Laboratory Markers Of Inflammation Research Articles

Updates on the Evaluation and Management of Febrile Neonates.

In August 2021, the American Academy of Pediatrics published a guideline, the first of its kind, to synthesize decades of research on the care of febrile neonates. The guideline is not meant to dictate one particular course of treatment for every clinical scenario, but rather to provide evidence-based recommendations to guide care in collaboration with the patient's caretaker(s). The guideline considers evolving bacteriology, costs of care, advances in laboratory testing and inflammatory markers, and known risks related to the hospitalization of young infants. The guideline highlights 21 key action statements to guide practitioners in the care of neonates presenting with fever, with the aim of optimizing outcomes while reducing risk and unnecessary costs. [Pediatr Ann. 2022;51(2):e49-e51.].

P208 Enthesopathies in patients with inflammatory bowel diseases

Abstract Background Background. The aim of study was to evaluate the enthesis in patients with inflammatory bowel diseases (IBD) and to assess the involvement of enthesis in different IBD behavior. Methods Methods. 95 IBD pts were prospectively enrolled into the study: 55 pts with ulcerative colitis (UC) and 40 - with Crohn’s disease (CD). The average duration of the disease was 48 (12; 102) months in UC, and 42 (18; 87) months in CD. The severity of UC exacerbation was assessed by the Mayo index, in CD – by Harvey-Bradshaw index. In UC, moderate and severe exacerbation was revealed in 40 pts (73%), in CD - in 17 (43%). Among 95 pts with IBD, extraintestinal manifestations occurred in 67 pts (71%), of which 34 (62%) pts with UC and 33 (82%) pts with CD. 70 enthesis were evaluated clinically and by US in each pt. The clinical examination included tenderness of enthesis, US examination with power Doppler detected inflammatory (hypoechogenicity of enthesis, thickening of enthesis, presence of vascularization) and structural (erosion, enthesophyte) changes in enthesis. Fisher’s exact test, Spearman’s coefficient and binary logistic regression to determine the odds ratio (OR) were used to calculate differences. Results Results. The duration of IBD course directly correlated with the number of tender entheses (SR = 0.24; p = 0.017), as well as the number of enthesophytes (SR = 0.20; p = 0.044). The severity of IBD exacerbation and enthesis involvement didn’t have statistically significant correlation. However, the inflammatory lesions of entheses (the number of erosions with vascularization) correlated with CRP level (SR = 0.25; p = 0.01). We also identified a relationship between the presence of extraintestinal manifestations and the enthesis involvement: for example, the presence of at least one extraintestinal manifestation increased the likelihood of detecting erosions by 4.77 times (95% CI 1.6–13.9, p = 0.003). The presence of joint pain increased the likelihood of detecting erosions of entheses by 3.37 times (95% CI 1.18–9.65, p = 0.02). Clinical signs of musculoskeletal system involvement (tenderness of enthesises on palpation) significantly increased the frequency of enthesitis, including vascularized enthesitis (p = 0.01). Conclusion Conclusion. In IBD pts with long disease duration and the presence of extraintestinal manifestations, structural (erosion, enthesophytes) changes in enthesis were observed significantly more often. The frequency of entheses erosions was higher in the presence of pain in the joints, and the number of erosions with vascularization with an increase in laboratory markers of inflammation (CRP).

Essential metals, vitamins and antioxidant enzyme activities in COVID-19 patients and their potential associations with the disease severity.

The role of micronutrient deficiency in the pathogenesis of COVID-19 has been reviewed in the literature; however, the data are limited and conflicting. This study investigated the association between the status of essential metals, vitamins, and antioxidant enzyme activities in COVID-19 patients and disease severity. We recruited 155 patients, who were grouped into four classes based on the Adults guideline for the Management of Coronavirus Disease 2019 at King Faisal Specialist & Research Centre (KFSH&RC): asymptomatic (N = 16), mild (N = 49), moderate (N = 68), and severe (N = 22). We measured serum levels of copper (Cu), zinc (Zn), selenium (Se), vitamin D3, vitamin A, vitamin E, total antioxidant capacity, and superoxide dismutase (SOD). Among the patients, 30%, 25%, 37%, and 68% were deficient in Se (< 70.08 µg/L), Zn (< 0.693 µg/mL), vitamin A (< 0.343 µg/mL), and vitamin D3 (< 20.05 µg/L), respectively, and SOD activity was low. Among the patients, 28% had elevated Cu levels (> 1.401 µg/mL, KFSH&RC upper reference limit). Multiple regression analysis revealed an 18% decrease in Se levels in patients with severe symptoms, which increased to 30% after adjusting the model for inflammatory markers. Regardless of inflammation, Se was independently associated with COVID-19 severity. In contrast, a 50% increase in Cu levels was associated with disease severity only after adjusting for C-reactive protein, reflecting its possible inflammatory and pro-oxidant role in COVID-19 pathogenesis. We noted an imbalance in the ratio between Cu and Zn, with ~ 83% of patients having a Cu/Zn ratio > 1, which is an indicator of inflammation. Cu-to-Zn ratio increased to 45% in patients with mild symptoms and 34%–36% in patients with moderate symptoms compared to asymptomatic patients. These relationships were only obtained when one of the laboratory parameters (lymphocyte or monocyte) or inflammatory markers (neutrophil-to-lymphocyte ratio) was included in the regression model. These findings suggest that Cu/Zn might further exacerbate inflammation in COVID-19 patients and might be synergistically associated with disease severity. A 23% decrease in vitamin A was seen in patients with severe symptoms, which disappeared after adjusting for inflammatory markers. This finding may highlight the potential role of inflammation in mediating the relationship between COVID-19 severity and vitamin A levels. Despite our patients’ low status of Zn, vitamin D3, and antioxidant enzyme (SOD), there is no evidence of their role in COVID-19 progression. Our findings reinforce that deficiency or excess of certain micronutrients plays a role in the pathogenesis of COVID-19. More studies are required to support our results.

Factors Associated With Noninfectious Fever After Endovascular Aortic Aneurysm Repair

Purpose: The post–endovascular abdominal aortic aneurysm repair (EVAR) inflammatory response, which is very often associated with fever, has been ascribed to a wide range of proinflammatory mediators and operative events. The aim of this study was to evaluate the impact of such factors in the development of fever of noninfectious origin after elective EVAR. Materials and Methods: A retrospective analysis of prospectively collected data of patients treated with standard elective EVAR between February 2017 and December 2020 was undertaken. The database included patients’ demographics and comorbidities, as well as laboratory inflammatory markers (white blood cell count, neutrophils, and C-reactive protein [CRP]) and anatomical characteristics (sac diameter, inferior mesenteric artery [IMA] patency and diameter, number of patent lumbar arteries, internal iliac artery [IIA] patency or occlusion). Intraoperative details, such as type of stent graft material and IIA overstenting, were also analyzed. Patients with infectious postoperative complications or previously receiving systemic anti-inflammatory medication were excluded. Statistical analysis was performed by SPSS 22.0 for Windows software (IBM Corp, Armonk, New York). Results: From 332 patients treated with elective EVAR between 2017 and 2020, 268 patients (all men) were included in the analysis. The mean age was 72.1±7.5 years and the mean aneurysm diameter was 59.1±12.1 mm. Seventeen patients were excluded due to a known infection site. From the study cohort, 114 (42.5%) patients presented with fever. Multivariate regression analysis confirmed that the occlusion of IMA ≥5 mm (p<0.008) and higher CRP (p<0.001) were independent factors associated with postoperative fever. A subanalysis was performed only on patients with patent IMA before EVAR. In the multivariate regression analysis of this subgroup, IMA ≥5 mm (p=0.008), presence of dyslipidemia (p=0.037), and higher CRP (p<0.001) were related to fever. Conclusion: Occlusion of an existing wide (≥5 mm) and patent IMA prior to EVAR may contribute to the development of post-EVAR pyrexia. The CRP is a reliable marker for post-EVAR fever. Further prospective studies are needed to corroborate these findings.

449. Performance of the Brighton Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C) Among a Large Single Center Cohort

BackgroundMultisystem Inflammatory Syndrome in Children (MIS-C) is a rare, life-threatening, hyperinflammatory condition presumed to follow SARS-CoV-2 infection. Whether MIS-C can also follow SARS-CoV-2 vaccination is not clear, making MIS-C an adverse event of special interest following immunization. Monitoring for post-vaccine MIS-C is complicated by the clinical overlap of MIS-C with numerous other inflammatory conditions including Kawasaki Disease, toxic shock syndrome, and viral myocarditis. A case definition for MIS-C was recently created with the Brighton Collaboration (BC). We aimed to determine the performance of the BC MIS-C case definition among a large, single-center MIS-C cohort.MethodsRetrospective review was performed for the first 100 MIS-C cases at our institution (May 2020-February 2021). All cases met the Centers for Disease Control and Prevention (CDC) case definition. Data on age, presentation, laboratory results and cardiac studies were collected and used to determine cases that fulfilled the BC case definition for MIS-C (see figure).Case Definition: Definite Case ResultsOf 100 children (age < 21 years) diagnosed with MIS-C using the CDC case definition, 93 patients also fulfilled the BC definition. All 100 patients had elevated laboratory markers of inflammation and positive SARS-CoV-2 antibodies. However, 1 patient was excluded for significant respiratory symptoms (pulmonary hemorrhage), 5 were excluded due to only 1 clinical feature, and an additional patient was excluded for having none of the measures of disease activity. Among the 93 patients fulfilling the revised case definition, 88 (95%) met criteria for a definite case. Five of the 93 patients (5%) were considered probable cases, 1 reported only 1 day of fever and 4 had only 1 measure of disease activity.ConclusionThe original case definitions for MIS-C were created rapidly following the first emerging reports of this hyperinflammatory state. Knowledge of the varied clinical presentations of this disorder has grown substantially. Modification of the case definition to include features truly representative of MIS-C will allow for more precise diagnosis in the face of conditions which mimic MIS-C, and for accurate and reliable monitoring for adverse events following immunization.Disclosures Flor M. Munoz, MD, Biocryst (Scientific Research Study Investigator)Gilead (Scientific Research Study Investigator)Meissa (Other Financial or Material Support, DSMB)Moderna (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Pfizer (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Virometix (Other Financial or Material Support, DSMB)

Acute appendicitis during the spring COVID-19 pandemic in 2020 - a comparative retrospective study.

Acute appendicitis (AA) is the most common abdominal emergency. This article aims to document the impact of the ongoing COVID-19 pandemic on timely diagnosis of AA, duration of symptoms before examination in a medical institution, levels of laboratory inflammatory markers, and the length of hospital stay. Collected data were compared with current world literature. Two datasets were created, comprising patients with the histological diagnosis of AA determined from March 1 to June 30, 2019 (before of the onset of the COVID-19 pandemic) and in the same period of the spring pandemic of COVID-19 in 2020. The following information was obtained from patient medical records: Demographic data, information on symptom duration before AA diagnosis, information on laboratory inflammatory marker levels, the used surgical method, antibiotic treatment, histopathological findings, and the length of hospital stay. These data were processed using descriptive statistics methods and the two created datasets were compared with the use of statistical methods (an unpaired t-test and Welchs t-test). Thirty seven patients (26 men and 11 women) with the median age of 41 years were operated on for acute appendicitis at the Department of Surgery, Military University Hospital in Prague from March 1 to June 30, 2019. Thirty four patients (19 men and 15 women) with the median age of 42 years were operated on in the same period of 2020. No significant differences were found between these two compared datasets in terms of symptom duration, laboratory inflammatory marker levels or the length of hospital stay. The distributions of histopathological findings and used antibiotic treatments were also similar. In our study, we were unable to demonstrate any statistically significant differences between the datasets of patients operated on before and after the onset of the COVID-19 pandemic.

Testosterone, free, bioavailable and total, in patients with COVID-19.

Low testosterone (mainly total testosterone [TTe]) has been noted in patients with COVID-19. Calculated free testosterone (FTe) and bioavailable testosterone (BavTe) may reflect more accurately this hormone's levels. In this study, we sought to assess TTe, FTe as well as BavTe in male patients with COVID-19. Sera were collected upon admission from 65 men (10 in the intensive care units [ICU] and 55 in the wards) with polymerase chain reaction - proven COVID-19. A group of age-matched COVID-19-negative men (N.=29) hospitalized in general medical wards served as controls. Age, Body Mass Index (BMI) and 28-day mortality were noted. Measurements included TTe, sex-hormone binding globulin, albumin (the latter two for calculating FTe and BavTe) and laboratory markers of inflammation (white blood cell count [WBC], D-Dimers [D-D], lactate dehydrogenase [LDH], ferritin [Fer] and C-reactive protein [CRP]). Profoundly low TTe, FTe and BavTe were noted in most patients, and were associated with disease severity/outcome (being the lowest in COVID-19 patients in the ICU and overall being lower in non-survivors; analysis of covariance P<0.05). Pearson's correlations for logTe, logFTe or logBavTe versus WBC, D-D, LDH, Ferr or CRP were negative, ranging from -0.403 to -0.293 (P=0.009 to 0.014). TTe, FTe and BavTe are prone to be low in patients with COVID-19, are negatively associated with disease severity and may be considered to have prognostic value.

Sex and Gender Differences in Testing, Hospital Admission, Clinical Presentation, and Drivers of Severe Outcomes From COVID-19.

BackgroundMales experience increased severity of illness and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared with females, but the mechanisms of male susceptibility are unclear.MethodsWe performed a retrospective cohort analysis of SARS-CoV-2 testing and admission data at 5 hospitals in the Maryland/Washington DC area. Using age-stratified logistic regression models, we quantified the impact of male sex on the risk of the composite outcome of severe disease or death (World Health Organization score 5–8) and tested the impact of demographics, comorbidities, health behaviors, and laboratory inflammatory markers on the sex effect.ResultsAmong 213 175 SARS-CoV-2 tests, despite similar positivity rates, males in age strata between 18 and 74 years were more frequently hospitalized. For the 2626 hospitalized individuals, clinical inflammatory markers (interleukin-6, C-reactive protein, ferritin, absolute lymphocyte count, and neutrophil:lymphocyte ratio) were more favorable for females than males (P < .001). Among 18–49-year-olds, male sex carried a higher risk of severe outcomes, both early (odds ratio [OR], 3.01; 95% CI, 1.75 to 5.18) and at peak illness during hospitalization (OR, 2.58; 95% CI, 1.78 to 3.74). Despite multiple differences in demographics, presentation features, comorbidities, and health behaviors, these variables did not change the association of male sex with severe disease. Only clinical inflammatory marker values modified the sex effect, reducing the OR for severe outcomes in males aged 18–49 years to 1.81 (95% CI, 1.00 to 3.26) early and 1.39 (95% CI, 0.93 to 2.08) at peak illness.ConclusionsHigher inflammatory laboratory test values were associated with increased risk of severe coronavirus disease 2019 for males. A sex-specific inflammatory response to SARS-CoV-2 infection may underlie the sex differences in outcomes.

Remdesivir in Severe COVID-19 and Non-Invasive Ventilation: A Real-Life Experience.

Background: Antiviral treatment is a hot topic regarding therapy for COVID-19. Several antiviral drugs have been tested in the months since the pandemic began. Yet only Remdesivir obtained approval after first trials. The best time to administer Remdesivir is still a matter for discussion and this could also depend upon the severity of lung damage and the staging of the infection. Methods: We performed a real-life study of patients hospitalized forCOVID-19 and receiving non-invasive ventilation (NIV). In this single-center study, a 5 day course of Remdesivir was administered as compassionate use. Further therapeutic supports included antibiotics, low molecular weight heparin and steroids. Data collection included clinical signs and symptoms, gas exchange, laboratory markers of inflammation, and radiological findings. Major outcomes were de-escalation of oxygen-support requirements, clinical improvement defined by weaning from ventilation to oxygen therapy or discharge, and mortality. Adverse drug reactions were also recorded. All data were collected during hospitalization and during a 20-day follow up after treatment. Results: 51 patients were enrolled. A global clinical improvement was recorded in 22 patients (43%) at 12 days, and 36 (71%) at 20 days; in particular, at 12 days, 27 patients (53%) also had a de-escalation of oxygen-support class from a therapeutic point of view. Remdesivir use was associated with a lower hazard ratio for clinical improvement in the elderly (older than 70 years) and in subjects with more extensive lung involvement (total severity score at HRCT of more than 14). The 20-day mortality was 13%. Conclusions: Results demonstrated that Remdesivir is associated with an improvement in clinical, laboratory and radiological parameters in patients with severe COVID-19 and showed an overall mortality of 13%. We conclude that, in this cohort, Remdesivir was a beneficial add-on therapy for severe COVID-19, especially in adults with moderate lung involvement at HRCT.

The prognostic value of cardiac troponin for 60 day mortality and major adverse events in COVID-19 patients

BackgroundThe variability of coronavirus disease 2019 (COVID-19) illness severity has puzzled clinicians and has sparked efforts to better predict who would benefit from rapid intervention. One promising biomarker for in-hospital morbidity and mortality is cardiac troponin (cTn). MethodsA retrospective study of 1331 adult patients with COVID-19 admitted to the Rush University System in Illinois, USA was performed. Patients without cTn measurement during their admission or a history of end stage renal disease or stage 5 chronic kidney disease were excluded. Using logistic regression adjusted for baseline characteristics, pre-existing comorbidities, and other laboratory markers of inflammation, cTn was assessed as a predictor of 60-day mortality and severe COVID-19 infection, consisting of a composite of 60-day mortality, need for intensive care unit, or requiring non-invasive positive pressure ventilation or intubation. ResultsA total of 772 patients met inclusion criteria. Of these, 69 (8.9%) had mild cTn elevation (> 1 to < 2x upper limit of normal (ULN)) and 46 (6.0%) had severe cTn elevation (≥ 2x ULN). Regardless of baseline characteristics, comorbidities, and initial c-reactive protein, lactate dehydrogenase, and ferritin, when compared to the normal cTn group, mild cTn elevation and severe cTn elevation were predictors of severe COVID-19 infection (adjusted OR [aOR] aOR 3.00 [CI: 1.51 – 6.29], P < 0.01; aOR 9.96 [CI: 2.75 – 64.23], P < 0.01, respectively); severe cTn elevation was a predictor of in-hospital mortality (aOR 2.42 [CI: 1.10 – 5.21], P < 0.05) and 60-day mortality (aOR 2.45 [CI: 1.13 – 5.25], P < 0.05). ConclusionIn our cohort, both mild and severe initial cTn elevation were predictors of severe COVID-19 infection, while only severe cTn elevation was predictive of 60-day mortality. First cTn value on hospitalization is a valuable longitudinal prognosticator for COVID-19 disease severity and mortality.

Multisystem Inflammatory Syndrome in Children; an Emerging Global Threat - A Review

MIS C (Multisystem Inflammatory Syndrome in Children) is a disease related to post COVID-19 sequelae. Differential diagnosis includes Kawasaki disease, Bacterial sepsis, toxic shock syndrome, Appendicitis, Macrophage activation syndrome. Clinical Presentations include high grade fever, rashes, Gastrointestinal symptoms like (abdominal pain, vomiting, diarrhea), hypotension and shock. The pathogenesis of MIS-C is unknown, and a postinfective etiology has been hypothetical but unproven. Antibodies to SARS-CoV-2 appear in the second week following infection, although their existence does not suggest infection resolution. Laboratory markers of inflammation, such as CRP, are elevated. IVIG, Glucocorticoids such as methyl prednisolone, Antibiotics, thromboprophylaxis with Light Molecular Weight Heparin are the management options. Since the available information doesn't allow to formulate well-established guidelines or recommendations for MIS-C treatment, and therefore the long-term sequelae of the illness aren't yet known. Keywords: MIS C, IVIG, Kawasaki disease.

Role of biomarkers in predicting prognosis of Coronavirus disease 2019 (COVID-19): A retrospective cross-sectional study: Perspective of a tertiary care hospital in India

Background: COVID-19 is a novel disease triggered by the SARS-CoV-2 virus, a beta coronavirus similar to MERS-CoV and SARS CoV. Inflammatory markers have a vital role in the pathogenesis of nCOVID 19; understanding the importance of these inflammatory markers in determining disease status is essential given the impact of the disease on healthcare. Thus, being able to triage cases with minimal tests is momentous to capture, which we have investigated as per our study guidelines of the role of inflammatory markers such as D-dimer, CRP (C - reactive protein), Ferritin, LDH (Lactate Dehydrogenase) in patients with COVID 19. In addition, limited data is available comparing the utility of these inflammatory markers to predict the following parameters as the need for ICU, oxygen support requirement, and duration of in-hospital stay, which can help guide the management protocol. Aim: This study aims to determine markers associated with poor prognosis in patients with Coronavirus disease 2019 (COVID-19). Objectives: 1) To assess the inflammatory markers that are routinely investigated in COVID- 19 patients. 2) To determine the most probable factor to estimate severity in COVID- 19 and thus predict prognosis. Methods: This is a retrospective cross-sectional observational study of patients who tested SARS COV 2 positive by RT PCR. The laboratory inflammatory markers, namely Lactate Dehydrogenase, C reactive protein, D-dimer, Ferritin, were assessed in the selected patients, and their clinical data and demographic details were taken into account. The parameters considered for contributing to the severity included the number of days of stay in the hospital, oxygen requirement, and ICU needs. Analyses relied upon analysis of variance for cross-sectional study design and a P&lt; 0.05 statistical significance criterion. Results: There was a statistically significant difference found between oxygen requirement and D dimer (p&lt;0.001), LDH (p= 0.002), and CRP (p= 0.024). There was a statistically significant difference found between admission to ICU and D Dimer (p= 0.001). Conclusion: A statistically significant association between the increasing D-dimer levels and all the outcome measures considered was found. The D-dimer, LDH, and CRP help predict oxygen requirement, and all the inflammatory markers can predict the number of days of stay in the hospital.

Severity of COVID-19 Respiratory Complications during Pregnancy are Associated with Degree of Lymphopenia and Neutrophil to Lymphocyte Ratio on Presentation: A Multicenter Cohort Study.

This study aimed to determine if laboratory inflammatory markers can predict critical disease in symptomatic COVID-19 pregnant women. Multicenter, retrospective cohort study of all pregnant women presenting to New York City Health + Hospitals emergency departments from March 1 to May 30, 2020. We assessed all symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive pregnant women with room air oxygen saturation <95% on presentation. Logistic regression modeled the relationship of inflammatory markers to outcomes. Area under receiver operating characteristic (ROC) curve and maximum Youden index determined prognostic ability and optimal predictive cut-off values. A total of 498 of 5,002 pregnant women were SARS-CoV-2 RT-PCR positive of which 77 presented with hypoxemia. The absolute lymphocyte count (ALC) and neutrophil to lymphocyte ratio (NLR) were highly sensitive for progression to severe illness. ROC curve analysis identified predictive cutoffs: ALC < 1.49 × 109/L (96% sensitivity, 52% specificity, area under the receiver operating characteristic curve [AUC] = 0.80 (95% confidence interval [CI]: 0.70-0.90) and NLR >8.1 (100% sensitivity, 70% specificity, AUC = 0.86 (95% CI: [0.76-0.96]). ALC and NLR on presentation are sensitive markers of progression to critical COVID-19 disease in symptomatic pregnant women. This finding provides a practical, rapid method for assessment and can assist clinicians with decision-making regarding triage, level of care, and patient management. · Few tools exist to gauge risk of severe COVID-19 disease in pregnancy.. · ALC and NLR are sensitive predictive markers of disease progression in symptomatic women.. · Cut-off values for ALC and NLR will help direct patient triage and management..

Prior immunosuppressive therapy is associated with mortality in COVID‐19 patients: A retrospective study of 835 patients

Though it is widely believed that chronic immunosuppressive medications increase the severity of coronavirus disease 2019 (COVID‐19) illness, there is little data to support this. We performed a retrospective study of COVID‐19 positive patients diagnosed at a single academic medical center between March 10, 2020 and October 13, 2020. A total of 835 patients diagnosed with COVID‐19 by polymerase chain reaction were included (median age 64 years; 52% female). Of these, 46 (5.5%) had a prescription for an immunosuppressive therapy before diagnosis, most commonly oral steroids (20, 43%), mycophenolate (12, 26%), or tacrolimus (11, 24%). Patients on immunosuppressive therapy with COVID‐19 had increased mortality (30% vs. 17%, p = 0.036; odds ratio 2.1, 95% confidence interval 1.11–4.04), which remained significant (p = 0.040) after performing multivariate logistic regression controlling for gender, age, race, and comorbidity status. Laboratory markers of inflammation were uniformly elevated in both patients on or not on immunosuppressive therapies who died, but lymphocytes and neutrophils were decreased in both COVID‐19 patients on immunosuppressive therapies who died and who remained alive. These findings demonstrate that COVID‐19 disease is more severe in patients taking prior immunosuppressive medications. This finding emphasizes the need for aggressive monitoring and supportive care for immunosuppressed patients who are diagnosed with COVID‐19.

Interrelationships Between Serum Levels of Procalcitonin and Inflammatory Markers in Patients Who Visited a General Medicine Department.

Various laboratory markers of inflammation are utilized in general practice, but their clinical diagnostic significance is often ambiguous. In the present study, we determined the clinical significance of the examination of serum levels of procalcitonin (PCT) by comparing the PCT levels with the levels of other inflammatory markers, based on a retrospective review of 332 PCT-positive patients, including cases of bacterial infection (20.5%), non-specific inflammation (20.8%), neoplasm (9.9%), connective tissue diseases (8.4%), and non-bacterial infection (7.2%), were analyzed. The serum PCT level was highest in the bacterial infection group (1.94 ng/ml) followed by the non-specific inflammatory group (0.58 ng/ml) and neoplastic diseases group (0.34 ng/ml). The serum PCT level was positively correlated with serum levels of C-reactive protein (rho=0.62), soluble interleukin-2 receptor (sIL-2R; rho=0.69), and ferritin, the plasma level of D-dimer, and white blood cell count, and negatively correlated with the serum albumin level (rho=-0.52), hemoglobin concentration, and platelet count. The serum PCT level showed a stronger positive correlation with the serum sIL-2R level than the other biomarkers. The results suggest that an increased PCT level may indicate not only an infectious state but also a non-bacterial inflammatory condition in the diagnostic process in general practice.

Facial nerve palsy may indicate coronary artery lesions in Kawasaki disease.

Facial nerve palsy (FNP) is extremely rare in Kawasaki disease (KD) and the incidence is just 0.9-1.3%. Our objective was to study the clinical features and prognosis of KD accompanied with FNP and to determine whether FNP indicated an increased risk of coronary artery lesions (CALs) in KD. An observational study was performed on 9 patients diagnosed as KD accompanied with FNP in Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China between September 2012 and December 2019. Patients were followed up from September 2012 till September 2020. Clinical features, laboratory and echocardiography findings, treatments, and prognosis were analyzed retrospectively. And the clinical data of patients with FNP (group A, n = 9) were compared to matched KD patients without FNP (group B, n = 27) in order to determine whether FNP indicated an increased risk of CALs in KD. The matching factors included sex, age, days of illness at the intravenous immunoglobulin use, and classic/incomplete KD forms. Clinical data of 9 patients were analyzed in this study. Patients tended to be younger than 24months of age (88.9%) and 55.6% were under 12months. Median onset of FNP was day 10 of illness. Eight patients (88.9%) showed unilateral FNP. The levels of laboratory inflammatory markers (White blood cells count, neutrophil percentage, C-reactive protein, erythrocyte sedimentation rate, etc.) were significantly increased in most cases. CALs were noted in 8 of 9 patients (88.9%). Coronary artery aneurysms occurred in 4 cases (44.4%) and the remaining 4 patients showed coronary artery dilation. All patients were given intravenous immunoglobulin therapy (2g/kg), aspirin (30-50mg/kg/day), and short-term dexamethasone. During follow-up, both FNP and CALs were completely recovered in all patients. The duration time of FNP ranged from 10 to 130days. And the time for CALs to normal ranged from 12 to 282days. The occurrence of CALs was significantly higher in patients with FNP than those without FNP (88.9% vs. 25.9%, P < 0.05). KD accompanied with FNP is rare but may indicate an increased risk of CALs. Clinicians should take KD into consideration when children suffer from long-term fever with FNP, even with incomplete diagnostic features. With a long-term follow-up, both FNP and CALs have a good prognosis. • Facial nerve palsy may indicate an increased risk of coronary artery lesions in Kawasaki disease. • Clinicians should take Kawasaki disease into consideration when children suffer from long-term fever with facial nerve palsy, even with incomplete diagnostic features. • Facial nerve palsy and coronary artery lesions have a good prognosis in a long-term follow-up.

Hypokalemia as a Surrogate Marker of Severity in COVID 19 Infection

Introduction: Patients with COVID-19 infection present with a variety of clinical symptoms such as fever, diarrhea, dyspnea, anosmia and various electrolyte abnormalities. Hypokalemia is an important electrolyte abnormality associated with infection due to SARS-CoV-2 as it may be associated with life threatening cardiac abnormalitiesObjective: To investigate the prevalence and clinical implications of of hypokalemia and its association with disease severity and various laboratory markers of inflammation.Materials and methods-design, setting and participants: This retrospective study was conducted at Peerless Hospital, Kolkata, West Bengal, India, from March 15, 2020, to September 30, 2020. Participants included patients who received a diagnosis of COVID-19 after testing positive by RT-PCR test and were admitted to the hospital. The patients were classified as having severe hypokalemia (plasma potassium <3 mmol/L), hypokalemia (plasma potassium 3-3.5 mmol/L), and normokalemia (plasma potassium >3.5 mmol/L). We categorized patients into 3 groups of disease severity- mild (fever/uncomplicated upper respiratory tract infection without hypoxemia), moderate (pneumonia with no signs of severe disease, respiratory rate > 24/min OR spO2 <94% in room air) and severe (respiratory distress requiring mechanical ventilation- NIV or invasive, respiratory rate > 30/min Or SpO2 <90% in room air). The clinical features, lab and ECG abnormalities, were compared between the 3 groups. Data analysis was conducted in October 2020.Interventions: The patients were given general support and antiviral therapy. Their epidemiological and clinical features were collected.Results: 122 patients(38.4%) had hypokalemia and 58 patients(18.2%) had severe hypokalemia. There was significant association between disease severity and hypokalemia. Fever had significant association with hypokalemia and severe hypokalemia. There was also significant association between dyspnea, anosmia, decreased oxygen saturation, ECG abnormalities and mortality with hypokalemic patients. Also there was significant association between degree of hypokalemia and markers of systemic inflammation such as IL-6 and CRP.Conclusions: The high prevalence of hypokalemia among patients with coronavirus disease 2019 suggests the presence of disordered rennin angiotensin system activity, which is increased as a result of the reduced counteractivity of angiotensin converting enzyme 2, which is bound by severe acute respiratory syndrome coronavirus. The study also indicates the need to monitor this group of patients for cardiac rhythm disturbances, especially when drugs like hydroxychloroquine and azithromycin, which are known to prolong the QTc interval and are known to reduce the rate of cardiac conduction and cause arrythmias, are used off-label to treat COVID-19.

Evaluation of Management of Spondylodiscits in Patients Admitted to Neurosurgery Department of Benha University Hospitals

Background: spondylodiscitis is a spinal infection by a pathogen affecting primarily the intervertebral disc and the adjacent vertebral bodies, starting at the endplates, but with secondary involvement of the intervertebral discs. Patient and methods: this prospective, cross-sectional, observational study conducted in neurosurgery department at benha university hospitals from dec 2019 to april 2021. We included all patients with spondylodiscits without privilege to age or gender, and at any vertebral region, we applying a scoring system for spondylodiscitis, which we term spondt (spondylodiscitis diagnosis and treatment) based on three traits: [1] the inflammatory marker c-reactive protein (crp) (mg/dl), [2] pain according to a numeric rating scale (nrs) and [3] magnetic resonance imaging (mri), to monitor its progression following treatment. Result :from this study on 19 patient the mean range of age was 47 years , 78,9% was spontenous spondylodiscits and 21.1% was post surgical infection , applying spondt score of spondylodiscits on admission was 7 and on discharge was 3 , 36.8% have surgical treatment versus 63.2% have conservative treatment. The lenght of stay in hospital mean range was 4 weaks. Conclusion: although the frequency of spondylolithesis has increased significantly, its diagnosis can be missed due to non specific presentation. We recommended performing laboratory inflammatory markers and mri with contrast to patient with sever low back pain. Conservative treatment is usually sufficient in most cases surgery is reserved to case with neurological deficits due to evident spinal stenosis compression and cases with marked instability.

P167 IgG4 related disease: response to immunosuppressive therapy: a single centre retrospective study in the United Kingdom

Abstract Background/Aims IgG4 related disease (IgG4-RD) is a rare immune-mediated condition, increasingly being recognised as a multi-organ disorder. It is a relatively new entity and the precise prevalence is not known. It is a chronic fibro-inflammatory condition with raised circulating levels of immunoglobulin G4 and accumulation of plasma cells and fibrosis in the affected tissue. We report a retrospective observational study of patients with IgG4 related disease (IgG4-RD). Methods We conducted a retrospective observational study of patients seen at Guy’s and St Thomas’ NHS Foundation Trust Hospitals, London, UK. The data collected was analysed for clinical presentation, laboratory markers of inflammation, immunoglobulin subsets, autoantibody profiles, imaging and histopathology and compared to the 2019 ACR/EULAR criteria to determine a confirmed diagnosis of IgG4-RD. Data was also collected post standard-of-care treatment, including patient clinical outcomes and possible improvement. Results The study included a multi-ethnic cohort of 83 patients with multi-organ involvement. Fifty-nine of the eighty-three patients were classified as confirmed IgG4-RD (71%). Seventy one patients had biopsies of which 49 of the 59 (91%) confirmed IgG4-RD patients had biopsies consistent with IgG4-RD. Fifty patients underwent PET-CT scanning of which uptake was seen in 76% of those with confirmed IgG4-RD (26/34). Immunoglobulin IgG subclass analysis showed significantly higher IgG4 levels in the confirmed IgG4-RD group as compared to possible IgG4. Treatments were with corticosteroids and immunosuppressants such as azathioprine, methotrexate, mycophenolate, cyclophosphamide and rituximab. P167 Table 1:IgG4 levels and inflammatory markers for pre and post treatment groupsPre-RxPost-Rxp-valueCRPmean29 mg/l9 mg/l0.0298*Range0-300 mg/l1-70 mg/lESRmean35 mm/hr17 mm/hr0.0002*Range2-131 mm/hr1-74 mm/hrSerum IgG4mean4.9 g/L2.83 g/L0.0001*Range0.1-24.2 g/L0.02-13.3 g/L Conclusion IgG4-RD is a fibro-inflammatory disorder involving multiple organs. If not treated adequately may develop severe organ damage. It often responds to corticosteroids but may require other immunosuppressive therapy. Treatment with biologics such as B cell depletion therapy results are encouraging. Disclosure S. Sangle: None. N.T. Morton: None. A. Casian: None. L. Nel: None. J. Hanna: None. A. Fernando: None. R. Bell: None. P. Taylor: None. J. Pattison: None. T. O'Brien: None. D. D'Cruz: None.

Does the Course of Disease Influence the Development of Fatigue in Rheumatoid Arthritis Patients?

Abstract Patients with rheumatoid arthritis (RA) typically have many permanently inflamed joints. The inflammation inside the body can lead to general physical weakness, exhaustion, and drowsiness. This feeling of extreme tiredness is also called “fatigue”. Some people find this to be the worst symptom of the disease. However, the clinical significance of fatigue and its pathogenesis have not been recognised. This study aimed to determine the development of fatigue depending on activity and aggressiveness of RA. To achieve the goal, patients were interviewed and indicators of disease activity and aggressiveness were determined: rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), immunoglobulins IgA RF, IgM RF, IgG RF and anti-carbamylated protein antibodies (anti-CarP). Based on the results of the survey, RA patients were divided into two groups — with and without fatigue. In the group of RA patients with fatigue, statistically more often an increase in IgA RF, IgM RF, and IgG RF levels was observed in those with elevated RF level, higher IgM RF and IgG RF levels were associated with increase in IgA RF level, and increase in the IgG RF and anti-CarP levels with elevation in the IgM RF level. A higher IgG RF level contributed to a higher anti-CarP level increase. Significant differences in the levels of clinical and laboratory inflammatory markers were not observed between the RA patients with and without fatigue. The obtained data suggest that the aggressive course of RA, more than inflammation, may contribute to the development of fatigue in RA patients.