Fulminant Cases Research Articles

Veno-venous extracorporeal membrane oxygenation in devastating bacterial pneumonia: a case report and review of the literature

BackgroundBacterial pneumonia is one of the most common causes of acute respiratory distress syndrome. In fulminant cases, when mechanical ventilation fails, veno-venous extracorporeal membrane oxygenation is required. However, this method is still associated with significant mortality and a wide range of potential complications. However, there are now many case reports of good outcomes even in patients with prolonged extracorporeal oxygenation, as in our rather complicated case report.Case presentationOur case report describes a complicated but successful treatment of a severe, devastating bacterial pneumonia in a 39-year-old European polymorbid woman with a rare form of diabetes mellitus, which had been poorly compensated for a long time with limited compliance, in the context of a combined immunodeficiency that strongly influenced the course of the disease. The patient’s hospitalization required a total of 30 days of veno-venous extracorporeal membrane oxygenation therapy and more than 50 days of mechanical ventilation. Numerous complications, particularly bleeding, required seven chest drains, two extracorporeal membrane oxygenation circuit changes, and one surgical revision. The patient’s mental state required repeated psychiatric intervention.ConclusionIt is possible that even the initially severely damaged lung parenchyma can develop its regenerative potential if suitable conditions are provided for this process, including a sufficiently long period of extracorporeal membrane oxygenation.We believe that this case report may also contribute to the consideration of the indications and contraindications of extracorporeal support. The authors also discuss the limitations and risks of prolonged veno-venous extracorporeal membrane oxygenation support and periprocedural anticoagulation strategies.

Surgical Management for Patients with Toxic Megacolon due to Ulcerative Colitis.

The present study reviewed cases of Toxic megacolon (TM) treated in our department, summarized the timing and technique of surgery, and considered key points for surgical management. This single-center retrospective study included the medical records of patients clinically diagnosed with TM who underwent surgery between 1985 and 2020. The diagnostic criteria and screening scores for sepsis, such as the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Modified Early Warning Score (MEWS), were validated. The preoperative clinical features and perioperative findings were also investigated. There were eight male and six female patients. Nine patients (64.3%) satisfied the criteria for toxemia proposed by Narabayashi, and 10 patients (71.4%) fulfilled the SIRS criteria. A positive qSOFA score was confirmed in 1 patient (7.1%). The MEWS was high in 2 patients (14.3%). Intestinal perforation occurred in 2 patients (14.3%), and 1 of them died from disseminated intravascular coagulation. The mortality rate of TM with perforation was 50%. Eleven patients (78.6%) underwent total colectomy with end ileostomy. TM does not have well-defined diagnostic criteria, in addition to developing sometimes as borderline or fulminant cases, and must be recognized at an early stage, taking various findings into consideration. The criteria proposed by Narabayashi and the SIRS criteria, which met in a high percentage of our cases, are recommended as indicators for determining the toxicity of TM. It is also important to consider surgery in the early stages of TM, even if clinical findings do not meet all the criteria.

A surge in fulminant idiopathic intracranial hypertension cases within 1 year from the coronavirus disease 2019 pandemic lockdown: A case series

A surge in fulminant idiopathic intracranial hypertension cases within 1 year from the coronavirus disease 2019 pandemic lockdown: A case series

Acute fibrinosis and organized pneumonia

Acute fibrinous and organizing pneumonia (AFOP), first described histologically by Beasley et al.1 in 2002. AFOP occurs in a wide age range (38-78 age) and in a non-sexist spectrum of patients. Although idiopathic cases have been reported, case series in which the underlying etiology is known. The histologically specific pattern is the presence of organized intra-alveolar fibrin and is the essential parameter for diagnosis. There is no significant difference in the radiological pattern except for the halo finding in the comparison of AFOP and COP. In patients presenting with an acute and more fulminant picture, the clinic presents with rapidly worsening respiratory failure. The main complaints were fever, cough and chest pain respectively. Since AFOP is a diagnosis of exclusion, most patients are diagnosed with pneumonia that does not respond to treatment or has delayed resolution during follow up. Although the clinical presentations of the fulminant and subacute forms of AFOP are different, a clear distinction cannot be made for treatment due to the high mortality of the fulminant form. The prognosis is poor in acute fulminant cases.

Fulminant myocarditis induced by SARS-CoV-2 infection without severe lung involvement: insights into COVID-19 pathogenesis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection often leads to pulmonary complications. Cardiovascular sequelae, including myocarditis and heart failure, have also been reported. Here, the study presents two fulminant myocarditis cases infected by SARS-CoV-2 exhibiting remarkable elevation of cardiac biomarkers without significant pulmonary injury, as determined by imaging examinations. Immunohistochemical staining reveals the viral antigen within cardiomyocytes, indicating that SARS-CoV-2 could directly infect the myocardium. The full viral genomes from respiratory, anal, and myocardial specimens are obtained via next-generation sequencing. Phylogenetic analyses of the whole genome and spike gene indicate that viruses in the myocardium/pericardial effusion and anal swabs are closely related and cluster together yet diverge from those in the respiratory samples. In addition, unique mutations are found in the anal/myocardial strains compared to the respiratory strains, suggesting tissue-specific virus mutation and adaptation. These findings indicate genetically distinct SARS-CoV-2 variants have infiltrated and disseminated within myocardial tissues, independent of pulmonary injury, and point to different infection routes between the myocardium and respiratory tract, with myocardial infections potentially arising from intestinal infection. These findings highlight the potential for systemic SARS-CoV-2 infection and the importance of a thorough multi-organ assessment in patients for a comprehensive understanding of the pathogenesis of COVID-19.

Medical treatment selection and outcomes for hospitalized patients with severe ulcerative colitis as defined by the Japanese criteria.

Hospitalization for ulcerative colitis (UC) is potentially life-threatening. Severe disease in the Japanese criteria which modifies the Truelove-Witts' criteria might encompass more fulminant cases than the definition for acute severe UC. However, few studies have investigated the predictive factors for clinical remission (CR) after medical treatments for severe hospitalized patients by Japanese criteria. Medical treatment selection, CR rates, and factors contributing to CR on day 14 were assessed in severe patients by Japanese criteria. We also investigated whether the reduction rate in patient-reported outcome 2 (PRO2) on day 3 could predict short-term prognosis. Eighty-five severe hospitalized patients were selected. Corticosteroids, tacrolimus, and infliximab were mainly selected as first-line treatments (76/85; 89.4%). The CR rates on day 14 were 26.8%, 21.4%, and 33.3% in patients receiving corticosteroids, tacrolimus, and infliximab, respectively. Extensive disease (odds ratio [OR] 0.022; 95% confidence interval [CI] 0.002-0.198), higher PRO2 (OR 0.306; 95% CI 0.144-0.821), and higher reduction rate in PRO2 on day 3 (OR 1.047; 95% CI 1.019-1.075) were independent factors predicting CR on day 14. If the cutoff value for the reduction rate in PRO2 on day 3 was 18.3%, sensitivity was 0.714 and specificity was 0.731 to predict CR on day 14. A higher reduction rate in PRO2 on day 3 (OR 0.922; 95% CI 0.853-0.995) was a negative factor to predict surgery within 28days. Tacrolimus and infliximab in addition to corticosteroids were used as first-line treatment in severe hospitalized patients. PRO2 on day 3 is a useful marker for switching to second-line therapy or colectomy.

Relapsing Autoimmune GFAP Astrocytopathy: Case Report

Introduction. Glial fibrillary acidic protein (GFAP) is the main component of intermediate astrocyte filaments. In 2016, anti-GFAP antibodies (Ab) were identified as the specific biomarker for the first established CNS inflammatory disorder subsequently called autoimmune astrocytopathy associated with anti-GFAP Ab (A-GFAP-A). Since GFAP is localized intracellularly, GFAP Ab do not appear to be directly pathogenic though serve as a biomarker of immune inflammation. Although presence of GFAP-Ab in the serum (but not in the CSF) could be observed in various CNS immune-mediated diseases, detection of GFAP-Ab in CSF is only characteristic for A-GFAP-A. A-GFAP-A usually develops after the age of 40 and mostly manifests acutely or subacutely with symptoms of meningoencephalomyelitis or its focal forms. Linear perivascular radial cerebral white matter enhancement is a specific MRI finding of A-GFAP-A. Concomitant neoplasms or autoimmune disorders, as well as co-expression of other antineuronal antibodies are not uncommon in A-GFAP-A. Usually, disease responds well to immunotherapy, and prolonged remission could be achieved, however recurrent disease course and fulminant cases are also described in the literature. In these cases, long-term immunosuppression is required. Data on epidemiology, etiological factors, and precise pathogenesis of A-GFAP-A are still limited. Due to the lack of long-term follow-up data, diagnostic criteria, generally accepted treatment strategies or prognostic risk factors for relapse and outcome of the disease have not yet been established and precised. We present the first description of a case of relapsing A-GFAP-A in Russia and an analysis of the current data on the pathogenesis, clinical features, as well as the diagnostic challenges and treatment approaches for A-GFAP-A.

Is There a Causal Link Between Acute Myocarditis and COVID-19 Vaccination: An Umbrella Review of Published Systematic Reviews and Meta-Analyses.

A few months after the beginning of the coronavirus disease of 2019 (COVID-19) vaccination, several reports of myocarditis secondary to the vaccines were published, sometimes with fulminant cases, but until today there is no proven causal link between these 2 events, but with many hypotheses proposed. A systematic review of current evidence regarding myocarditis after COVID-19 vaccination was performed by searching several databases including PubMed/Medline and Web of Science. The quality of Meta-analysis was assessed using the AMSTAR-2 tool as well as other qualitative criteria. Our umbrella review appraised 4 Meta-analysis of retrospective studies (range: 5-12), The number of vaccine doses included ranged from 12 to 179 million, with the number of myocarditis cases observed ranging from 343 to 1489. All types of vaccines were evaluated, with no exclusions. The overall incidence ranged from 0.89 to 2.36 cases of myocarditis per 100 000 doses of vaccine received. Heterogeny was assessed in 3 of the Meta-analysis, and was highly significant (>75%) in all included studies, and with a significant P-value (P < .05). Regarding publication bias, 3 of the Meta-analysis conducted the egger and begg regression, with a significant result in only 1. Regarding the assessment of the methodology by the AMSTAR-2 scale indicating that the quality was very critical in 1, low in 2, and moderate in 1 Meta-analysis. The quality of current non-randomized evidence on real causality and incidence of myocarditis after COVID-19 vaccine is still low.

Myocarditis after vaccination against COVID-19: an umbrella review of systematic review and meta-analysis

Abstract Introduction A few months after the beginning of the COVID-19 vaccination, several reports of myocarditis secondary to the vaccines were published, sometimes with fulminant cases, but until today there is no proven causal link between these two events, but with many hypotheses proposed. Purpose We conducted an umbrella review of all systematic reviews with meta-analyses published in this sense, in order to carry out a critical review to be able to draw relevant conclusions for our practice. Methods A systematic review of current evidence regarding myocarditis after COVID-19 vaccination was performed by searching several databases including PubMed/Medline and Web of Science. The quality of MAs was assessed using the AMSTAR-2 tool as well as other qualitative criteria. The evidence was graded from convincing (Class I) to weak (Class IV), according to the type of studies included (prospective or retrospective), p-value of the overall effect, level of heterogenicity, sample size, or inclusion or not of the null value in the 95% confidence interval. Results Our umbrella review appraised 4 MAs of retrospective studies (range: 5–12), The number of vaccine doses included ranged from 12 to 179 million, with the number of myocarditis cases observed ranging from 343 to 1489. All types of vaccines were evaluated, with no exclusions. The overall incidence ranged from 0.89 to 2.36 cases of myocarditis per 100,000 doses of vaccine received (Figure 1). Heterogeny was assessed in 3 of the MAs, and was highly significant (&amp;gt;75%) in all included studies, and with a significant p-value (p &amp;lt;0.05). Regarding publication bias, three of the MAs conducted the egger and begg regression, with a significant result in only one. Of the 4 MAs included, only one was not registered in the PROSPERO database. Writing guidelines and reporting, including Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), were used in all included Mas. Regarding the assessment of the methodology by the AMSTAR-2 scale indicating that the quality was very critical in one, low in 2 MAs, and moderate in one MA. All MAs were classified as level IV evidence except one, which was classified as level III, and this was due to the retrospective nature of the included studies and the failure to report the p-value of the overall effect. Conclusion Despite the power of meta-analysis to increase sampling and precision, the quality of current non-randomized evidence on real causality and real incidence of myocarditis after COVID-19 vaccine is still low.

Anti-Islet Autoantibodies in Type 1 Diabetes.

Anti-islet autoantibodies serve as key markers in immune-mediated type 1 diabetes (T1D) and slowly progressive T1D (SPIDDM), also known as latent autoimmune diabetes in adults (LADA). Autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA), tyrosine phosphatase-like protein IA-2 (IA-2A), and zinc transporter 8 (ZnT8A) are currently employed in the diagnosis, pathological analysis, and prediction of T1D. GADA can also be detected in non-diabetic patients with autoimmune diseases other than T1D and may not necessarily reflect insulitis. Conversely, IA-2A and ZnT8A serve as surrogate markers of pancreatic β-cell destruction. A combinatorial analysis of these four anti-islet autoantibodies demonstrated that 93-96% of acute-onset T1D and SPIDDM cases were diagnosed as immune-mediated T1D, while the majority of fulminant T1D cases were autoantibody-negative. Evaluating the epitopes and immunoglobulin subclasses of anti-islet autoantibodies help distinguish between diabetes-associated and non-diabetes-associated autoantibodies and is valuable for predicting future insulin deficiency in SPIDDM (LADA) patients. Additionally, GADA in T1D patients with autoimmune thyroid disease reveals the polyclonal expansion of autoantibody epitopes and immunoglobulin subclasses. Recent advancements in anti-islet autoantibody assays include nonradioactive fluid-phase assays and the simultaneous determination of multiple biochemically defined autoantibodies. Developing a high-throughput assay for detecting epitope-specific or immunoglobulin isotype-specific autoantibodies will facilitate a more accurate diagnosis and prediction of autoimmune disorders. The aim of this review is to summarize what is known about the clinical significance of anti-islet autoantibodies in the pathogenesis and diagnosis of T1D.

An in-depth appraisal of clinico-biochemical and radiological findings of COVID-19 patients during the COVID-19 pandemic in a dedicated COVID Care Hospital in Eastern India and its outcome in relation to the COVAXIN vaccination status: A 2-year study.

COVID-19 pandemic hit Odisha province from April 2020 to December 2020, then from April 2021 to August 2021 and from February 2022 to April 2022 as the first, second, and third waves, respectively, with the most severe form witnessed during the second wave. Kalinga Institute of Medical Sciences hospital in Odisha was declared a Dedicated COVID Hospital (DCH) during those three waves and witnessed 9485 cases of admissions among which there were 1214 deaths. COVAXIN vaccination of the vulnerable population was launched in February 2021 onwards. This study has been done to know the clinic-biochemical profiles, radiologic findings of COVID-19 admitted patients, the predictors of mortality in the second wave, and clinical outcomes in the three waves in relation to COVAXIN vaccination status. This was a serial three-round retrospective study from the electronic medical records using multistage random sampling where we collected and critically analyzed the demographic, and all the relevant possible health data of the cases that consist of 514 cases admitted in three waves. The data from death certificates among the 555 cases in the second wave have been analyzed to conclude predictors of mortality. Mortality increased with age, male gender, comorbidities, and raised C-reactive protein level. High NL ratio, extent of pulmonary involvement. There was a wide variation in incidence and spectrum of illness starting from 79% incidence of mild symptomatic in the initial and third wave, but remained in the range of 35-65% in the second wave, respectively, and the most noticeable symptomatic illness was that of the upper respiratory tract. In fulminant cases, the mode of presentations was severe pneumonia and acute respiratory distress syndrome. Males were more sufferers than females. Children had better outcomes compared to adults. COVID-associated coagulopathy had a normal platelet count. Subsequently, in 2021 year onwards vaccination of the vulnerable population was launched in a phased manner that changed the dynamics of the disease outcome by better survival chances despite intercurrent COVID infection by induction of herd immunity. On the contrary, there was a higher prevalence of serious illness among non-vaccinated individuals. While the cases continued during the second wave of the pandemic, long COVID became a clinical entity of symptomatic that persisted or recurred among the COVID illness recovered cases after reverse transcriptase polymerase chain reaction results for COVID-19 became negative. The symptoms consisted of fatigue, cough, dyspnea as pulmonary manifestations and extra-pulmonary involvement of the cardiac, renal, and central nervous systems and the pulmonary imaging features consisted of interstitial pneumonia, consolidation, cavity pattern, and prone to microbial infection. These events lead to morbidity and admission. Coinciding with the vaccination of all population of Odisha province with the first dose of the vaccine by around the period of the first quarter of 2022, there was a new variant named Omicron responsible in the third wave, in which the majority of the admitted cases had.mild upper respiratory illness. This was not as lethal as its predecessors due to its lower propensity to invade the lungs and blood vessels. Immune dysregulation plays a central role in the pathogenesis of the manifestations. Vaccine-induced protection and the induction of herd immunity played a proactive role in the waning of the severity of clinical presentations.

Rapidly Progressive, Lethal Microangiopathy of the Brain: Two Cases of Malignant Susac Syndrome? (P9-5.015)

<h3>Objective:</h3> To present two fulminant cases of suspected Susac syndrome refractory to immunomodulatory therapy. <h3>Background:</h3> Susac syndrome (SS) is a presumed immune-mediated endotheliopathy characterized by a triad of encephalopathy, hearing loss, and branch retinal artery occlusions (BRAO). SS may vary in clinical presentation and course and yet typically responds to immunosuppressive therapy. Fatal cases of SS have been rarely reported. <h3>Design/Methods:</h3> NA <h3>Results:</h3> We describe two cases, 15 years apart, of suspected malignant SS. Our patients, a 36-year-old man and a 35-year-old woman presented with several symptoms including encephalopathy, hearing loss, and, in one case, blurred vision. Neither demonstrated BRAO. The first patient had a positive toxicology screen for methamphetamines. The second patient had a history of hypertension and morbid obesity. Serial MRIs demonstrated progressive scattered punctate foci of restricted diffusion throughout the brain, including the cerebrum, corpus callosum, brainstem, and cerebellum. An area of leptomeningeal enhancement was appreciated in our second patient. Extensive workup in both cases failed to yield an alternative diagnosis. Our patients were treated with high-dose intravenous methylprednisolone and intravenous immunoglobulin without improvement. The second patient also received intravenous cyclophosphamide, aspirin, clopidogrel, therapeutic heparin, and rituximab. Both declined in the hospital despite treatment and died shortly following withdrawal of life-sustaining treatments: the man on hospital day 25 and woman on hospital day 42. Autopsy in both cases demonstrated innumerable microscopic and lacunar infarcts of varying ages throughout the brain, interpreted as most consistent with SS. <h3>Conclusions:</h3> These cases highlight an uncommon aggressive variant of suspected SS leading to death within weeks of symptom onset despite intensive therapies. SS poses a diagnostic and treatment dilemma particularly in patients with a fulminant course. <b>Disclosure:</b> Dr. Tierney has nothing to disclose. Dr. Kazanci has nothing to disclose. Dr. Weinstein has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Longstreth has received research support from NIH. Dr. Davis has nothing to disclose. Desiree A. Marshall, 431 has nothing to disclose. Dr. Yoda has nothing to disclose.

Molecular and Clinical Links between Drug-Induced Cholestasis and Familial Intrahepatic Cholestasis.

Idiosyncratic Drug-Induced Liver Injury (iDILI) represents an actual health challenge, accounting for more than 40% of hepatitis cases in adults over 50 years and more than 50% of acute fulminant hepatic failure cases. In addition, approximately 30% of iDILI are cholestatic (drug-induced cholestasis (DIC)). The liver's metabolism and clearance of lipophilic drugs depend on their emission into the bile. Therefore, many medications cause cholestasis through their interaction with hepatic transporters. The main canalicular efflux transport proteins include: 1. the bile salt export pump (BSEP) protein (ABCB11); 2. the multidrug resistance protein-2 (MRP2, ABCC2) regulating the bile salts' independent flow by excretion of glutathione; 3. the multidrug resistance-1 protein (MDR1, ABCB1) that transports organic cations; 4. the multidrug resistance-3 protein (MDR3, ABCB4). Two of the most known proteins involved in bile acids' (BAs) metabolism and transport are BSEP and MDR3. BSEP inhibition by drugs leads to reduced BAs' secretion and their retention within hepatocytes, exiting in cholestasis, while mutations in the ABCB4 gene expose the biliary epithelium to the injurious detergent actions of BAs, thus increasing susceptibility to DIC. Herein, we review the leading molecular pathways behind the DIC, the links with the other clinical forms of familial intrahepatic cholestasis, and, finally, the main cholestasis-inducing drugs.

The long-term adverse events and persisting clinical symptomatology post COVID-19 infection among the healthcare workers of a tertiary care hospital in West Bengal

COVID -19, a global pandemic, has dominated every person’s life worldwide. The clinical presentation of COVID-19 ranges from asymptomatic, mild symptomatic to fulminant and fatal cases, having consequences for many organ systems. In a cross-sectional study, 128 healthcare workers of a tertiary care medical college hospital, 4 weeks following the COVID infection agreed to participate in the study. Self-developed subject data sheet and the self-reporting symptoms tool based on the WHO case report form were used for data collection. A significant number of health care workers (HCWs) had long COVID symptomatology in terms of constitutional, muscular-skeletal, respiratory, otolaryngology, and CNS symptoms. The commonly experienced symptoms were myalgia (45.3%), malaise (39%), fatigue and tiredness (69.5%), loss of taste (21.1%), loss of smell (20.3%) and night sweats (11.7%), lack of sleep (20.3%), and anxiety (12.5%). The cardiovascular and integumentary were the less affected organ systems. About one-third of the HCWs reported that symptoms like myalgia, malaise and tiredness got worse after physical activity (29.7%). Aggravation of symptoms with any form of mental activity was reported in 11.7% of the study participants. One in every ten HCWs (12.5%) had reported not being able to perform daily activities that they were doing before getting COVID-19 infection. However, all resumed their job after the recovery. Long COVID symptoms were reported by a significant number of HCWs, necessitating the need for the establishment of follow-up clinics for the care of healthcare workers.

Oxidative stress-A key determinant of complications and negative outcome in hepatitis E virus infected pregnancies: A comprehensive account involving cases from northeast India.

Regulated oxidative stress (OS) is important during pregnancy. Sporadic studies suggest the significance of deregulated OS in hepatitis E virus (HEV) infected pregnancy, but with limited reactive oxygen species (ROS) or antioxidant markers. The present novel study, therefore, aimed to evaluate the significance of ROS-antioxidant imbalance and resulting altered OS in HEV infected pregnancy complications like preterm delivery (PTD) and outcome. Difference in serum levels of ROS and antioxidant panel of markers were evaluated by ELISA for HEV immunoglobulin M RNA positive genotype 1 cases (including acute [acute viral hepatitis, AVH] and fulminant [fulminant hepatic failure, FHF] cases) and healthy term delivery subjects, and analyzed statistically. Direct ROS marker H2 O2 levels and indirect OS marker for DNA damage 8-hydroxy-2'-deoxyguanosine was significantly increased in HEV-cases compared to controls, and was associated and prognostic factor for PTD and fetal death in HEV cases. A comparatively lower total serum antioxidant capacity was observed in the FHF cases compared to the control subjects and the AVH cases. Glutathione (GSH) levels and superoxide dismutase (SOD) activity were significantly associated with PTD in the FHF sub-cohorts (p = 0.017) and AVH sub-cohorts (p < 0.001), respectively, and was associated with poor prognosis in HEV cases. The serum H2 O2 levels were found to be negatively correlated with SOD activity (p = 0.016) and GSH levels (p = 0.001) in the HEV-AVH cases; and positively correlated with the viral load in HEV cases (p = 0.023). The ROS-antioxidant imbalance resulting OS plays a detrimental associative role in HEV infected pregnancy complications like PTD and adverse pregnancy outcomes; and holds therapeutic significance.

390. Eravacycline combination therapy for severe, recurrent, or fulminant Clostridioides difficile infection

Abstract Background Eravacycline (ERV) is a fluorocycline with in vitro activity against Clostridioides difficile infection (CDI). The purpose of this study was to evaluate the usage of ERV in the management of CDI. Methods IRB-approved, retrospective case series in a health system that added ERV to formulary in 9/2019. All patients between 9/2019 and 2/2020 treated with adjunctive ERV for &amp;gt; 24 hours for severe, recurrent, or fulminant CDI were included. Exclusion criteria: pregnant, age &amp;lt; 18 years. Primary outcome: all-cause mortality at 30 days (d) from start of ERV. Secondary outcomes: clinical cure, colectomy, and recurrence within 30 d. Data was reported using descriptive statistics and measures of central tendency. Results 14 patients included: severe (4, 29%), recurrent (4, 29%), and fulminant CDI (6, 43%) (table 1). Infectious diseases consult: 14/14, median time to consult 1 (1, 2) d. Surgery consult: 1 severe and 5 fulminant CDI cases, median time to consult 1 (1, 3) d. Prior to ERV initiation, 10 patients were on oral vancomycin (PO VAN) and intravenous metronidazole (IV MTZ), one was on PO VAN, two were on IV MTZ, and one was on no CDI therapy. After ERV was initiated, six patients were on ERV, PO VAN, and IV MTZ combination and eight patients were on ERV and PO VAN concurrently. The reason for using ERV was fulminant CDI (6, 42.8%), severe CDI (4, 29%), unable to tolerate other CDI medications (3, 21%), refractory CDI (3, 21%), and recurrent CDI (1, 7%). Time to eravacycline initiation 1.5 d (1, 3.75) with median duration of 6 d (4.5, 7.75). 30-day all-cause mortality 2 (14%), all were in-hospital; 1 (7%) hospice. Clinical cure occurred in 12 (86%). Two (14%) required colectomy; one received surgery on the same day of CDI diagnosis and ERV initiation and the other had surgery 4 days before ERV initiation. Two patients with recurrent CDI received fecal microbiota transplant outpatient, one of which also received bezlotoxumab. Zero recurrences and one readmission within 30 d. Table 1.Patient demographics, severity, and clinical outcomes Conclusion ERV appears to be a potential adjunctive therapy for severe, recurrent, or fulminant CDI. Prospective studies are needed to further investigate the safety and efficacy of ERV in serious CDI. Disclosures All Authors: No reported disclosures.

A Successful Case of Cardiac Arrest due to Acute Myocarditis with COVID-19: 120 Minutes on Manual Cardiopulmonary Resuscitation then Veno-Arterial Extracorporeal Membrane Oxygenation

Acute myocarditis is one of the common complications of coronavirus disease 2019 (COVID-19) with a relatively high case fatality. Here reported is a fulminant case of a 42-year-old previously healthy woman with cardiogenic shock and refractory cardiac arrest due to COVID-19-induced myocarditis who received veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) after 120 minutes of cardiopulmonary resuscitation (CPR). This is the first adult case of cardiac arrest due to COVID-19-induced myocarditis supported by ECMO that fully recovered with normal neurological functions. The success of the treatment course with full recovery emphasized the potential role of ECMO in treating these patients.

The Prevalence, Demographics, Clinical Features, Neuroimaging, and Inter-ethnic Differences of MOGAD in Malaysia with Global Perspectives

IntroductionCNS IIDDs11Central Nervous System Idiopathic Inflammatory Demyelinating Diseases tested positive for anti-MOG22Myelin Oligodendrocyte Glycoprotein are known to have a distinct clinical profile with a better overall prognosis. ObjectivesWe aim to determine the prevalence, demographic and clinical characteristics of MOG antibody disease (MOGAD) specifically identifying any ethnic variations unique to our local population, with global perspectives. MethodsThis is a cross-sectional study conducted at the Neurology Department, Kuala Lumpur Hospital from January 2018 to January 2021. Out of 750 CNS IIDDs, seventy-eight consecutive anti-AQP4 antibody negative NMOSD/high risk undifferentiated relapsing or monophasic CNSIIDD subjects were tested for anti-MOG. ResultsAnti-MOG was positive in thirty six out of seventy-eight (%)(46.1%) seronegative patients. The prevalence of MOGAD in our Malaysian population is 0.12 per 100,000 persons with less marked female preponderance of 2:1 and younger age at onset of 23.8 ± 14.4 years. Despite a predominantly ethnic Malay population, a high proportion of our MOGAD patients were Indian (Proportion of Malay:Chinese:Indian:others; 16:9:10:1, prevalence 0.5 per 100,000 population for Indians) with favourable disease course in the most with minor exceptions. Monophasic and relapsing disease course was seen in 11.2% and 88.8% of patients respectively. However, fulminant aggressive disease can occur especially amongst the Chinese and paediatric cohorts. Optic neuritis, NMOSD and ADEM were the commonest presentations at onset and first relapse. EDSS at diagnosis, first relapse, and last follow-up were 4.5±2.5, 3±2.0, and 1.75(range 1-3). Neuroimaging showed large, fluffy, PRES- like supratentorial cortical, periventricular deep white matter ,diencephalon lesions,enhancing anterior optic nerve with or without chiasmal sparring lesions and cervical/cervicothoracic involvement. Area post rema lesions were rare. Threshold steroid levels exist relapsing on withdrawal some fulminantly requiring Immunosuppressants(rituximab) and intravenous immunoglobulins to maintain remission. ConclusionMalaysian MOGAD profile was similar to its international descriptions of the disease with ethnic selectivity for Indians. Prolonged steroid maintenance is essential to prevent relapses. Fulminant aggressive cases of MOGAD especially amongst Paediatric patients and the Chinese cohort have been reported.

Acute fulminant rhino-orbito-cerebral mucormycosis: Our experience with open approach in the COVID era

Objectives: Rhino-orbito-cerebral mucormycosis (ROCM) is a quite rare and an extremely aggressive infection which can cause profound destruction of tissues. A high index of suspicion is required to diagnose and treat this infection. Although mostly occurring in diabetic or immunosuppressed patients, a sudden surge of these patients has been observed in the COVID era. Mortality is extremely high in neglected cases and can range from 40%–85% or even more. In this article, we aim to highlight patient demographics, clinical features, diagnosis, management, and outcome of fulminant ROCM in patients managed jointly by plastic surgeons and maxillofacial surgeons by the open approach. Materials and Methods: Between May 2021 and August 2021, there was a sudden upsurge of mucormycosis patients admitted in our institute (IPGME and R, Kolkata). Less severe fulminant forms of the disease were managed by the department of otorhinolaryngology by endoscopy, whereas fulminant cases with extensive involvement were managed by the department of plastic surgery in conjunction with the department of maxillofacial surgery. The surgical management involved open access to the involved tissues and resection under direct vision combined with appropriate medical management. Results: In total, we operated on eight cases of fulminant ROCM of which 4 patients were male and 4 females. Apart from this, two male patients and one female patient were also planned for extensive debridement surgery but the same could not be performed because of poor anesthetic risk. Biopsies were taken in all of these patients. Therefore, out of a total of 11 patients with fulminant ROCM, 9 patients did not survive taking the mortality rate in fulminant cases to 82%. Conclusion: ROCM can be an extremely difficult disease to treat and is associated with a very high mortality rate in fulminant cases. Early diagnosis coupled with adequate debridement and systemic amphotericin B has the prospect of salvaging patients with this dreaded disease.

Massive intravascular hemolysis is an important factor in Clostridium perfringens-induced bacteremia.

Clostridium perfringens bacteremia is rare but often fatal. In particular, once bacteremia with massive intravascular hemolysis (MIH) occurs, the mortality rate is extremely high. However, because of its rarity, the detailed pathophysiology of this fulminant form of bacteremia is unclear. To elucidate the detailed pathogenesis of MIH, we retrospectively reviewed the data of all patients with C. perfringens bacteremia from two university hospitals from 2000 to 2014. The medical records and laboratory data of 60 patients with bacteremia, including 6 patients with MIH and 54 patients without MIH, were analyzed. Patients with MIH had higher rates of intense pain at onset, impaired consciousness, shock at presentation, hematuria, metabolic acidosis, and gas formation than patients without MIH. The antibiotic susceptibility of the clinical isolates was not significantly different between the two groups. All patients with MIH, although treated with appropriate antimicrobial agents, died within 26h of admission due to rapidly progressive acute lung injury or acute respiratory distress syndrome, and the median time from arrival at the hospital to death was only 4h and 20min. When clinicians observe intravascular hemolysis in blood samples from patients with characteristic symptoms of MIH, they should prepare for a severe disease outcome. The underlying pathophysiology of fulminant cases must be investigated.