Multiple Organ Failure Research Articles

Extracorporeal pediatric renal replacement therapy: diversifying application beyond kidney failure.

The utilization of extracorporeal renal replacement therapy (RRT), including continuous renal replacement therapy (CRRT) and hemodialysis (HD), beyond the treatment of volume overload and acute kidney injury (AKI) has witnessed a significant shift, demonstrating the potential to improve patient outcomes for a range of diseases. This comprehensive review explores the non-kidney applications for RRT platforms in critically ill children, focusing on diverse clinical scenarios such as sepsis, inborn errors of metabolism, liver failure, drug overdose, tumor lysis syndrome, and rhabdomyolysis. In the context of sepsis and septic shock, RRT not only facilitates fluid, electrolyte, and acid/base homeostasis, but may offer benefits in cytokine regulation, endotoxin clearance, and immunomodulation which may improve multi-organ dysfunction as well as hemodynamic challenges posed by this life-threatening condition. RRT modalities also have an important role in caring for children with inborn errors of metabolism, liver failure, and tumor lysis syndrome as they can control metabolic derangements with the efficient clearance of endogenous toxins in affected children. In cases of drug overdose, RRT is a crucial tool for rapid extracorporeal clearance of exogenous toxins, mitigating potential organ damage. The intricate interplay between liver failure and kidney function is examined, elucidating the role of RRT and plasma exchange in maintaining fluid and electrolyte balance when hepatic dysfunction complicates the clinical picture. Furthermore, RRT and HD are explored in the context of rhabdomyolysis, highlighting their utility in addressing AKI secondary to traumatic events and crush syndrome.

Complications and multiple organ dysfunctions in canine babesiosis: A review

Complications and multiple organ dysfunctions in canine babesiosis: A review

8089 Myxedema Coma Presenting with Reversible Cardiomyopathy and Acute Renal Failure

Abstract Disclosure: A. Mubashir: None. F. Sajid: None. M. Sattar: None. Myxedema Coma is a life-threatening complication of hypothyroidism and often presents with multi-organ failure. However, reversible cardiomyopathy and acute renal failure are rare. Here, we present a case of iatrogenic hypothyroidism leading to myxedema coma with reversible organ failure. Case Presentation: A 58-year-old male with a past medical history of iatrogenic hypothyroidism after total thyroidectomy for follicular thyroid cancer, noncompliant with levothyroxine for the past three years, was brought to the hospital due to worsening mental status, low energy, and cold extremities for three days. On admission, vital signs were within normal limits. Laboratory studies revealed Random Glucose 113 (74-200 mg/dl), Na 134 (135-149 mmol/l), TSH: 217 (0.39-4.08 MCIU/ml), Free T4 <0.25 (0.58-1.64 ng/dl), Free T3 1.01 (2.53-3.87 pg/ml), BUN 53.3 (7-21 mg/dl), Creatinine 4.9 (0.5-1.3mg/dl). Urinalysis was positive for protein of 300 mg/dl (negative). Urine studies showed hematuria, total protein/cr 3.18 (<0.10), with increased total protein of 60/24 hours (0-12 mg/dl), suggesting glomerular etiology. Additionally, Bence Jones protein and monoclonal band were negative, interpreted as mild glomerular proteinuria. FeNa >2%, Urine sodium of >40 (20-40mmol/l) suggest acute tubular necrosis. EKG showed normal sinus rhythm with low voltage. To rule out diastolic dysfunction, an echocardiogram was performed, which revealed depressed systolic function with an ejection fraction of 31-35% and a large pericardial effusion with echocardiographic features of tamponade. He also had global cardiomyopathy with akinesis, especially in the inferior segments. He was treated with IV levothyroxine. Repeat imaging in one month showed an increase in ejection fraction to 55% with moderate-sized pericardial effusion and no echocardiographic features of tamponade. Global cardiomyopathy had also resolved. However, left ventricular systolic function was borderline, with delayed diastolic expansion of the right ventricle. Repeat creatinine was 2mg/dl. The patient’s condition greatly improved, and he was discharged with follow-up with endocrinology, nephrology, and cardiology. Discussion: In the available literature, diastolic dysfunction is associated with severe hypothyroidism. However, reversible global cardiomyopathy with decreased systolic function is rare. The pathogenesis of this myopathy is not well understood. Similarly, known mechanisms of renal injury in hypothyroidism include renal hypoperfusion, rhabdomyolysis, decreased kidney-to-body weight ratio, truncated tubular mass, and altered glomerular architecture. While the need to perform a renal biopsy or the use of goal-directed therapy for dilated cardiomyopathy remains questionable in such cases, reversible complications of severe hypothyroidism should be investigated in patients with suspected myxedema. Presentation: 6/2/2024

6698 Rapidly Progressive Type 1 Diabetes Mellitus Complicated By Hyperglycemic Crisis And Bowel Ischemia

Abstract Disclosure: D. Bondarenko: None. D. Deyar: None. R. Nadeem: None. M. Herrera: None. L.E. Arzeno: None. Introduction: Type 1 diabetes mellitus (T1DM) stems from insulin deficiency due to islet-related autoantibodies. Misclassification of T1DM as type 2 diabetes mellitus (T2DM) occurs in 40% of those developing T1DM after age 30. Fulminant T1DM (FT1DM), described in East Asia, exhibits rapid progression and is diagnosed by ketosis, blood glucose ≥288 mg/dL, HgbA1c <8.7%, and fasting C-peptide <0.3 ng/mL. We present a case of rapidly progressing T1DM in a white male presenting as a hyperglycemic crisis (HC) complicated by multiorgan failure and bowel ischemia. CASE:A 52-year-old male, T2DM diagnosed by HgbA1c of 8% (normal <5.7%) 1 month prior, presented to the emergency room obtunded with two days of nausea and vomiting. Vital signs were normal other than tachycardia and tachypnea. Blood work showed pH 7.0 (normal 7.31-7.41), creatinine 4.58 mg/dL (0.7-1.3 mg/dL), glucose >1500 mg/dL (normal 65-139 mg/dL), beta-hydroxybutyrate 114.7 mg/dL (normal 0.2-2.8 mg/dL), lactate 5.7 mmol/L (normal 0.5-2 mmol/L), serum osmolarity 438 mOsmol/kg (normal 275-295 mOsmol/kg), WBC 26.2 B/L (4-11 B/L) and 4% bands (normal 0%), Hgb A1c 17.1% , C-peptide 0.11 ng/mL (0.8 - 3.85 ng/mL), GAD65 1:600 - 1:1200 (normal < 1:600). He was intubated Day 1-5. HC was treated with intravenous (IV) fluids and IV insulin infusion. He transitioned to subcutaneous insulin by Day 2. 10 days hemodialysis achieved renal recovery. He was diagnosed with latent autoimmune diabetes of adult (LADA). No triggers were identified for his HC. From Day 1, his abdominal exam was notable for guarding. Initial abdominal computed tomography (CT) was normal. Abdominal pain and distension persisted despite normalized blood work. Repeat CT showed ileus vs obstruction. Surgery on Day 12 showed multifocal bowel ischemia requiring surgical resection. Conclusion: FT1DM is a subtype of T1DM seen in Asia characterized by rapid β-cell destruction with hyperglycemia and ketoacidosis. LADA subset of T1DM manifests in adults and may take up to three years to progress to insulin dependence. Triggers for both include autoimmunity, infections, and pregnancy. HC has been associated with increased risk of occlusive and nonocclusive bowel ischemia. While this case does not meet all criteria of FT1DM, the rapid progression of the HgbA1c and disease severity is an unusual presentation of LADA. Raising awareness of the complications of this severe metabolic disorder can improve timely interventions and medical outcomes. Presentation: 6/1/2024

12431 14-year-old Presenting With Thrombocytopenia-Associated Multi-Organ Failure In The Setting Of Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic Syndrome

Abstract Disclosure: N.C. Gunaratne-Breaux: None. D. Deplewski: None. Title: 14-Year-Old Presenting with Thrombocytopenia Associated Multi-Organ Failure in the setting of Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic Syndrome Background: Coagulation complications are rare in hyperglycemia emergencies in children and adolescents. In patients presenting with severe and atypical hyperglycemia emergencies, special considerations need to be made to rule out life-threatening coagulopathy. Clinical Case: A 14-year-old male with history of Type 1 Diabetes presented in severe Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic Syndrome overlap. Initially had severe hypotension and altered mental status concerning for cerebral edema. Initial venous blood gas showed pH of 6.82, pCO2 17.1, and HCO3 2.8, serum glucose was 1375 mg/dL, serum ketones >7.00 mmol/L, and serum osmolality was 384 mOsm/kg. Once insulin drip was started, glucose, ketones, and serum osmolality improved, but patient continued to be encephalopathic and had worsening tachypnea and desaturations. Patient was eventually intubated. After intubation, patient’s acidosis improved, but patient developed kidney failure (prompting initiation of dialysis), liver injury, decreased cardiac function, and high inflammatory state. A comprehensive multi-specialty team including pediatric intensive care, infectious diseases, rheumatology, neurology, and cardiology were involved in the care. On day three of admission, patient had multiple areas of ischemia on fingertips and ear and clotting of multiple IV and dialysis catheters, prompting a coagulopathy evaluation. Labs showed microcytic anemia (hemoglobin 10.0 g/dL; mean corpuscular volume 75fL), thrombocytopenia (platelet count 17 10e3/uL), coagulopathy (prothrombin time 16.8 sec, INR 1.3, prolonged thrombin time 48.8 sec), and elevated ferritin (507 ng/mL). Given labs and multi-organ involvement, determined by hematology to be Thrombocytopenia Associated Multi-Organ Failure (TAMOF). Patient was started on plasmapheresis and had dramatic improvement – was eventually extubated and returned to neurologic baseline without any notable deficits. Multi-specialty team ruled out all other possible causes of TAMOF; determination that the TAMOF developed secondary to DKA/HHS. Conclusion: Hyperglycemia emergencies can lead to a hyperinflammatory state that can lead to disruption of the coagulation cascade, including disseminated intravascular coagulopathy or thrombotic thrombocytopenia purpura. There have been rare reports of thrombocytopenia associated multi-organ failure provoked by DKA, thought secondary to critical illness mediated low ADAMST13 levels. This is a novel case of TAMOF caused by DKA/HHS overlap syndrome. It is important to screen for coagulopathy in cases of patients with DKA or DKA/HHS who do not show clinical improvement with resolution of ketosis and hyperosmolarity. Presentation: 6/2/2024

12372 A Rare Case Of Silicon Granulomatosis Induced Hypercalcemia In A Transgender Female

Abstract Disclosure: O.A. Aluko: None. I. Singh: None. Introduction: Hypercalcemia has been described in patients with most granulomatous disorders, of which sarcoidosis and tuberculosis are the most common. Granuloma formation is a rare, however well known complication of silicon implants and injections. We present a case of silicon granulomatosis induced hypercalcemia in a transgender female. Case Report 60-year-old transgender female, with past medical history of HIV on HAART was referred to Endocrinology for evaluation of hypercalcemia. She Bloodwork done a few weeks prior revealed elevated calcium 12.3 and low PTH of 9. Reported symptoms include worsening abdominal pain similar to prior gastritis flare, insomnia and significant weight loss. Denied any constipation, joint pain, mood changes, no history of bone fractures or kidney stones. Admitted to significant dairy intake - half a gallon of milk within 3 days and daily yogurt consumption. Endorsed inadequate daily fluid intake and she was not taking oral calcium or Vitamin D supplementation. Quit tobacco 9 years ago. Vitals were significant for tachycardia with HR 120/min, BP stable. Patient was referred to the ER for IV hydration and further evaluation with initial suspicion of malignancy. Repeat corrected calcium was 14.7, ionized calcium 6.8, PTHrP undetectable <2, borderline high 1,25 dihydroxyvitamin D 74.5, low vitamin D 17.9 and normal free T4 1.5. ACE, SPEP, UPEP levels within normal limits. Vitamin A low. CT chest/abdomen/pelvis revealed innumerable soft tissue foci in the subcutaneous adipose tissue of the flanks and lateral gluteal areas; nodular liver, suspected cirrhosis and portal hypertension. Imaging findings prompted further discussion regarding prior procedures. She endorsed history of silicone fillers in hips and breast implants 30 years ago. Images reviewed with radiology confirmed calcification around bilateral breast implants, with intracapsular rupture. Calcium improved with IV Fluids, bisphosphonates and steroids. The most probable cause of hypercalcemia was believed to be secondary to silicone granulomatosis. Innumerable granulomas were deemed irresectable, removal of the breast implants considered however not performed. She was later diagnosed with hepatitis B, cirrhosis and succumbed to sepsis and multiorgan failure. Conclusion Eliciting a detailed history, physical exam and correlating with imaging findings is imperative to establishing an uncommon diagnosis. PTHrP was low and there were no bony metastases making the possibility of malignancy related hypercalcemia less likely. FDG-PET if performed would reveal hypermetabolic nodules, often an initial indication to the underlying etiology. Presentation: 6/2/2024

8281 Continuous Low-Dose Etomidate Infusion For The Management Of Severe Hypercortisolism In Metastatic Adrenocortical Carcinoma

Abstract Disclosure: A. Jamil: None. N. Mohammad: None. S. Narayana: None. Background: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy of the adrenal glands with a poor prognosis that often presents with excess hormone secretion. Approximately, 45% of cases present with hypercortisolism.1 A key component of management is achieving control of hypercortisolism. Though there are multiple enteral therapies that can inhibit cortisol production, few treatment options are available for use in critically ill patients who are not surgical candidates and cannot take oral medications. Though primarily known as a short-acting intravenous anesthetic agent used for sedation, etomidate also inhibits 11-β-hydroxylase, a key enzyme involved in corticosteroid biosynthesis.2 Clinical Case: A 28-year-old woman with metastatic adrenocortical carcinoma with associated hypercortisolism was initially admitted for anemia and thrombocytopenia, with an initial cortisol on admission of 29.3 μg/dl (normal range: 2.3-19.4 ug/dl). Due to her large tumor burden with metastasis to the liver and invasion into the inferior vena cava, she was deemed a poor surgical candidate with a poor overall prognosis. Her hospital course was complicated by acute hypoxemic respiratory failure requiring intubation, and thus her enteral steroidogenesis inhibitors (mitotane, ketoconazole, and metyrapone) were discontinued as none were administrable via nasogastric tube. Consequently, her hypercortisolism worsened rapidly with a cortisol level of 351.3 μg/dl , prompting initiation of continuous low-dose etomidate infusion, which resulted in significant improvements in her cortisol levels. After eight days of etomidate treatment, her cortisol levels reached a goal value of 25.0 μg/dl. However, she then suffered an ischemic cerebrovascular event and multiorgan failure, and was subsequently transitioned to hospice care. Conclusion: Low-dose etomidate infusion is an effective therapeutic agent for hypercortisolism in patients with ACC that are unable to take oral medications.

CD151 identifies an NK cell subset that is enriched in COVID-19 patients and correlates with disease severity

Severe coronavirus disease 2019 (COVID-19) often leads to acute respiratory distress syndrome and multi-organ dysfunction, driven by a dysregulated immune response, including a cytokine storm with elevated proinflammatory cytokine levels. Natural killer (NK) cells are part of the innate immune system with a fundamental role in the defense against viral infections. However, during COVID-19 acute infection, they exhibit an altered phenotype and impaired functionality contributing to the immunopathogenesis of the disease. In this work, we have studied a cohort of patients with COVID-19 (ranging from mild to severe) by analyzing IL-15, TGF-β, PlGF and GDF-15 plasma levels and performing multiparametric flow cytometry studies. Our results revealed that severe COVID-19 patients exhibited high levels of IL-15, PlGF and GDF-15, along with an enrichment of anNK cell subset expressing the CD151 tetraspanin, which correlated with IL-15 plasma levels and disease severity. In patients, these CD151+ NK cells displayed a more activated phenotype characterized by an increased expression of HLA-DR, CD38 and granzyme B, a distinct receptor repertoire, with lower levels of CD160 and CD31 and higher levels of CD55 and, remarkably, a higher expression of tissue-resident markers CD103 and the NK cell decidual marker CD9. Last of all, in individuals with severe disease, we identified an expansion of a CD151brightCD9+ NK cell subset, suggesting that these cells play a specific role in COVID-19. Altogether, our findings suggest that CD151+ NK cells may have a relevant role in COVID-19 immunopathogenesis.

7045 A Rare Case of Lyme-Associated Thyroiditis in an Otherwise Healthy Patient

Abstract Disclosure: M. Windham: None. S.K. Majumdar: None. Introduction: Lyme disease, a common tick-borne illness, causes multiorgan inflammation and dysfunction. It commonly affects the musculoskeletal, neurologic, cardiovascular, and integumentary systems. The endocrine system is rarely involved. We report a case of Lyme-associated thyroiditis in an otherwise healthy 41-year-old man. Case: A 41-year-old man with a history of hypertension, gastroesophageal reflux and a known BRCA2 mutation presented to the emergency department due to one week of frequent palpitations, fatigue, dyspnea on exertion, and dry cough. Laboratory testing revealed thyrotoxicosis with an undetectable TSH (n 0.270—4.200 µIU/mL), FT4 of 7.04 ng/dL (n 0.80—1.70 ng/dL), and TT3 of 253 ng/dL (n 92.0—224 ng/dL). He denied any recent illnesses or pain in his thyroid. Further work up revealed negative TSI and TPO but did show an elevated high sensitivity CRP of 4.3 mg/L (n <1.0 mg/L) and a sedimentation rate of 33 mm/hr (n 0—20 mm/hr). A thyroid uptake and scan showed markedly decreased uptake suggestive of thyroiditis. The patient was started on a prednisone taper with improvement in his TFTs. At his follow up visit approximately one month later, he reported increasing stiffness in his bilateral jaw and continuing palpitations with movement despite near normalization in his FT4 and TT3, suggestive of possible underlying cardiac conduction defects. He did not recall a tick bite but lived in an area with endemic Lyme disease. Lyme antibodies were sent and returned with a positive Lyme IgG and an indeterminate Lyme IgM, which would be consistent with an active Lyme disease infection at the time of his initial presentation. Treatment for Lyme disease was prescribed. Conclusion: Between 1991 and 2021, the incidence of Lyme disease in the United States doubled due to the combined effects of climate change, increasing host species populations, and human encroachment on animal habitats. People who live in areas with endemic Lyme disease, such as the Northeast and upper Midwest regions of the United States, are at risk even if they do not recall a specific exposure. Although Lyme thyroiditis is extremely rare, its incidence is expected to increase as the overall incidence of Lyme disease increases. Therefore, it is important to consider Lyme disease in the differential when a patient from an endemic area presents with unexplained thyroiditis. Presentation: 6/2/2024

5128 Role of Plasmapharesis- A Tale of Two Thyroid Storms

Abstract Disclosure: Z. Zhang: None. S. Joseph: None. A.M. Kodali: None. D. Eagerton: None. Background: Thyroid storm is an acute life threatening endocrinological emergency. The standard treatment for a thyroid storm is antithyroid medication, iodine, beta blockers and corticosteroids. However, when patients are refractory to standard treatment, plasmapheresis may be an effective and safe intervention. Case 1: A 49-year-old male with typical symptoms of hyperthyroidism, presented with a Ventricular tachycardia arrest. After the return of spontaneous circulation, he was febrile, and developed new onset atrial fibrillation (AF) and Amiodarone drip was started. Physical exam showed a thin gentleman with an enlarged thyroid. ECHO showed LVEF 50% with moderate to severe dilatation of left atrium and mild mitral and tricuspid valve regurgitation. CT abdomen/pelvis and CTA chest did not show any pathology. Labs showed TSH of 0.02 (reference range: 0.465-4.68); Free T 4 >6.99 (reference range: 0.78- 2.19). He was started on Propylthiouracil (PTU), Hydrocortisone, Potassium Iodide, and Cholestyramine. His blood pressure was too low to tolerate a beta blocker. He developed increased liver enzymes thought to be due to shocked liver. PTU was switched to Methimazole due to less risk of hepatotoxicity. A Thyroid Stimulating immunoglobulin was 13.40 (reference range 0.00-0.55), confirming Graves’ disease. He developed multiorgan failure and plasmapheresis was initiated. His Free T4 level prior to his first apheresis was still >6.99 but improved to 6.20 after two days. After the second session, free T4 level drastically improved to 2.65. He sustained a level of 2.09 until his hospital discharge. Case 2: A 59-year-old male with untreated hyperthyroidism and AF, who presented with shortness of breath. He was tachycardic, febrile and developed AF with rapid ventricular response. A TSH and free T4 level showed <0.02 (reference range: 0.465-4.68); and >6.99 (reference range: 0.78- 2.19), respectively. Physical exam shows a cachectic man with an enlarged thyroid. ECHO showed reduced ejection fraction of 35% with biventricular failure. He was initially started on PTU, Potassium Iodide, hydrocortisone and esmolol drip and eventually Cholestyramine. Patient developed multisystem organ failure and PTU was switched to methimazole due to continued deterioration of his liver enzymes. Plasmapheresis started with a total of 3 sessions. His free T4 improved from 4.32 to 3.59 by the second session. Round three was performed when his Free T4 increased back to 4.56. Unfortunately, he had a sudden decline in mentation and CT head showed an acute/subacute left anterior parietal stroke and after family discussion, was palliatively extubated and expired. Discussion: This case series shows two cases of thyroid storm treated with plasmapheresis and had two stark contrasts. Further studies should be done to elucidate the usefulness of plasmapheresis for thyroid storm when refractory to standard of treatment. Presentation: 6/2/2024

12618 A Rare Case Of Diabetic Ketoacidosis Leading To Severe Hypertriglyceridemia-induced Necrotizing Pancreatitis

Abstract Disclosure: E.R. Perez Roman: None. D.A. Lopez Rodriguez: None. K. Ramirez Gorbea: None. M. Sanchez Cordero: None. Y. Garcia Cruz: None. Acute pancreatitis is an acute inflammatory process of the pancreas that if left untreated can become complicated resulting in multiple organ damage and a fatal outcome in approximately 10%-40% of patients. There are well-known causes that can lead to pancreatitis such as alcohol, hereditary disorders, cholelithiasis, prior pancreatitis, and medications. Less frequently, it can be related to poorly controlled diabetes mellitus and diabetic ketoacidosis (DKA), given that in a state of low or deprived insulin, there is a breakdown of triglycerides into toxic fatty acids by pancreatic lipases; this lipotoxicity can result in the development of acute pancreatitis. We present a case of a 50-year-old woman with a past medical history of untreated hyperlipidemia and previous pancreatitis who was transferred to our institution with acute epigastric pain radiating to the back, nausea, and persistent vomiting. Upon arrival, blood glucose was 299 mg/dL, HbgA1c of 11.4%, lactic acid of 3.6 mmol/L, hypocalcemia of 6.0 mg/dl, hypoalbuminemia, and elevated pancreatic enzymes, amylase 869 U/L and lipase 2,493 U/L. The lipid panel was remarkable for total cholesterol of 1,085 mg/dL and triglycerides of 4,369mg/dL. Abdominopelvic CT scan confirmed acute pancreatitis with extensive peripancreatic and regional mesenteric edema. This patient was treated with aggressive IV fluid resuscitation and treated for DKA as per protocol. Despite prompt treatment, the patient rapidly deteriorated, developing pulmonary effusions and impending respiratory failure requiring mechanical ventilation. Her hyperglycemia was challenging to control and in the setting of severe hypertriglyceridemia, insulin requirements were higher, as intravenous insulin is useful in patients with concomitant findings, in the absence of plasmapheresis availability. Despite the marked reduction of triglyceride to 978 mg/dL and a decrease in pancreatic enzymes, multiorgan failure developed. Unfortunately, the patient died. Repeated abdominopelvic CT imaging revealed the progression of the disease to necrotizing pancreatitis involving the pancreatic head, uncinate process, and neck of the pancreas with evidence of a small hypodense lesion at the level of the tail of the pancreas. This case emphasizes the importance of prompt recognition of acute pancreatitis secondary to uncontrolled hyperglycemia with concomitant severe hypertriglyceridemia since it can lead to a worse clinical outcome as seen in our patient who developed rapid progression to necrotizing pancreatitis. It is paramount not to delay treatment with aggressive fluid resuscitation, continuous insulin infusion, and if available, plasmapheresis; as these treatment strategies in conjunction can be life-saving. Presentation: 6/3/2024

8091 Clinical Features Associated with ICU Admission and Mortality in Thyroid Storm and Impending Thyroid Storm

Abstract Disclosure: E.D. Zhang: None. I. Hussain: None. Introduction: Thyroid storm is a rare, life-threatening manifestation of thyrotoxicosis characterized by a clinical syndrome of acute multi-organ failure, which can result in significant morbidity and mortality. Impending thyroid storm is a stage of thyrotoxicosis that may progress to thyroid storm if untreated. The aim of this study was to evaluate the demographics and outcomes of patients with thyroid storm at our institution and determine the clinical features associated with severe complications and mortality. We also evaluated the differences in clinical features and outcomes in patients diagnosed with impending thyroid storm versus thyroid storm. Methods: This was a retrospective single-center cohort study evaluating patients aged 18 years or older who were clinically diagnosed with thyroid storm or impending storm at two affiliated tertiary academic centers from 2008-2021. A search of the electronic medical record system using ICD-10 codes for thyroid storm identified patient charts which were reviewed for eligibility. Results: This study included 121 admissions, with 75 (62.0%) patients with thyroid storm and 46 (38.0%) patients with impending thyroid storm. Our study cohort was notably more racially and ethnically diverse than prior U.S. studies with 5.0% non-Hispanic White, 52.9% Black, 33.9% Hispanic, and 8.3% Asian patients. The mortality rate was 4.7%, with all patient deaths occurring in the thyroid storm group. Multivariable logistic regression analysis showed atrial fibrillation (OR 4.09, 95% CI 1.21, 13.85, p=0.02) and acute respiratory failure (OR 22.18, 95% CI 2.29, 215.19, p=0.008) to be significantly associated with a composite outcome of intensive care unit (ICU) admission or death. Comparison of impending storm and thyroid storm groups showed fever (p=0.02), acute respiratory failure (p=0.03), and ICU admission (p=0.02) to be significantly different between groups. Conclusions: This study describes the largest published single-center cohort of patients treated for thyroid storm in the United States. Furthermore, our study contributes importantly to the data for racial/ethnic minorities who are under-represented in prior studies. The mortality rate in this study is lower than most recent studies. The presence of atrial fibrillation and acute respiratory failure were noted to be significantly associated with a composite outcome of ICU admission or death, and the five fatal cases had high rates of cardiac arrest and shock. These findings suggest that complications involving cardiopulmonary compromise are clinically important in predicting severe disease and poor outcomes. Acute respiratory failure was also noted to be significantly different between impending storm and thyroid storm groups indicating that while not currently included in existing diagnostic systems, it is an important complication of thyroid storm that may have prognostic value. Presentation: 6/2/2024

7335 Myxedema Coma in an Adolescent Patient: A rare, lethal manifestation of profound hypothyroidism

Abstract Disclosure: C. Rodriguez: None. E.M. Mejias: None. L.R. Berrios: None. C. Currais: None. Myxedema coma is a rare, life-threatening condition that represents the most severe manifestation of profound hypothyroidism. It is characterized by extensive end-organ dysfunction. Therefore, it is crucial to have a high index of suspicion in order to identify it promptly and initiate treatment. We report a case of an adolescent patient with past medical history of Type 1 Diabetes Mellitus and hypothyroidism who was initially admitted to pediatric wards due to hypertension, constipation and acute kidney injury (AKI). The patient was transferred to the pediatric intensive care unit (PICU) after he developed multi-organ failure secondary to myxedema coma. His laboratory work up was remarkable for severe hypothyroidism with a thyroid-stimulating hormone (TSH) > 679, uncontrolled diabetes mellitus (Glycosylated Hemoglobin 13.1%) and chronic kidney disease (Creatinine 2.56). During his hospital course, he required long term hemodialysis, mechanical ventilation and underwent cardiorespiratory resuscitation multiple times. Since myxedema coma is an uncommon manifestation of pediatric hypothyroidism, pediatric guidelines are not available. We aim to reinforce the awareness of myxedema coma and encourage physicians to have a high index of suspicion as the widespread availability of TSH assays and its use can aid in the diagnosis and treatment of these patients. Furthermore, we emphasize an interdisciplinary approach to avoid mortality and long-term complications. Presentation: 6/1/2024

The Modulation of Septic Shock: A Proteomic Approach.

Sepsis poses a significant challenge due its lethality, involving multiple organ dysfunction and impaired immune responses. Among several factors affecting sepsis, monocytes play a crucial role; however, their phenotype, proteomic profile, and function in septic shock remain unclear. Our aim was to fully characterize the subpopulations and proteomic profiles of monocytes seen in septic shock cases and discuss their possible impact on the disease. Peripheral blood monocyte subpopulations were phenotype based on CD14/CD16 expression by flow cytometry, and proteins were extracted from the monocytes of individuals with septic shock and healthy controls to identify changes in the global protein expression in these cells. Analysis using 2D-nanoUPLC-UDMSE identified 67 differentially expressed proteins in shock patients compared to controls, in which 44 were upregulated and 23 downregulated. These proteins are involved in monocyte reprogramming, immune dysfunction, severe hypotension, hypo-responsiveness to vasoconstrictors, vasodilation, endothelial dysfunction, vascular injury, and blood clotting, elucidating the disease severity and therapeutic challenges of septic shock. This study identified critical biological targets in monocytes that could serve as potential biomarkers for the diagnosis, prognosis, and treatment of septic shock, providing new insights into the pathophysiology of the disease.

The relationship between positive end-expiratory pressure (PEEP) and intra-abdominal pressure (IAP) in mechanically ventilated patients: A prospective observational study.

Positive end-expiratory pressure is a crucial mechanical breathing parameter. Intra-abdominal hypertension is well defined as a sustained increase in the intra-abdominal pressure ≥12 mmHg. There are still controversies about mechanical ventilation's effect and use of positive end-expiratory pressure on intra-abdominal pressure. We aimed to delineate the relationship between positive end-expiratory pressure and intra-abdominal pressure in mechanically ventilated patients admitted to the intensive care units of a large tertiary hospital in Upper Egypt. This study was a prospective observational study. The study was conducted at a university hospital from October 2023 to February 2024. The enrolled adult patients were allocated into two groups based on their positive end-expiratory pressure: group I, low pressure (<8 cm H2O) and group II, high pressure (8-10 cm H2O). A total of 120 patients were enrolled, 60 patients in each group. The most commonly encountered diagnoses were pneumonia (32/120, 26.7%) and acute respiratory distress syndrome (ARDS) (31/120, 25.8%), respectively. There was a significant difference between the intra-abdominal pressure mean values of the two patient groups, 18.9 ± 3.3 versus 24.4 ± 5.9 mmHg in the group of low versus high pressure (correlation value of .454, p < .001), respectively. There were highly significant correlations between intra-abdominal pressure categories and the patient groups (correlation value of .495, p < .001). There were 24 (40%) versus 0 (0%) patients of high pressure versus low pressure within the category IV group of intra-abdominal hypertension (>25 mmHg). We observed a significant relationship between positive end-expiratory pressure and intra-abdominal pressure in mechanically ventilated patients. The patient group with high pressure had higher mean values compared with the group with low pressure. The study highlights the importance of closely monitoring intra-abdominal pressure in mechanically ventilated patients who receive positive end-expiratory pressure. Further studies are warranted. The relationship between positive end-expiratory pressure and intra-abdominal pressure is an essential issue in daily critical care nursing clinical practice. Considering the occurrence of multiple organ dysfunction as a result of a non-detected increase in intra-abdominal pressure, critical care nurses should pay attention to measuring this pressure to maintain intra-abdominal pressures that are safe for mechanically ventilated and critically ill intensive care unit patients, thereby preventing these undue effects.

Reprint-Necrotizing Fasciitis: A Case Report and A Review of the Literature

Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. Diagnosis may be delayed because of the initial minimal skin cellulitis, even as the subcutaneous tissue suffers extensive necrosis and pronounced systemic toxicity develops. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) might be useful in cases where signs are equivocal or diagnosis is in doubt. Computed tomography scans are estimated to have a sensitivity of 80% for detecting necrotizing soft tissue infections. We present a case of limb salvage in a 52-year-old patient with misunderstood type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome. Necrotizing fasciitis is a soft tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures and fascia. Background: the characteristic of this case was aggression and rapid extension. Case presentation: a 59-year-old woman was observed in a very serious condition, with fever and a large necrotic area that smelled of the right inguinal-femoral region in extension to the thigh. No history of illness. Obesity. Diagnosis may be delayed due to minimal initial cutaneous cellulite. A delay in diagnosis can lead to the progression of the disease shown by shock, multiple organ failure and, ultimately, death. Computed tomography and Magnetic Resonance Imaging could be useful in cases where the signs are equivocal or the diagnosis is in doubt. A detailed review of the literature is presented and the current treatment modalities are described. In this case, the aggressive surgical debridement, the complete medical management of sepsis and comorbidities and the timely closure of the wound by dermo-epidermal grafting were essential for a positive result. Conclusions: necrotizing fasciitis is an uncommon life-threatening soft tissue infection, which spreads rapidly and progressively along the deep fascia. The prognosis depends on accurate diagnosis and immediate treatment.

A-282 Purpura fulminans caused by Haemophilus influenzae: case report of unusual etiology

Abstract Background Fulminant purpura is a clinical syndrome characterized by a purplish, ischemic-looking skin rash, commonly accompanied by systemic symptoms ranging from acute febrile syndrome to septic shock. Due to high lethality of possible infectious etiologies, immediate recognition and early initiation of empirical antimicrobial therapy are crucial to ensure better outcomes. Interdisciplinary collaboration among healthcare teams, infectious disease specialists and microbiologists is essential to ensure accurate and early microbiological diagnosis. Methods This work aims to report a case of Haemophilus influenzae-induced purpura fulminans that occurred in Fortaleza-CE, a coastal city in northeastern Brazil, highlighting clinical recognition and microbiological identification, based on review of medical records. Results Case report A 59-year-old man, originally from Germany, was on vacation in Brazil. He presented to emergency medical service with an acute onset of fever, abdominal pain and diarrhea, progressing to decreased level of consciousness and purplish ischemic skin lesions with hemorrhagic bullae on trunk and extremities (Figure 1), with no history of trauma. Upon admission, the blood exams showed bicytopenia - 1900 leukocytes/µL (86% segmented) and 51,000 platelets/µL - and very high C-reactive protein (41.58 mg/dL). Although empirical antimicrobial therapy with vancomycin and piperacillin-tazobactam was initiated, patient progressed to septic shock, hepatic dysfunction, requiring mechanical ventilation, vasopressor support, and renal replacement therapy. Blood cultures from hospital admission were positive after about 14 hours and allowed isolation of small and translucent colonies in Chocolate PVX plate Agar (BioMerieux™). Maldi tof analysis by Vitek MS identified H. influenzae (99.9 % accuracy). Despite prolonged hospitalization due to multiple organ dysfunctions, patient had a positive outcome. Conclusions This case illustrates the importance of immediate recognition of the syndrome coupled with assertive empirical treatment and early microbiological diagnosis for a positive clinical outcome, even in a severe presentation. Multiprofessional approach is essential for accurate and early diagnosis.

Neonatal encephalopathy multiorgan scoring systems: systematic review.

Neonatal encephalopathy (NE) is a condition with multifactorial etiology that causes multiorgan injury to neonates. The severity of multiorgan dysfunction (MOD) in NE varies, with therapeutic hypothermia (TH) as the standard of care. The aim is to identify current approaches used to assess and determine an optimum scoring system for MOD in NE. The systematic review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search was conducted using PubMed, EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Scopus, and CINAHL for studies of scoring systems for MOD in NE. The search yielded 628 articles of which 12 studies were included for data extraction and analysis. Five studies found a positive correlation between the severity of NE and MOD. There was significant heterogeneity across the scoring systems, including the eligibility criteria for participants, the methods assessing specific organ systems, the length of follow-up, and adverse outcomes. The neurological, hepatic, cardiovascular, respiratory, hematological, and renal systems were included in most studies while the gastrointestinal system was only in three studies. The definitions for hepatic, renal, and respiratory systems dysfunction were most consistent while the cardiovascular system varied the most. A NE multiorgan scoring system should ideally include the renal, hepatic, respiratory, neurological, hematological, and cardiovascular systems. Despite the heterogeneity between the studies, these provide potential candidates for the standardization of MOD scoring systems in NE. Validation is needed for the parameters with adequate length of follow-up beyond the neonatal period. Additionally, the evaluation of MOD may be affected by TH considering its multiorgan effects.

Therapeutic Plasma Exchange to Reverse Plasma Failure in Multiple Organ Dysfunction Syndrome.

Plasma plays a crucial role in maintaining health through regulating coagulation and inflammation. Both are essential to respond to homeostatic threats such as traumatic injury or microbial infection; however, left unchecked, they can themselves cause damage. A well-functioning plasma regulatory milieu controls the location, intensity, and duration of the response to injury or infection. In contrast, plasma failure can be conceptualized as a state in which these mechanisms are overwhelmed and unable to constrain coagulation and inflammation appropriately. This dysregulated state causes widespread tissue damage and multiple organ dysfunction syndrome. Unlike plasma derangements caused by individual factors, plasma failure is characterized by a heterogeneous set of plasma component deficiencies and excesses. Targeted therapies such as factor replacement or recombinant antibodies are thus inadequate to restore plasma function. Therapeutic plasma exchange offers the unique ability to remove harmful factors and replete exhausted components, thereby reestablishing appropriate regulation of coagulation and inflammation.

Establishment and Validation of a Nomogram Clinical Prediction Model for Nosocomial Candidemia: An 18-Year Retrospective Analysis.

Nosocomial candidemia is a life-threatening condition, and the incidence has increased in recent years. Thorough epidemiological data is still lacking in China. A retrospective cohort study was conducted to investigate the patients admitted to Zhongshan Hospital Xiamen University from 1 January 2004 to 31 December 2022. This study included 205 individuals who were diagnosed with candidemia as subjects. Additionally, 303 cases with blood cultures were negative during the same period and were from the same department as a control group. We randomly assigned them to the training and validation groups in a 7:3 ratio. The least absolute shrinkage and selection operator regression, univariate and multivariate logistic regression analyses were used to filtrate independent factors associated with nosocomial candidemia. A nomogram model was established based on the selected variables. Receiver operating characteristic (ROC) curve, calibration plots and decision curve analysis (DCA) were used to evaluate clinical utility. Two hundred and five nosocomial candidemia patients were reported, containing a high proportion of Candida albicans (n = 91,44.39%), followed by Candida parapsilosis (n = 40, 19.51%), Candida tropicalis (n = 37,18.05%), Candida glabrata (n = 23, 11.22%) and Candida guilliermondii (n = 9,4.39%). Multiple organ dysfunction syndrome (OR = 10.372, 95% CI: 4.745-24.14 P < 0.001), increased urea nitrogen of serum (OR=1.088,95% CI: 1.039-1.144 P<0.001), decreased albumin of serum (OR = 0.922 95% CI: 0.850-0.997 P=0.045), mechanical ventilation (OR=4.074,95% CI: 1.397-12.77 P=0.012), central venous indwelling catheter (OR=7.422,95% CI: 3.189-18.41 P<0.001) and solid tumor (OR = 3.036 95% CI: 1.276-7.359 P=0.012) were identified as independent risk factors of candidemia. The area under the curve (AUC) of the nomogram model was 0.925 (95% CI: 0.898-0.952) in the training group and 0.946 (95% CI: 0.881-0.963) in the validation group. The calibration curve revealed good agreement between the probability and the observed values. DCA indicated that this nomogram might be clinically beneficial. The nomogram including multiple organ dysfunction syndrome, elevated blood urea nitrogen, decreased albumin, mechanical ventilation, central venous indwelling catheter and solid tumor could provide reference value to clinicians for identifying nosocomial candidemia.