Normal WBC Count Research Articles

Enterobius Vermicularis Unusual Cause of Appendicitis: A Case Report

Abdominal pain is common in children (under 18 years) with a strong female preponderance in those aged over 8 years. Of those presenting with acute abdominal pain requiring inpatient assessment, only 25% have acute appendicitis. Pinworms are the most common helminth infection in the USA and Western Europe, with prevalence rates in some communities of as high as 30-50%. Pinworms generally live in the gastrointestinal tract, and helminth infestations have been noted in over one-quarter of acute appendectomies on histologic examination. Acute appendicitis is one of the most common emergent surgeries. Generally, appendicitis is inflammation of the appendix. The medical procedure for the departure of the reference area is called an appendectomy. Appendectomy can be performed through an open or laparoscopic medical procedure, and it is the most effective way to prevent complications is to remove the inflamed appendix early by open surgery or laparoscopically. This case was a 14 years old female with abdominal pain and acute appendicitis that underwent surgery shows Occiur patch was the cause of her signs and symptoms of acute appendicitis that performed resection of appendix and discharge healthy. The present study presents a classic case of parasitic appendicitis in a teenage girl and discusses the clinical features, treatment and global burden of disease. Atypical presentations may indicate an unusual anatomical placement of the appendix. Preoperative diagnosis using cross-sectional computed tomography imaging and a thorough understanding of these situations frequently result in early diagnosis and expeditious surgical care. EV was seen in 9.8% of pediatric appendectomies in our study. Pruritus anus, normal WBC count, normal neutrophil count, and normal CRP level at presentation could predict EV infection in children who present with right iliac fossa pain. E. vermicularis is responsible for 7% of acute appendicitis. It is responsible for a significantly higher negative appendectomy rate which if predicted may avoid unnecessary appendectomy and associated morbidity. Enterobius vermicularis associated appendicular colic and acute appendicitis are rarely encountered in the United States. The high rate of inflammation on pathology found among our patients with pinworm appendicitis suggests an association with presentation as acute appendicitis. Enterobius vermicularis is known to be associated with appendicitis, however a causal relationship between Enterobius and appendicitis has not been established. The aim of this study was to explore the relationship between appendiceal Enterobius and histologic appendicitis. Enterobius-associated appendicitis cases and compare them with acute appendicitis cases in terms of parameters such as the neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP)-to-lymphocyte ratio (CLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII). Enterobius vermicularis infections are usually asymptomatic and may only cause anal pruritis, with occasional reported cases of ectopic migration into the appendix or the female genital tract by adult pinworms.

An Eosinophilic Variant of Orbital Granulomatosis with Polyangiitis with Ocular Motility Disorder

Purpose: To present the case of a patient with localized orbital granulomatosis with polyangiitis (GPA) characterized by a significant ocular motility disorder, increased eosinophilia, and hyper-immunoglobulin E (hyper-IgE).Case Summary: A 61-year-old male, with no previous history of allergy, atopy, asthma, sinonasal disease, respiratory disease, or renal disease, came to our hospital due to a 2-day history of binocular diplopia. His left eye exhibited inward and upward deviation, along with gaze limitation. His vision was 20/20 in both eyes, and the pupillary light reflex and color test were normal. He had severe eyelid swelling and conjunctival injection without tenderness in his left eye, and retinal vessel congestion around the optic nerve, without proptosis. Laboratory tests revealed a positive cytoplasmic antineutrophil cytoplasmic antibody (cANCA), a normal WBC count, elevated eosinophils at 28.3% (2,462/mm<sup>3</sup>), and high serum levels of IgE (400 KU/L). Magnetic resonance imaging showed an inferolateral orbital mass with an enlarged lacrimal gland and myositis of the extraocular muscles. A biopsy of the lacrimal gland revealed nonspecific chronic inflammation with an eosinophilic infiltrate. The presence of cANCA, in combination with clinical and pathological findings, led to the diagnosis of an eosinophilic variant of localized orbital GPA. This variant was primarily confined to the orbital tissue, marked by elevated eosinophil and IgE levels, and was treated with oral steroids without requiring surgery for the ocular motility disorder.Conclusions: GPA may present as acute strabismus with orbital inflammation, even in the absence of systemic signs. Therefore, it should be considered in the differential diagnosis of unexplained acute orbital syndromes.

Clinicopathologic characteristics of myeloproliferative neoplasms with JAK2 exon 12 mutation

The presence of JAK2 exon 12 mutation was included by the 2016 World Health Organization (WHO) Classification as one of the major criteria for diagnosing polycythemia vera (PV). Few studies have evaluated the clinical presentation and bone marrow morphology of these patients and it is unclear if these patients fulfill the newly published criteria of 5th edition WHO or The International Consensus Classification (ICC) criteria for PV. Forty-three patients with JAK2 exon 12 mutations were identified from the files of 7 large academic institutions. Twenty patients had complete CBC and BM data at disease onset. Fourteen patients met the diagnostic criteria for PV and the remaining six patients were diagnosed as MPN-U. At diagnosis, 9/14 patients had normal WBC and platelet counts (isolated erythrocytosis/IE subset); while 5/14 had elevated WBC and/or platelets (polycythemic /P subset). We found that hemoglobin and hematocrit tended to be lower in the polycythemia group. Regardless of presentation (P vs IE), JAK2 deletion commonly occurred in amino acids 541–544 (62 %). MPN-U patients carried JAK2 exon 12 mutation, but did not fulfill the criteria for PV. Half of the patients had hemoglobin/hematocrit below the diagnostic threshold for PV, but showed increased red blood cell count with low mean corpuscular volume (56–60 fL). Three cases lacked evidence of bone marrow hypercellularity. In summary, the future diagnostic criteria for PV may require a modification to account for the variant CBC and BM findings in some patients with JAK2 exon 12 mutation.

734 APHASIC AORTITIS - A CASE REPORT

Abstract A 66yo man, without previous cardiological history, 3-month history of asthenia and left leg claudication, presence of tibial painless nodular lesions, was admitted at our emergency department in the clinical context of an acute aortic syndrome with chest and interscapular pain, fluctuating systemic BP (215/90 ←→ 90/60 mmHg) ​​and 60 mmHg pressure gradient between the arms. EKG documented diffuse negative T waves. Echocardiography revealed normal biventricular morphology and function and normal valve system. TC angiography documented a dilated aortic root (46mm), diffuse thickening of the aortic walls from the valvular plane (8mm), with involvement of the coronary and epiaortic arteries (50% stenosis of left subclavian artery), extended up to the aortic bifurcation to affect the common iliac arteries. Blood chemistry showed high C-reactive protein levels (29 mg/L; n.v. <5 mg/L) and low troponin levels. In the suspicion of an aortic wall hematoma, the patient was rushed to the OR with evidence of a lardaceous-looking aorta and free from wall hematomas. Surgery was stopped. Histological sample of left inguinal artery showed diffuse wall sclerosis and rare intramural lymphocyte infiltration. PET-CT showed an increased metabolism of the aortic walls. On the second postoperative day, the patient developed fluctuating aphasia aggravated by orthostatic position and arterial hypotension. In the suspicion of TIA, CT angiography was performed and showed no acute brain lesions, but a critical stenosis of the right carotid bifurcation, a right vertebral artery occlusion and a left internal carotid subocclusion. DAPT (clopidogrel + aspirin) was initiated. Blood chemistry showed normal WBC count, elevated C-reactive protein (133 mg/L; n.v. < 5 mg/L) and erythrocyte sedimentation rate (90 mm/h; n.v. < 35 mm/h). Blood and urine cultures, bacterial serology (syphilis, tubercolosis), viral serology (HBV, HCV, HIV) and autoantibodies tested (ANA, ENA, ANCA, MPO, PR3) resulted negative. In the context of a great vessel arteritis, IV methylprednisolone was introduced with clinical and biochemical response (C-reactive Protein 10 mg/L). MRI on day 10 demonstrated the presence of two cerebral subacute ischemic lesions with hemorrhagic infarction. Aspirin was discontinued. In suspicion of Takayasu arteritis, methotrexate was initiated with clinical benefit. Takayasu arteritis has an incidence of 2.6/1 million, female:male 8:1 and the age of onset is usually between 15 and 30 years. The cause is unknown. It can manifest as an acute aortic syndrome. It is important to be aware of this disease and to consider it in clinically ambiguous cases like this one.

EVALUATION OF SERUM C REACTIVE PROTEIN IN ACUTE APPENDICITIS AND ITS CORRELATION WITH HISTOPATHOLOGY

Background: Acute appendicitis is the most common abdominal surgical emergency, but its diagnosis remains an enigmatic challenge, plagued by a high rate of negative explorations. There is no single reliable test with satisfactory sensitivity and specicity. Ultrasonography is not often available at a rural surgical setup. This study is intended to evaluate the importance Aim: of serum C-reactive protein (CRP) level estimation in diagnosis of acute appendicitis, by comparing with histopathology report. In a Methods: prospective study,100 patients clinically diagnosed as acute appendicitis were selected by purposive sampling method and evaluated as per criteria for serum CRP levels, leucocyte count preoperatively and were followed up postoperatively with histopathology reports. The data was analysed for nding the signicance of serum CRP in the diagnosis of acute appendicitis. CRP was positive in 75 of the 77 patients who Results: had histologically proven acute appendicitis and in 3 with normal appendix. The sensitivity, specicity and diagnostic accuracy were 97.4%, 86.96% and 95% respectively. Leucocytosis and neutrophilia when used alone were not specic for acute appendicitis, but when combined with CRP value, diagnostic accuracy was high. Ultrasonography was useful in establishing alternative diagnoses, but had low sensitivity for acute appendicitis. CRP contains important diagnostic information and hence should always Interpretation & Conclusion: be included in the diagnostic workup of acute appendicitis. Since acute appendicitis is very unlikely in those patients with normal WBC count and CRP value, conservative treatment is advised.This study does not undercut the skill of an experienced surgeon in diagnosing acute appendicitis, but CRP estimation compliments clinical diagnosis.

Post Prostatectomy Abdominal Pain

A 56-year-old man with a history of prostate cancer presented to the emergency department (ED) for abdominal pain, vomiting, and tenesmus. Four days before the presentation, he had undergone robotic radical prostatectomy. His examination was significant for diffuse abdominal tenderness without frank peritonitis. Although his vitals were initially normal, he became progressively more hypotensive despite fluid resuscitation and eventually required vasopressors. Laboratory evaluation revealed an anion gap metabolic lactic acidosis with a normal WBC count. Initial computed tomography of the abdomen and pelvis with intravenous contrast (Figure 1) showed mild nonspecific circumferential thickening of the distal rectum. Because of the patient’s clinical deterioration, he was sent for repeat computed tomography with rectal contrast (Figure 2), which revealed his diagnosis.Figure 2Computed tomography of the abdomen and pelvis with rectal contrast (axial view) showing rectal perforation, with the rectal contrast extending through a full-thickness defect at the 10 o’clock position of the lower rectum into the pelvis and peritoneal cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Postoperative rectal perforation. The patient was treated with antibiotics and was immediately taken to the operating room for abdominal washout, which revealed 3 L of feculent material in the abdomen. He had a prolonged hospital stay and was discharged to a skilled nursing facility 1 month later. Postoperative rectal injury is a rare but known complication of robotic radical prostatectomy. Most cases are discovered and repaired during surgery. However, cases that are not diagnosed during surgery often have significant morbidity.1Wedmid A. Mendoza P. Sharma S. et al.Rectal injury during robot-assisted radical prostatectomy: incidence and management.J Urol. 2011; 186: 1928-1933Crossref PubMed Scopus (42) Google Scholar Therefore, a high index of suspicion is needed to diagnose postoperative rectal injuries, and it is one of the few instances when rectal contrast should be routinely considered.2Marres C.C.M. Engelmann E.W.M. Buskens C.J. et al.The importance of rectal contrast in CT assessment to detect anastomotic leakage after colorectal surgery.Colorectal Dis. 2021; 23: 2466-2471Crossref PubMed Scopus (2) Google Scholar Those cases identified in the ED will require admission and surgical consultation because their management requires bowel diversion with delayed fistula closure.

EXTENSIVE PNEUMATOCELES DUE TO PNEUMOCYSTIS JIROVECI PNEUMONIA IN A PATIENT NEWLY DIAGNOSED WITH HIV INFECTION

EXTENSIVE PNEUMATOCELES DUE TO PNEUMOCYSTIS JIROVECI PNEUMONIA IN A PATIENT NEWLY DIAGNOSED WITH HIV INFECTION

S3238 A Case of Concurrent Cholecystitis and Stauffer Syndrome

Introduction: Stauffer syndrome (SS) is a paraneoplastic syndrome seen in some malignancies, most commonly 4-15% of primary renal cell carcinomas, resulting in nephrogenic hepatic dysfunction. SS commonly results in elevated alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and prothrombin time (PT) as well as decreased albumin in the absence of liver metastasis. The etiology of SS is unknown, although three have been suggested: elevated interleukin-6, elevated colony stimulating factor or, least likely, autoimmune. We describe a case of a woman presenting with right upper quadrant (RUQ) pain who was found to have indirect predominant hyperbilirubinemia and acute cholecystitis and renal mass on ultrasound. Case Description/Methods: An 81-year-old female presented to an outside hospital for RUQ and epigastric pain that worsened after fatty meals. Imaging showed acute cholecystitis as well as a right renal mass. Physical exam at the time was remarkable only for diffuse tenderness to abdominal palpation, most notably in the RUQ. There was no scleral icterus or costovertebral angle tenderness on exam. Labs on presentation can be seen in Table 1. Given the elevated indirect bilirubin, gastroenterology was consulted and suggested Gilbert syndrome (GS) or SS given their concern for renal cell carcinoma (RCC). The next day the patient underwent a laparoscopic cholecystectomy notable for acute gangrenous cholecystitis with cholelithiasis, and had rapid normalization of bilirubin over 48 hours. The patient followed with outpatient urology for renal biopsy, which was positive for clear cell RCC. Follow up imaging revealed scattered pulmonary nodules up to 1.1cm, with concern for metastasis. Surgery was deemed inappropriate and the patient was conservatively managed, given her wishes to prioritize quality of life and not undergo chemotherapy. (Figure) Discussion: This case illustrates an interesting clinical picture where a patient with confirmed cholecystitis also has a new renal mass, with elevated indirect bilirubin and PT, consistent with SS. The diagnosis of SS is made clinically, with hopeful resolution of abnormal lab values upon RCC resection. In this case, surgery was not indicated, hemolysis was ruled out with stable hemoglobin and normal peripheral smear, and the diagnoses of acute cholecystitis and RCC causing SS was made. In addition to hemolysis, GS, and Criggler-Najjar when working up indirect hyperbilirubinemia, it is imperative to include SS on the differential diagnosis.Figure 1.: CT abdomen with right renal mass. Table 1. - Patient labs on presentation and 2 days post-cholecystectomy Lab Admission Post-Op Day 2 Normal WBC Count (103 cells/uL) 17 14 4.1-9.3 Platelet (103/uL) 246 248 130-350 Hemoglobin (g/dL) 10.6 9.8 11-14.7 Albumin (g/dL) 3.3 2.7 3.5-5.2 Total Bilirubin (mg/dL) 2.8 0.9 0.1-1.2 Indirect Bilirubin (mg/dL) 2.4 0-0.9 Alkaline Phosphatase (IU/L) 96 102 30-115 AST (IU/L) 23 20 5-45 ALT (IU/L) 12 16 5-60 Lipase (U/L) 12 11-82 Prothrombin Time (s) 14.3 9.4-12.9 INR 1.2 0.83-1.14 AST = aspartate transaminase, ALT = alanine transaminase.

Is high hemoglobin a hindrance factor for blood donation? A pilot observational study from the coastal region of India.

Blood donors with high Hb are often deferred for the presumed risk of polycythemia vera (PV). However, adequate data to substantiate or refute this hypothesis is lacking. We conducted an observational study on blood donors found to have high hemoglobin (Hb≥18g/dL) during the pre-donation screening process using a portable hemoglobinometer at our blood center for four months. We adopted a cost effective methodology wherein a questionnaire was used to elicit the secondary causative factors of high hemoglobin and a complete blood count test to observe the blood cell parameters and JAK2V617F mutation test was performed in a subset of donors lacking secondary erythrocytosis (SE) history. Of the total 7076 donors enrolled, 112 male donors (1.58%) had high hemoglobin. The majority (70.4%) were repeat donors with mean age of 31.4 years. About 61% of the donors had attributable factors for SE like smoking, occupational exposure to carbon monoxide. The mean hemoglobin value of capillary and venous hemoglobin demonstrated a statistically significant difference (P<0.05) where 2.7% of donors had venous Hb<18g/dL. The hematological profile of all the donors showed increased RBC but normal platelet and WBC count. Of 24 donors included for the JAK2V617F test, none had a positive report. This study suggests high hemoglobin in blood donors is less likely due to PV. Hence, re-considering their deferral may help alleviate donor anxiety and allow donor return. However, multi-centric studies are required to develop consensus statements on PV risk status and blood donation eligibility.

P051 A rare mimic of inflammatory arthritis

Abstract Background/Aims Rosai-Dorfman syndrome is a rare disorder, primarily affecting young males, characterised by overproliferation and accumulation of histiocytes. It commonly affects lymph nodes but can affect the nervous system, kidneys and skin. Bone involvement is rare (around 5%) and presents as lytic lesions. Diagnosis can be challenging as many cases spontaneously resolve. In severe cases steroids, radiotherapy or chemotherapy may be used. Methods We present a case of a 34-year-old gentleman with a 4-month history of fatigue, widespread arthralgia and unintentional weight loss. Pain was severe, nocturnal and involved joints and long bones. There was no joint swelling. He had recently had a self-limiting episode of headaches and night sweats that was presumed secondary to a viral infection. He had no rash and no features suggestive of connective tissue disease. He did not smoke or drink alcohol and had no recent travel history. His symptoms responded to NSAIDS but recurred quickly. Results On examination, he had a tender right elbow and tender bilateral tibia. There was no evidence of synovitis. He had no lymphadenopathy. X-rays of elbows and knees showed no effusion or erosions. Viral and autoimmune screens were negative. He had a normocytic anaemia with Hb 108. His CRP was rising at 57, having been 27 when initially referred; this was felt inconsistent with a reactive arthritis. LDH was normal along with normal WBC count. A PET-CT was requested to investigate for malignancy, this showed multiple foci of tracer uptake throughout the skeleton but no lymph node involvement. He was referred to haematology for tissue diagnosis and had two bone biopsies, one of which was suspicious for histiocytosis. A bone marrow biopsy showed non-necrotising histiocytic granulomas. Langerhan's Histocytosis was considered and a repeat PET arranged. This showed progressive increased uptake throughout the skeleton and bone marrow with new lytic lesions. There was tracer uptake in the skin, lung and kidneys, reported as possible Rosai-Dorfman disease. No evidence of primary malignancy was found after extensive investigations. He then developed frontal and occipital skin lesions. MRI head showed dural lesions, suspicious for meningioma. He was referred to dermatology for biopsy of skin lesions. However, the skin and dural lesions spontaneously resolved. This was associated with resolution of fatigue and arthralgia. His CRP settled to 2.8 and anaemia resolved 6 months after presenting. A diagnosis of spontaneously remitting Rosai-Dorfman disease was made in conjunction with the national histiocytosis advisory panel. He remains under surveillance. Conclusion This case highlights a rare presentation of a rare condition. As rheumatologists we often see cases which present a diagnostic challenge. Rosai-Dorfman disease has characteristic appearances on PET and should be considered as a diagnosis in patients with atypical joint pain and abnormal PET-CTs. Disclosure M. Cox: None. M.F. Kazmi: None.

Prognostic Importance of WBC Count in Acute Myocardial Infraction

Background: The objective of this study was to determine whether the WBC count is associated with in-hospital mortality &amp; morbidity for patients with ischemic heart disease after controlling for potential confounders.&#x0D; Methods: This study was prospective study. 100 patients presenting within 24hrs with Acute MI and qualifying inclusion criteria were enrolled and written consent was taken regarding participation in the study.&#x0D; Results: Out of 100 patients had LV dysfunction, among these 30 patients 21were having elevated WBC count and 9 had normal WBC count. Among 100 patients 14 had cardiogenic shock, among these patients 9 had elevated WBC count and 5 had normal WBC count. Among 100 patients 8 patients died, among these patients 7 patients had elevated WBC count and 1 patient had normal WBC count.&#x0D; Conclusion: Elevated WBC count within 24 hours was associated with high rate of complications after acute myocardial infarction.&#x0D; Keywords: ST, Non ST, WBC.

The Role of Chest CT Radiomics in Diagnosis of Lung Cancer or Tuberculosis: A Pilot Study.

In many low-income countries, the poor availability of lung biopsy leads to delayed diagnosis of lung cancer (LC), which can appear radiologically similar to tuberculosis (TB). To assess the ability of CT Radiomics in differentiating between TB and LC, and to evaluate the potential predictive role of clinical parameters, from March 2020 to September 2021, patients with histological diagnosis of TB or LC underwent chest CT evaluation and were retrospectively enrolled. Exclusion criteria were: availability of only enhanced CT scans, previous lung surgery and significant CT motion artefacts. After manual 3D segmentation of enhanced CT, two radiologists, in consensus, extracted and compared radiomics features (T-test or Mann–Whitney), and they tested their performance, in differentiating LC from TB, via Receiver operating characteristic (ROC) curves. Forty patients (28 LC and 12 TB) were finally enrolled, and 31 were male, with a mean age of 59 ± 13 years. Significant differences were found in normal WBC count (p < 0.019) and age (p < 0.001), in favor of the LC group (89% vs. 58%) and with an older population in LC group, respectively. Significant differences were found in 16/107 radiomic features (all p < 0.05). LargeDependenceEmphasis and LargeAreaLowGrayLevelEmphasis showed the best performance in discriminating LC from TB, (AUC: 0.92, sensitivity: 85.7%, specificity: 91.7%, p < 0.0001; AUC: 0.92, sensitivity: 75%, specificity: 100%, p < 0.0001, respectively). Radiomics may be a non-invasive imaging tool in many poor nations, for differentiating LC from TB, with a pivotal role in improving oncological patients’ management; however, future prospective studies will be necessary to validate these initial findings.

533 Uncommon ECG presentation in Tako-tsubo syndrome

Abstract Aims We present the case of an 80-year-old woman without prior cardiovascular history, recent instrumental diagnosis of peritoneal carcinomatosis and ongoing oncologic diagnostic work up. Methods and results The patient was admitted to our ED for acute-onset worsening dyspnoea. On first clinical evaluation, she denied typical angina, remarkable clinical features were dyspnoea, tachycardia and hypotension. Admission ECG showed sinus rhythm with posterior and inferior ST elevation (leads DII, aVF, V5, V6) with reciprocal ST segment depression in leads V1–V2. Echocardiography confirmed infero-postero-lateral akinesia determining moderate reduction of LVEF (35–40%), normal aortic root, no pericardial effusion. Laboratory tests revealed normal WBC count, mild anaemia (HB 10.7 g/dl), normal renal function, elevated C-reactive protein (139 mg/l, n.v. &amp;lt; 8). Cardiac troponin I (cTnI) was normal on admission, with significant delta on second determination (0.012 &amp;gt; 2.5 ng/ml, nv &amp;lt; 0.023). ST elevation persisted after BP normalization and hypoxia treatment; so, taken into account the increased procedural risk due to patient’s age and comorbidities, however we decided to perform urgent coronary angiography. Surprisingly, coronary angiography revealed absence of any significant stenosis, with TIMI 3 flow in any coronary segment. The patient was then admitted to the ICU with diagnosis of MINOCA. The next day ECG revealed normalization of ST segment and Q wave in V2–V3. On day 2 new ECG showed new ventricular repolarization abnormalities with T wave inversion in precordial leads. Peak hs-cTnI was &amp;gt;15 000 ng/l. Repeat echocardiography on day 2 reported complete akinesia of all the apical segments of the LV with normo-hyperkinesia of the mid-basal segments (apical ballooning pattern) and severely depressed systolic function (FE 32–35%). During the following days patient’s symptoms improved, with rapid weaning from oxygen therapy and stable haemodynamic parameters. After 10 days the patient repeated echocardiography, which revealed improvement of global LVEF and persisting mild apical hypokinesia, suggesting the diagnostic hypothesis of Tako-Tsubo Syndrome (TTS) or TTS-phenocopy (unfortunately cardiac MRI was not performed). The patient was therefore transferred to oncology department to complete the diagnostic work-up; primary mammary neoplasia was identified, moreover associated with metastasis in the liver and the brain. Unfortunately, the patient died a month later due to non-cardiac causes. This is the case report of an uncommon MINOCA, which presented mimicking inferolateral acute STEMI, but subsequent ECG and echocardiographic evolution showed the more typical TTS pattern, with apical ballooning on echo and deep negative T waves in anterior leads. Conclusions The prevalence of MINOCA is estimated to be 6% to 8% among patients diagnosed with MI, especially women, however it is more common in patients with NSTEMI compared with STEMI; moreover in cases of TTS presenting with ST elevation, usually the elevation is found in anterior leads without reciprocal ST depression; in this patient instead ST elevation was inferolateral with reciprocal anterior ST depression. Absence of obstructive CAD and clinical/echocardiographic evolution allowed us to confirm the diagnosis of MINOCA/TTS.

Superiority of lymphocyte ratio over total leukocyte count in detecting the severity of COVID- 19 pneumonia

BackgroundCoronavirus disease (COVID-19) is an infectious disease caused by a recently discovered coronavirus. Blood test including complete blood count is crucial in diagnosing of several viral and bacterial infection. AimsThis study aimed to assess the association between lymphocyte ratio and other WBC types and severity of COVID-19 pneumonia. MethodsThe design of this study was a cross-sectional study. A complete blood count and erythrocyte sedimentation rate (ESR) was done for one hundred twenty-six COVID-19 patients (76 males and 50 females; aged 20–70 years). Patients were randomly recruited from multicenter in Al-Najaf Governorate, Iraq. ResultsThe study had revealed an inverse correlation between severity of COVID-19 infection and both lymphocytes and monocytes ratio even in patients with normal WBC count. Additionally, there was a direct correlation between platelets and leukocyte count. The relation between leukocyte count and ESR level was significant in a patient with elevated WBC only. ConclusionLymphocytes and monocyte ratios inpatient with COVID-19 infection can be used as predictors for the severity of infection. Increased leukocyte count resulted in increases in platelets inpatient with COVID-19.

FLUOROURACIL-INDUCED PULMONARY TOXICITY PRESENTING AS DIFFUSE ALVEOLAR HEMORRHAGE

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Fluorouracil (5-FU) is a chemotherapy medication often used alone or in combination with other agents (e.g., FOLFOX regimen) to treat gastrointestinal malignancies. Adverse effects of 5-FU include pancytopenia, alopecia, cardiotoxicity, and gastrointestinal symptoms. We describe a rare case of pulmonary toxicity associated with 5-FU. CASE PRESENTATION: The patient is a 78-year-old female with a history of unresectable metastatic cholangiocarcinoma on maintenance FOLFOX chemotherapy without Oxaliplatin (discontinued due to peripheral neuropathy and thrombocytopenia) presented with acute onset of dyspnea and pleuritic chest pain five days after a 5-FU and Leucovorin infusion. On initial evaluation, a chest radiograph showed pulmonary infiltrates for which she was treated with oral Levofloxacin as an outpatient. Despite this, she had progressive worsening of dyspnea, prompting further evaluation. Blood work revealed normal WBC and platelet counts, mild anemia with hemoglobin 9.4 g/dL, and normal BNP and troponin levels. ECHO showed normal systolic function. She was noted to be hypoxemic, requiring supplemental oxygen necessitating hospitalization. Repeat Chest radiograph showed worsening left upper lobe and lingular infiltrates. Her oxygen requirements rapidly increased from 3-4 L/min via nasal cannula to 12L/min via Oxymask. Despite treatment with broad-spectrum IV antibiotics, her dyspnea and hypoxia persisted. CTA chest was then performed, revealing extensive bilateral infiltrates and reactive enlarged mediastinal/hilar lymph nodes with no evidence of pulmonary embolism. She had a negative infectious workup, including a COVID-19 PCR. She underwent diagnostic bronchoscopy, which showed no endobronchial lesions or secretions. Bronchoalveolar lavage of the right middle lobe with three serial aliquots obtained progressively bloody returns diagnosing diffuse alveolar hemorrhage (DAH). The procedure was complicated by worsening hypoxia, and the patient required emergent intubation and transferred to the critical care unit, where she was treated with pulse dose steroids for three days. She was extubated to supplemental O2 via NC within 24 hours of treatment. Further lab evaluation showed negative ANA, ANCA, Anti GBM antibodies, Anti-dsDNA, and normal C3, C4 levels. Cytology of BAL was negative for malignancy. Given negative infectious and autoimmune workup, the diagnosis of DAH due to 5-FU was made. Steroid dose was reduced to Prednisone 1mg/kg with slow taper with improvement in clinical status and oxygen requirements. DISCUSSION: The diagnosis of 5-FU related pulmonary toxicity is based on clinical suspicion upon exclusion of infection, autoimmune disease, heart failure, and cancer progression. CONCLUSIONS: 5-FU induced pulmonary toxicity presenting as DAH is a rare entity. Prompt diagnosis can lead to early drug cessation and the use of high-dose steroids can improve patient outcomes. REFERENCE #1: Fernandez, L., Dominguez, A., Martinez, W., Sanabria, F., Leib, C. S., & Biomedical Research Group in Thorax. (2018). Pulmonary Toxicity Due to 5-Fluorouracil (5-FU) Manifested as Diffuse Alveolar Hemorrhage: Case Report. In D34. LUNG TRANSPLANT AND DRUG INDUCED LUNG DISEASE: CASE REPORTS (pp. A6577-A6577). American Thoracic Society. DISCLOSURES: No relevant relationships by Rajesh Kunadharaju, source=Web Response No relevant relationships by Puja Mehta, source=Web Response No relevant relationships by Ahmed Munir, source=Web Response No relevant relationships by Vandana Pai, source=Web Response No relevant relationships by Musa Saeed, source=Web Response

INCIDENTAL AND ASYMPTOMATIC SPLENIC INFRACTION AND INFRARENAL THORMBUS IN A PATIENT WITH COVID-19

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: In the COVID-19 pandemic, pathogenesis and complications of COVID-19 were studied intently. Due to the associated cytokine storm, it is theorized that this triggers a hypercoagulable state for venous and arterial thromboembolism. Elevated D-dimer, fibrinogen, c-reactive protein (CRP), ferritin, and procalcitonin were seen in thrombotic complications. CASE PRESENTATION: A 66 year old male with dyslipidemia presented 11 days after diagnosis of COVID-19. He had worsening shortness of breath, myalgias, and loss of taste. He denied any diarrhea, nausea, or vomiting. On physical exam, he had crackles with diminished lung sounds using his accessory muscles. He was hypoxic with oxygen saturation of 81% on room air. Labs showed normal WBC count, d-dimer of 1.42 mg/L, ferritin of 961 ng/mL, lactate dehydrogenase of 621 U/L, and CRP of 2.1 mg/dL. Chest x-ray showed atypical pneumonitis with patchy abnormalities. He was started on vapotherm 40 L with FiO2 of 100% proning as tolerated. He received dexamethasone, prophylactic enoxaparin, 1 unit of plasma therapy, remdesevir, ceftriaxone, and azithromycin. On day 2, dexamethasone was increased to twice daily due to hypoxemia. Due to elevated d-dimer of 2.64 mg/L, enoxaparin was changed to twice daily. On day 5, he required continuous positive airway pressure (CPAP) with pressure support of 10 and FiO2 of 85% with dexamethasone every eight hours. His d-dimer increased from 1.65 to 3.51 mg/L. Computed tomography angiogram (CTA) of chest showed extensive ground glass opacities and 2.4 x 1.9 x 1.3 cm distal thoracic aortic intraluminal thrombus. He was started on a heparin drip, and enoxaparin was discontinued. CTA of aorta showed thrombus or hypoattenuation within splenic artery and areas of wedge-shaped extending from the hilum and possible infarction with a six mm thrombus in the infrarenal abdominal aorta. Vascular surgeon recommended no surgical intervention since he was asymptomatic. His d-dimer peaked to 6.92 mg/L but trended down. After two days of heparin drip, he was transition to enoxaparin 1 mg/kg twice daily. He remained asymptomatic with no flank pain. DISCUSSION: At least 17 cases thus far found splenic infarction as a rare thrombotic complication of COVID-19. Presentation is usually with left flank pain, which our patient did not have. Elevation of d-dimer were predictive of thrombosis complications in those hospitalized. Management includes therapeutic dose anticoagulation like subcutaneous low molecular weight heparin before being discharge home with oral anticoagulant. CONCLUSIONS: Although pulmonary embolism is the most common thromboembolism complication of COVID-19, arterial thrombosis are common especially in critically ill patients. Physicians need to consider arterial and venous thrombosis and investigate appropriately based on symptoms in order to manage. Prophylactic anticoagulation is recommended for hospitalized COVID-19. REFERENCE #1: Santos Leite Pessoa M, Franco Costa Lima C, Farias Pimentel AC, et. al. Multisystemic Infarctions in COVID-19: Focus on the Spleen. Eur J Case Rep Intern Med. 2020 Jun 3;7(7):001747. doi: 10.12890/2020_001747. REFERENCE #2: 2. Klok FA, Kruip MJHA, van der Meer NJM, et. al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 Jul;191:145-147. doi: 10.1016/j.thromres.2020.04.013. REFERENCE #3: 3. Besutti G, Bonacini R, Iotti V, et. al. Abdominal Visceral Infarction in 3 Patients with COVID-19. Emerg Infect Dis. 2020 Aug;26(8):1926-1928. doi: 10.3201/eid2608.201161. DISCLOSURES: No relevant relationships by Jayaramakrishna Depa, source=Web Response No relevant relationships by Cassandra Do, source=Web Response No relevant relationships by shyam Ganti, source=Web Response No relevant relationships by Mythili Kanthi Gudipati, source=Web Response

Potential Excess Intravenous Antibiotic Therapy in the Setting of Gram-Negative Bacteremia

(1) Background: Excessive intravenous therapy (EIV) is associated with negative consequences, but guidelines are unclear about when switching to oral therapy is appropriate. (2) Methods: This cohort included patients aged ≥18 years receiving ≥48 h of antimicrobial therapy for bacteremia due to Escherichia coli, Pseudomonas aeruginosa, Enterobacter, Klebsiella, Acinetobacter, or Stenotrophomonas maltophilia from 1/01/2008–8/31/2011. Patients with a polymicrobial infection or recurrent bacteremia were excluded. Potential EIV (PEIV) was defined as days of intravenous antibiotic therapy beyond having a normal WBC count for 24 h and being afebrile for 48 h until discharge or death. (3) Results: Sixty-nine percent of patients had PEIV. Patients who received PEIV were more likely to receive intravenous therapy until discharge (46 vs. 16%, p < 0.001). Receipt of PEIV was associated with a longer mean time to receiving oral antimicrobials (8.7 vs. 3 days, p < 0.001). The only factors that impacted EIV days in the multivariable linear regression model were the source of infection (urinary tract) (coefficient −1.54, 95%CI −2.82 to −0.26) and Pitt bacteremia score (coefficient 0.51, 95%CI 0.10 to 0.92). (4) Conclusions: PEIV is common in inpatients with Gram-negative bacteremia. Clinicians should look to avoid PEIV in the inpatient setting.

A Man With Testicular Pain

An 86-year-old male with a history of diabetes presented to the emergency department (ED) with left testicular pain for 2 days. Physical examination demonstrated an uncircumcised male with a normal testicular lie, left testicle enlargement, erythema, and tenderness to palpation. The patient was afebrile, with a WBC count of 9,000 cells/uL, and urinalysis revealed leukocytes. ED point-of-care ultrasonography was obtained (Figures 1 and 2).Figure 2Sonographic image of the left testicle in the sagittal plane obtained with a high frequency linear transducer demonstrated a hypoechoic structure (arrow) with increased surrounding vascular flow demonstrating inflammatory changes (star) within the testicle. Scrotal wall thickening was seen (asterisk).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Testicular abscess. Testicular abscess on ultrasonography is typically spherical or elliptical, with a focal area of mixed echogenicity due to necrotic cellular debris.1Gaillard F. Testicular abscess: radiology reference article.https://radiopaedia.org/articles/testicular-abscess?lang=usDate accessed: December 12, 2020Google Scholar,2O’Rourke K. Kibbee N. Stubbs A. Ultrasound for the evaluation of skin and soft tissue infections.Mo Med. 2015; 112: 202-205PubMed Google Scholar Testicular abscess may also demonstrate enlargement of the affected testicle and a reactive hydrocele. Testicular abscess is rare and typically results from untreated or severe epididymo-orchitis. In sexually active patients, common pathogens include Neisseria gonorrhea and Chlamydia trachomatis. However, those who are not sexually active can have other gram-negative and gram-positive organisms.1Gaillard F. Testicular abscess: radiology reference article.https://radiopaedia.org/articles/testicular-abscess?lang=usDate accessed: December 12, 2020Google Scholar,3Mevorach R.A. Lerner R.M. Dvoretsky P.M. et al.Testicular abscess: diagnosis by ultrasonography.J Urol. 1986; 136: 1213-1216Crossref PubMed Google Scholar,4Hackett B. Sletten Z. Bridwell R.E. Testicular abscess and ischemia secondary to epididymo-orchitis.Cureus. 2020; 12e8991PubMed Google Scholar Typically, patients will report testicular pain, swelling, and fever. The differential diagnosis includes testicular torsion, epididyomo-orchitis, epididymal abscess, testicular cancer, and testicular trauma. Ultrasound is the initial imaging modality needed to differentiate testicular abscess from other similarly presenting diagnoses. Treatment depends on the size of the testicular abscess and clinical parameters. Minor cases (those in patients who have normal WBC counts, are afebrile, are able to urinate, and do not have signs of necrotizing fasciitis) can be treated with antibiotics, while more severe cases may require surgical debridement or orchiectomy. ED treatment includes initiation of antibiotic therapy and urology consultation.

PROGNOSTIC IMPORTANCE OF WBC COUNT IN ACUTE MYOCARDIAL INFRACTION

Background: Coronary artery disease is a major cause of death and is a global health problem becoming an epidemic in both developed as well as in developing countries.&#x0D; Methods: 100 patients presenting to hospital within 24hrs with Acute MI and qualifying inclusion criteria were enrolled and written consent was taken regarding participation in the study.&#x0D; Results: In a total of 100 patients participated in our study 69 patients were male and 31 patients were females. Out of 100 patients 26 had LV dysfunction, among these 23 patients 17 were having elevated WBC count and 9 had normal WBC count. Among 100 patients 11 had cardiogenic shock, among these 11 patients 8 had elevated WBC count and 3 had normal WBC count. &#x0D; Conclusion: Elevated WBC count within 24 hours was associated with high rate of complications after acute myocardial infarction.&#x0D; Keywords: STEMI, NSTEMI, WBC

Interactions of Consanguinity and Number of Siblings with Childhood Acute Lymphoblastic Leukemia.

Acute lymphoblastic leukemia (ALL) is a common malignancy in children. Consanguinity has a high prevalence in developing countries and increases the probability of homozygosity for many genes which may affect ALL and its prognosis. We conducted a study to explore the impact of consanguinity and number of siblings on ALL as there are currently no studies to describe this effect. Data were collected from patients' records from the Children's University Hospital of Damascus University, which is the major cancer centre for children in Syria. This study included 193 children with ALL over one year. Number of siblings was not with the French–American–British (FAB) classification, gender, ALL subtype, or risk of ALL children. When comparing consanguinity degrees and complete blood counts at diagnosis, significant contradicting data were found in the third-degree and fourth-degree consanguinity when compared to one another and to not having consanguineous parents as third degree consanguinity was associated with normal platelets but lower WBC counts, and fourth-degree consanguinity was associated with normal haemoglobin levels and WBC counts, but lower platelet counts. Having consanguineous parents was also associated with acquiring ALL at an older age, L2 FAB classification, having a positive family history for malignancies, and not having hepatosplenomegaly (P < 0.05). Although L2 is known to be a poor prognosis indicatory, no association was found with consanguinity and risk. Finally, no association was found with ALL subtype or risk (P > 0.05). Although consanguinity and number of siblings have affected some variables and prognostic features of childhood ALL, the aetiology is not clear and we need further studies to clarify such an association as this will help in optimising therapy and accurately determine the risk.