then applied to chilled pork in conjunction with a high-voltage electrostatic field (HVEF) to mitigate quality deterioration during refrigerated storage. The particle size of CNE ranged from 60 to 150 nm and was positively correlated with the amount of added cinnamaldehyde. The polydispersity index and zeta potential of CNE ranged from 0.25 to 0.30 and − 12 to −11 mV, respectively, indicating a narrow size distribution and stability. The CNE released the odor specific to cinnamaldehyde to pork in the first 4 days of chilling; however, it had little effect on the taste. HVEF pretreatment reduced the initial total viable count (TVC) in pork by 1.14 log cycle. The combination of CNE with HVEF successfully slowed down the loss of moisture, decrease in pH, and accumulation of total volatile basic nitrogen in pork during refrigeration. Furthermore, it mitigated the increase in TVC of pork. Therefore, this integrated method appears to be suitable for extending the shelf life of chilled pork.

Abstract 16036: Concomitant Culture-Negative Left-Sided Native Valve Endocarditis With Splenic Emboli and Babesiosis: A Case Report

Description of Case: A 76-year-old man with type 2 diabetes and a previously drained hepatic abscess presented with 3 days of fevers and chills associated with dizziness, weakness, and fatigue after hiking at a New York State Park. He denied any shortness of breath, chest pain, abdominal pain, diarrhea, skin rashes, insect bites, IV drug use, recent travel or sick contacts but reported having dental work one month prior to admission. Initial vital signs were notable for a fever of 38.4°C with a blood pressure of 145/76, heart rate of 90, and physical examination was unremarkable. Extensive laboratory studies were drawn, which initially were notable for normocytic anemia, thrombocytopenia, low haptoglobin and elevated lactate dehydrogenase. Empiric antibiotics were initiated as the patient met criteria for systemic inflammatory response syndrome (SIRS). CT abdomen and pelvis was remarkable for right-sided spleen with polysplenia and multiple peripheral wedge-shaped splenic infarcts. A transthoracic echocardiogram (TTE) was inconclusive for infective endocarditis (IE). A subsequent transesophageal echocardiogram (TEE) showed vegetations on the aortic and mitral valves with mild regurgitation respectively. After cardiothoracic surgery evaluation, he was deemed not a surgical candidate. Blood and urine cultures remained negative, but the Babesia antibodies IgM and IgG antibodies, and Babesia microti PCR was detected. He was started on atovaquone 750 mg twice daily and azithromycin 250 mg once daily for 10 days for babesiosis. He was discharged on vancomycin 1g every 12 hours and ceftriaxone 2g every 24 hours for a total of 6 weeks for empiric IE treatment given splenic emboli. Discussion : We describe a rare case of fever caused by culture-negative mitral and aortic valvular endocarditis with splenic emboli and babesiosis. Recent dental work and hiking outdoors in the Northeast United States of America were the key predisposing factors. Given splenic infarcts, pursuing a TEE was pivotal in ascertaining the diagnosis. The patient received empiric IE treatment for gram-positive cocci, HACEK organisms and babesiosis with improvement of symptoms. Identifying and treating unusual causes of fever and SIRS are crucial in reducing mortality and morbidity.

Rare Sighting of an Unstable Hemoglobin Variant [ Β11 (A8) Val → Asp]: Hemoglobin Windsor

Hemoglobin (Hb) is the major blood oxygen carrier where Hb subunits bind oxygen via the heme iron buried within a hydrophobic pocket that faces the outside of HbA tetramers. Iron must be in its reduced (ferrous, Fe2+) state for Hb to bind oxygen. Oxidized or metHb (ferric, Fe3+) cannot bind oxygen and is relatively unstable. Globin mutations that alter amino acids within the ligand pocket lead to changes in affinity for oxygen, and increased rates of metHb formation and heme loss. We present the case of a patient with a rare variant “Hb Windsor” which has only been described once in the literature. The patient is a 20-year-old Mexican male with a history of hepatitis B presenting with three days of fevers, chills, nausea and vomiting. The patient reported a diagnosis of hepatitis at the age of eight in Mexico and with jaundice all his life. He had no prior hospitalizations or blood transfusions. He denied any unusual food ingestions or recent foreign travel. In the emergency room, the patient was hypoxic with a SpO2 73% and tachypneic which improved with supplemental oxygen. On physical examination, the patient was jaundiced with scleral icterus and the spleen was easily palpable to the midline. CT scan confirmed splenomegaly measuring 20 cm. Labs showed a white blood count 21.6 nl, hemoglobin 4.2 g/dl, platelet count 33 nl, lactate dehydrogenase 13 unit/L and reticulocyte count 24%, total bilirubin 16 mg/dl, direct bilirubin 4 mg/dl and methemoglobin 20.9%. The patient was administered methylene blue and transfused two units of packed red blood cells with hemoglobin increasing to 7.1 g/dl. HIV, hepatitis B and C, direct antiglobulin test, and G6PD testing were negative. The peripheral smear showed numerous nucleated red cells, increased polychromasia with red cells showing numerous microspherocytes, microanthocytes, and bubbled cells with significant basophilic stippling. No fragmented cells were present. The clinical history and lab findings suggested a chronic hemolytic anemia, and the peripheral smear suggested a possible hemoglobinopathy. Hemoglobin electrophoresis by high performance liquid chromatography showed an unknown hemoglobin of 22.5%. Isoelectric focusing showed Hb A 71.9%, F, Hb A2 4.6%, Hb F 0.3%, and an abnormal band of 23% in the hemoglobin M range. Specimens were sent for DNA sequencing and a point mutation in the beta chain was found leading to a valine to aspartate substitution in the A8 position. Protein analysis showed a valine is substituted with aspartic acid in the ligand pocket which is the unstable varian Hb Windsor. This substitution in the base of the heme pocket results in instability of the hemoglobin molecule and an increase in oxygen affinity. The residues lining the heme pocket function as a hydrophobic basket from the heme iron, preventing its oxidation to the ferric state. Valine, which occupies position A8 is a hydrophobic amino acid. However, in Hb Windsor, the valine is substituted by aspartic acid, a polar molecule. The hydrophilic nature of aspartic acid, a polar molecule, may disrupt the hydrophobic nature of the heme pocket. The valine at position A8 also acts as a contact with the H helix which is lost in Hb Windsor leading to decreased Hb stability. These substitutions cause heme iron to auto-oxidize which results in methemoglobinemia. Hb M has iron in the ferric state (Fe3+) and is unable to carry oxygen which produces cyanosis. Our patient was found to be hypoxic requiring oxygen supplementation and found to have methemoglobinemia. We present a rare case of a hemoglobin variant Hb Windsor in a Mexican adult which has only been previously documented in a nine-month-old Anglo-Saxon infant. This variant seems to be a spontaneous de novo mutation as both patients had no family history of anemia. It is hypothesized that the hemolysis was precipitated by oxidative stress of an acute infection in the setting of an unstable hemoglobin. The patient was found to have stable hemoglobin of 12 g/dl and methemoglobin of 4.9% in follow up several years later.

Integrating machine learning and environmental variables to constrain uncertainty in crop yield change projections under climate change

Robust crop yield projections under future climates are fundamental prerequisites for reliable policy formation. Both process-based crop models and statistical models are commonly used for this purpose. Process-based models tend to simplify processes, minimize the effects of extreme events, and ignore biotic pressures, while statistical models cannot deterministically capture intricate biological and physiological processes underpinning crop growth. We attempted to integrate and overcome shortcomings in both modelling frameworks by integrating the dynamic linear model (DLM) and random forest machine learning model (RF) with nine global gridded crop models (GGCM), respectively, in order to improve projections and reduce uncertainties of maize (Zea mays L.) and soybean (Glycine max [L.] Merrill) yield projections. Our results demonstrated substantial improvements in model performance accuracy by using RF in concert with GGCM across China’s maize and soybean belt. This improvement surpasses that achieved using DLM. For maize, the GGCM+RF models increased the r values from 0.15 to 0.61–0.64–0.77 and decreased nRMSE from approximately 0.20 to 0.50–0.13–0.17 compared with using GGCM alone. For soybean, the models increased r from 0.37 to 0.70–0.54–0.70 and decreased nRMSE from 0.17 to 0.35–0.17–0.20 compared with using GGCM alone. The main factors influencing maize yield changes included chilling days (CD), crop pests and diseases (CPDs), and drought, while for soybean the primary influencing factors included CPD, tropical days (based on exceeding a maximum temperature), and drought. Our approach decreased uncertainties by 33–78% for maize and by 56–68% for soybean. The main source of uncertainty for GGCM was the crop model. For GGCM+RF, the main source of uncertainty for the 2040–2069 period was the global climate model, while the main source of uncertainty for the 2070–2099 period was the climate scenario. Our results provide a novel, robust, and pragmatic framework to constrain uncertainties in order to accurately assess the impact of future climate change on crop yields. These results could be used to interpret future ensemble studies by accounting for uncertainty in crop and climate models, as well as to assess future emissions scenarios.

ODP580 A Case of New Onset Primary Adrenal Insufficiency in COVID Infection

Abstract Background Accumulating body of evidence shows that SARS-CoV-2 infection in COVID-19 is linked to a variety of autoimmune complications including autoimmune endocrinopathies. Here we report a case of newly diagnosed Addison's disease post-COVID-19 infection. Case Description A 23-year-old male with a history of three episodes of acute disseminated encephalomyelitis (ADEM) in childhood, was brought into the emergency department (ED) by EMS after being found down with a blood glucose of 28 at the field. Prior to presentation, he reported 3 days of sore throat, nausea, vomiting, fatigue, and chills. He takes no home medications, and is not vaccinated against COVID-19. In the ED, the physical exam is notable for temperature 39°C, pulse 145, BP 80/42, RR 39, and no mucocutaneous hyperpigmentation. Labs revealed a positive COVID test, serum sodium 125 mmol/L (135-145), potassium 3.1 mmol/L (3.5-4.1), and persistent hypoglycemia. TSH 1.89 μIU/mL (0.45-4.12). A morning baseline cortisol was 4 mcg/dl (ref: >18) with ACTH level of >1250 pg/ml (0-45). A high-dose 250 mcg ACTH stimulation test followed; with cortisol levels of 3, and 3 mcg/dl (ref: >18) at 30, and 60 minutes; respectively. Aldosterone <3. 0 ng/dl (4. 0-31. 0), and anti-21-hydroxylase antibody was positive (ref: negative). A CT scan of the abdomen with contrast demonstrated mildly atrophied bilateral adrenal glands. The hypotension and hyponatremia resolved after initiation of intravenous hydrocortisone, and he was discharged on hydrocortisone and fludrocortisone. Conclusion The patient's symptoms, elevated ACTH, low cortisol, and presence of 21-hydroxylase antibodies, are consistent with autoimmune Addison's disease. Since ADEM is an autoimmune condition, it is likely that the patient had underlying undiagnosed Addison's disease and COVID-19 triggered an adrenal crisis. There is also a possibility that SARS-CoV-2 infection may have induced a higher titer of adrenal antibody, leading to the exacerbation of Addison's disease. The case highlights the importance of considering adrenal insufficiency as a diagnostic differential in hemodynamically unstable COVID-19 patients, especially those with underlying autoimmune conditions. Presentation: No date and time listed

Legionnaires' Disease Causing Severe Rhabdomyolysis and Acute Renal Failure: A Case Report.

Legionnaires' disease is a multisystem disease involving respiratory, gastrointestinal, and neurologic systems. This is a case of a previously healthy 44-year-old man who was diagnosed with Legionella pneumonia causing acute kidney failure and rhabdomyolysis. The patient presented with four days of chills, shortness of breath, chest discomfort, diarrhea, and myalgias. Laboratory testing revealed hyponatremia, leukocytosis, elevated inflammatory markers, renal failure, and rhabdomyolysis. He was admitted to the intensive care unit for acute hypoxemic respiratory failure, received a course of antibiotics, and more than two weeks of intermittent hemodialysis with full recovery of renal function. The pathophysiologic mechanisms by which Legionella causes rhabdomyolysis and acute kidney failure are not fully understood, although numerous mechanisms have been proposed including direct invasion of myocytes and renal tubular cells. Legionnaires' disease is one of several infections that can cause rhabdomyolysis and kidney failure. Although rarely described in the literature, it is important for emergency physicians to be aware of this clinical entity in order to implement early diagnostic testing and empiric treatment.

REACTIVATION MILIARY TB IN THE SETTING OF POSTINFECTIOUS COVID-19 LUNGS

REACTIVATION MILIARY TB IN THE SETTING OF POSTINFECTIOUS COVID-19 LUNGS

Anaplasmosis-Induced Atrial Flutter Resolving With Antibiotic Therapy

Anaplasma phagocytophilum is a rickettsial bacterium that causes human granulocytic anaplasmosis and is carried by the Ixodes scapularis tick. We describe a case of a 56-year-old man with recent tick exposure who presented in atrial flutter with variable atrioventricular block after 3 days of fever, chills, and arthralgias. The patient was successfully treated and stably returned to sinus rhythm after initiation of antibiotics without cardioversion and was found to be positive for A. phagocytophilum but negative for Lyme disease. To our knowledge, this represents the first reported case of anaplasmosis-associated atrial flutter. As infections increase in incidence, clinicians in endemic areas should be aware of the potential manifestations and treatment considerations of tick-borne carditis.

Identification of Chilling-Responsive Genes in Litchi chinensis by Transcriptomic Analysis Underlying Phytohormones and Antioxidant Systems.

Litchi (Litchi chinensis Sonn.) is an important subtropical and tropical evergreen fruit tree that is seriously affected by chilling stress. In order to identify genes that may be involved in the response to chilling in litchi, we investigate the physiological and biochemical changes under chilling stress and construct 12 RNA-Seq libraries of leaf samples at 0, 4, 8, and 12 days of chilling. The results show that antioxidant enzymes are activated by chilling treatments. Comparing the transcriptome data of the four time points, we screen 2496 chilling-responsive genes (CRGs), from which we identify 63 genes related to the antioxidant system (AO-CRGs) and 54 ABA, 40 IAA, 37 CTK, 27 ETH, 21 BR, 13 GA, 35 JA, 29 SA, and 4 SL signal transduction-related genes. Expression pattern analysis shows that the expression trends of the 28 candidate genes detected by qRT-PCR are similar to those detected by RNA-Seq, indicating the reliability of our RNA-Seq data. Partial Least Squares Structural Equation Modeling (PLS-SEM) analysis of the RNA-Seq data suggests a model for the litchi plants in response to chilling stress that alters the expression of the plant hormone signaling-related genes, the transcription factor-encoding genes LcICE1, LcCBFs, and LcbZIPs, and the antioxidant system-related genes. This study provides candidate genes for the future breeding of litchi cultivars with high chilling resistance, and elucidates possible pathways for litchi in response to chilling using transcriptomic data.

COVID-19 INFECTION AND DRASTIC DECREASE IN CD4

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: It is well known now that COVID-19 cause lymphopenia. In the retrospective study the number of total T cells, CD4+ and CD8+ T cells were dramatically reduced in COVID-19 patients, especially in patients requiring Intensive Care Unit (ICU) care. (1) Lymphopenia and drastic reduction of CD4+ T cell counts in COVID-19 patients have been linked with poor clinical outcome too. (2) We present a case of a patient with well controlled HIV infection with stable absolute CD4 count but significant drop during COVID infection CASE PRESENTATION: A 67 year-old-man with history of HIV on ARV therapy with undetectable viral load, panhypopituitarism with central hypothyroidism, adrenal insufficiency and hypogonadism, recurrent DVT/PE on AC therapy, BPH, overactive bladder, stable angina presented with 3 days of fever, chills, diarrhea and malaise to ER. He received first dose of Moderna vaccine 2 weeks before admission. VS -saturation 79% on RA, and 96% on NRB mask, HR 122 beats/min, BP 159/87 mmHg, RR 18/min, T 101. PE unremarkable. Labs: Covid PCR +, WBC 15.3 K/cmm, ferritin 585.8 ng/ml, LDH 489 U/LAST 122 U/l, ALT 100U/L, CRP quant 321 mg/L, D dimer 1287 D-DU ng/ml, HIV RNA quant undetectable, CD4 67 cell/Ul, previous CD4 568 cmm 2 weeks prior admission. CXR:b/l patchy infiltrates. He was treated with dexamethasone, therapeutic Lovenox and received 1 U of convalescent plasma. His oxygen saturation improved, overall course was uneventful and patient was discharged home. CD4 count improved to 523 cmm 2 months later. DISCUSSION: It is shown that HIV infection does not increase the occurrence of COVID-19 and there is no increase in morbidity and mortality (2). The exact influence of COVID-19 on absolute T4 cells subset in HIV and their significance is presently unknown. Our patient had stable absolute CD4 count for years. He was compliant with ART and HIV viral load was undetectable. However, there was a drastic decline in his CD4 count that occurred during an acute COVID infection although he was on the same medications. CD4 recovered to baseline after COVID infection resolved. CONCLUSIONS: This is a unique case with such a dramatic drop of absolute CD4 count in acute COVID infection and further investigation on CD4 cells and it effects on HIV infection will need to be studied. REFERENCE #1: Diao B, Wang C, Tan Y, et al. Reduction and Functional Exhaustion of T Cells in Patients With Coronavirus Disease 2019 (COVID-19). Front Immunol. 2020;11:827. Published 2020 May 1. doi:10.3389/fimmu.2020.00827 REFERENCE #2: Peng Xiaorong, Ouyang Jing, Isnard Stephane, Lin John, Fombuena Brandon, Zhu Biao, Routy Jean-Pierre, Sharing CD4+ T Cell Loss: When COVID-19 and HIV Collide on Immune System, JOURNAL=Frontiers in Immunology VOLUME=11, YEAR=2020, PAGES=3307, URL=https://www.frontiersin.org/article/10.3389/fimmu.2020.596631 DOI=10.3389/fimmu.2020.596631, ISSN=1664-3224 DISCLOSURES: no disclosure on file for Moses Bachan;no disclosure on file for Zinobia Khan;No relevant relationships by Mirjana Petrovic Elbaz, source=Web Response No relevant relationships by Robert Siegel, source=Web Response

Xanthogranulomatous pyelonephritis: A rare case report of a 54year old female (a potentially fatal infection).

Introduction and importanceXanthogranulomatous pyelonephritis (XPGN) is a rare pathology of the kidneys occurring in 0.6 to 1% of all cases of renal infections, in both men and women. It is characterized by severe inflammation of the renal parenchyma leading to formation of granulomatous tissue containing lipid-laden macrophages. This condition may mimic less aggressive or benign conditions but may worsen or be fatal if not treated aggressively.Case presentationOur patient is a 54 year old Caucasian female who presented with five days of left flank pain, hematuria, chills, nausea and vomiting. Imaging and biopsy results showed that the patient had XPGN.Clinical discussionXPGN is a difficult condition to diagnose as the symptoms are non-specific relative to renal cell carcinoma or other common renal infections. Definitive diagnosis is made with a biopsy; however, clues in various imaging modalities are used to make a tentative diagnosis. It is unclear whether earlier surgical intervention would have improved overall patient outcomes. Currently, a partial or complete nephrectomy is the only effective treatment.ConclusionAggressive management including early diagnosis, antibiotics and nephrectomy appears to be critical in preventing progression and complications of XPNG.

Chilling rather than photoperiod controls budburst for gymnosperm species in subtropical China

AbstractThe mechanisms regulating spring phenology have been extensively studied in angiosperm species. However, given that gymnosperms and angiosperms diverged 300 million years ago, phenology may be triggered by different cues in gymnosperm species. The regulatory mechanisms of phenology in subtropical regions remain largely unknown. In combination, it remains untested whether subtropical gymnosperm species have chilling requirements and are photosensitive. We conducted a climate chamber experiment with three chilling and three photoperiod treatments to investigate budburst during an 8-week forcing period. We tested whether budburst of eight gymnosperms species (Cryptomeria japonica, Cunninghamia lanceolata, Cupressus funebris, Ginkgo biloba, Metasequoia glyptostroboides, Pinus massoniana, Pseudolarix amabilis and Podocarpus macrophyllus) was photoperiod sensitive or has strong chilling requirements and whether photoperiod or chilling was more important for advancing budburst. Chilling advanced budburst and increased the percentage of budburst for gymnosperm species. Gymnosperm species required moderate chilling days to advance budburst. Interestingly, the forcing requirement for gymnosperm species was higher than that for angiosperms in the same forest, suggesting that gymnosperms may need more cumulative forcing to initiate budburst than do angiosperms. Compared with temperate gymnosperm species in Germany (194–600 °C days), the subtropical species studied here had a much higher forcing requirement (814–1150 °C days). The effects of photoperiod were minor, suggesting that chilling outweighs photoperiod in advancing budburst of gymnosperm species in this subtropical region. These results reveal that increased winter temperatures with continued global warming may impact not only angiosperms but also gymnosperms, leading to their delayed spring budburst.

Divergent shifts in flowering phenology of herbaceous plants on the warming Qinghai–Tibetan plateau

Both advanced and delayed shifts of different magnitude in flowering phenology, based on limited controlled experiments and ground-based observational studies, have been reported on the Qinghai–Tibetan Plateau (QTP). To clarify flowering phenological changes, we collected 1646 ground-observed phenological records of 21 species, from 27 stations, for 78 time series, and daily average air temperature data from 1983 to 2017 on the QTP. Trends in the first flowering date (FFD) and changes with temperature increase were analyzed using regression models. The FFD of early flowering time series showed an overall trend for significant advance (-0.371 ± 0.149 days/year, p < 0.001), whereas the mid-to-late-flowering showed a delayed trend (0.158 ± 0.193 days/year, p = 0.108). This finding is in contrast with the stable trend for early flowering species and the advanced trend for midsummer and late-flowering species in high latitude and Arctic regions, where the low-temperature environment is similar. The growing degree days from 1 January to the day of the observed occurrence of the FFD for early flowering time series kept stable (p = 0.531) and FFD showed a positive regression with chilling days; however, the growing degree days of mid-to-late-flowering time series increased significantly at a rate of 5.375 ± 2.519°C-days/year (p < 0.001), indicating the limitation on FFD from other related climatic factors except for forcing temperature may strengthen, and FFD showed no relationship with chilling days. The mid-to-late-flowering time series showed vernalization sensitivity in the spring of the flowering year, whereas the early flowering time series did not. This indicated that retarded vernalization completion may be responsible for the delayed flowering phenology of mid-to-late-flowering species. The FFD of early flowering species, with flower preformation in the preceding autumn, was mainly controlled by forcing temperature in spring; decreased chilling days indicating warmer winter were also beneficial for development and fitness of preformed floral organs, and thus, temperature increase significantly advanced the FFD. These findings suggest that divergent flowering phenology shifts may alter the species composition and ecosystem services of alpine ecosystems, causing challenges in grassland management.

Clinical Reasoning: A 29-Year-Old Man With Fevers and Rapidly Progressive Cranial Neuropathies.

A 29-year-old man with no prior known medical diagnoses presented to the emergency department with 5 days of fevers, chills, vomiting, headache, and neck pain followed by voice changes, difficulty swallowing, and intractable hiccups. The patient denied vision changes, weakness, numbness, recent travel, new medications, or illicit drug use. He had no personal or family history of neurologic illness. On questioning concerning possible toxic exposure, he noted recent consumption of sushi and raw meat at a restaurant; a friend who had eaten with him also experienced gastrointestinal illness after that meal.

Disseminated Mycobacterium Fortuitum Infection in Bilateral Lung Transplant Recipient

Introduction Lower respiratory tract secretions from lung transplant recipients are known on rare occasions to yield a low inoculum of non-tuberculous mycobacteria. However, despite the intense systemic immunosuppression required in these recipients, disseminated mycobacterial disease has rarely been reported. Case Report A 66-year-old male with history of right total knee arthroplasty in 2007 and bilateral lung transplant in 2019 (cytomegalovirus [CMV] donor seropositive/recipient negative) was admitted with two days of fevers, chills, and dyspnea. Immunosuppression therapy included basilixumab induction and maintenance immunosuppression with mycophenolate mofetil, tacrolimus, and prednisone. A CT chest demonstrated patchy opacities in the left lung allograft and right middle lobe with a moderate partially loculated left pleural effusion. A bronchoscopy with bronchoalveolar lavage (BAL) was performed and cultures demonstrated Veillonella parvula, anaerobic gram negative bacilli, and M. fortuitum. Two months earlier, BAL cultures had demonstarted M. fortuitum, but treatment had been deferred at that time as recipient was asymptomatic. Now, with rapid improvement on cephalosporin therapy, treatment for M. fortuitum was again not pursued. The recipient was readmitted one month later with left knee pain, fever, and diarrhea, and was diagnosed with hemarthrosis and CMV colitis. Four weeks later the recipient experienced right knee pain and when joint aspiration demonstrated M. fortuitum he underwent two stage revision at which time intraoperative cultures again yielded M. fortuitum. Following this surgery the recipient then was found to have a chest wall abscess, which when incised also yielded M. fortuitum. Treatment with imipenem and ciprofloxacin for six weeks was initiated, with transition to oral ciprofloxacin for one year. Summary This case illustrates the potential for M. fortuitum pulmonary infections to result in disseminated disease in lung transplant recipients. While rarely reported in the literature, non-tuberculous mycobacterium infections have been associated with bronchiolitis obliterans syndrome and mortality in lung transplant recipients. Dissemination of M. fortuitum is uncommon and prompt recognition is crucial for appropriate source control and antibiotic therapy initiation.

Assessment of Chilling Requirement and Threshold Temperature of a Low Chill Pear (Pyrus communis L.) Germplasm in the Mediterranean Area

In temperate climates, bud break and shoot and flower emission of deciduous fruit tree species are regulated by precise chilling and heating requirements. To investigate this aspect, sixty-one accessions of European pear (Pyrus communis L.) collected in Sicily were phenotyped for three consecutive years for harvest date, bud sprouting and blooming to determine both the chilling requirements and the threshold temperature using the Chill Days model. The whole germplasm collection was grown in two different experimental fields located at 10 and 850 m above sea level representing two Mediterranean-type climates in which pear is commonly cultivated. Results revealed a mean threshold temperature of 6.70 and 8.10 °C for the two experimental fields, respectively, with a mean chilling requirement ranging from −103 and −120 days. Through this approach, novel insights were gained on the differences in chilling requirement for early flowering cultivars to overcome dormancy. Furthermore, to better dissect differences in chilling requirement between accessions, the sprouting bud rate of six cultivars was assessed on excised twigs stored at 4 ± 0.1 °C from 300 to 900 h followed by a period at 25 ± 0.1 °C varying from seven to twenty-eight days. Results of both experiments highlighted that Sicilian pear germplasm is characterized by a low chilling requirement compared to other pear germplasm, making Sicilian local accessions valuable candidates to be used for selecting novel cultivars, coupling their low chilling requirements with other traits of agronomical interest.

Differential Diagnosis in the Age of COVID-19 and the Need to Maintain a Broad Differential

During the coronavirus pandemic, patients admitted to emergency departments (ED) with constitutional symptoms, respiratory complaints, and/or history of sick contacts have high clinical suspicion for COVID-19 regardless of whether initial screening tests are negative. Although communities seek daily coronavirus infection rates of less than one percent, physicians can be highly focused on narrow differentials despite adequate history and physical exams. This case report focuses on an elderly patient with a past medical history of hypertension, chronic kidney disease (CKD), and gout who presented with three days of fevers, chills, body aches, and shortness of breath and reported a home oxygen saturation of 89%. The patient was a health care worker with high risk of contracting COVID-19, and on admission was febrile and found to have lymphopenia. Nevertheless, COVID-19 Polymerase Chain Reaction (PCR) testing returned negative on two separate occasions prompting the team to broaden their differential. Leukopenia, thrombocytopenia and mildly elevated transaminases can all be due to COVID-19, but should also lead medical teams to include tick-borne illnesses as a potential etiology. Parasite serology returned positive for Babesia microti via IgG antibodies (1:512) and Anaplasma phagocytophilum via PCR and the patient was discharged on appropriate antimicrobial therapy. It is important for providers to understand and recognize the following: 1) overlapping symptoms of tick-borne disease and COVID-19, 2) proper diagnosis and management of babesiosis and anaplasmosis, and 3) benefits of broad differentials for patient care during the COVID-19 pandemic.

PROFOUND ENDOTHELIAL DYSFUNCTION AS A CAUSE OF STROKE IN COVID-19: A CASE REPORT

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: There are recent reports of neurological manifestations (NMs) from COVID-191. We present a healthy male who developed multiple strokes likely from direct endothelial dysfunction (ED). CASE PRESENTATION: 66M with GERD presents with 5 days of cough, fever, and chills. He was febrile and hypoxic. Work-up revealed CRP 19 mg/dL, ferritin 594 ng/mL, D-dimer 2.01 mg/L, positive COVID-19 PCR, and normal lipid panel. He had wheezing and no NMs. He was treated with antibiotics, enoxaparin, and oxygen. On day 14 he acutely developed altered mental status, aphasia, and unilateral weakness. CT head revealed acute left ischemic infarct. CTA head/neck revealed proximal left ICA dissection. Aspirin and Atorvastatin were given. Further studies revealed D-dimer 0.4 mg/L, no inheritable hypercoagulopathy, and negative TTE and lower extremity venous duplex. MRI brain confirmed multiple acute infarcts. Left ICA thrombectomy and stent placement were performed. It was found that there was a pseudo-dissection with a ruptured plaque and an overlying thrombus resulting in a 75% stenosis. DISCUSSION: Arterial complications from COVID-19 have recently been reported.3 Studies from Wuhan, China showed that 36.7% of COVID-19 patients had NMs, most commonly dizziness (16.8%) and headache (13.1%); 5.7% had acute ischemic stroke. These patients had severe respiratory symptoms and developed neurologic signs in 1-2 days.1 Another study revealed that stroke occurred in elevated CRP (51.1 vs 12.1 ng/L) and D-dimer (6.9 vs 0.5 mg/L)2. It is believed that the virus directly invades and injures endothelial cells (ECs), changes prothrombotic factors, and promotes a hypercoagulable state secondary to a profound inflammatory response4. ACE-2-receptors on ECs are used for viral adhesion. Viral replication causes EC apoptosis, which promotes vasoconstriction, organ ischemia, tissue edema, and microvascular prothrombotic sequelae.5 In our case, COVID-19 had profound ED distal to the carotid artery bifurcation. Arterial bifurcations are sites of turbulent blood flow that are athero-prone.6 The stroke occurred in the setting of moderate elevations of D-dimer, suggesting an alternate mechanism.2 Plaque rupture occurred with prophylactic anticoagulation and normal lipid panel. At the time of the stroke, D-dimer and inflammatory markers largely normalized. His late onset NMs indicate that prothrombotic sequelae and ED persist after the cytokine storm has improved.1 Further studies are needed to investigate the duration of cytokine storm and prothrombotic state, and appropriate screening measures. CONCLUSIONS: Clinicians must be cognizant of NMs from COVID-19 such as thromboembolic strokes from direct ED. Reference #1: 1. Mao L et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. Epub 2020 Apr 10. Reference #2: 2. Li Y, Wang M, Zhou Y, Chang J. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Available at SSRN: https://ssrn.com/abstract=3550025. 2020 Mar 3. Reference #3: 3. Oxley, Thomas et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. Epub 2020 Apr 28. 4. Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. Epub 2020 Apr 27. 5. Ferrario CM et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation. 2005;111:2605-10. 6. Ku DN, Giddens DP, Zarins CK, Glagov S. Pulsatile flow and atherosclerosis in the human carotid bifurcation: positive correlation between plaque location and low oscillating shear stress. Atherosclerosis. 1985 May-Jun; 5:293-302 DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Luke Alessi, source=Web Response No relevant relationships by David Capone, source=Web Response No relevant relationships by Olga McAbee, source=Web Response No relevant relationships by Heidi Roppelt, source=Web Response No relevant relationships by Fredric Weinbaum, source=Web Response No relevant relationships by Daisy Young, source=Web Response

A CASE OF LIFE-THREATENING NON-INFECTIOUS PNEUMONITIS IN A PATIENT TREATED WITH EVEROLIMUS FOR METASTATIC NON-SMALL CELL LUNG CANCER

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Everolimus, an oral inhibitor of mTOR, is a targeted anti-neoplastic therapy for advanced NSCLC. We present a case of non-infectious pneumonitis (NIP) in a patient being treated with everolimus. Prompt recognition and management is essential. CASE PRESENTATION: 64-year-old male with Stage IV NSCLC, recently started on 6th line salvage therapy with everolimus, presented with 4 days of dyspnea, fatigue, intermittent chills, productive cough, and scant hemoptysis. On arrival, patient was afebrile, tachycardiac and hypoxic to 88% on room air. He was found to have mild anemia and elevated LDH without leukocytosis or thrombocytopenia. CT chest showed increase in RUL perihilar mass and new peribronchovascular airspace disease in all lobes. Differential diagnosis included infectious and noninfectious findings of new airspace disease. Everolimus was discontinued and patient was started on oxygen supplementation to maintain oxygen saturation >88%, along with 60 mg IV solumedrol q24 hours, broad-spectrum antibiotic coverage with piperacillin-tazobactam, linezolid, and azithromycin. Bronchoalveolar lavage (BAL) was negative for mycobacterium, fungal or bacterial pathogens. Patient improved symptomatically after starting steroids along with reduction in oxygen requirement. DISCUSSION: Everolimus is used in select cases of advanced NSCLC. NIP is a potentially fatal adverse effect of mTOR inhibitors, more frequently seen in NSCLC as compared to other solid malignancies and in patients with baseline interstitial lung disease. Severe or life-threatening symptoms requiring discontinuation of therapy, as seen in our patient, are uncommon and require prompt diagnosis and treatment. Common presentation includes cough, dyspnea, and hypoxemia. Hemoptysis, as seen in our patient, is rare. Radiographic changes in everolimus associated NIP include, lower lobe predominant ground-glass and reticular opacities, focal parenchymal consolidations, and rarely, pleural effusions. Pulmonary function tests can show a restrictive pattern or abnormally low DLCO. Histological testing including BAL, lung biopsy, and sputum cultures help exclude infection, granulomatous disease or malignancy. Management is guided by grade of pneumonitis, and includes close clinical observation, dose reduction or discontinuation. Systemic steroids can be given to patients with grade ≥2 pneumonitis until symptoms improve to grade ≤1. CONCLUSIONS: Patients on everolimus therapy for advanced NSCLC are at high risk of developing NIP, that can sometimes lead to life-threatening hypoxic respiratory failure. Urgent diagnosis and guideline directed management of this adverse effect is highly important. Reference #1: Alvarez RH, Bechara RI, Naughton MJ, Adachi JA, Reuben JM. Emerging Perspectives on mTOR Inhibitor-Associated Pneumonitis in Breast Cancer. Oncologist. 2018;23(6):660-669. Reference #2: Grünwald V, Weikert S, Pavel M, et al. Practical Management of Everolimus-Related Toxicities in Patients with Advanced Solid Tumors. Onkologie. 2013;36:295-302. Reference #3: White DA, Schwartz LH, Dimitrijevic S, Scala LD, Hayes W, Gross SH. Characterization of Pneumonitis in Patients with Advanced Non-small Cell Lung Cancer Treated with Everolimus (RAD001). Journal of Thoracic Oncology. 2009;4(11):1357-1363. DISCLOSURES: No relevant relationships by zainub ajmal, source=Web Response No relevant relationships by Sana Ghalib, source=Web Response No relevant relationships by Boris Shkolnik, source=Web Response No relevant relationships by Fatima Tuz Zahra, source=Web Response

S2400 Typhoid Fever: An Unusual Cause of Acute Hepatitis

INTRODUCTION: Typhoid fever, a disease highest in incidence in South Asia, is due to Salmonellae ingestion via feces-contaminated food or water. While hepatic involvement is not rare given colonization of reticuloendothelial tissues, an acute hepatitis picture, as seen here, is unusual. CASE DESCRIPTION/METHODS: A 25 year old female without past medical history presented febrile, tachycardic, and hypotensive after 8 days of fatigue, fevers, chills, myalgias, headaches, nausea, and emesis following a trip to Miami. She had taken daily Acetaminophen since onset and denied other medication, herbal, and alcohol consumption. Of note, the patient emigrated to the United States 9 months prior and made a 3 month trip home to the Indian subcontinent 3 weeks before presentation. While there, she took Acetaminophen and a course of Amoxicillin. She and multiple family members also experienced fever, nausea, emesis, and diarrhea after consuming raw vegetables. Notable labs include leukopenia at 4.1, AST 593, ALT 560, and ALP 148. Urgent care labs 2 days prior were significant for AST 68, ALT 59, ALP 106, and negative hepatitis serologies. She received Ceftriaxone, IV fluids, and NAC, though plasma Acetaminophen level resulted as < 5 mcg. After blood cultures yielded gram negative rod bacteremia, antibiotics were changed to Piperacillin/Tazobactam. Abdominal ultrasound was unremarkable and triple phase CT showed mild hepatic heterogeneity. Repeat hepatitis serologies, CMV, EBV, autoimmune markers, malarial smears, and HIV were among tests ordered to determine acute transaminitis etiology. Blood cultures eventually revealed Salmonella enterica susceptible to Amoxicillin. Transaminases continued to downtrend after 5 days of hospitalization and she was successfully discharged home. DISCUSSION: Acute febrile illness in a patient recently abroad prompts investigation into diseases endemic to the region from which a patient has travelled. For the Indian subcontinent, typhoid fever may be a culprit, but its nonspecific presentation renders suspicion difficult especially when complicated by acute transaminitis and DILI concerns. As with our patient, diseases such as malaria, hepatitis, and HIV should also be considered. Depending on individual inoculum as well as host immunocompetence, incubation may be 5-21 days with prolonged fever for up to 1 month if the disease goes untreated. Interestingly, leukopenia is noted in 15-25% of cases. Blood cultures, integral to the work-up of recurrent fever, ultimately led to our diagnosis.