Second Week Of Hospitalization Research Articles

Olive Oil and Vegetable Extract in Modified Hospital Enteral Formula Improves Glycemic Variability in Critically-Ill Diabetic Ketoacidosis Obese Patient: A Case Report

Background: Severe hyperglycemia in diabetic ketoacidosis may elevate pro inflammatory cytokines, oxidative stress, and metabolic disruptions, impacting the nutritional status of critically ill patients. Diabetes-specific formula (DSF) administration is linked to favorable glycemic control, but research on the role of modified hospital enteral formulas in diabetic critical illness is lacking.
 Case Description: An obese 29-year-old male at risk of malnutrition, presented to the emergency room with decreased level of consciousness due to metabolic encephalopathy, diabetic ketoacidosis due to suspected type 1 diabetes mellitus, hypertension, and acute kidney injury. Medical nutritional therapy was provided via enteral route according to recent ESPEN, ASPEN and ADA recommendation. The administered enteral formula was a modified hospital-based enteral formula, consisting of a special kidney hospital-based enteral formula mixed with olive oil as source of monounsaturated fatty acid (MUFA) and vegetables as source of fibers. During the first week of hospitalization, the patient’s coefficient of variation (%CoV) of glycemic variability ranged between 17–61%, in addition, at the beginning of the second week of treatment there was also an increase in glycemic variability to 53%. This could be influenced by several factors. However, improvement in glycemic variability was observed in the following days. This improvement was in line with the gradual increase in MUFA and fiber intake, which reached its highest intake during the second week of hospitalization.
 Conclusion: Hospital-based enteral formula modified with olive oil and vegetable extract can be made to resemble the nutrients composition of diabetes specific formula and has a favorable effect on glycemic variability.

Features of the course of COVID-19 in patients with type 2 diabetes mellitus

To identify the features of the course of COVID-19 in patients with type 2 diabetes mellitus (T2DM), depending on the intake of hypoglycemic therapy at the prehospital stage, in conjunction with the functional state of the kidneys. A retrospective analysis of 291 case histories of patients with COVID-19 and T2DM hospitalized in the infection department of Semashko Regional Clinical Hospital from January to December 2021, including the main clinical and laboratory parameters.Results. Among hospitalized patients with COVID-19, patients with T2DM had a higher mortality rate. An analysis of the case histories of deceased patients with COVID-19 and T2DM showed that at admission, body mass index (BMI), C-reactive protein, and creatinine were higher than those of survivors and amounted to BMI - 33 [30; 39] and 33 [28; 36] kg/m3; p=0.039, C-reactive protein - 77 [47.5; 106.0] and 57 [27.0; 89.0] mg/l; p=0.015, in terms of creatinine level - 89 [70.0; 144.0] and 82 [66.0; 101.0] µmol/l; p=0.039, respectively. It was found that in the second week of hospitalization in the group of deceased patients with COVID-19 and T2DM, the creatinine level was statistically significantly higher than in surviving patients and amounted to 94.5 [71.5; 141.0] and 72.5 [57.0; 88.0] µmol/L; p<0.001, respectively. The probability of death in hospitalized patients with type 2 COVID-19 and T2DM depended on BMI and creatinine levels at the second week of hospitalization. Patients with prehospital correction of hyperglycemia dipeptidyl peptidase-4 inhibitors (iDPP-4)/ glucagon-like peptide-1 receptor agonists (agGLP-1)/ sodium-glucose co-transporter 2 inhibitors (iSGLT-2) had significantly lower creatinine levels at week 2 of hospitalization. In patients with moderate to severe COVID-19 with concomitant T2DM, special attention should be paid to the combination of high BMI and creatinine in the second week of hospitalization, which is a prognostically unfavorable predictor of death in such patients.

Clinical and treatment factors associated with the mortality of COVID-19 patients admitted to a referral hospital in Indonesia.

Indonesia had the second-highest number of COVID-19 cases and deaths in South-East Asia. We aimed to determine the factors associated with this mortality and the effect of the recommended COVID-19 treatment regimen during the first 10 months of the epidemic. This was a retrospective cohort study using secondary data from medical records. In total, 689 adult COVID-19 inpatients hospitalized between March and December 2020 were enrolled. Clinical characteristics, laboratory parameters, and treatments were analyzed by survival outcome. Kaplan-Meier statistics were used to estimate survival. Of the 689 patients enrolled, 103 (14.9%) died. Disease severity was highly associated with mortality (hazard ratio [HR]: 7.69, p<0.001). Other clinical factors associated with mortality were older age and comorbidities. Based on laboratory parameters, higher procalcitonin and C-reactive protein contents and a neutrophil-to-lymphocyte ratio >3.53 were also linked to mortality. Favipiravir was associated with lower mortality, with adjusted HRs of 0.24 (0.11-0.54) and 0.40 (0.17-0.98) among the mild/moderate and severe cases, respectively. Among patients with severe disease, steroids showed some beneficial effects in the early days of hospitalization. Older age and comorbidities were associated with disease severity and, consequently, higher mortality. Higher mortality after the second week of hospitalization may be related to secondary bacterial infection. Favipiravir showed significant benefit for COVID-19 survival, while steroids showed benefit only in the early days of admission among patients with severe disease. This research did not receive a specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The cascade of multiorgan dysfunction in COVID 19 patients. A case presentation.

Introduction: The SARS COV 2 epidemic has caused thousands of deaths due to different mechanisms of organ injury, starting from the respiratory and cardiovascular system and followed with significant involvement of kidneys, liver, pancreas and several metabolic dysfunctions which all caused a rapid progression of disease leading to death within the second week of hospitalization. Method: We present the case of a 67-year-old woman who died within 24 hours of admission due to a rapid deterioration of her clinical condition with several successive complications. Results: The patient developed a fulminant clinical course, starting with flu-like prodromal symptoms proceeding to altered mental status, metabolic acidosis, acute respiratory distress syndrome (ARDS) and renal failure within 3 days. The rapid involvement of several vital organs predicted a poor diagnosis since the first evaluation in admission which resulted to be irreversible. Conclusion: The predictors of poor prognosis and severity may help clinicians to apply therapeutic regimens in order to avoid disease progression to multiorgan damage and potentially death. Key words: Covid-19, multi-organ dysfunction, cascade, case report.

Fungal complications with the new coronavirus infection COVID-19

BACKGROUND: The growth of fungal pathology observed in the last decade, including life-threatening invasive mycoses, is associated with the spread of immunodeficiency states of various etiologies. The COVID-19 pandemic has made a negative contribution, causing a significant increase in the number of patients with fungal complications.&#x0D; AIM: To characterize the types of fungal complications in the acute period of a new coronavirus infection COVID-19 based on an analysis of the clinical course and therapeutic tactics for managing the underlying disease.&#x0D; MATERIALS AND METHODS: The results of a bacteriological study of 1284 cultures from sputum samples of patients with suspected secondary pneumonia in COVID-19 are considered. The study included 404 cultures of various types of fungi. The analysis of the clinical picture was carried out in 70 patients with fungal complications of various localization, who were treated in a regional covid hospital. This group included the results of microbiological examination of sputum, bronchoalveolar lavage (BAL), scrapings from lesions in the oropharynx, urine, blood, biopsy and autopsy material. The study was conducted from April 01, 2020 to December 31, 2021. The patients were divided into subgroups depending on the isolated pathogen: Candida spp. ― 64 patients, and fungi (Aspergillus spp. and Mucor spp.) ― 6 patients; outcome of the disease: favorable 66, lethal 4.&#x0D; RESULTS: In the microbial landscape of the respiratory tract in patients with COVID-19, gram-negative microbial flora prevailed, one third of the cultures were represented by fungi. During the two years of the pandemic, the proportion of fungal cultures increased from 26.9% in 2020 to 34.2% in 2021, while maintaining sensitivity to amphotericin B and fluconazole in most cases. In 2021, there was a negative growth trend in the sputum of molds of the species Aspergillus spp. (5 cultures) and Mucor spp. (1 culture).&#x0D; Typical fungal complications of COVID-19 were: candidiasis stomatitis caused by Candida albicans (71%), candidiasis of other urogenital localizations in the form of candiduria (20%), lung damage of mixed viral-fungal etiology in isolated cases, leading to death due to invasive mycosis. Only fungal flora was isolated in 57.1% of cases, various combinations of fungal and bacterial flora in 42.9%. Candidiasis stomatitis was diagnosed on average on day 11.61.08 of COVID-19, which corresponded to days 2-3 of hospitalization. Preceding outpatient treatment, in most cases, included antibiotics and hormonal therapy with glucocorticosteroids. Urogenital Urogenital fungal infection was diagnosed on the 17.75.17 day of illness, on the second week of hospital treatment (8.03.11 days). Fungal flora in sputum was determined on average on the 18.54.33 day of illness, on the second third week of hospitalization against the background of intensive immunosuppressive therapy.&#x0D; CONCLUSION: Risk factors for the development of fungal complications are the age of patients older than 50 years, overweight and hypertension, uncontrolled use of antibiotics and glucocorticosteroids at the prehospital stage. Mycoses are recorded in both severe and moderate COVID-19. An additional factor in their development is immunosuppressive therapy of the underlying disease. The most formidable complication of the course of COVID-19, worsening the prognosis of survival, is the addition of fungi with invasive growth Aspergillus spp., Mucor, as well as the development of fungal-bacterial associations with damage to the lung tissue.&#x0D; In the context of the ongoing SARS-CoV-2 pandemic, the use of immunomodulatory agents, including the combined use of corticosteroids and targeted immunosuppressive drugs, it is important to develop a risk-based approach in diagnosis and treatment for patients at risk of generalized and invasive mycoses.

Does Route of Full Feeding Affect Outcome among Ventilated Critically Ill COVID-19 Patients: A Prospective Observational Study.

The outbreak of the new coronavirus strain SARS-CoV-2 (COVID-19) highlighted the need for appropriate feeding practices among critically ill patients admitted to the intensive care unit (ICU). This study aimed to describe feeding practices of intubated COVID-19 patients during their second week of hospitalization in the First Department of Critical Care Medicine, Evaggelismos General Hospital, and evaluate potential associations with all cause 30-day mortality, length of hospital stay, and duration of mechanical ventilation. We enrolled adult intubated COVID-19 patients admitted to the ICU between September 2020 and July 2021 and prospectively monitored until their hospital discharge. Of the 162 patients analyzed (52.8% men, 51.6% overweight/obese, mean age 63.2 ± 11.9 years), 27.2% of patients used parenteral nutrition, while the rest were fed enterally. By 30 days, 34.2% of the patients in the parenteral group had died compared to 32.7% of the patients in the enteral group (relative risk (RR) for the group receiving enteral nutrition = 0.97, 95% confidence interval = 0.88–1.06, p = 0.120). Those in the enteral group demonstrated a lower duration of hospital stay (RR = 0.91, 95% CI = 0.85-0.97, p = 0.036) as well as mechanical ventilation support (RR = 0.94, 95% CI = 0.89–0.99, p = 0.043). Enteral feeding during second week of ICU hospitalization may be associated with a shorter duration of hospitalization and stay in mechanical ventilation support among critically ill intubated patients with COVID-19.

201. Comparison of Bloodstream Infections Between Hospitalized Patients with and without COVID-19 Infection During the First Wave of the COVID-19 Pandemic in a Community Hospital in South Bronx: An Observational Study

BackgroundComparative data on bloodstream infections (BSI) in hospitalized patients with and without SARS-CoV2 positive test is lacking.MethodsA retrospective observational study comparing (BSI) with and without COVID-19 infection was performed was performed from Jan1- May 1, 2020. Patient demographics, clinical microbiological characteristics of infections, therapeutic interventions and outcomes was compared between the two groups. ResultsOf 155 patients with BSI, 104 were SARS-CoV2 PCR negative (N) while 51 were positive (Table 1). Majority of SARS-CoV2 positives (P) had ARDS (58.8%), required mechanical ventilation (73%), inotropic support (55%), therapeutic anticoagulation (28%), proning (35%), Rectal tube (43%), Tocilizumab (18%), and steroids (43%) (Table 2). BSI was higher in N with HIV (16.3% vs 3.9% p=0.027). Duration of antibiotic therapy (DOT) prior to BSI was significantly longer in P (15 days vs. 5 days, p < 0.0001) (table 2). In-hospital mortality was significantly higher among P with BSI (49% vs. 21% p < 0.0001). 185 BSI events were observed during the study period with 117 in N patients and 68 in P. Primary BSI was predominant (76%) in N while secondary BSI (65%) was common in P of which 50% were CLABSI. Median time from admission to positive culture was 0.86 days in N compared to 12.4 in P (p = 0.001). Majority of BSI in P were monomicrobial (88%) and hospital acquired (71%) when compared to N (p< 0.001). Enterococcus spp (28%), Candida spp(12%), MRSA (10%) and E.coli (10%) were predominant microbes in P compared to Streptococcus grp (16%), MSSA (14%), MRSA (13%) and E.coli (12%) in N (figure 1). Mortality from BSI was associated with COVID-19 infection (OR 2.403, p = 0.038), DM (OR 2.335, p = 0.032), Charlson comorbidity index >3 (OR 1.236, p = 0.004), and mechanical ventilation (OR 11.398, p < 0.001) on multivariate analysis. Comparison of Microorganisms isolated in the BSI X-axis represents the number of BSI events whereas the number at the end of each bar represents the percentage ConclusionIncreased events of hospital acquired, secondary BSI (CLABSI) due to Enterococcus was observed in adult P compared to N. These patients were critically ill, developed BSI in the second week of hospitalization, had longer DOT prior to positive cultures and worse outcomes. Breakdown of infection control measures and inappropriate antimicrobial use during the surge could be contributory. Disclosures All Authors: No reported disclosures

27. Co-infections and antimicrobial use in patients hospitalized with COVID-19

BackgroundIn-hospital antimicrobial use among COVID-19 patients is widespread due to perceived bacterial and fungal co-infections. We aim to describe the incidence of these co-infections and antimicrobial use in patients hospitalized with COVID-19 to elucidate data for guiding effective antimicrobial use in this population.MethodsThis retrospective study included all patients admitted with COVID-19 from January 1, 2020, to February 1, 2021 at any of the three teaching hospitals of the NYU Langone Health system. Variables of interest were extracted from the health system’s de-identified clinical database. The nadir of hospital admissions between the first and second peaks of hospital admissions in the dataset was used to delineate the First Wave and Late Pandemic periods of observation. A cut-off of 48 hours after admission was used to differentiate Co-infections and Secondary infections respectively among isolates of clinically relevant bacterial or fungal pathogens in blood or sputum samples. Population statistics are presented as median with interquartile range (IQR) or total numbers with percentages. Results663 of 7,213 (9.2%) inpatients were found to have a positive bacterial or fungal culture of the respiratory tract or blood during the entire course of their initial admission at our hospitals for COVID-19. Positive respiratory cultures were found in 437 (6.1%) patients, with 94 (1.3%) being collected within 48 hours of admission. Blood culture positivity occurred in 333 patients (4.6%), with 115 (1.6%) identified within 48 hours of admission. Infection-free survival decreased with duration of hospitalization, with rate of secondary infections steadily rising after the second week of hospitalization as seen in Figure 1. 70.2% of inpatients received antimicrobials for a median duration of 6 antimicrobial days (IQR 3.0 – 12.0) per patient. A higher proportion of patients received antimicrobials in the first wave than in the late pandemic period (82.6% vs. 51.8%). Table 1. Table 2 Figure 1 Infection free survival represented as duration of admission in days on the X-axis, and proportion of admitted patients remaining infection-free in the Y-axis. The blue line represents blood cultures and the orange line represents sputum cultures.ConclusionThere was a very low incidence of co-infection with SARS-CoV-2 infection at admission. A longer duration of hospitalization was associated with an increased risk of secondary infections. Antimicrobial use far exceeded the true incidence and detection of co-infections in these patients.Disclosures All Authors: No reported disclosures

Abnormal Liver Tests during Hospitalization Predict Mortality in Patients with COVID-19: A Multicenter Study from South America

Background The role of liver function tests (LFT) as prognostic factors in patients admitted with COVID-19 has not been fully investigated, particularly outside resource-rich countries. We aimed at evaluating the prognostic value of abnormal LFT on admission and during hospitalization of patients with COVID-19. Methods We performed a retrospective study that included 298 adult patients hospitalized for COVID-19, between 05/2020 and 02/2021, in 6 hospitals from 5 countries in South America. We analyzed demographic and comorbid variables and laboratory tests on admission and during hospitalization. LFT over twice the upper limit of normal (ALEx2) were also evaluated in relation to a variety of factors on admission and during hospitalization. De novo-ALEx2 was defined as the presence of ALEx2 at one week of hospitalization in patients without ALEx2 on admission. Patients were followed until hospital discharge or death. Multivariable analysis was used to evaluate the association between ALEx2 on admission and during hospitalization and mortality. Results Of the total of 298 patients, 60% were male, with a mean age of 60 years, and 74% of patients had at least one comorbidity. Of those, 137 (46%) patients were transferred to the intensive care unit and 66 (22.1%) patients died during hospitalization. ALEx2 on admission was present in 87 (29.2%) patients and was found to be independently associated with 1-week mortality (odds ratio (OR) = 3.55; 95% confidence interval (95%CI) 1.05–12.05). Moreover, 84 (39.8%) out of 211 patients without ALEx2 at admission developed de novo-ALEx2, which was independently associated with mortality during second week of hospitalization (OR = 6.09; 95%CI 1.28–29) and overall mortality (OR = 2.93, 95%CI 1.05–8.19). Conclusions A moderate elevation of LFT during admission was associated with a poor short-term prognosis in patients hospitalized with COVID-19. In addition, moderate elevation of LFT at one week of hospitalization was an independent risk factor for overall mortality in these patients.

PULMONARY CRYPTOCOCCOSIS COMPLICATING POST-COVID-19 PULMONARY FIBROSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary cryptococcosis (PC) is an opportunistic invasive mycosis common in immunocompromised patients, presenting as dyspnea and cough(1). Studies have shown opportunistic infections such as pulmonary aspergillosis, candida and pneumocystis pneumonia in critically ill patients with COVID-19. However data on incidence of PC in this subset of patients is sparse(2). We discuss a patient with post-COVID-19 pulmonary fibrosis(PF) who developed PC. CASE PRESENTATION: A 62-year-old lifelong non-smoker male presented with worsening dyspnea and cough. One month prior to this, he was treated for new hypoxic respiratory failure secondary to COVID-19 pneumonia and pulmonary embolism and was on baseline oxygen therapy 4L/min since. On presentation, he was noted to be afebrile, tachycardic HR of 114/min, tachypneic with RR 24/min, and saturating 93% on 6L O2. He had bilateral crackles on chest auscultation. Initial labs were unremarkable except ABG showing normal pH of 7.38, with hypoxia pO2 58 and hypercarbia pCo2 65. COVID-19 PCR remained positive. Chest X-ray was suggestive of multifocal pneumonia. Chest CT revealed severe multifocal pneumonia with interval development of bronchiectasis. Patient was initiated on IV linezolid, meropenem, remdesivir and dexamethasone;he required BiPAP support due to respiratory failure. Worsening respiratory failure despite completion of antibiotic course, prompted initiation of ceftazidime. He was also started on trial of IV methylprednisolone 125mg every six hourly in view of suspected post-COVID-19 PF, administered for two weeks. Patient's hospitalization was further complicated by critical illness myopathy, atrial fibrillation and flutter. Subsequently fungal serology returned positive for cryptococcal antigen and fluconazole therapy was initiated. He had no history of immunocompromise such as HIV, Diabetes, ESRF etc. CSF analysis was deferred since he had no CNS manifestations. Patient showed clinical improvement into second week of hospitalization and repeat CT scan done 18 days after starting fluconazole showed interval improvement of multifocal infiltrate. DISCUSSION: Post-COVID-19 pulmonary fibrosis is increasingly identified with evolving clinical data. Dysregulated release of matrix metalloproteinases, epithelial injury, and fibroproliferation are all implicated in the pathogenesis of post infective PF(3). CONCLUSIONS: High dose steroids used in the management of PF pose serious risk of complications related to immunosuppression and subsequent opportunistic infections such as pulmonary cryptococcosis and pneumocystis pneumonia. As the pandemic is still evolving, it will be interesting to see if PF and opportunistic infections become an established post-COVID-19 sequela. REFERENCE #1: Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol. 2019 Feb 1;57(2):133-150. doi: 10.1093/mmy/myy086. PMID: 30329097. REFERENCE #2: Salehi M, Ahmadikia K, Badali H, Khodavaisy S. Opportunistic Fungal Infections in the Epidemic Area of COVID-19-19: A Clinical and Diagnostic Perspective from Iran. Mycopathologia. 2020;185(4):607-611. doi:10.1007/s11046-020-00472-7 REFERENCE #3: Tale S, Ghosh S, Meitei SP, Kolli M, Garbhapu AK, Pudi S. Post-COVID-19-19 pneumonia pulmonary fibrosis. QJM. 2020;113(11):837-838. doi:10.1093/qjmed/hcaa255 DISCLOSURES: No relevant relationships by Sangeetha Isaac, source=Web Response No relevant relationships by Shalom Isaac, source=Web Response No relevant relationships by Evans Kyei-Nimako, source=Admin input No relevant relationships by Amos Lal, source=Web Response No relevant relationships by Mohammed Afraz Pasha, source=Web Response

Characteristics and Outcomes of Adults Hospitalized with Dengue Viral Infection and Acute Kidney Injury in Southern Thailand.

Dengue viral infection (DVI) among adult patients is increasingly problematic in tropical and subtropical regions. Acute kidney injury (AKI) after DVI poses substantial clinical outcomes and economic impact. This prospective study focused on the characteristics, risk factors, and outcomes of adult patients with AKI due to DVI hospitalized in nine network hospitals within Southern Thailand from January 2017 to December 2019. Among 120 adult patients hospitalized due to DVI without preexisting kidney diseases, 17 patients (14%) presented with AKI. During hospitalization, four patients required acute hemodialysis. The predominant characteristic of urinalysis was proteinuria, followed by pyuria and hematuria with remarkable dysmorphic red blood cells. Complications included acidosis, followed by hyperkalemia and volume overload. Most complications and deterioration of renal function occurred within the first week, but renal function recovered in second week of hospitalization. Stability of renal function was regained within the fourth week to the third month. However, four AKI patients recovered, with estimated glomerular filtration rate >60 mL/min/1.73 m2 within 3 months. Forty-day mortality rate and resource utilization, including hospital cost and length of hospitalization, among those with AKI were significantly higher than those without AKI. Thirty-day and in-hospital mortality rate among those with AKI was also higher than those without AKI. High APACHE II scores due to bleeding disorder and current use of non-steroidal anti-inflammatory agent were significantly associated with the emergence of AKI. Acute kidney injury among adult patients hospitalized due to DVI should be a concern and should be monitored for prompt treatment and follow-up.

2272 A Case of Cryptococcal Hepatitis in HIV Patient With a Negative Serum Cryptococcal Antigen

INTRODUCTION: Infectious Cryptococcus neoformans occurs primarily in immunocompromised patients. The primary organ affected is the lungs, but CNS and skin involvement can also be seen. Disseminated Cryptococcosis can involve any organ in the body. However, hepatic involvement is rare. Here we offer a case of Cryptococcus hepatitis in a patient who presented with persistently elevated liver enzymes. CASE DESCRIPTION/METHODS: A 56-year-old Hispanic female with no known past medical history presented with fever, abdominal pain, nausea, unintentional weight loss, and diarrhea for two months. On physical examination, she was tachycardic with a heart rate of 110 bpm, and her abdomen was soft but tender to palpation in the right upper quadrant. Her liver function tests (LFTs) revealed elevated Aspartate Aminotransferase (AST) (415 U/L), elevated Alanine Aminotransferase (ALT) (201 U/L), elevated Alkaline Phosphatase (ALP) (763 U/L), normal total Bilirubin (0.9 mg/dl), and additional laboratory results in Table 1. Her HIV antigen screening was reactive, and absolute CD4 count was 22/ mcL. CT scan of the chest revealed two small calcified granulomas, for which she was started prophylactically on Azithromycin and TMP/SMZ. Over the course of her hospital stay, the patient's liver enzymes continued to trend upward while further workup ruled out hepatitis A, B, C, Wilson's disease, Hemochromatosis, AIH, PBC, PSC, other causes of viral hepatitis (CMV, EBV, HSV), with negative Histoplasma antibodies and negative serum Cryptococcal antigen titers. During the second week of hospitalization, her liver enzymes continued to rise with an ALP of 4046 U/L, AST of 407 U/L, and ALT of 276 U/L. With a persistent elevation of the liver enzymes without any definitive cause, an ultrasound-guided biopsy was warranted and performed. Pathology revealed Cryptococcal hepatitis (Figures 1 and 2), and the patient was started on a 15-day course of Amphotericin B with an 8-week course of Fluconazole 400 mg with LFTs nearly normalizing at 6 weeks. DISCUSSION: This case demonstrates an unusual manifestation of Cryptococcosis. Our patient did not present with the typical Cryptococcal pulmonary or central nervous system infection. As well, our patient's serum Cryptococcal antigen titers were negative, but biopsy results revealed Cryptococcal hepatitis, despite a very high sensitivity and specificity of the serum Cryptococcal antigen test. This case demonstrates the importance of maintaining a broad differential, specifically in immunocompromised patients.

Dynamics of blood pressure and neurological deficit in the acute phase of stroke among patients with and without diabetes mellitus

Aim. The haemodynamics of patients with diabetes mellitus 2 during acute ischaemic stroke and their connection with the recovery of neurological deficit has been inadequately studied.Materials and Methods. We studied the blood pressure dynamics of 183 patients with mild-to-moderate acute ischaemic stroke receiving antihypertensive therapy, depending on whether or not they had type 2 diabetes mellitus.Results. In patients with diabetes, high blood pressure persisted during the first week, mainly because of the diastolic index, and they had a more rapid decline in blood pressure in the second week than those without diabetes. However, reaching the target blood pressure of 160/100 mmHg was faster in patients with diabetes, regardless of the intensity of antihypertensive therapy. Although diabetes significantly correlated with the efficiency of recovery of neurological deficit, it also showed a tendency to frequent functional impairment in patients with diabetes than those without diabetes.Conclusions. The results suggest that patients with diabetes and hypertension require less aggressive treatment, particularly in the second week of hospitalization. This may affect the efficiency of recovery of functional deficits. Further study of blood pressure dynamics and their relation to functional recovery of neurological deficit is required during the acute period after an ischaemic stroke in patients with diabetes.

Successful Eculizumab Therapy in Thrombotic Thrombocytopenic Purpura (TTP) Refractory to Plasma Exchange, Steroids and Rituximab

IntroductionWe present a case of TTP refractory to usual therapies treated successfully with eculizumab.Case presentationA 64 year-old African American female with history of diabetes and hypertension presented with left sided weakness and seizure-like activity preceded by 2 days of headaches and 2 weeks of easy bruising. On admission her vital signs and physical exam were unremarkable. Her basic metabolic panel, ANA panel, hepatitis panel, HIV, and anti-phospholipid panel was negative. Her hemoglobin was 9.0 g/dL, platelets were 13K/uL, LDH was 954IU/L, haptoglobin <30 mg/dL, eGFR was 50, and blood smear showed 4-5 schistocytes/high power field. ADAMTS13 activity was <5% and there was an inhibitor level of 1.1BU. C3 level was 75.3 (normal range 90-180mg/dL), C4 was <10 mg/dL (normal range 15-45 mg/dL). On day 1, she was started on oral prednisone (1mg/kg/day) and daily plasma exchange (TPE). changes. After 6 days of TPE without signs of improvement, the first dose of rituximab 375 mg/msq/dose was given on day 7. During the second week of hospitalization, patient also developed delirium and mental status changes. Vincristine 2 mg was given on day 13 for refractory TTP. Due to clinical worsening of microangiopathy and mental status, a decision was made to administer eculizumab 900 mg on day 17. Within a few hours of eculizumab administration, her platelets improved from 8k/uL to 21k/uL and to 47k/uL 12 hours later. After the second dose of eculizumab on day 24, platelets improved to 117k/uL and continued to rise. Eculizumab 900 mg was given weekly for 4 weeks, at which time ADAMTS13 activity was 75% and ADAMTS13 inhibitor was undetectable. Eculizumab 1200 mg was then given every two weeks, for a total of 3 more doses, during which the CBC, LDH, and haptoglobin remained in the normal range. Eculizumab was stopped, and after four months of close follow up, platelets, LDH, renal function and mental status were still normal range. C3 level was 203 (normal range 90-180 mg/dl), C4 was 35 mg/dl (normal range 15-45 mg/dl), ADAMTS 13 activity assay is >100% and there is no inhibitor.DiscussionTTP and aHUS are both thrombotic microangiopathies (TMA). TTP is caused by acquired or inherited deficiency of the ADAMTS 13 protein or due the formation of an inhibitor to the ADAMTS13 protein. aHUS results, in most cases, from a genetic mutation in complement factor H in the alternative pathway of the complement cascade. Recent studies have described the importance of the complement system in all forms of TMA (Update on the role of the complement system in the pathogenesis of thrombotic microangiopathies. Prilozi. 2014;35(1):115-22). While plasma exchange is the cornerstone of TTP treatment, complement inhibition with drugs such as eculizumab is the treatment of choice for aHUS. The use of complement inhibiting drugs has not yet been studied in TTP.We report an unusual case of TTP, with confirmed ADAMTS 13 inhibitor and low activity, which did not respond to conventional treatment for TTP. Theorizing that this patient either had concurrent aHUS or had TTP with a dysregulated alternate complement pathway, we used eculizumab, to which the patient had a remarkable and persistent response.There are other reports in literature of patients with aHUS having reduced levels of ADAMTS13 protein; however, these patients did not have an inhibitor as was seen in our patient (Partial ADAMTS13 deficiency in atypical hemolytic uremic syndrome. Blood. 2013 Aug 22;122(8):1487-93). There is one other case in the literature where TTP was treated successfully with eculizumab. In that case, discontinuation of eculizumab was associated with a relapse of TTP and so had to be continued (Eculizumab in the treatment of refractory idiopathic thrombocytopenic purpura. Br J Haematology. 2012 June;157 (6):772-4). To our knowledge, we report the first case of a confirmed diagnosis of TTP treated successfully with eculizumab with remission continuing 3 months after discontinuation of the drug.The use of eculizumab and the role of the complement pathway in TTP deserves further study. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Severe acute pancreatitis: clinical findings and therapeutic tools in Internal Medicine practice

BACKGROUND Recent advances in pathophysiology and therapeutic measures suggest that patients suffering from acute pancreatitis (AP) should undergo an early evaluation and treatment in Internal Medicine wards. Severe AP, usually associated with pancreatic necrosis and peripancreatic fluid collections, may be frequently complicated by distant organ(s) involvement. RESULTS The dreadful multi-organ failure may occur as an early event (during the first week of the disease) or in association with the infection of pancreatic necrosis in a later stage. So, during the clinical outcome, physicians may be compelled to counteract cardio-circulatory, pulmonary, renal, hepatic, haematological and hydro-electrolytic complex derangements. Arterial hypotension and shock may be consequence of hypovolemia and/or hearth failure or septic shock syndrome. Pleural effusions are frequent in the early phase of the disease as well as pulmonary densifications and renal insufficiency. Urinary, pulmonary, and biliary infections may intervene during all phases of the disease whereas pancreatic necrosis and fluid collections infections are more frequent after the second week of hospitalization. Prognostic evaluation should be obtained by simple and precise scoring system such as the modified Marshall score and CT-scan severity index. CONCLUSIONS Treatment must be initiated as soon as possible with special focusing on fluid and nutritional supplementation, pain control, cardio-respiratory support, antiproteases and antibiotics. Invasive procedures such as endoscopic sphincterotomy in biliary AP with cholangitis and/or obstruction and percutaneous drainage should be utilized in specific cases. Surgical necrosectomy is mandatory in patients with documented infection of pancreatic necrosis.

A Rheumatological Emergency in a Child: Case of Henoch-Schönlein Purpura (HSP) Presenting with Sudden Loss of Consciousness

Henoch Schönlein vasculitis (HSV) is the most common leukocytoclastic vasculitis of childhood characterized by arthritis, arthralgia, abdominal pain, gastrointestinal bleeding and glomerulonephritis. Central nervous system (CNS) involvement is one of its rare complications.A six year- old girl with a diagnosis of HSP admitted with sudden loss of consciousness, convulsions was presented, because of clinical rheumatologic emergency. CNS involvement was found in MRI of the patient who developed HSP three months ago and treated with steroid and cyclophosphamide because of renal involvement. Immediately sequential high-dose intravenous steroid therapy was applied for three days, and the patient was discharged within the second week of hospitalization.&nbsp;&nbsp;

Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment

A growing literature describes the clinical presen- tation, diagnosis, and pathophysiology of anti-NMDA (N-methyl-d-aspartic acid) receptor encephalitis. Once conceptualized as a condition primarily affecting adult women and frequently associated with tumors, anti- NMDA receptor encephalitis is increasingly recognized in males, in children, and in the absence of tumors. Despite the expanding knowledge base, much remains to be un- derstood about effective treatments. The little available information on management focuses primarily on tumor management and immunotherapy to control the anti- body response. Limited information is available on the management of psychiatric symptoms in these complex, often critically ill patients. Here we describe, through an illustrative case example, the clinical characteristics of anti-NMDA receptor encephalitis in an adolescent male. We also outline other disease processes to be considered in the differential diagnosis and describe currently used interventions, including psychotropic medications.

Mycoplasma pneumoniae community-acquired pneumonia (CAP) in the elderly: Diagnostic significance of acute thrombocytosis

The most common cause of nonzoonotic atypical community-acquired pneumonia (CAP) is Mycoplasma pneumoniae. M. pneumoniae CAP is most common in young adults but may occur at any age. Like other atypical CAPs, M. pneumoniae is associated with a characteristic pattern of extrapulmonary organ involvement and nonspecific laboratory tests. M. pneumoniae CAP is frequently accompanied by gastrointestinal manifestations (eg, loose stools/diarrhea), nonexudative pharyngitis, or skin involvement (ie, erythemamultiforme). Central nervous system involvement with M. pneumoniae is rare and accompanied by highly elevated cold agglutinin titers. Cardiac, hepatic, and renal involvement are not features of M. pneumoniae CAP. Because M. pneumoniae CAP is most frequent in ambulatory young adults, it is an easily overlooked diagnosis in elderly patients hospitalized with CAP. The hallmark clinical finding of M. pneumoniae CAP is protracted nonproductive cough. The characteristic nonspecific laboratory test finding uniquely associated with M. pneumoniae CAP is elevated cold agglutinin titers. Seventy-five percent of patients with M. pneumoniae infection have elevated cold agglutinin titers. However, the absence of elevated cold agglutinin titers does not argue against the diagnosis of M. pneumoniae. If cold agglutinins are present in a patient with CAP, the higher the cold agglutinin titer is (>1:64), the more likely the cold agglutinins are due to M. pneumoniae. Q fever is the only other atypical CAP that is rarely associated with cold agglutinins. We present a hospitalized patient with CAP in whom all microbiologic and serologic diagnostic test results were negative during the first week of her hospitalization. M. pneumoniae CAP was not suspected because of her age. Her initial M. pneumoniae immunoglobulin-M and cold agglutinin titers were negative. During the second week of hospitalization, an increased platelet count was noted. It is a common misconception that acute thrombocytosis is an acute phase reactant. Her acute thrombocytosis increased and persisted. The diagnostic clue to the cause of this hospitalized patient with CAP was acute thrombocytosis. In a patient with CAP, acute thrombocytosis is usually associated with Q fever pneumonia and less commonly with M. pneumoniae. If Q fever can be excluded on the basis of a recent/proximate zoonotic vector contact history, then acute thrombocytosis is an important clue to M. pneumoniae CAP. Acute thrombocytosis due to M. pneumoniae and Q fever occurs during weeks 1 and 2 of the infection. In patients with CAP, acute thrombocytosis that occurs during weeks 1 and 2 of the illness should suggest M. pneumoniae in patients without recent zoonotic vector contact history.

Non-convulsive status epilepticus secondary to valproic acid-induced hyperammonemic encephalopathy

Valproic acid (VPA) may induce hyperammonemic encephalopathy. On the other hand, seizure-inducing effects of antiepileptic drugs (AEDs) may be a paradoxical reaction or a result of AED-induced encephalopathy (commonly induced by VPA). We present the case of a 19-year-old male who developed acute mental status changes consistent with encephalopathy evolving into repetitive seizures with oral automatisms induced by relatively small doses of VPA. Although serum hepatic enzymes, such as AST and ALT, were normal, serum ammonia concentration was high, i.e. 70 micromol/l (normal range 9-33 micromol/l). Administration of VPA was discontinued immediately after admission. The patient's condition improved during the second week of hospitalization and ammonium levels returned to normal. In conclusion, although uncommon, a possible induction of non-convulsive status epilepticus by valproate-induced hyperammonemic encephalopathy should be taken into account and properly managed by discontinuation of the drug.

The disk of bileaflet mechanical mitral valve prosthesis jammed by ruptured papillary muscle

The disk of bileaflet mechanical mitral valve prosthesis jammed by ruptured papillary muscle