123 Argininosuccinate lyase deficiency (ASLD) incidence and management in Oklahoma

FM Boulos*

Y Enchautegui-Colon

D DeMarzo

S Palle

AC Tsai

The University of Oklahoma Health Sciences Center, Edmond, OK

Case Report

Argininosuccinate Lyase Deficiency (ASLD) is a rare disorder of the urea cycle. Argininosuccinate lyase is the enzyme that cleaves argininosuccinic acid (ASA) to produce arginine and fumarate in the fourth step of the urea cycle. For ASLD, while dietary restrictions of protein and supplementation with arginine are mainstays of management; the liver could still sustain damage from ASA accumulation and patients eventually become candidates for orthotopic liver transplantation (OLT).

ASLD is found at relatively higher incidence in a Burmese refugee population in northeastern Oklahoma, the Zo people whose native language is Zomi. These patients present with consanguinity borne of seclusion. We have had the unique opportunity to manage 9 patients identified after the initiation of statewide expanded newborn screen with ASLD, ages ranging from 5.5 months to 8 .5 years old with a 4:5 male: female ratio. Four patients were of Zo origin, with the unique homozygous missense pathogenic variant c.707G>A, p.Arg236Gln presenting with hyperammonemia while the other 5 patients presented with variable degree of developmental delay with or without liver disease. We are conducting a longitudinal follow up study with emphasis on some key differences in management and outcome. Our outcome measures include the amount of arginine supplementation and need for OLT.

Our data suggest that the deleterious nature of the pathogenic variants played an important role in the clinical manifestations of the disease?. – (This sentences is was hard to read, so check this out?) A recent study suggests limiting arginine dose to 100 mg/kg/day, however based on our experience this dose is not sufficient with the severe pathogenic variant identified in our cohort: c.707G>A, p.Arg236Gln. Indeed, the dose of arginine also depends on the protein intake of the patients which should be adjusted critically during the first 2 years of life, with dosages as high as 300 mg/kg/day. OLT was performed in 4/9 (44%) of these patients. These preliminary findings provide basis for continued expansion of early detection and further research into the treatment algorithms needed to optimize quality of life for those affected with this unique disorder.

124 Adverse childhood experiences correlate to depressive symptoms in adolescents

R Garrison*

K Tawse-Butha

S Myers

JJ Burns

University of Florida, Pensacola, FL

Purpose of Study

Adverse childhood experiences (ACE’s) such as child abuse, parental mental illness/substance abuse, domestic violence and parental absence confer lifelong health risks. The purpose of this study is to determine if there is a correlation between childhood ACE’s and adolescent depression.

Methods Used

The research team conducted a retrospective chart review including patients who completed the ACE’s assessment questionnaire and the PHQ-9 depression screen at their visit to an Adolescent Medicine teaching clinic. ACE’s scores were then compared to PHQ-9 scores categorically using a 2 × 2 cross-table (Chi-square). Scores on ACE’s ≥4 and PHQ-9 ≥10 were defined as high scores based on the literature.

Summary of Results

119 adolescents completed both ACE’s and PHQ-9 screening surveys at the time of their visit, with 92 (77.3%) having ACEs scores <4, and 27 (22.7%) having scores of ≥4. There were 90 (75.6%) with PHQ-9 depression scores <10, and 29 (24.4%) having scores ≥10.

On crosstab analysis, those with ACE’s scores <4, had PHQ-9 depression scores ≥10 in 18 (19.6%; (expected count 22.4) whereas for those with ACE’s scores ≥ 4, PHQ-9 scores were ≥10 in 11 (40.7%; expected count 6.6). This difference was statistically significant (Chi-square 5.1, p=0.024). Table 1.

Conclusions

Having high number of adverse childhood experiences correlates with depressive symptoms later in adolescents. Early interventions during childhood to prevent the mental health consequences of ACE’s should be a priority.

125 Predicting inpatient croup outcomes

WC Hancock^1,2*

M Scott¹

J Winer^1,2

¹The University of Tennessee Health Science Center, Memphis, TN

²Le Bonheur Children’s Hospital, Memphis, TN

Purpose of Study

To describe inpatient racemic epinephrine (RE) use for croup through emergency department (ED) parameters including time between RE treatments.

Methods Used

We completed a retrospective chart review of patients admitted with a diagnosis of croup age 2 months to < 7 years old from 2016 to 2019 at a mid-south children’s hospital. All patients received at least one treatment of RE prior to admission. Patients with congenital airway anomalies, prior tracheal surgery, initial PICU admission, complex medical conditions, previous admission within the past 30 days, other primary diagnoses, or missing records were excluded. We assessed patient demographics, laboratory studies, radiologic studies, and other management in the ED. Data was analyzed using logistic regression.

Summary of Results

Of 386 identified patients, 238 were included. 59 (24.7%) of these patients received additional RE during admission. The median time between 1st and 2nd doses of RE in the ED did not differ between patients who did not receive inpatient RE and those that did (1.90 hours vs. 1.85 hours, p = 0.71). Overall length of stay for patients who did not receive inpatient RE was significantly less with a median of 16.7 hours (p <0.001). Patients with age-defined tachypnea (OR 2.33, p = 0.10) and who were afebrile (OR 0.417, p = 0.016) in ED triage were more likely to require RE during admission.

Conclusions

In patients admitted with croup, duration of time between RE doses did not provide significant predictive value for whether patients would require additional RE in the inpatient setting. Absence of fever and age-related tachypnea were found to be significant predictors of inpatient RE use.

126 Gastric perforation: a rare complication in anorexic patients

A Hassan*

A Landmann

S Lawlis

A Ruiz-Elizalde

AB Middleman

The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Case Report

Spontaneous gastric perforation in patients with eating disorders is a rare entity associated with high mortality. We present a case of an anorexia nervosa patient who had a gastric perforation. This patient’s poor nutrition likely led to impaired immune response which simultaneously masked and protected against this life-threatening condition.

A 13-year-old girl with a history of anorexia nervosa was admitted for severe malnutrition. Her diet had been very poor prior to presentation, mean estimated body mass index (MEBMI) was 61.5%. She denied binge eating, vomiting, diet pill, or diuretic use. She had cachexia, breast atrophy and cool extremities. She was started on a low intake (~1400 calories/day) refeeding plan. On day 1, she had mild abdominal pain that responded well to Tylenol. She had difficulty finishing her meals on day 2 and was given naso-gastric feeds to supplement. Her belly was soft and bowel sounds were present through the afternoon of day 2. At breakfast on day 3, the patient collapsed; she had a distended abdomen, absent bowel sounds, blue lips and a blood pressure of 65/35. Abdominal imaging revealed free air under the diaphragm. Emergent laparotomy was done with aspiration of ~4 liters of undigested food, including the salad she had at lunch on her first day. The stomach was perforated with partial necrosis. Dusky appearance of diaphragm, peritoneum and colon indicated abdominal compartment syndrome. The patient had a sub-total gastrectomy with J tube placement and, over time, was slowly transitioned to oral feeds with good weight gain.

Gastric perforation in anorexic patients is due to smooth muscle atrophy, diminished cytokinin release and autonomic dysfuntion. The contents of aspiration indicate that she had a perforation well before the clinical signs manifested. Immune abnormalities due to severe malnutrition likely caused this delayed response. Although rare, providers managing refeeding among severely malnourished patients should be aware of the risk of perforation as well as the possibility that such a critical condition may be masked by immune system derangement.

127 Louisiana pediatricians’ beliefs and practices regarding adolescent parents

N Khorsandi*

S Dumas

LSUHSC-New Orleans, Metairie, LA

Purpose of Study

Parenting adolescents face unique medical and psychosocial obstacles. Therefore, pediatricians are recommended to provide a medical home for both adolescent parents and their children. Pediatricians can provide guidance regarding contraception, continued education, social resources, and domestic violence and mental health screening. It is unknown how many pediatricians continue to provide such vital primary care for adolescent parents.

Methods Used

An anonymous, 20-question survey was sent via email to 886 Louisiana pediatricians who were either members of the national or state chapter of the American Academy of Pediatrics. The survey included questions on pediatricians’ demographic characteristics, sexual health counseling practices, and beliefs and experiences with adolescent parents.

Summary of Results

Of 101 respondents (11% response rate) the majority were white, female, and ages 30–49. Of all respondents, 79% indicated they provide primary care to adolescent mothers; nearly all agreed that adolescent mothers are at higher risk of social problems (99%) and mental health issues (92%); and 73% felt equally as comfortable treating adolescent females as younger children. Only 20% felt less qualified than other physicians to provide care for adolescent mothers. While 54% felt that adolescent mothers should continue receiving care from pediatricians, 70% felt that adolescent fathers should.

Conclusions

Louisiana pediatricians recognize the social and mental health disparities faced by adolescent mothers and the majority continue providing their primary care. However, many more pediatricians believe they should care for adolescent fathers than believe they should care for adolescent mothers. Although further analyses of this data is ongoing, these initial findings generate hypotheses that merit further examination, such as what beliefs or biases may influence pediatricians’ attitudes about adolescent mothers, and whether further pediatrician training and support in the area of reproductive health can improve their confidence in providing the pediatric-focused primary care that adolescent mothers need.

128 Remaining flexible: a case of meningoencephalitis

M Lai*

H Elaasar

S Sarkar

Louisiana State University, New Orleans, LA

Case Report

In the US, due to the availability of MMR vaccination, the incidence of mumps is 1 per 100,000. With increased rates of vaccine exceptions, we may begin to see a reemergence of historic diseases. In areas without access to this vaccine, mumps is the cause of up to 20% of meningitis and meningoencephalitis cases. Here we present an unusual case of meningoencephalitis potentially related to this phenomenon.

A 14-year-old unvaccinated male was admitted to hospital for a 7-day history of headache, fever, photophobia, and neck pain. Lumbar puncture showed opening pressure 51 mmHg, 88 WBC, 39 glucose, and 158 protein. MRI revealed diffuse supratentorial and infratentorial leptomeningeal enhancement with corresponding T2 FLAIR hyperintensity, compatible with meningitis. The patient developed altered mental status, hypotension, and papilledema. Acyclovir was started, and he was transferred to the PICU, where he was intubated for respiratory failure. Meningitis/Encephalitis PCR panel, bacterial cultures, and autoimmune encephalopathy panel were negative. Given unvaccinated history, mumps IgM/IgG were obtained and found to be 1.03/<0.2.

In the PICU, he developed an AKI requiring CRRT. After extubation, he reported profound weakness. MRI brain was repeated and showed increased T2 signal intensity along the bilateral corticospinal tracts extending from the posterior limb of the internal capsule to the bilateral cerebral peduncles and the ventral medulla oblongata, consistent with meningoencephalitis. MRI spine showed ill-defined increased T2 signal involving the length of the central spinal cord with increased leptomeningeal enhancement along the conus medullaris, concerning for diffuse myelopathy or longitudinal extensive transverse myelitis. The patient received IVIG and five courses of plasmapheresis with symptom improvement. Repeat testing revealed elevated mumps IgG, but due to IVIG therapy, diagnosis could not be confirmed without future repeating testing.

While this patient initially presented with classic aseptic meningitis, his clinical course evolved rapidly and unexpectedly, requiring constant reassessment to guide workup. This case demonstrates the importance of keeping a broad differential, maintaining clinical flexibility, and tailoring workup for special populations, such as unvaccinated patients.

129 Vitamin K and ECMO for neonatal hypoxic respiratory failure

N Lock*

A Sawyer

L Wise

J Bhatia

B Stansfield

Augusta University, Augusta, GA

Purpose of Study

The need to maintain a relative coagulopathy during ECMO runs leads to complications from thrombotic or hemorrhagic events. Decreased vitamin K concentration or activity may underscore many of the bleeding complications observed in critically ill neonates. The study centered around evaluating the complications and outcomes in neonatal ECMO patients who received intravenous vitamin K during circuit runs to determine if vitamin K was safe and would improve the complication rates during ECMO use.

Methods Used

A retrospective single center review compared complications (both thrombotic and hemorrhagic) and blood product use for neonates who received (n=21) or did not receive (n=18) a single dose of intravenous vitamin K after initiation of ECMO for respiratory failure. Following implementation of routine vitamin K for prothrombin time (PT) ≥14s during ECMO, outcomes were described in 89 consecutive neonates supported with ECMO for respiratory failure from 2014 to 2019. A subgroup of babies with congenital diaphragmatic hernia on ECMO was also described to compare.

Summary of Results

Neonates who received vitamin K experienced fewer thrombotic complications and similar hemorrhagic complications as neonates who did not receive vitamin K. Total blood product exposure was modestly increased in neonates who received vitamin K, which was attributed to a higher exposure to fresh frozen plasma. ECMO run time, survival off ECMO, survival to discharge, and length of stay did not differ between cohorts. In the descriptive cohort, survival off ECMO for the cohort was 94.4%. Thrombotic complications occurred in 35.9% of the cohort and 100% of CDH neonates while bleeding complications occurred in 15.7% of the cohort and 13.3% of CDH neonates who received vitamin K for PT ≥14s during ECMO.

Conclusions

Intravenous vitamin K is safe for use during ECMO and may be beneficial in neonatal ECMO to help reduce complication rates.

130 Breastfeeding versus formula feeding in an urban academic general pediatrics clinic

MK McEwen*

J Yaun

L Correa

J Gutman

LBonheur Children’s Hospital, Memphis, TN

Purpose of Study

Exclusive breastfeeding through 6 months of life is recommended by the AAP. Benefits for the infant include a decrease in infections and obesity, and benefits to the mother include a decrease in postpartum bleeding and cancer. Despite these benefits, many mothers in our clinic choose not to breastfeed. According to the TN Department of Health, 75.8% of TN infants born in 2017 had ever breastfed, compared to the national average of 84.1%. The rates appear to be even lower in our patient population. Our study seeks to determine the rate of breastfeeding in our clinic and the motivation behind the choice to breastfeed or formula feed. This information can be used to guide resident counseling to mothers in hopes of increasing our clinic breastfeeding rate.

Methods Used

IRB approval was obtained. A 16-question multiple-choice survey was given to mothers of newborn infants at their newborn well child checks. The surveys, without identifying factors, were collected by residents. The data was entered into a database for analysis.

Summary of Results

25 surveys were collected, and 22 were fully completed. Based on preliminary data, 36% of mothers are formula-feeding exclusively, 28% are breastfeeding exclusively, and 36% are doing both. The majority of first-time mothers are planning on breastfeeding. Almost 50% of mothers who choose to breastfeed state their motivation is believing it’s ‘best for the infant.’ The infant-feeding practices of friends did not influence mothers; however, their own mothers’ practices had influence. 17% of women noted work was the reason they are formula-feeding and 17% noted free formula received through WIC led them to formula-feed; 21% of women choose formula because they had used it prior. 80% of women stated they have received breastfeeding education. Finally, most women receive WIC benefits.

Conclusions

Our results indicate that most women are formula-feeding or supplementing with formula. Most women who choose to formula-feed do so out of convenience or because they receive WIC benefits. Some women had not received education about breastfeeding or its benefits. These results confirm lower breastfeeding rates in our clinic and support a need for reevaluation of our understanding of mothers’ choices for infant-feeding. The information gathered can be used to guide counseling for our community.

131 Rare case of severe COVID-19 in otherwise healthy infant at 4 days of life

J Morris*

A Gubbels

C Meyer

NP Shah

University of Alabama at Birmingham, Birmingham, AL

Background

COVID-19 is considered to be relatively rare in the neonatal period. Transmission primarily occurs via respiratory droplets from a caregiver in the postnatal period. Two groups of neonates are currently believed to be higher risk of severe disease– preterm infants and those with underlying medical conditions.

Methods Used

We present case report of a neonate with severe COVID-19 presenting at our institution.

Case presentation

4-day-old female, born at 39 weeks via normal spontaneous vaginal delivery with no birth complications, experiences a brief resolved unexplained event (BRUE) during outpatient COVID swab. Family reported infant had not been feeding well and at that time five household members were known COVID-positive. She was admitted to the Pediatric Intensive Care Unit (PICU) after desaturation to 87% while feeding. She was confirmed to be COVID positive.

She had persistent apneic and bradycardic spells that prompted intubation until day 3 of stay. Following extubtation, she repeatedly desaturated to the mid-80s while on high flow nasal cannula, requiring reintubation on day 5. During this time, sepsis workup was done which was negative; additional negative studies included head ultrasound, pre/post-ductal saturation, viral respiratory panel, HSV PCR, and metabolic panel. On day 12, she again desaturated and was found to have a right pneumothorax on chest x-ray necessitating chest tube placement. On day 17, she was given convalescent plasma and dexamethasone for lung support due to persistent viremia. She was extubated on day 25 and transferred to a floor bed on day 26.

She had to be retransferred to the PICU twice during hospitalization for persistent respiratory distress with recurrent right pneumothorax. In addition to broad-spectrum antibiotics, she also received remdesivir on compassionate-use basis. She was discharged at day 68 of stay with 41 days of admission to PICU.

Conclusions

Contrary to popular belief, severe neonatal COVID-19 infection is not limited to infants born prematurely and those with preexisting medical conditions. It is critical to counsel families on the risk of exposing newborns to known COVID-positive individuals.

132 Persistent eosinophilia and fever in pancreatitis: a clinical conundrum

JP Noel*

N Sharma

A Fields

R Arrouk

Augusta University, Augusta, GA

Case Report

A healthy 11-year-old girl presents with epigastric abdominal pain, fever, weight loss, and decreased appetite for one month. On physical exam, she appears ill, dehydrated, and cachectic. Her abdominal exam is significant for large ascites with a fluid wave and is non-tender to palpation. Her labs show leukocytosis with an eosinophilic predominant granulocytosis and an absolute eosinophil count of 6,800/mm³. She has elevated serum inflammatory markers, hypoalbuminemia, and lipase is 5,000 U/L. Her renal and liver function panels were normal. MRCP shows an irregular and dilated pancreatic duct throughout the pancreatic body and tail with no evidence of pancreatic divisum or choledocholithiasis. She was diagnosed with pancreatitis with pancreatic duct obstruction and subsequently underwent ERCP with pancreatic stent placement, paracentesis, and colonoscopy. Her peritoneal fluid was significant for an eosinophilic predominant granulocytosis with no evidence of malignancy on flow cytometry. All cultures and gram stains were negative. Her gastrointestinal biopsies showed no specific abnormalities on pathology review with no evidence of eosinophilia involving her gastrointestinal mucosa.

Following stent placement, her lipase initially decreased. However, on postoperative day 18, she developed a fever with night sweats. On exam, she was febrile, tachycardic with abdominal distention. Empiric, broad-spectrum antibiotics were initiated due to concern for infected pancreatic necrosis versus spontaneous bacterial peritonitis. Repeat MRCP showed interval development of two peripancreatic fluid collections and re-accumulation of ascites. She continued to have daily fever ranging from 39–40°C. Repeat paracentesis and evaluation of her peritoneal fluid showed resolution of eosinophilia with an elevated neutrophil count, negative gram stain, and no growth on culture. She completed a 10-day course of antibiotics, however, remained febrile with elevated inflammatory markers and leukocytosis throughout her hospitalization. A genetic panel to evaluate for a hereditary cause of chronic pancreatitis was sent and returned positive for a mutation of the serine protease inhibitor Kazal type 1 (SPINK1).

133 Pediatric clonidine poisoning a quarter-century later

JC Pruett¹*

NP Shah¹

K Gutermuth¹

B Whitworth²

A Slattery²

K Monroe¹

MH Nichols¹

¹University of Alabama in Birmingham School of Medicine, Hoover, AL

²Alabama Poison Information Center, Birmingham, AL

Purpose of Study

Clonidine, originally designed as an antihypertensive agent, has also been used in the treatment of various behavior and sleep disorders. Over time, prescription of clonidine to children for these conditions have increased. In our prior study on clonidine, the epidemiology, management, and a review of clonidine related hospitalizations in children were studied from 1987–1992. The purpose of this study is to describe the changes in these parameters for clonidine exposures at the same institution, a quarter-century later.

Methods Used

We conducted a retrospective study of clonidine ingestion in children ages 0–6 from 2013–2018. Our poison center’s database was queried and a list of cases was obtained. Only cases where clonidine was the sole ingestant were included. Using electronic medical records we obtained demographic information and patient management data including use of and response to naloxone. Descriptive analysis was performed to calculate frequencies and proportions. We compare findings from this study with the prior study.

Summary of Results

80 cases were included in the current study, there were also 80 cases in the prior study. The median age of all patients was 2.4 years (IQR: 1.8 to 3.1). Clonidine prescribed most often belonged to the patient’s sibling (30.0%), the patient’s grandparent (26.3%), or self (12.5%); compared to the previous study of 1987–1992 where clonidine most commonly belonged to the grandmother (54%). 88.8% of patients in this study utilized Medicaid as their primary insurance, compared to 34% with Medicaid coverage as their primary insurance in the prior study. 88.8% of patients were admitted to an intensive-care unit for monitoring, with an average length of stay of 21.6 hours. 11.5% of patients required intubation due to respiratory failure. Naloxone was utilized in 53.8% of patients, with 60.5% noting symptom improvement, compared to 49% of patients receiving Naloxone with 16% showing improved symptomatology in the prior study.

Conclusions

As clonidine is being prescribed more frequently to pediatric patients, toxic exposures in children are more likely to come from a sibling or a medication prescribed to self than a grandparent. Naloxone as an antidote for clonidine can prove to be effective.

134 Teenager with history of vaping diagnosed with E-cigarette or vaping product use-associated lung injury (EVALI)

R Ramakrishnan*

C Murray

MR Roca Garcia

University of South Alabama, Mobile, AL

Introduction

Recent data has shown that usage of electronic cigarettes (e-cigarettes) is steadily increasing among high school students in the U.S. Reports have shown e-cigarettes to cause a broad spectrum of pulmonary disease including lipoid pneumonia, acute eosinophilic pneumonia, hypersensitivity pneumonitis and diffuse alveolar hemorrhage. More recently this entity called E-Cigarette or vaping product use-associated lung injury (EVALI) has been more widely seen.

Case Description

13-year-old female admitted due to respiratory distress with concern of atypical pneumonia evident on chest X-ray. She was otherwise healthy with no underlying disorders. Initial laboratories showed leukocytosis at 23,000 and a CRP of 4.7. Patient disclosed daily use of multiple vaping products including Bidi^TM Stick, TKO ^TM, Bang ^TM, Vuse ^TM, and NJOY ^TM. The patient was managed with albuterol, ceftriaxone, azithromycin as well as systemic steroids and did not require supplemental oxygen while admitted. Patient was provided cessation education and a cessation hotline number on discharge along with antibiotics and steroids to complete dosing course.

Discussion

E-cigarettes function by conversion of liquid to vapor by adding heat, thus the term ‘vaping’ is commonly used. Symptoms of EVALI include dyspnea, chest pain, cough, hemoptysis and gastrointestinal symptoms like nausea, vomiting, abdominal pain with fever and malaise. Patients often present with tachycardia, tachypnea, fever and hypoxemia, like our case. Computed Tomography is the preferred imaging modality to diagnose EVALI and the mainstay treatment is administration of steroids. A positive response to steroids suggests an inflammatory pathway in the progression of EVALI, as evident in our patient.

Conclusions

Increasing use of e-cigarettes and vaping products are linked with significant lung injury in adolescent population. In teenagers presenting with respiratory distress, the likelihood of EVALI should be considered. Investigation into personal history of vaping is the cornerstone of diagnosis and can be challenging. It is imperative to highlight case reports and implement education with community support to aid in cessation of use.

135 Nurse practitioner-performed point-of-care ultrasound to assess bladder fullness prior to formal transabdominal pelvic ultrasound in a pediatric emergency department: a randomized controlled trial

S Ruffenach¹*

KR Richard²

NP Shah¹

M Baker¹

M Thompson¹

¹The University of Alabama at Birmingham, Birmingham, AL

²Duke University, Durham, NC

Purpose of Study

At many institutions, the standard of care is to place a urinary catheter which is then used to instill saline into the bladder to ensure fullness prior to formal pelvic ultrasound (US) in Pediatric Emergency Departments (ED). This study aims to evaluate whether a certified registered nurse practitioner (CRNP)-performed bladder US to ensure bladder fullness prior to formal US can reduce the time in minutes needed to complete pelvic imaging compared to the invasive urinary catheter method. Additionally, it aims to compare patient-reported pain with these two methods.

Methods Used

This study utilizes a randomized controlled trial with 2-group parallel design with female patients aged 8–18 years in the Children’s of Alabama Pediatric ED requiring pelvic US. After informed consent, patients were randomized to one of two groups: the standard group received a urinary bladder catheter followed by formal pelvic US and the experimental group underwent periodic CRNP-performed point-of-care bladder US in addition to self-reported sensation of bladder fullness. When the bladder was found to be full patient was sent for formal pelvic US. Once imaging completed patients were asked to report the pain associated with receiving a catheter versus point-of-care ultrasound. Data collected included demographics, time when pelvic US ordered, time when pelvic US completed, pain score on a scale of 0–10. Primary outcomes were the time in minutes from when the pelvic US was ordered to when the images were available and patient-reported pain score. The secondary outcome was the success rate of obtaining pelvic US images on first attempt. As per power analysis, the total sample size required for the study is 48 with 24 in each group.

Summary of Results

Enrollment is underway, results pending completion of enrollment. To date, 30 patients have been enrolled.

Conclusions

Enrollment is underway, conclusions pending completion of enrollment.

136 Acute flaccid paralysis, a lesson in timing

A Sarma¹*

M Huttner²

K Moussavi²

I Temple³

¹Tulane University, New Orleans, LA

²University of Queensland, Ochsner Clinical School, New Orleans, LA

³Ochsner Medical Center – New Orleans, Ochsner Medical Center – New Orleans, New Orleans, LA, US, Hospital, New Orleans, LA

Case Report

Huttner, Madelyn; Moussavi, Kiana; Sarma, Arunava; Temple, Israel

Introduction

Acute flaccid paralysis is term which groups a number of uncommon but potentially devastating childhood nervous system diseases, including but not limited to acute flaccid myelitis, transverse myelitis, Guillain Barre, and disseminated encephalomyelitis. There is wide variation in the etiology of these diseases but the treatment and diagnostic studies are similar.

Background

We describe the case of a previously healthy 3-year-old female with no significant medical history who presented with a 2-day history of refusal to walk, urinary retention, and increasing lethargy. MRI at time of admission showed cord expansion from the cervicomedullary junction to T12 as well as diffuse leptomeningeal enhancement. An acute flaccid paralysis workup was initiated. She was started on IVIG and solumedrol for treatment of the inflammation. Plasmapheresis was considered but declined due to risks and decreased likelihood of efficacy due time from initial symptoms. She was also provided Fluoxetine due to some evidence showing in vitro response in CNS enterovirus infections. Infectious disease labs were only notable for HHV IgG + as well as HSV+, rheum labs were only notable for mildly elevated SSA. Encephalitis workup was negative. AFM panel was negative. The patient had minimal response to steroids and IVIG, with continued need for bladder caths and limited ability to move bilateral legs. She was transferred from our facility to neuro-rehab continued care.

Discussion

Acute flaccid paralysis is a broad term for a number of neurological disease processes characterized by weakness or paralysis and reduced muscle tone. Both the diagnostic evaluation and treatment are time-sensitive and should be initiated as soon as possible after the patient develops symptoms. Diagnostic evaluation includes MRI, CSF studies, autoimmune studies, and stool, serum, nasopharyngeal swabs for viral etiologies. Treatments are usually aimed at reducing the inflammatory state and include IVIG, steroids, plasmapheresis but studies are limited and it is difficult to make conclusions about efficacy.

137 Kidney allograft outcomes in pediatric patients transitioning to adult care-a single center pilot study

S Subramanyam*

KM Wille

M Seifert

V Kumar

G Towns

G Agarwal

S Ong

The University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

The transition of healthcare for young people with kidney transplants from pediatric to adult care settings is an area of need, hitherto under-recognized in adult care centers. The outcomes of pediatric patients transitioned to adult care has not been studied rigorously at our transplant center and may help identify areas for intervention.

Methods Used

We performed a pilot study to retrospectively review the outcomes of the recent 29 kidney transplant patients who transitioned care from Children’s of Alabama to University of Alabama at Birmingham between 1/1/2017 and 9/30/2020. Statistical analyses were performed using JMP (Cary, NC).

Summary of Results

61.1% of our patients were male, 45% were African American and 40% were White. Median age at transplant and at transition were 16.2 years (IQR 13.9–17, range 9–18.4) and 19.9 years (IQR 19.6–20.7, range 18.5–21.9) respectively and median age at last follow up was 21 years (IQR 20–22). Median time from transplant to transition was 4.3 years (IQR 2.5–5.0). Median creatinine at transition was 1.3 (IQR 1.1–1.9). At the time of transition, ten patients (34%) had a history of organ rejection, 6 (21%) had a history of a positive donor-specific antibody (DSA). Within 2 years following transition, 6 (20%) developed de novo DSA, 4 patients (14%) developed acute rejection and 4 (14%) developed graft failure (3 had acute and 1 had chronic rejection). Nearly all patients received maintenance immunosuppressive regimen consisting of tacrolimus (93%), mycophenolate mofetil (86%) and prednisone (93%). All 4 graft losses occurred within 1 year of transition and of the 4, 3 had a pre-transition history of acute rejection and/or DSA. On bias-reduced logistic regression analysis models that included de-novo DSA, acute rejection after transition and creatinine at transition were not associated with graft loss within 2 years of transition.

Conclusions

A significant number of patients transitioning to adult care already have a history of organ rejection and DSA. In a 2 year period following transition, graft loss rate was low. None of the factors studied were associated with graft loss likely due to the low event rate. Additional data collection is underway to verify this finding and to identify areas for future intervention.

138 A rare cause of acute acalculous cholecystitis

A Alexander¹*

F Ibrahim²

¹The University of Alabama at Birmingham, Huntsville, AL

²UAB-Huntsville, Huntsville, AL

Case Report

A 40 yo male presented to the emergency department with 2 days of abdominal pain, nausea, vomiting, and poor oral intake following 2 weeks of diarrhea. The pain was burning, worse with meals, and rated as a 10/10 at its worst. He denied fever, chills, hematochezia, melena, chest pain, or shortness of breath. He had no past medical history, recent travel or sick contacts, and was taking no prescribed or over the counter medications. Exam was significant for RUQ tenderness without guarding, rigidity, organomegaly, or masses. Laboratory results were significant for total bilirubin 2.8 mg/dL, direct bilirubin 2.5 mg/dL, alkaline phosphatase 358 EU/L, ALT 1771 EU/L, AST 1535 EU/L. Abdominal ultrasound found no abnormality of the liver, but a contracted gallbladder, with wall thickening measuring 3.4 mm. CT scan of the abdomen confirmed mucosal hyperemia and pericholecystic edema, no gallstones were visualized. Hepatitis panel was reactive for hepatitis A IgM, indicating acute viral infection. The patient was managed symptomatically, without improvement. On day 4, total bilirubin increased to 4.8 mg/dL. HIDA scan confirmed biliary obstruction with cholecystitis. Laparoscopic cholecystectomy was performed without complication, finding an acutely edematous, distended, acalculous gallbladder. Abdominal pain, nausea, and vomiting resolved, diarrhea improved. Patient was discharged home with self-care.

This patient had acalculous cholecystitis superimposed on acute hepatitis A. Hepatitis A remains asymptomatic or presents with self-limiting abdominal pain, nausea, vomiting, diarrhea, or jaundice. Hepatitis A Virus has rarely been associated with the invasion of the biliary ducts and gallbladder epithelium. The subsequent cell mediated immune response can lead to acute acalculous cholecystitis. Persistent, severe abdominal pain in the setting of increased bilirubin indicates further evaluation for biliary obstruction, as treatment with laparoscopic cholecystectomy may lead to symptomatic improvement and prevent life threatening complications of gangrene, perforation, and empyema. It is important to consider acalculous cholecystitis as a potential etiology of RUQ pain in the setting of hepatitis A with hyperbilirubinemia, with surgical excision as the curative treatment.

139 Mollaret’s meningitis

E Alshaikh*

A Baggett

Univeristy of Alabama at Birmingham – Huntsville Hospital, Huntsville, AL

Case Report

A 31-year-old female presented with progressive headache, nausea and neck stiffness for 2 days. She reported a history of aseptic meningitis and herpes zoster infection. She had photophobia, neck stiffness and positive meningeal signs.

She had unremarkable complete blood count, comprehensive metabolic panel, brain computerized tomography and brain magnetic resonance imaging. Lumbar puncture showed colorless CSF, with 333 cells/mm3 (62% lymphocyte), 88 mg/dl protein and 58 mg/dl glucose. Meningitis panel was positive for HSV2.

Initially, she received Vancomycin, Cefrtiaxone and Gancyclovir which were discontinued after the negative blood and CSF cultures. The patient improved with Acyclovir and discharged on Valacyclovir.

Discussion

Mollaret’s meningitis (recurrent benign aseptic meningitis) is a rare condition, characterized by multiple episodes of fever and meningeal irritation. It is most commonly caused by Herpes Simplex Virus type 2 (HSV-2). It can be associated with HSV-2 genital ulcers and Varicella Zoster virus.

Lifelong HSV prophylaxis has been proposed for Mollaret’s meningitis in some case reports however data to support prophylaxis use remains limited. At least one case report showed a possible reduction in the frequency of recurrence with the continuous suppressive Acyclovir therapy. On the other hand, one randomized control study concluded that Valacyclovir cannot be recommended for prevention.

One of the characteristic features of Mallaret’s meningitis is the spontaneous resolution of symptoms in few days to weeks. Despite that several medications have been used in many reported cases including antiviral therapy like Acyclovir and Valacyclovir. There are no studies to prove the benefits of antiviral treatment nor clear treatment guidelines which could be attributed to the small number of reported cases.

We report this case to improve the awareness, reduce the use of unnecessary medications and provide more data for future investigations regarding treatment and prevention.

140 ‘TOE’ing the line: COVID19 and acro-ischemia

L Al-Sukhni*

I Ivyanskiy

T Naguib

Texas Tech University HSC Amarillo, Amarillo, TX

Case Report

The coronavirus (COVID-19) has infected more than 6.5 million people in the United States. Worldwide, confirmed deaths are nearing the 1 million mark.

Severe COVID-19 infection is characterized by an upregulated innate immune response, a hypercoagulable state, and a range of pulmonary, gastrointestinal, and dermatological manifestations. Various polymorphous cutaneous lesions have been described in the evolving literature, including livedoid eruptions, morbilliform rashes, and acral lesions. The underlying pathophysiology could include vasodilation, hypercoagulability, or increased vascular permeability.

Here, we present two cases of severe COVID-19 infection that involved a prolonged stay in the ICU and intubation. The hospital course was complicated by an acute kidney injury, requiring renal replacement therapy, and septic shock. Early during the hospitalization, both cases developed acro-ischemia, also referred to as pseudo-chilblains, of the distal lower extremities. Both patient survived and subsequenlty discharged to rehabilitation facility.

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Abstract 140 Figure 1

141 An unusal cause of pleural effusion

R Bankusli*

RK Bankusli

University of Mississippi Medical Center, Jackson, MS

Introduction

Urinothorax is a rare thoracic complication involving the presence of urine in the pleural cavity through a retroperitoneal leakage frequently caused by obstructive uropathy or mechanical genitourinary (GU) injury. Diagnosis of urinothroax requires a high clinical suspicion specially in patients with recent abdominal surgical intervention.

Case Description

A 21 year old man with recent hospitalization for left kidney stone presented with fever, shortness of breath and new large left sided pleural effusion. During his recent hospitalization, he underwent percutaneous nephrostomy tube placement, and lithotripsy that was complicated by MRSE bacteremia. He was discharged with appropriate antibiotics. On admission, thoracentesis of the left pleural cavity showed exudative fluid with inflammatory cells and pleural to serum Cr ratio of 1. A repeat CXR the following day showed re-accumulation of fluid in the left pleural cavity requiring a second thoracentesis yeilded similar fluid analysis. A technetium 99m renal scan demonstrated increased radiotracer uptake in the left hemithorax suggestive of urinothroax; however, it was unable to delineate a definitive sinus tract between urinary systems and chest cavity. Given the recurrence of fluid in the left hemithorax, chest tube was placed with intra-pleural alteplase and dornase to expedite the drainage of exudative effusion. The rate of fluid accumulation decreased over time, and the chest tube was removed. He was discharged on antibiotics.

Conclusion

Urinothroax is a clinical diagnosis and should be included in the differential diagnosis of pleural effusion in any patient with a recent history of urological, gynecological, or intra-abdominal procedure. Pleural fluid analysis seen in our patient showing both infectious and urinoma was intriguing and required further investigation with radiotracer renal scan. Although pathological tract was not discovered, the evidence of radiotracer in the left hemithorax cemented our differential diagnosis. Urinothorax may self-resolve with supportive measures such as serial thoracentesis or chest tube placement with the resolution of obstructive uropathy.

142 More than a headache: anaplastic pleomorphic xanthoastrocytoma

AM Bonano-Rios*

K Andino Lebron

W Caceres-Perkins

VA Caribbean Healthcare System, San Juan, Puerto Rico

Case Report

Chronic headache is a common complaint in the outpatient setting with multiple etiologies, including malignancy. Anaplastic Pleomorphic Xanthoastrocytoma (APXA) is a rare brain tumor composing less than 1% of all astrocytoma and 62 adults diagnosed per year. APXA presents as a slow-growing mass in the temporal lobe, with new onset of seizures. We present the case of a successful treated patient of APXA which presented with indolent headaches.

A 41-year-old man with a two-month history of progressive headaches, described as pressure-sensation 10/10 located at bitemporal area. These headaches were associated with photophobia and phonophobia and interfered with his activities. Rest of review of system was negative. Physical examination negative for neurological deficits. CT scan revealed a mass on right frontal lobe. MRI with IV gadolinium showed an intra-axial mass measuring 2.7 cm with vasogenic edema and mass effect upon right lateral ventricle, displacement of frontal horn and a midline shifting. Staging CT Scans negative for metastasis. Vasogenic edema was treated with Dexamethasone and the patient had resection of tumor.

Pathology report had leptomeningeal and subarachnoid invasion. Tumor cells with nuclear pleomorphism, multilobed and multinucleated forms, nuclei with herniated eosinophilic cytoplasmic profiles, and up to 7 mitoses 10 high-power fields. Immunohistochemistry (IHC) was + S100, +GFAP and +vimentin and negative for the mutation in V600 of BRAF gene. The patient was diagnosed with APXA WHO Grade III. The patient had full recovery and is on active surveillance with serial Brain MRIs without recurrence.

APXA has an overall survival rate of 40–50% within five years. This case demonstrates the importance of adequate history and physical examination for headache stratification and workup. Also, the importance of IHC and cytogenetic testing for prognosis and identification of target therapy. Medicine is dynamic and multidisciplinary, but its foundation starts with an assertive history and physical examination for adequate management of a time-sensitive diagnosis.

143 A heart too sweet: a case report of myocardial infarction triggering diabetic ketoacidosis

CM Cepero-Jimenez*

V Vando-Rivera

GJ Torres-Rivera

Z Mirza

J Casal-Hidalgo

CA Cortes

VA Caribbean Healthcare System, Aibonito, Puerto Rico

Case Report

Diabetes ketoacidosis (DKA) is a life-threatening complication more commonly seen with type 1 than type 2 diabetes mellitus (T2DM), with an increasing hospitalization rate of more than 140,00 per year. DKA can be precipitated by severe stressors like infections, medication noncompliance, drugs, or new-onset diabetes. Non-infectious etiologies for DKA responsible for 4% of the cases include myocardial infarction, cerebrovascular accidents, pancreatitis, among others. We present a case of acute myocardial infarction (MI) triggering diabetic ketoacidosis in a patient with T2DM.

A 73-year-old male with hypertension, T2DM and chronic kidney disease, presented with nausea, vomiting, and diarrhea. Patient was found critically ill and hemodynamically unstable, requiring intravenous fluids and vasopressors. Laboratories showed leukocytosis, hyperglycemia over 1500 mg/dL, high anion gap metabolic acidosis, lactatemia, elevated b-hydroxybutyrate, acute kidney injury and severe hyperkalemia. Elevated highly sensitive troponins of 439 ng/L, which peaked at 6915 ng/L. EKG showed peaked T waves and wide QRS complex managed with intravenous calcium gluconate, insulin and emergent hemodialysis was started. Subsequent EKG showed atrial fibrillation with fast ventricular response and inferolateral ST segment depressions. No infectious foci were found, nor culprit drugs on further review. Cardiac catheterization showed 90% stenosis of the mid left anterior descending coronary artery and branch, and the patient underwent bypass graft surgery upon resolution of his DKA. Findings were consistent with a type 1 non–ST segment elevation myocardial infarct as the cause of his DKA.

MI accounts for approximately 1% of the precipitating causes of DKA in T2DM and responsible for 28% of the deaths in these patients. Painless acute coronary syndrome should always be considered in the setting of DKA without apparent precipitant, especially in elderly patients with multiple risk factors for coronary events as they have been associated with high mortality risk. Early detection of DKA precipitants allows prompt guided therapy, metabolic recovery, and improved prognosis.

144 Fourth time’s the charm: the importance of clinical judgement in COVID-19

CM Cepero-Jimenez*

E Partida-Rodriguez

V Vando-Rivera

AM Bonano-Rios

J Gutierrez-Nuñez

VA Caribbean Healthcare System, Aibonito, Puerto Rico

Case Report

SARS-CoV-2 is an enveloped positive-stranded RNA that is part of the same family as MERS and SARS. This virus is responsible for the current COVID-19 pandemic. Symptoms varies from asymptomatic carriers to a viral-like illness with fever, shortness of breath, and cough. The preferred initial testing is a nucleic acid amplification test with reverse-transcription polymerase chain reaction assay (RT-PCR) from a nasopharyngeal (NP) swab. We present a case of positive SARS-CoV-2 infection in a patient with multiple false-negative results.

A 69 years-old male presented with fever, chills, malaise, anorexia, nausea, watery diarrhea and dry cough for 5 days. He denied sick contacts or recent travel. Vital signs were remarkable for fever and borderline blood pressures. The physical exam was unremarkable. Chest x-ray showed bibasilar airspace disease. Chest CT scan showed focal left lower lobe consolidation. He was started on empiric antibiotic therapy for community-acquired pneumonia. Laboratories were remarkable for elevated LDH, CRP, and d-dimers. Initial NP RT-PCR for SARS-CoV-2 was negative. The test was repeated on three different occasions, given the high clinical suspicion of COVID-19 pneumonia, all were negative. The patient continued with high fevers and saturation levels of less than 90%. Chest CT scan was repeated which revealed worsening with development of multifocal bilateral peripheral ground glass and air space opacities. Laboratories showed ferritin on increasing trend and CRP decreasing. Bronchoscopy was done and RT-PCR SARS-CoV-2 from bronchoalveolar lavage was positive. The patient was discharged under isolation measures. Repeated testing was negative, and he made a full recovery.

Comparative data on the accuracy of testing is limited. Preliminary data suggest that sensitivity varies between sampling specimens. Possible mechanisms include viral RNA sample degradation and poor sampling. Recent data favors testing within eight days after exposure and three days after onset of symptoms. Care must be taken in interpreting tests during the early infection period. If high clinical suspicion, infection should not be ruled out only based on NP RT-PCR SARS-CoV-2.

145 Overflow diarrhea and aki due to fecal impaction

D Dave*

I Ivyanskiy

T Naguib

Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX

Case Report

Fecal impaction is a known complication of chronic constipation and particularly bothers the elderly. Common complications include hemorrhoids, megacolon, overflow diarrhea and obstructive uropathy among others. Overflow diarrhea is often misdiagnosed and treated with antidiarrheals leading to worsening impaction. Obstructive uropathy is a well-established complication of fecal impaction with obstruction occurring at any level. The elderly are at high risk due to multiple factors including diabetes mellitus, dementia, opioid use, depression among others. Many case reports have been published with fecal impaction and obstructive uropathy though none reported overflow diarrhea as a presentation.

An 82-year-old male patient presented with diarrhea and acute kidney injury that was caused by fecal impaction that led to obstructive uropathy. He had a 4-week history of non-bloody watery diarrhea with associated fecal incontinence and generalized abdominal pain and a long-standing history of constipation prior to this. Generalized abdominal tenderness with mild diffuse distention and a distended urinary bladder were noted on exam, along with normal rectal tone and loose brown stool in absence of hemorrhoids or prostate enlargement. Lab work showed elevated creatinine and hypokalemia. Upon IV fluid resuscitation and foley catheter placement, CT abdomen was done which showed bilateral hydronephrosis. Stool studies showed no evidence of infection. He was managed with laxatives and had significant improvement in kidney function as well as reduced stool burden.

Our patient had multiple risk factors for impaction including age, immobility, diabetes, and medications including azacitidine.

Chronic constipation in our patient led to fecal impaction which eventually led to overflow diarrhea and obstructive uropathy. It is important to consider impaction as a cause of fecal incontinence and diarrhea in the elderly as it can lead to high morbidity and mortality. The treatment of this diarrhea is counterintuitive since the impaction benefits from catharsis not antidiarrheals. Diet counseling, biofeedback, and rarely surgical intervention can be used in refractory cases.

146 Not so superficial after all

CS Diaz Loza¹*

S Garcia²

A Febles²

¹VA Caribbean Healthcare System, San Juan

²Universidad de Puerto Rico, San Juan, Puerto Rico

Case Report

Melanoma is the most aggressive type of skin cancer and the sixth most common cancer in North America. Acral lentiginous melanoma accounts solely for 5% of all melanomas. However, it is considered the most common type of melanoma among Asians.

A 69-year-old Asian male with type 2 diabetes mellitus, psoriasis, and arterial hypertension presented with one-week history of altered mental status with associated memory loss, poor appetite, weight loss, weakness and imbalance. Initial vitals and laboratories were unremarkable. Brain CT scan revealed multiple brain lesions, but chest and abdominopelvic CT were negative. The patient had a questionable history of uncooked pork consumption. Steroids were given without improvement. Repeated head CT without contrast yielded innumerable hyper-attenuating lesions throughout the parenchyma with evolving hematoma and worsening edema, suggestive of hemorrhagic metastatic deposits. A thorough examination was solely remarkable for poor dentition with caries, psoriatic plaques throughout knees and elbows, as well as a callous-like ulceration with scant black spots in the left heel. MRI revealed an increase in the number and size of supratrentorial and infratrentorial lesions with edema, mass effect and mild left to right midline shift without herniation. Given a significant increase in the number of lesions in three days, an infectious etiology was highly suspected. Empiric antibiotic therapy was provided despite negative infectious workup. Transthoracic echocardiography revealed vegetations in pulmonic and mitral valves and a speckled pattern in the myocardium. Blood cultures remained negative. A transesophageal echocardiogram could not be performed. Biopsy of an evolving left heel callous-like ulceration with purplish hue and darker tone yielded a diagnosis of acral lentigious melanoma. New imaging revealed metastatic lesions in the abdomen, pelvis, and chest.

Acral lentiginous melanoma usually presents in the soles of the feet. This patient’s presentation is consistent with a diagnosis of metastatic melanoma with possible cardiac involvement. This case illustrates the importance of a thorough physical examination and history. By raising awareness of such an uncommon, aggressive diagnosis, we aim to ensure prompt diagnosis and better outcomes.

147 Ramsay hunt syndrome and the importance of early diagnosis

S Ginjupalli*

A Bhuiyan

Augusta University, Augusta, GA

Case Report

58 yo female w PMH of multiple sclerosis (MS) and varicella in childhood presents for eval of L cheek swelling and L ear pain. She was discharged the prior week after inpatient treatment of L otitis externa (OE) secondary to MSSA w outpatient course of Keflex and Cipro ear drops. Vitals stable and physical exam normal besides mild swelling of L cheek. Labs unremarkable. IV cefepime and vanc started w concern for malignant OE.

The next morning, L facial paralysis observed. Stroke immediately ruled out w CT. ID consulted and patient started on high-dose prednisone and acyclovir for suspicion of Ramsay Hunt Syndrome (RHS). MRI demonstrated an incidental finding of a 5 mm vestibular schwannoma (VS) near the L CN VII. DDx: RHS, Bell’s Palsy 2/2 L CN VII impingement by VS, MS flare, malignant OE. Prednisone treated both possible diagnoses of RHS and MS flare. Symptoms showed varying degrees of improvement w the start of treatment.

Critical information: ED note from initial encounter for OE details a vesicular rash on L side of the face. This was lost when presented 2/2 OE confirmed w positive pus culture of MSSA. Rash resolved prior to this hospitalization and diagnosis of RHS was missed for over one week from its initial presentation.

RHS is the reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion of CN VII. It commonly presents as a vesicular rash of the external ear/tongue/palate and acute facial paralysis. Other symptoms of RHS experienced by this patient: medial deviation of L eye (L CN VI nerve palsy), horizontal nystagmus, and hearing loss. Symptoms of RHS like nausea, vertigo, and gait abnormalities could not be discerned from her baseline 2/2 her MS.

Gold standard for diagnosis of VZV is PCR, but this test was unavailable acutely. As such, emphasis was placed on patient treatment over her diagnosis. D/t her advanced age, PMH of varicella as a child, the stress of MS, and her recent otitis externa, this patient had a higher risk for VZV reactivation. Combined w her rash from her prior ED visit and her improvement w treatment, RHS could reasonably be diagnosed.

At six-month f/u, patient continued to experience facial paralysis w difficulty closing her L eye. D/t the poor prognosis of facial paralysis 2/2 RHS, prompt diagnosis and treatment are key to prevention and good outcomes.

148 Myxoid mix-up

A Heng¹*

R Mailapur²

¹University of Alabama at Birmingham School of Medicine, Huntsville, AL

²Huntsville Hospital, Huntsville, AL

Case Report

A 58yo female w/a hx of HTN, hypothyroidism, depression, and fibromyalgia presented w/gradual onset of pain and swelling in her L buttock for 3 months. She described associated pain as sharp and debilitating. The pain radiated down her L leg and was aggravated by movement w/o relieving factors. She denied recent trauma, discharge, redness, numbness, or weight loss. Prior to presentation, she started taking Lyrica and had been unable to work for 5–6 wks due to generalized pain. Physical exam demonstrated a palpable 4 cm subcutaneous mass in her L buttock. The mass was non-tender, partly mobile, and firm in consistency. U/S showed a 2.3 × 1.3 × 2.5 cm hypoechoic mass. MRI w/contrast revealed a 2.7 × 2.2 × 2.0 cm mass involving the inferior L gluteus medius/maximus chest inferior to the ischial tuberosity w/iso- to hypointense signal on T1 imaging, hyperintense signal on T2 imaging, and peripheral rim enhancement. She underwent radical wide local excision of the intramuscular mass, which yielded a 6.0 × 4.5 × 3.7 cm specimen of yellow-white, fibrofatty tissue covered by small amounts of red, striated muscle. Due to concern for a soft tissue sarcoma, the specimen was serially sectioned and revealed a well-circumscribed mass measuring 2.7 × 2.5 × 1.8 cm. The mass had a white, whorled gelatinous appearance. Findings were c/w an intramuscular myxoma.

Intramuscular myxoma (IM) is a rare, benign neoplasm of mesenchymal origin w/an incidence of 1:1,000,000. Majority of lesions present in the 4th to 6th decade of life w/slight female predilection. The tumor most frequently involves large muscle groups of proximal extremities. IMs usually appear as a slow-growing solitary, painless mass that is firm and partly mobile. Sx may arise if the tumor compresses nearby structures. Multiple IMs can be observed in association w/fibrous dysplasia, in which Mazabraud’s syndrome and McCune-Albright syndrome should be considered. Nonspecific clinical sx and radiologic findings make pre-op dx challenging to distinguish IMs from other myxoid lesions, especially low-grade malignant myxofibrosarcomas. MRI is the preferred imaging modality, which characteristically shows hypointense signal on T1 imaging, hyperintense signal on T2 imaging, and peripheral enhancement. Established dx requires histopathological examination. Surgical excision is curative, and recurrence is unlikely.

149 Bullous pemphigoid mimicking cellulitis

I Ivyanskiy*

D Dave

A Dweik

J Yeary

H Yousuf

T Naguib

Texas Tech University HSC Amarillo, Amarillo, TX

Case Report

Bullous Pemphigoid (BP) is the most prevalent autoimmune blistering skin disease in the Western world affecting mainly the elderly population. The diagnosis is based on clinical assessment along with specific immunopathologic findings on skin biopsy. Risk factors include genetic factors, environmental exposures, and several infections including hepatitis B, hepatitis C, Helicobacter Pylori, Toxoplasma Gondi and Cytomegalovirus. A variety of drugs have been associated with bullous pemphigoid including but not limited to dipeptidyl peptidase-4 (DPP-4) inhibitors, loop diuretics, spironolactone and neuroleptics. Associated neurologic disorders (dementia, Parkinson’s disease, bipolar disorder, previous stroke history and multiple sclerosis) have also been described. Common clinical presentation consists of extremely pruritic inflammatory plaques that resemble eczematous dermatitis or urticaria, followed by formation of tense bullae with subsequent erosions. Typical distribution involves the trunk and extremities. Mucosa is typically spared affecting only 10–30% of patients. Several unusual clinical presentations of bullous pemphigoid have been described such as nonbullous forms with erythematous excoriated papules, plaques, and nodules. Other reported findings include urticarial lesions, prurigo-like nodules, multiple small vesicles resembling dermatitis herpetiformis or pompholyx, vegetating and purulent lesions localized in intertriginous areas, and even exfoliative erythroderma. Recognition and management of such cases can present a diagnostic challenge to clinicians. Here we describe another variant which to our knowledge is the first case to present with a cellulitis-like presentation in a patient with a known history of bullous pemphigoid.

150 COVID-19 associated with catatonia and abnormal CSF: a case report

F Jaber*

U Aisueni

T Torrico

C D’Assumpcao

T Kiong

K Sabetian

R Kuran

Kern Medical Center, Bakersfield, CA

Background

Understanding the full impact of the Coronavirus disease 2019 (COVID-19) pandemic remains a challenge for healthcare providers. Although respiratory symptoms remain the cardinal presentation, there are increasing numbers of reports documenting neuromuscular and psychiatric complications in COVID-19. To our knowledge, only two cases of COVID-19 infection associated with catatonia have been previously reported.

Case presentation

A 36-year-old African American diabetic female who has no past psychiatric history presented with vomiting, slurred speech and ataxia. Due to gastrointestinal symptoms, she was tested for COVID-19 by nasopharyngeal PCR which came back positive. MRI of the brain showed no acute intra-cranial abnormalities. Lumbar puncture showed mild CSF pleocytosis with lymphocytic predominance, increased protein and normal glucose. Common causes of aseptic meningitis/encephalitis were ruled out. As hospital course continued the patient developed ataxia and experienced behavioral changes. Starting with increased agitation and selective mutism, she eventually developed full catatonic, retarded type symptoms. The patient received IV methyl prednisone out of concern for autoimmune or paraneoplastic encephalitis with no clinical improvement. Catatonic symptoms quickly resolved with intravenous lorazepam. Neuromuscular and psychiatric symptoms had also resolved before discharge. The patient was discharged home with complaint of poor memory of her hospital course.

Conclusion

COVID-19 can present with neuropsychiatric symptoms, including catatonic symptoms, associated with inflammatory CSF changes.

151 ‘Vision loss’ in a patient with lynch syndrome

SG Jones*

R Martindale

JO Mason

University of Alabama at Birmingham Callahan Eye Hospital, Birmingham, AL

Case Report

A 47-year-old CM with PMH of Lynch Syndrome with partial colectomy presented to the ocular ED with a 1-week history of painless vision loss. The vision loss was sudden-onset, slowly progressive, and distributed like a curtain drawn down over his superior visual field. He also noted new-onset floaters and a visible ‘dust trail.’ Left eye fundoscopy revealed bullous inferior retinal detachment with an inferior mass obscuring the periphery. The mass notably had scant peripheral pigmentation with heme over the superior edge. B-scan showed low-lying serous retinal detachment in the left eye and a 12 × 16 × 14 mm echodense ciliary body tumor.

He was referred for left eye enucleation and cytology with differential of retinal detachment secondary to metastatic adenocarcinoma vs primary amelanotic melanoma of the ciliary body. Colonoscopy and endoscopy were WNL 3 months prior. Cytology was consistent with amelanotic melanoma. He was referred for metastasis workup including LFTs, CT chest and abdomen, and MRI brain.

Discussion

Retinal detachment (RD) classically presents with painless peripheral vision loss, new-onset flashes or floaters, or a curtain drawn down over the peripheral visual field. Unlike rhematogenous RD which involves a retinal tear that leads to detachment, exudative RDs occur in the absence of retinal breaks and may arise secondary to choroidal neoplasms (e.g., ciliary body melanoma). Lynch syndrome is a cancer syndrome commonly involving GI and gynecological malignancies such as adenocarcinomas. Though rare, adenocarcinomas can metastasize to the ciliary body of the eye. In this case the eye was enucleated based on COMS guidelines, which recommend observation for small tumors (<2.5 mm apical height), brachytherapy for medium-sized (2.5–10 mm height and <16 mm diameter), and enucleation for large (>10 mm height or >16 mm diameter). Primary ciliary melanoma warrants screening with LFTs and abdominal & chest imaging.

Conclusion

RD may be the presenting manifestation of ocular tumors, especially in the context of hereditary cancer syndromes. RD and suspected ocular tumor workup includes dilated eye exam and B-scan imaging. Tumor size in conjunction with differential may dictate surgical intervention prior to cytology.

152 An unusual case of non-cardiogenic pulmonary edema and hepatitis due to rickettsial infection

L Kantamneni¹*

I Ingle²

¹University of Alabama Huntsville Regional Medical Center, Huntsville, AL

²Park Avenue Lasek, New York, NY

Case Report

A 42 yr old African American male presented with myalgia, abdominal pain and diarrhea, he was admitted to ICU due hypotension of 90/63 mmHg. On examination his abdomen was tender with a rapid shallow breathing at the rate of 35/min. Labs were significant for WBC 14.99k, AST 119, ALT 98, Bili 4.9 mg/dl and lactate of 2.3 mmol/L. He was started on Metronidazole, Cefepime for a possible abdominal source of infection and IV vancomycin was added. Extensive workup failed to localize the source of infection. Bedside ultrasound showed diffuse B lines in all fields and no consolidation concerning for pulmonary edema. Echo revealed a EF of 20% without LVH or dilated cardiomyopathy. Right heart catheterization showed normal RA and capillary wedge pressures with reduced CO suggestive of non-cardiogenic pulmonary edema. Despite treatment he progressed with worsening WBC, transaminitis and bilirubin which prompted a liver biopsy which was normal and no congestion was noted. RMSF titres were found to be significantly elevated at IgG 1:256 and IgM 1:64. He was started on doxycycline, and he gradually improved with a down trending WBC, liver enzymes and was extubated.

RMSF is a tick-borne disease which presents with non-specific flu-like symptoms which can complicate the diagnosis but can have fatal outcomes unless treated appropriately. Our patient has all factors known to cause high case fatality associated with RMSF including African American race, alcohol abuse, G6PD deficiency, and male gender. The unlikely presentation in our patient was a challenging diagnosis until positive titres returned for RMSF. Rash usually presents late, and is difficult to appreciate due to the patient‘s skin color. The tick carries bacteria and transmits them into the bloodstream, which rapidly multiply within endothelial cells and disseminate through the blood to various areas of the body causing the multi-system disease which can rapidly prove to be fatal if not identified and treated appropriately.

153 Is concomitant steroid use and morbid obesity a risk for propofol infusion syndrome?

L Kantamneni¹*

I Ingle²

¹UAB Huntsville Regional Medical Center, Huntsville, AL

²Park Avenue Lasek, New York, NY

Case Report

58 year old morbidly obese African American female with history of end stage renal disease admitted for acute hypoxic respiratory failure due to COVID-19 pneumonia was intubated and placed on ventilator support. Fentanyl for analgesia and Propofol for sedation were the agents of choice. Propofol was initiated at a rate of 58 mcg/kg/min and maintained between 58–60 mcg/kg/min. On day three of admission she was found to have lipid emulsified blood in the CRRT circuit and labs revealed triglycerides 670 mg/dl, CPK 2074 U/L, potassium of 5.3 mmol/L. A diagnosis of propofol infusion syndrome was made and propofol was switched to midazolam. Over the next two days her CPK, triglycerides improved and returned to normal. Patient has multiple risk factors for the suspected propofol infusion syndrome including the dose and duration of infusion, age, obesity, concomitant steroid and vasopressor use.

Although propofol is commonly used in the Intensive Care Units, propofol infusion syndrome is a rare and potentially fatal complication. It is associated with high dose propofol infusion (>83 mcgkgmin) for a duration of more than 48 hrs. Usual presentation includes metabolic acidosis, elevated triglycerides, rhabdomyolysis, hepatomegaly, bradycardia, AKI, hyperkalemia. It is possibly secondary to impaired tissue metabolism due to inhibition of mitochondrial respiratory chain or fatty acid metabolism. Early diagnosis with a high index of suspicion, avoiding a high rate of infusion and terminating the infusion once diagnosis is established is vital. Hemofiltration is recommended when renal clearance is impaired due to the concomitant AKI which can eliminate metabolites to hasten recovery.

154 Medullary and papillary thyroid collision tumor

H Kreit*

J Guzman

F Dihowm

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Purpose of Study

Papillary thyroid cancer (PTC) and medullary thyroid cancer (MTC) have differing pathologies, histological findings, and clinical presentations. The simultaneous occurrence of both in the same thyroid accounts for less than 1% of all thyroid cancers. The purpose of this case report is to add more data to the English literature about this phenomenon, as there have only been a few cases of this occurrence.

Methods Used

Not applicable.

Case Report

A 64-year-old male with a history of COPD was recently diagnosed with PTC presented with acute hypoxemic respiratory failure, dysphagia, weight loss, and hoarseness. Patient was hemodynamically stable on admission requiring supplemental oxygen saturating 98% via nasal cannula. Physical exam was remarkable for non-tender bilateral cervical lymphadenopathy and a palpable, non-tender mass in the right anterior neck; CT neck showed a tumor in the right thyroid extending into the superior mediastinum and eroding into the trachea with cervical metastatic lymph nodes. Labs: TSH 1.19, Ca 8.8, PTH 32.1, CEA 1270, calcitonin 4070. Molecular testing: RET. Initial right neck biopsy exhibited PTC. Immunohistochemistry: positive for PAX8, Ck7, CK AE1/3, TTF1 and negative for thyroglobulin.

Left neck lymph node biopsy exhibited MTC. Immunostains: positive for CK7, calcitonin, CD56, chromogranin, synaptophysin, and negative for thyroglobulin. Mass Resection and debulking was not feasible. The patient was transferred to an outside facility for tracheal stent placement. He was to undergo radiotherapy and based on molecular testing results, the patient will be started on systemic treatment with selpercatinib.

Conclusion

The random collision theory provides an answer for the simultaneous occurrence of MTC and PTC. Theory states that two separate, distinct tumors get initiated near one another resulting in a polyclonal neoplasm. Coexistence of these cancers can be seen as mixed tumors or collision tumors. Collision tumors are two histologically distinct tumors that developed in the same site. Due to these rare findings, the clinical outcomes are poorly studied, presenting a diagnostic and treatment challenge.

155 Interesting presentation of pituitary macroadenoma

MB Lewis*

P Patel

S Duckworth

University of Mississippi Medical Center, Jackson, MS

Case Report

Pituitary tumors present with a diverse symptomatology depending on whether they secrete hormones or cause mass effect. However, 12–37% of pituitary tumors are non-functional and present asymptomatically or with minor complaints, making this a particularly challenging diagnosis. Herein, we describe a case of a hormonally inactive pituitary tumor with anatomical compression.

A 70 year old Punjabi male with type 2 diabetes and hypertension presented with altered mental status and fatigue. He had progressive memory decline and reduced mobility for three weeks. He was recently hospitalized and treated for community acquired pneumonia. At our hospital, he had dyspnea and nausea. Physical exam was remarkable for tachypnea. He was euvolemic, and the remaining exam was benign. Labs were notable for serum sodium 126 mmol/L, urine sodium 77 mmol/L, serum osmolarity 267 mOsm/kg, and urine osmolarity 448 mOsm/kg. Though we suspected syndrome of inappropriate antidiuretic hormone secretion (SIADH), patient’s sodium did not improve after fluid restriction. Further workup revealed cortisol 0.33 mcg/dL, ACTH 5.9 pg/mL, TSH 1.26 mcIU/mL, and free T4 0.447 ng/dL. He was started on stress dose hydrocortisone and levothyroxine for central adrenal insufficiency/central hypothyroidism. Low LH, FSH, and testosterone indicated central hypogonadism. MRI showed a 1.9 cm pituitary mass with superior displacement of the optic chiasm. Ophthalmology evaluation revealed only bilateral cataracts. Neurosurgery performed a transsphenoidal pituitary resection without complications. The patient had symptomatic and clinical improvement post-surgery.

Pituitary tumors present in various ways, and our case demonstrates that a thorough evaluation of nonspecific symptoms may reveal an unexpected diagnosis. SIADH is a diagnosis of exclusion, so it is important to explore other etiologies such as thyroid dysfunction, adrenal insufficiency, or primary polydipsia. Additionally, early identification of pituitary tumors can improve outcome due to their slow-growing nature. Therefore, this is a diagnosis that should not be missed. This case will change our practice in terms of considering uncommon diagnoses like our patient’s nonfunctioning pituitary tumor.

156 The impact of stressor choice on measuring physical resilience: the aric study

MR McMullan¹*

B Windham¹

M Griswold¹

J Henegan¹

C Blackshear¹

A Kucharska-Newton³

P Palta²

J Schrack⁴

K Bandeen-Roche⁴

T Mosley¹

¹University of Mississippi Medical Center, Jackson, MS

²Columbia University Medical Center, New York, NY

³Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC

⁴Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

Purpose of Study

Physical resilience (PR), defined generally as the ability to maintain or recover function following a stressful event, may present differentially depending on the pairings of stressors and functional measures employed. We examined effects of 3 different stressors on gait speed (GS) resiliency.

Methods Used

Among Visit 5 participants in the Atherosclerosis Risk in Communities Study (2011–13: mean age 76.35.3 years, 42% male, 24% black), 2,231 (38%) had good gait (GS>1 m/s). Resiliency was defined as maintaining good gait at Visit 6 (V6, 2016–2018) following one of three stressors occurring between V5 and V6: (1) adjudicated heart failure (HF), (2) self-reported hospitalization, or (3) self-reported low social support (lowSS; lack of help with decisions or tasks). Non-resilience included post-V5 death, (N=162, 7% of those with good V5 gait). Age-adjusted generalized linear models estimated relative rates (RR) of V6 GS>1 m/s, comparing those who experienced a stressor to those who did not.

Summary of Results

Of 74 participants with good V5 gait and a HF stressor, 22% maintained good V6 gait (i.e. 22% were GS-HF resilient). Comparatively, 57% of the 1,485 without a HF stressor retained good V6 gait; thus, good gait maintenance was 62% less likely among those with a HF stressor compared to those without, RR=0.38 (95%CI: 0.24, 0.59). GS-hospitalization resiliency was 46% (300 of 646 with any hospitalization had V6 GS>1 m/s) versus 62% (564/913 without hospitalization), RR=0.75 (0.68,0.83) and GS-lowSS resiliency was 61% (83/136), similar to the 60% (655/1,093) of those not reporting a lowSS stressor, RR=1.02 (0.88,1.17).

Conclusions

Pairing different stressors with a particular physical function measure can substantially impact resiliency classifications. Physical resilience studies should heavily consider which specific function-stressor pairings may be optimal. Comparisons of those without intermediary stressors can shed light on the importance of a function-stressor resilience pairing.

157 A rather large hiccup

R Mestres*

C Diaz

CA Cortes

VA Caribbean Healthcare System, San Juan, Puerto Rico

Case Report

Lateral Medullary Syndrome (LMS) also known as Wallenberg syndrome refers to occlusion of the posterior inferior cerebellar arteryor vertebral artery. A characteristic presentation of this condition is loss of pain and temperature sensation on the ipsilateral side of the face and contralateral side of the body. However, it also presents as intractable hiccups, vertigo, Horner syndrome, nystagmus, dysarthria, dysphagia, and ipsilateral ataxia. The mechanism for hiccups in LMS is not well understood and there has been a documented incidence of 56% secondary to lateral medullary infarction.

This is the case of an 80 year old male patient with past medical history of diabetes mellitus type II and hypertension who was brought to the emergency department due to imbalance, difficulty with right upper extremity movement, dizziness, nausea, and hoarseness since about 2 hours prior to arrival. Associated symptoms included hiccups that preceded development of other symptoms and persisted on initial evaluation. The patient was previously independent in all activities of daily living. Physical exam on arrival was remarkable for hoarseness/dysphonia, asymmetric palate elevation, right upper extremity motor strength 4/5, and right dysdiadochokinesia. Vitals were unremarkable. Head CT without contrast was done on arrival and failed to show any acute changes. However, it displayed calcification of the bilateral intracranial vertebral arteries as well as proximal basilar artery. Therefore, suspected etiology of acute stroke was atherosclerotic disease. Given absence of contraindications for tissue plasminogen activator (TPA) and presentation within window period, TPA was administered. Subsequently, head CTA was done and results showed occlusion of the right intracranial vertebral artery and possible occlusion of the proximal right PICA, compatible with the patient’s history of acute right medullary syndrome.

The diagnosis of lateral medullary syndrome is often encountered and missed by non- neurologists. Therefore, this case serves to bring awareness to the importance and prevalence of this diagnosis and the fact that hiccups should not be undervalued. Persistent hiccups are often encountered and overlooked in the presentation of LMS; however, this could lead to further complications such as aspiration pneumonia, esophagitis, and even respiratory depression.

158 Taking care of monkey business: a case of baboon syndrome

D Ramos Ramirez*

C Cortes Sanchez

D Rivera

A Ortiz Vicil

VA Caribbean Healthcare System, Aguada

Case Report

Symmetrical drug related intertriginous and flexural exanthema (SDRIFE), also known as Baboon Syndrome given its resemblance to the red buttock of a female Baboon, is an uncommon type of drug-induced eruption. The reaction debuts within hours to days of exposure to the offending drug. Drug-induced cutaneous reactions affect around 2 to 3 percent of hospitalized patients and may represent a significant cause of outpatient morbidity.

An 87-year-old man presented to the emergency department with a diffuse maculopapular rash days after completing therapy for pneumonia. He was admitted to internal medicine ward where dermatology service evaluated the rash and identified it as a Drug eruption secondary to recent Ceftriaxone therapy. They recommended avoiding Ceftriaxone and using topical steroids for itch as needed. During his admission, he developed sepsis secondary to a multidrug resistant Pseudomonas aeruginosa bacteremia sensitive solely to Meropenem. He was started on antibtiotics but on his 10th day of therapy, a new rash, visibly different from the first, was observed over inguinal folds and flexural surface. Immunology service was consulted and confirmed the development of SDRIFE secondary to Meropenem. A biopsy was remarkable for dermal eosinophil, lymphocyte and plasma cell infiltrate supporting the diagnosis. Throughout treatment no severe reactions were observed and bacteremia therapy was safely completed. The drug was subsequently discontinued, and supportive therapy provided.

Given his multidrug resistant bacteremia was solely susceptible to the offending agent, Meropenem, the decision to cautiously continue therapy while treating his hypersensitivity reaction resulted in a positive outcome and response. In this particular case, SDRIFE proved not to be a complete contraindication to continuing therapy when concomitant topical corticosteroids were provided. Adverse cutaneous drug reactions may be commonly observed, around 1 in 1000 hospitalized patients suffer serious cutaneous drug reactions. When approaching a drug-induced cutaneous reaction, risks vs benefits of discontinuing or changing therapy must be considered to achieve the best possible outcome in each individual case.

159 A peculiar case of a gunshot wound to the abdomen

SS Raza¹*

K Tyler^2,1

RJ Najjar^2,1

¹The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL

²Huntsville Hospital, Huntsville, AL

Case Report

Discussion

The prevalence of penetrating trauma is only seen in 3/100,000 live births. In these rare cases, the mainstay management of pregnant patients with trauma is to stabilize the mother to increase fetus viability. The primary assessment of hypovolemic shock required 2 large-bore IVs to administer a total of 6 units of PRBCs, 2 L of crystalloid, and 3 units of FFP. Pt’s airway was secured, breathing noted as symmetric, and no disability appreciated. These measures were instrumental to stabilize the patient for surgery and limit organ hypoperfusion. Furthermore, immediate ultrasound of the fetus and HR monitoring is required; hence, the OB/Gyn team was consulted to assess fetal viability.

In terms of management of trauma in pregnancy, bleeding needs to be localized and limited. With a uterine injury, it was beneficial to deliver the fetus, ligate the uterine arteries, and apply continuous uterine massage. REBOA was utilized to provide adequate circulation to vital organs. Zone 1 placement allowed initial stabilization and blood flow to the heart and brain. Shifting the REBOA to Zone 3 allowed for preserved circulation to the kidneys and liver. Focused approaches to restrict bleeding and provide adequate circulation eventually stabilized the patient and were imperative in recovery.

160 Vocal cord paralysis associated with multiple sclerosis

M Samman¹*

C Tang²

¹New York Center for Voice and Swallowing Disorders, New York, NY

²Kaiser Permanente Medical Center, San Francisco, CA

Case Report

A 57 year old male with a history of MS initially presented to the Head and Neck Surgery clinic with laryngeal candida. One month after presentation, patient developed new left vocal cord paralysis.

Results

Computed Tomography scan of the neck did not reveal any masses or abnormalities along the path of the recurrent laryngeal nerve. Patient’s voice improved after vocal cord injection augmentation and voice therapy.

Conclusion

Although MS was first described in 1964 to be a cause of vocal cord paralysis, a vocal cord deficit is rare, as there have been less than 10 articles regarding this subject matter. We describe a case of vocal cord paralysis associated with a central nervous system demyelinating disease and review the literature on such etiology.

161 The unidentified offender

TN Sanders¹*

KS Ivey²

¹Edward Via College of Osteopathic Medicine – Auburn Campus, Auburn, AL

²UAB-Huntsville, Gadsden, AL

Case Report

63-year-old man with history of myelofibrosis, s/p allogeneic stem cell transplant in 2018, off immunosuppression for 3 months, who presented with 5 weeks of intermittent fevers up to 102.7, malaise, productive cough, and dyspnea, with hypoxia on admission, requiring up to 5L O2. Labs showed WBC 10.8, 53% PMNs, CRP 12.9 mg/dL, ESR >80, ferritin 2563, and Na 130. CTA chest showed patchy groundglass opacities and tree-in-bud nodularity; repeat CT five days later due to ongoing fevers despite cefepime and doxycycline showed worsened diffuse GGO in the bilateral upper lobes and RML. Echo revealed newly reduced EF 35–40% with global hypokinesis. Cardiac MRI showed myocardial edema and transmural enhancement, suggestive of myocarditis.

Infectious workup was unrevealing, including blood and sputum cultures, respiratory viral panel, CMV and EBV DNA PCR, fungal serologies, Q-fever, Bartonella, tickborne serologies, HIV, T-spot, and Legionella. He had two negative COVID-19 tests (unknown type) prior to admission, and two negative NP PCR tests and a negative SARS-CoV-2 antibody test in-house. Late in his course, transbronchial biopsy showed mild nonspecific inflammation with negative stains and cultures. He defervesced, and was discharged on room air after 11 days.

His acute hypoxemic respiratory failure was presumed to be due to viral pneumonia and myocarditis. In an allogeneic SCT recipient with respiratory symptoms, various infectious and noninfectious etiologies (GVHD, autoimmune, drug toxicity, etc.) should be considered. Bronchoscopy can provide a more definitive etiology, and was delayed in this case due to some concern for COVID-19 despite multiple negative tests.

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Abstract 161 Figure 1

Axial view. Diffuse ground-glass opacity; can be seen with COVID-19 pneumonia, but nonspecific.

162 Hereditary hypophosphatasia in a 30 year old female with chronic bone pain

KR Stanek*

M Shank

University of Colorado, Highlands Ranch, CO

Case Report

Hereditary hypophosphatasia (HPP) is a rare autosomal recessive disorder, characterized by disrupted mineralization of bones and teeth. It is often caused by loss-of-function mutations in the ALPL gene that encodes the tissue-nonspecific isoenzyme of alkaline phosphatase. Symptoms include defective mineralization of bones and teeth, premature loss of teeth, and decreased serum alkaline phosphatase activity. Sever cases may also include fractures, rickets, and respiratory insufficiency. Chronic bone pain is a common symptom, but less specific, and often preceded by gross deformities. Adult onset HPP can be missed, given the uncommon and complex nature of the disease. There have been few reports of HPP presenting in adulthood, which were often mistaken for osteoporosis.

In the current case, the patient was a 29 year old female with a long history of chronic, progressive bone pain who presented to her family medicine physician. As a child and adolescent, her bone pain was classified as growing pain. Her alkaline phosphatase level at the time of the visit was 31 U/L (Reference: 35–147 U/L). She previously had decreased alkaline phosphatase levels intermixed with levels on the low side of the normal range. The bone pain was extremely distressing for the patient and she voiced her concerns to her family medicine physician. He noted decreased alkaline phosphatase levels and discussed possible genetic causes. Genetic testing identified an ALPL gene .571G>A (p.Glu191Lys) mutation, indicating HPP. Since diagnosis, she has had normal DEXA scans, tibial x-rays, and renal ultrasound negative for stones. Her course of treatment has mostly consisted of pain management with tapentadol 200 mg, gabapentin 300 mg, and buprenorphine 10 mcg/hour weekly transdermal patch. Her and her geneticist have discussed treatment with alkaline phosphatase replacement therapy and teriparatide--modified parathyroid hormone that promotes bone growth.

HPP is important to consider in patients with chronic bone pain, regardless of the consistency of alkaline phosphatase levels. It is also imperative to distinguish bone pain compared to pain of muscular origin, as seen with fibromyalgia. Diagnosis of HPP may provide more treatment options with teriparatide and alkaline phosphatase replacement.

163 Altered mental status in a patient with psychiatric history: medication noncompliance or medical etiology?

B Walterscheid*

N Eshak

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

An altered mental status (AMS) in patients with a past psychiatric history is often credited to medication non-compliance, substance use, or an exacerbation of their underlying psychiatric illness. Such biases could preclude these patients from necessary medical workups. We illustrate a case of a 58-year-old postmenopausal female whose AMS was initially attributed to medication noncompliance but was ultimately found to have vitamin B12 deficiency due to pernicious anemia.

The patient had visited the emergency room five times over the course of two weeks, presenting each time with a, in total, four-week history of progressively worsening symptoms of nausea, vomiting, weakness, diffuse abdominal tenderness, numbness of the extremities, poor balance, confusion, and memory loss. Her past medical history included hypothyroidism, anxiety with recurrent panic attacks, severe recurrent major depression, chronic pain, and reported polypharmacy. Initially, her symptoms were suspected to be due to her anxiety and withdrawal from polypharmacy—the patient was having difficulty paying for her medications, as her neuropathy impeded her work as a hairdresser. But at this fifth visit, laboratory studies revealed megaloblastic anemia with a hemoglobin of 9.7. Further workup and physical examination showed a low B12, elevated homocysteine and methylmalonic acid, and decreased sensation to vibration and pinprick. All of these are consistent with a diagnosis of pernicious anemia, and intrinsic factor antibody testing was positive. Our patient’s condition and polyneuropathy improved with monthly vitamin B12 injections.

This case illustrates the critical importance of holistically evaluating patients with AMS so to combat inherent biases against patients with past psychiatric histories. Aside from psychiatric illness exacerbation, the differential diagnosis in this patient population should include both external etiologies, such as toxic ingestion, substance use, and medication noncompliance, as well as intrinsic medical pathology, such as hypoglycemia or, as in this patient, autoimmune induced AMS.

164 A diagnosis that really gets under the skin: a case of pyoderma gangrenosum

KA Winter¹*

A Winter¹

J Burks²

L weatherly^1,2

¹University of Mississippi Medical Center, Jackson, MS and

²UMMC, University of Mississippi Medical Center, Jackson, MS, US, academic/hospital, Jackson, MS

Introduction

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that varies in presentation; the most common being ulcerative PG. Typically presenting as a rapidly progressive ulcer, ulcerative PG is often misdiagnosed as infection. Pathergy, the provocation of new lesions by trauma, has been described in patients with PG. It must be considered when suspected skin infections are resistant to antibiotics or worsen after debridement. Here we present a case of PG in a patient who failed to improve after numerous antibiotics and multiple surgical interventions.

Case Report

A 48-year-old female presented to clinic with cellulitis of her left lower extremity several weeks in duration caused by injury from a door. Her wound had progressed from a small erythematous area to a larger necrotic lesion flanked by erythematous skin. She was prescribed Augmentin and Bactrim with no response to treatment. She then presented to the hospital where she was started on intravenous clindamycin and received a debridement. The patient worsened and her antibiotics were broadened to vancomycin and cefepime. The patient’s wound further necrosed, leading to two additional debridements. Surgical cultures were negative for infectious organisms. Clindamycin was reinitiated followed by a fourth debridement. After sustained lack of response to antibiotics, the patient was started on oral prednisone due to concern for an autoimmune process and pathergy. On hospital day 14, pathology from a biopsy showed dense neutrophilic infiltrates associated with pyoderma gangrenosum. After initiating prednisone, the necrosis halted, and granulation tissue began forming. The patient’s wound continued to improve, and she was discharged on oral steroids.

Discussion

PG is a rare cause of skin ulceration that is commonly mistaken for infectious cellulitis. When confronted by an antibiotic-resistant, necrotizing wound that worsens with debridement, a clinician should always consider a non-infectious process such as PG as prompt treatment may avoid morbidity and complications of prolonged antibiotic therapy, unnecessary surgical procedures, and delayed wound healing.

165 Not all leg edema is cardiac-related: a case of leg edema secondary to breast cancer metastases

KA Winter¹*

Y Ali²

¹University of Mississippi Medical Center, Jackson, MS

²UMMC, University of Mississippi Medical Center, Jackson, MS

Introduction

Bilateral lower extremity (LE) edema is a physical exam finding most commonly seen in patients with heart failure, liver or renal disease, or chronic venous disease. Less commonly, it can be caused by direct compression of LE venous return. Excluding common causes of LE edema is vital to defining the underlying etiology. Here, we report an unusual presentation of LE edema caused by recurrent metastatic breast cancer.

Case Report

A 57-year-old female presented to the hospital with episodic vomiting. She had a history of right-sided triple-negative breast adenocarcinoma treated with mastectomy, radiation, and chemotherapy. Physical exam revealed bilateral LE edema and left axillary lymphadenopathy of one month in duration. Renal function tests were consistent with pre-renal failure; urinalysis and liver function tests were unremarkable. Her prior chemotherapy regimen included doxorubicin; thus, dilated cardiomyopathy was included as a potential cause of her edema. A chest x-ray revealed bilateral pleural effusions; however, a transthoracic echocardiogram showed a 65% ejection fraction, which was unchanged from prior studies. Additionally, no features of cardiomyopathy were recognized, making it an unlikely cause of the patient‘s edema. Abdominal computed tomography showed retroperitoneal adenopathy and infiltration of the right psoas muscle. We hypothesized that the muscular infiltration caused compression on the venous return from the LE. Thoracentesis of the patient’s pleural effusion revealed malignant cells. An excisional axillary lymph node biopsy was performed which showed recurrence of her previous breast adenocarcinoma. Oncology was consulted for further evaluation of the patient’s breast cancer recurrence.

Discussion

In the right clinical setting, rare causes of bilateral LE edema should be pursued. It is reasonable to consider the associated symptoms, significant clinical history, and physical exam to limit the possible etiologies. Initial workup should focus on excluding cardiac, renal, and hepatic causes. In patients with a strong suspicion for alternative etiology (e.g. with a history of cancer), further workup is warranted.

166 Occult multiple myeloma unmasked by an acute kidney injury

KA Winter¹*

Y Ali²

¹University of Mississippi Medical Center, Jackson, MS

²UMMC, University of Mississippi Medical Center, Jackson, MS

Introduction

Multiple myeloma (MM) is a monoclonal neoplastic proliferation of plasma cells. The most common presenting features include anemia, bone pain, renal failure, hypercalcemia, and recurrent infections. However, these symptoms are not always present, making the diagnosis of MM more challenging. Here we report an atypical presentation of MM that was unmasked by an acute kidney injury (AKI) secondary to sepsis.

Case Report

A 67-year-old male with type 2 diabetes mellitus and hypertension presented to the hospital with encephalopathy and urinary incontinence. Initial workup revealed a white cell count of 19.8k, creatinine of 2.21 mg/dL, alkaline phosphatase 210 units/L, and total bilirubin 2.93 mg/dL; hemoglobin and calcium were unremarkable. Blood cultures revealed Klebsiella pneumoniae. Abdominal computed tomography showed diffuse gallbladder wall thickening. Surgery evaluated and treated the patient‘s acute cholecystitis via cholecystostomy tube and a 7-day course of ceftriaxone. The patient‘s initial decline in renal function was presumed secondary to sepsis in conjunction with his pre-existing comorbidities; however, the patient’s kidney function continued to worsen, resulting in creatinine of 4.79 mg/dL prompting further workup. Fractional excretion of urea was found to be 32.8%, suggestive of pre-renal azotemia, and a 24-hour urine sample revealed nephrotic proteinuria of 3.8 grams. Serum and urine electrophoresis revealed a monoclonal light chain restriction. A bone marrow biopsy showed a neoplasm consistent with MM (>15% plasma cells). Treatment with cyclophosphamide, bortezomib, and dexamethasone was initiated. The patient was discharged with follow-up in hematology clinic.

Discussion

An AKI is defined as ‘resolving’ if a 25% decrease in creatinine from maximum is seen within 72 hours after diagnosis of the AKI. If injury to the kidney lasts longer than 7 days, it is considered acute kidney disease which warrants further evaluation. In a patient with an AKI unresponsive to treatment, additional causes should be evaluated. Even in the absence of typical clinical findings, MM should be considered in an elderly patient with nephrotic proteinuria and kidney dysfunction out of proportion to the inciting event.

167 Rare case of systemic lupus erythematous

IR Burgos*

WD Marrero

C Rodriguez Negron

V Fonseca-Ferrer

HR Cintrón-Colón

Hospital Municipio de San Juan, Canovanas, Puerto Rico

Case Report

We present the case of a 33-year-old female with a medical history of gastritis who presented to the urgency department with periorbital swelling, generalized edema, and intractable abdominal pain that have progressively worsened in the last 2 months. Abdominal pain described as an intermittent and epigastric area. Symptoms included weight gain, arthralgia, generalized weakness, and dry skin. Physical examination nonpainful palpable lymphadenopathy on the left axilla, epitrochlear area, and anasarca with eye swelling and non-pitting edema. Stable GFR and hypoalbuminemia of 2.7 g/dl. Chest X-ray, TSH, Hepatitis, Syphilis, IgG, and Herpes 8 IGg negative. Urine analysis with no infectious process, with the presence of a protein of 30 mg/dl with urine cast. Collected 24-hour urine protein consistent with 272 mg of protein, ruling out nephrotic syndrome. Therapy with diuresis with the response of generalized edema. Recurrent angioedema episode occurred. At the time, an allergic reaction was suspected, therapy included corticosteroids, antihistamine, and epinephrine with no resolution and requirement of rapid sequence intubation for airway protection. Follow up labs showed leukopenia, hypoalbuminemia, and a new rash with an annular form that affected the abdomen and upper extremity. Other labs show positive ANA 1:40, Low Complement C3 and C4, elevated Sed rate and CRP, positive anti-Smith and anti-RNP. Left palpable axillary node pathology was consistent with follicular hyperplasia and prominent plasmacytosis. Bone marrow biopsy normocellular bone marrow, no evidence of metastatic cells, granulomas, or vasculitic skin Skin Biopsy showed subacute lupus rash, fulfilling SLE criteria as a definitive diagnosis. Also, CH50 12 positive result and C1 Esterase inhibitor pending to assess the acquired nature of her angioedema with and no vasculitis involvement with negative P ANCA and C ANCA and positive Anti -C1 inh antibody for an autoimmune-related type. Hypoalbuminemia consistent with probable Lupus protein-losing enteropathy given a recent diagnosis of Lupus with unexplained edema, a urine protein collection of 24 hours less than 0.5 gm, positive ANA pattern, and hypocomplementemia, with the positive response to steroids, still pending for fecal alpha 1 antitrypsin clearance test.

168 Tattoo sarcoidosis

IR Burgos*

V Fonseca-Ferrer

C Rodriguez Negron

Hospital Municipio de San Juan, Canovanas

Case Report

We report a 26-year-old male, no past medical history with 2 years of persistent itchy lesions that affected involved tattooing. He had a permanent tattoo for the last 5 years. The affected area with pruritus for a year progressed to a raised desquamating, and edematous lesion. One week before our evaluation started with bilateral ocular pain with symptoms of blurred vision and photophobia. Diagnosis of uveitis, with anterior chamber inflammation. Chest x-ray, Chest CT with no evidence of pulmonary fibrosis, and abdominal ultrasound with findings consistent with splenomegaly. CBC with thrombocytopenia of 143K, and no other abnormality. Biopsy consistent with non-caseating granulomatous dermatitis with a dense granulomatous infiltrate. He was initiated with oral prednisone and methotrexate with a good response.

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Abstract 168 Figure 1

Non-caseating granulomatous dermatitis

169 Vasculitis v.s. thrombosis: a case of antiphospholipid syndrome

N Eshak*

B Walterscheid

A Wichmann

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX, US, Lubbock, TX

Case Report

A 38-year-old male smoker presented to our institution with worsening left lower extremity pain for the past week. He reported a gradually worsening left leg pain exacerbated by movement and partially relieved by analgesics. His past medical history was significant for a left pontine infarction 4 years earlier, and a similar episode in his right leg 3 years ago. CT angiography at the time revealed non-opacification of vessels beyond the mid-calf, a picture suggestive of Buerger’s disease, and he underwent right below-knee amputation (BKA). Clinical examination was significant for absent peripheral pulses and cold left foot.

The patient underwent peripheral angioplasty with the restoration of pulsations. Later he started to complain of left hip and foot pain. MRI showed multiple areas of avascular necrosis involving the femoral head, calcaneus, and talus (figure 1).

Buerger’s disease is an inflammatory disease characterized by thrombotic occlusion of distal small and medium-sized arteries and presents with distal limb ischemia in young male smokers. At this time it seemed that there was another underlying pathophysiology. The clinical picture seemed to fit more with a hypercoagulable state rather than vasculitis. A review of his medical records revealed a hypercoagulable workup 4 years earlier that was positive for Lupus anticoagulant (LA). Repeat LA was positive, establishing a diagnosis of antiphospholipid syndrome (APS), and warfarin was started.

APS is an autoimmune disease characterized by venous, arterial or small vessel thrombosis in the presence of LA or autoantibodies including anti-B2GPI, or anti-cardiolipin antibodies. The mainstay treatment for arterial thrombosis is life-long anticoagulation. The first clue to the diagnosis was the history of CVA, which is unlikely with Buerger’s, the presence of positive LA, and finally, the widespread thrombosis.

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Abstract 169 Figure 1

170 SLE presenting with acute heart failure and tamponade

N Eshak*

J Abdelmalek

E Elgwairi

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Systemic lupus erythematosus is an autoimmune disease characterized by multisystem involvement and the production of autoantibodies. SLE can involve almost any organ; cardiac involvement is one of the lesser-known and frequently overlooked manifestations.

We report a 33-year-old patient with a history of SLE, class V lupus nephritis, and pulmonary embolism. She presented to the ER complaining of 3 days worsening shortness of breath. Labs were significant for leucopenia and a high ESR at 90 mm/hr, serology for SLE showed elevated anti-ds DNA and consumed C3 and C4.

CT showed old pulmonary emboli, and cardiomegaly with a large pericardial effusion and an urgent echo revealed cardiac tamponade and a left ventricular ejection fraction of 20–25% with global hypokinesia. An emergency pericardial window was performed. Cardiac MRI showed no myocardial infiltration or enhancement.

In the setting of a SLE patient, with several clinical and serological markers of lupus activity, pericarditis and myocarditis with heart failure were attributed to a lupus flare.

Anti-heart failure measures were initiated, Rheumatology was consulted, and treatment for severe SLE flare was initiated with corticosteroids and cyclophosphamide.

At 3 months follow-up the patient was symptom-free, her TTE revealed an improved EF to 45%. It is important to recognize that pericarditis and myocarditis may be signs of a SLE flare and that treatment includes immunosuppressive therapy in addition to standard anti-failure measures.

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Abstract 170 Figure 1

171 Acute generalized skin eruptions in a patient with coronavirus disease-2019 pneumonia: severe generalized urticaria

F Etaee¹*

M Eftekharian²

Z Hashemi²

N Niknezhad³

A Suggs⁴

T Naguib¹

¹Texas Tech University Health Sciences Center, Amarillo, TX

²Hamadan University of Medical Sciences, Hamadan, Iran (the Islamic Republic of)

³Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

⁴Duke University, Durham, NC

Case Report

An 18 years old man was admitted with low-grade fever, dry cough, dyspnea, and skin eruptions. Upon admission, he tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A high-resolution computed tomography scan of the chest showed a diffuse bilateral ground-glass opacities consistent with coronavirus disease 2019 (COVID19) interstitial pneumonia.

A pruritic skin rash started 48 hours before admission, 1 day after respiratory symptoms, mostly on his trunk. On examination, a generalized urticarial skin rash characterized by erythematous, smooth, slightly elevated papules and wheals, associated with severe pruritus was detected. The patient reported neither similar episodes in the past nor allergies to drugs or foods. Further, he had not taken any new medication recently. Dermatology consultation confirmed the diagnosis of generalized urticaria due to COVID19.

White blood cell count was normal (no lymphopenia or lymphocytosis or eosinophilia), C-reactive protein was 12.1 mg/dL, but liver enzymes were normal. Systemic treatment with intravenous dexamethasone, oral hydroxyzine, oral famotidine, in addition to antiviral therapy was started. In the subsequent days, urticaria and his respiratory function improved gradually, and he was discharged on daily loratadine.

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Abstract 171 Figure 1

172 A rare skin complication of hydroxychloroquine therapy for positive coronavirus disease 2019 infection: acute generalized exanthematous pustulosis

F Etaee¹*

N Ghanei²

A Suggs³

T Naguib¹

¹Texas Tech University Health Sciences Center, Amarillo, TX

²Shahid Sadoughi University of Medical Sciences, Yazd, Iran (the Islamic Republic of)

³Duke University, Durham, NC

Case Report

A 49-year-old woman with a past medical history of hypertension presented to the emergency department for shortness of breath, low-grade fever, and dry cough. She was tested for COVID-19 and it was positive. Due to normal oxygen saturation, she received a 5-day treatment with oral azithromycin and Hydroxychloroquine (HCQ) 400 mg orally twice daily on the first day, then 400 mg once daily for the next 4 days. 6 days after the completion of the treatment, the patient developed a pruritic rash on her face and neck. Over the next 5 days, she developed widespread erythema, scale, and pustules covering more than half of her body surface area. She had prominent facial and trunk involvement. She complained of fever (38.1°C (100.6°F)), chills, and generalized aches. She had a white blood cell count of 22,700 with a left shift and no eosinophilia. Her septic workup was negative. ESR was 35. Two punch biopsies and swabs of the pustules were taken. The patient was started on intravenous methylprednisolone. Intravenous vancomycin was started empirically with suspicion of bacterial skin superinfection. The patient started to better clinically, and her skin showed evidence of desquamation and healing. Both biopsy reports showed intraepidermal collections of neutrophils as well as subcorneal collections consistent with a diagnosis of acute generalized exanthematous pustulosis. There was no parakeratosis to suggest psoriasis. Finally, the patient was discharged home on a tapering dose of oral prednisone. After 4 weeks, her rash resolved.

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Abstract 172 Figure 1

173 Multisystem inflammatory syndrome in children: a new challenge in the covid-19 pandemic

B Ferguson*

MD Kala

DG Hodge

VA Harrison

University of Mississippi School of Medicine, Jackson, MS

Case Report

Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe inflammatory syndrome temporally associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although MIS-C is rare, clinicians should have a high index of suspicion in febrile children with evidence of systemic inflammation because prompt intervention is essential. MIS-C affects older children and adolescents and is defined by the CDC as fever, laboratory evidence of inflammation, and multisystem organ involvement in an individual with current or recent SARS-CoV-2 infection or exposure to a suspected or confirmed case within 4 weeks of onset of symptoms. MIS-C causes severe systemic inflammation with complications such as cardiac dysfunction, shock, and even death. This case highlights the diagnosis and management of MIS-C in a healthy child with preceding SARS-CoV-2.

A 7 year old male presented with fever and abdominal pain for one week. Past medical history was significant for SARS-CoV-2 infection diagnosed one month prior. Exam was significant for conjunctivitis and abdominal distention and tenderness, but no mucocutaneous changes or rash. Laboratory studies revealed evidence of systemic inflammation with elevated D-dimer, Ferritin, CRP, and ESR. Chest XR revealed bilateral perihilar and basilar opacities with small bilateral pleural effusions. Pro-BNP was elevated. EKG revealed sinus rhythm. Echocardiogram was normal. Presentation was concerning for MIS-C. Although Kawasaki disease was a consideration, the patient did not meet diagnostic criteria. Multiple pediatric subspecialists were consulted. The patient was treated with supportive care including IV fluids and supplemental oxygen as well as IV Methylprednisolone 500 mg daily for 3 days, Lovenox 0.5 mg/kg twice daily, and Aspirin 45 mg/kg daily. With these interventions, the patient stabilized and defervesced. He was discharged on a Dexamethasone taper, Lovenox for one week, and Aspirin for 6 weeks.

MIS-C is a rare, but severe and potentially life-threatening syndrome. The diagnosis is challenging given the variety of presentations and potential features of other inflammatory or infectious conditions. However, early diagnosis and treatment is crucial to prevent associated morbidity and mortality.

174 Reversible cerebral vasoconstriction syndrome: an underdiagnosed cause of neurovascular disease

CE McGill*

S Moore

A Cecchini

R Burgess

ETSU, Kingsport, TN

Case Report

Transient ischemic attacks, cerebrovascular accidents, and intracranial hemorrhages are a common reason for admission to the hospital. The cause or inciting factor for these events is often not found. Reversible cerebrovascular vasoconstriction syndrome (RCVS) is an under-recognized and often misidentified cause of these disease processes (Nesheiwat O, 2020). Described below is a case of RCVS that was misidentified as a Primary Angiitis of the Central Nervous System (PACNS) due a positive antineutrophil cytoplasmic antibodies (ANCA).

A 57 year old female presented to the emergency department with a one hour history of headache, weakness, facial droop, and slurred speech. She had recently returned from a trip to Utah where she had been hiking at a high elevation, and taking an over the counter multi-symptom sinus medication. Imaging on admission revealed a right basal ganglia hemorrhage with extension into the lateral ventricle, and vascular irregularity in multiple arterial branches posteriorly. Lack of significant hypertension on admission lead to investigation of other causes of the intracranial bleeding. The patient was noted to be ANCA positive with a ratio of 1:80, but testing for complements C3, C4 cryoglobulins, hepatitis, human immunodeficiency virus, rapid plasma reagent, Lyme disease, Rocky Mountain spotted fever, and peripheral smear all without significant abnormality. Positive ANCA with the absence of infection raised concern for primary central nervous system vasculitis. The patient was treated with high dose 1 mg/kg of intravenous methylprednisolone for 4 days, then transitioned to a long taper of oral prednisone starting at 60 mg daily, and discharged.

The patient was then evaluated in the rheumatology clinic for follow up. Further elicitation of history revealed absence of any hemoptysis, nasal crusting, renal disease, uveitis, fever, joint pain/swelling, or rash to suggest small vessel vasculitis which are associated with ANCA positivity. Labs revealed negative ANCA, MPO, and PR-3. It was noted that ANCA does not play a role in the diagnosis of PACNS (Daniel Strunk, 2019). The patient was referred to a vasculitis clinic for a second opinion, and subsequently diagnosed with RCVS due the multiple areas of vasospasm on angiogram.

175 Overlap syndrome complicated with diffuse alveolar hemorrhage

F Mubeen¹*

A kamat¹

N Davey-Ranasinghe^1,2

¹Texas Tech University Health Sciences Center, Amarillo, TX

²Amarillo Center for Clinical Research, Amarillo, TX

Case Report

Overlap syndromes in rheumatology are a group of conditions that have clinical features and meet classification criteria for more than one well-defined rheumatic disease. While Rhematoid arthritis(RA) is commonly seen with lupus and other autoimmune diseases, Anti-neutrophil cytoplasmic antibody(ANCA) associated vasculitis (AAV) rarely presents in association with other immune mediated disease. AAV has significant morbidity and mortality and has worse outcome with delay in diagnosis. We describe a case of RA with AAV presenting as pulmonary renal syndrome.

47 year old lady with known untreated severe RA with high titer anti citrullinated protein(CCP) antibodies, untreated chronic vasculitis with cutaneous involvement and persistently positive PR-3 antibodies presented to ED with one week history of lethargy, poor oral intake and oral sores. In addition she had a dry cough and mild dyspnea. She was found to have acute kidney injury, lactic acidosis and bilateral air space disease on chest imaging and was admitted for sepsis secondary to pneumonia and treated with antibiotics. Later she was intubated and put on mechanical ventilation for worsening acute hypoxemic respiratory failure. Interim she had hemoptysis, a diffuse maculopapular rash and her renal function deteriorated with evidence of red blood cells in her urine. She was seropositive for ANCA-PR3. A renal biopsy showed crescentic glomerulonephritis. Bronchoscopy had evidence of diffuse alveolar hemorrhage(DAH). She was started on pulse steroids and rituximab with pneumocystis pneumonia prophylaxis and mycophenolate. Due to ongoing DAH and severe blood loss anemia plasmapheresis was started. Her stay was complicated with streptococcal bacteremia. Despite aggressive management the patient continued to worsen and family decided to withdraw care to ally patient’s suffering.

ANCA associated vasculitis is rarely associated with other autoimmune diseases. However, there are previous case reports of AAV overlapping with RA in which renal involvement was commonly seen, though DAH has not been described. Pulmonary renal syndrome in untreated RA patient definitely warrants further investigations to rule out other immuno medicated disease to guide further management.

176 Henoch-schonelin purpura presenting in an adult

R Musa*

S Moore

East Tennessee State University, Johnson City, TN

Case Report

Henoch-Schönlein Purpura (HSP) is a self-limiting small vessel vasculitis mediated by IgA deposition that primarily affects children and is usually preceded by an infectious process. It has also been known to affect adults where it typically has a more complicated course. This is especially important since the incidence of renal insufficiency develops in almost 50% of adult patients² and up to 36% may suffer permanent renal damage³. We report a 25 year old male who required hospitalization for worsening rash without preceding evidence of infection and was found to have leukocytoclastic rash and diagnosed with Henoch-Schonlein Purpura. He presented to an urgent care center and was given a short course of prednisone which helped with the swelling but the rash continued to progress. It initially appeared on the left heel which spread bilaterally upwards towards his waist, associated with bilateral foot and hand swelling. Patient was then seen in the ER with elevated blood pressure (197/111 mmhg), HR (114/min, NSR). On physical examination, palpable rash was evident on anterior surface of lower extremities extending up to the abdomen below the umbilicus. Blood work showed elevated white cell count (15.9), normal Hgb, platelets, BUN and Creatinine. Moderate proteinuria with hematuria was noted on urinalysis. ESR, CRP, ANA, ANCA, Rheumatoid factor, CCP, SSA, SSB, cryoglobulins and HCV serology were within normal limits. Skin biopsy of one of the lesions on left lower extremity showed leukocytoclastic vasculitis. He received IV methylprednisolone 1 g for 3 days and later discharged on prednisone 60 mg/day. Subsequently, he was followed up in the rheumatology office where he was found to have progressive proteinuria.

Full case report and list of references available.

177 An atypical initial presentation of diffuse alveolar hemorrhage and systemic lupus erythematosus in an adult male

DS Nichols¹*

H Jhaveri¹

S Streit²

M Kumar²

¹University of Florida Health, Gainesville, FL

²University of Florida Health Jacksonville, Jacksonville, FL

Case Report

Systemic Lupus Erythematosus (SLE) is notorious for its diffuse and variable manifestations. Initial presentations of SLE often perplex clinicians, leading to diagnostic and treatment delays. This is especially true in males with atypical presenting symptoms. We herein report a case of a 27-year-old Indian male with no history of SLE who presented to the hospital with one week of dysphagia, myalgia, and a rash. Two months prior to presentation, he was treated for suspected erythema multiforme at an outside hospital and was discharged on a short course of oral steroids. Following admission at our hospital, initial laboratory workup revealed pancytopenia, and after 24 hours, he became hypotensive and tachycardic, with new-onset respiratory distress requiring ICU-level care. A diagnosis of DAH was made with bronchoscopy and serology demonstrated an ANA titer of 1:320, dsDNA of 235 IU/mL, and anti-Smith antibodies greater than 8.0 AI, confirming SLE. Through reporting this case, it is our hope that increased awareness of atypical SLE manifestations may prevent a severe complication, such as DAH, from occurring. It is especially important to maintain high-clinical suspicion for SLE in all patients presenting with diffuse and seemingly unrelated symptoms, regardless of sex and ethnicity.

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Abstract 177 Figure 1

Rash sparing the nasolabial folds (posted with permission).

178 Hashimoto’s thyroiditis and renal transplant failure

B Sigman¹*

D Linder¹

W Bollag^1,2

J Waller¹

SL Baer^1,2

AA Mohammed¹

S Tran¹

M Kheda¹

V Spearman¹

C Isales¹

B Siddiqui¹

¹Augusta University, Augusta, GA

²Augusta VA Medical Center, Augusta, GA

Purpose of Study

Hashimoto’s Thyroiditis (HT) is a common autoimmune disorder of the thyroid and cause of hypothyroidism. The potential effects of HT on long-term renal transplant survival have not been fully examined. To study this, we examined renal transplant patients and compared the time from transplant to failure in patients with and without HT.

Methods Used

We queried the United States Renal Database for patients initiating end-stage renal disease (ESRD) services between January 1, 2005 and December 31, 2014. Patients aged 18 and older with at least one renal transplant were included. Patients that experienced acute renal transplant failure, defined as rejection occurring within 14 days of initial transplant, were excluded. Kaplan-Meier (KM) estimates of first renal graft survival probability and a multivariable Cox proportional hazards model (CPH) of time to graft failure were used to assess differences in graft survival by HT status.

Summary of Results

Among the 90,301 patients meeting study inclusion criteria, 144 were identified as having HT prior to renal transplant. Compared to those without HT, HT patients were more likely to be female (77.1% vs. 38.6%; p<0.001), White (85.4% vs. 69.8%; p=0.035), and diagnosed with cytomegaloviral (CMV) disease (27.1% vs. 17.1%; p=0.038). ESRD patients with a HT diagnosis prior to initial renal transplant had a significantly reduced graft life expectancy (p<0.001) and a significantly increased adjusted hazards ratio (aHR) for graft failure compared to those without HT (aHR=1.44; 95% CI 1.05–1.99). An increased risk of graft failure was also associated with being Black vs. White (aHR=1.60; 95% CI 1.54–1.66) and CMV disease (aHR=1.81; 95% CI 1.74–1.88).

Conclusions

In ESRD patients with renal transplant, a prior HT diagnosis was associated with increased risk of renal graft failure and reduced graft life expectancy compared to those without HT. Further studies may reveal whether the specific autoimmune mechanism underlying HT or currently unknown factors explain these observed associations between HT and renal transplant failure.

179 Inflammatory pseudo-tumor in a patient with systemic lupus erythematosus

P Tiwari*

C Aguiar

M Aguiar

Eastern Virginia Medical School, Norfolk, VA

Introduction

Inflammatory Pseudotumor (IPT) of the lymph node is a syndrome of lymphadenopathy characterized histologically as a non-neoplastic proliferation of various cells, here we report a case of IPT associated with SLE.

Case Report

A 17-year-old old African American female presented with a 1-month history of subjective fevers, decreased appetite, 20-pound weight loss and lymphadenopathy. Laboratory studies were notable for a white blood cell count 3.9 x10^3ul, hemoglobin 9.6 gm/dl, platelet 401 x10^3ul, absolute neutrophil count 2874ul, erythrocyte sedimentation rate >120(mm/hr), c-reactive protein 3.3 mg/dl and lactate dehydrogenase 795 unit/liter (nl <670) with a normal uric acid 3.2 mg/dl. Infectious work-up including Ebstein Barr Virus (EBV), Cytomegalovirus, Bartonella, Tuberculosis and HIV studies did not reveal acute infection. A CT scan of the neck and chest was notable for multiple enlarged cervical, supraclavicular and axillary lymph nodes, and a 5 mm pulmonary nodule A left supraclavicular lymph node biopsy showed reactive lymphoid hyperplasia with prominent capsular and trabecular fibrosis, fibroblastic and vascular proliferation and mixed inflammatory cell infiltrate including eosinophils and many plasma cells consistent with Inflammatory Pseudotumor. Laboratory studies came back notable for a positive Anti-Nuclear Antibody (ANA) 1:2560 (speckled pattern), anti-double stranded DNA (dsDNA) 61 IU/ml (nl <4), anti-Sjogren’s A (>8), Anti- Smith (>8), Anti-RNP (>8) with negative anti-Sjogren’s B and normal complements 3 and 4 (97 mg/dl and 23 mg/dl respectively). The diagnosis of SLE with Inflammatory Pseudotumor of the lymph node was made. The patient was started on Prednisolone, Hydroxychloroquine and Mycophenolate Mofetil and on follow-up had appropriate resolution of symptoms.

Discussion

Systemic Lupus Erythematosus pathology usually reveals non-specific lymphoid follicular hyperplasia, scattered immunoblasts, plasma cells and increased vascularity (2). Inflammatory Pseudotumor of the lymph node has been reported in Rheumatoid Arthritis (3), but its presence in patients with SLE has not been previously reported. The unique finding of IPT in our patient with SLE highlights evaluating for autoimmune conditions that can co-exist.

180 Dehydrated human amnion/chorion membrane allograft for treatment of resistant pyoderma gangrenosum

AS Weissman*

VS Patel

W Moore

Augusta University, Augusta, GA

Case Report

Pyoderma gangrenosum (PG) is a rare, sterile, inflammatory neutrophilic dermatosis that is painful with necrotizing ulcerations. It can be idiopathic or in association with systemic disease such as PG, acne, hidradenitis suppurativa (PASH) syndrome. PASH syndrome itself is rare, consists of multiple neutrophilic dermatoses, and is thought to be caused by an underlying genetic predisposition. Due to recurrence and poor healing, treatment for PG ranges from wound care to topical and oral medications to surgical procedures. Usually, a combination of most, if not all, of these therapies are necessary to resolve PG. Some patients, however, are resistant to many of the currently used treatment options and live with debilitating pain and extensive wound care regimens. Human amniotic tissue has been used to treat a variety of wounds over the last century. However, it has rarely been utilized in the setting of treatment resistant PG, with only two other cases reported in the literature to our knowledge. The patient presented in this case developed worsening PG in the setting of PASH syndrome and systemic lupus erythematous that was refractory to multiple treatment methods. After undergoing four allograft treatments with dehydrated human amnion/chorion membrane (dHACM) (figure 1), the patient began to notice drastic improvements of her PG. This case emphasizes the success of dHACM in treating PG and how it should be considered for patients whose PG does not resolve with more traditional treatments.

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Abstract 180 Figure 1

Pyoderma gangrenosum in response to four dHACM allograft therapy treatments over the span of four months. A) First treatment complete. B) Second treatment complete. C) Third treatment complete. D) Fourth treatment complete.

181 A rare pheochromocytoma presentation: prolonged qt interval with ventricular fibrillation cardiac arrest

J Abdelmalek*

M Elmassry

M Abohelwa

E Elgwairi

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Pheochromocytoma is mostly an adrenal gland benign catecholamine secreting tumor. Patients with pheochromocytoma usually present with a triad of episodic headaches, sweating and tachycardia. Atypical presentations have been described in literature, however very few cases have presented with cardiac repolarization abnormalities, QTc interval prolongation and ventricular fibrillation cardiac arrest.

Here we report a 26-year-old female with past history of chronic headaches, anxiety and panic attacks. Patient was found unresponsive and pulseless by EMS, cardiac resuscitation was performed, initial rhythm was ventricular fibrillation and patient achieved ROSC after 17 minutes.

At hospital patient was later extubated and had good neurological recovery, however she continued to have persistent hypertension initially requiring nicardipine drip in the medical ICU. Cardiac echocardiography and ischemic work-up were unremarkable. Her EKGs showed prolonged QTc intervals up to 655 ms. Abdominal CT scan showed a 5 cm left adrenal incidentaloma, that measured 44 Hounsefield units. Plasma metanephrines were increased by 27 folds.

Patient was diagnosed with pheochromocytoma, she was initially treated with alpha blockers that were later titrated, and then beta-blockers given her long QTc on EKGs.

She underwent surgery for adrenalectomy and pathology proved benign adrenal pheochromocytoma.

Follow-up EKGs showed normalized QTc intervals.

Work-up of patients with QTc interval prolongation, especially those who present with fatal cardiac arrhythmias is of crucial importance. Moreover, pheochromocytoma in these patients should always be suspected when alarming clinical presentation is present.

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Abstract 181 Figure 1

182 The role of C-reactive protein to measure periodontal inflammation producing coronary artery disease and other inflammatory processes

PI Altieri^1,2*

N Escobales¹

V Covas¹

R Sánchez¹

C Quiñones¹

HL Banchs^1,2

¹University of Puerto Rico Medical Sciences Campus, San Juan

²Cardiovascular Center of Puerto Rico and the Caribbean, San Juan, Puerto Rico

Purpose of Study

To explain the importance of measuring C-Reactive Protein (CRP) in all diseases which includes inflammation, especially obesity, Type 2 diabetes mellitus, hypertension and periodontal inflammation, as an important contributing factor in the progression of inflammation in different conditions producing tissue damage in a Hispanic country.

Methods Used

Literature and Puerto Rican experience.

Summary of Results

Our work in the heart center shows that 67% of patients (P) have metabolic syndrome (MS) with a rate of 20% having acute myocardial infarction or variant of coronary artery disease. This population shows a positive CRP (30%) with an increase of circulating monocytes migrating to the infarcted myocites, probably at those stages-macrophages due to changes of monocytes to macrophages. More than 80% have moderate to severe periodontal disease.

Conclusions

The acute reactant CRP is a well-known acute inflammatory protein during cardiovascular events as acute infarction and variants of others inflammatory diseases. This protein, as well as other cytokines, appears in 24–45 minutes after the event or exists chronically. The role of statins, ASA and omegas like omega 3 or 7; and other treatments will be discussed as a way to improve these abnormalities reflected as (+) CRP. It is important to check CRP in all P. with periodontal disease to find a population of high risk which attacks the immunological system, including infiltration of monocytes-macrophage system, affecting the coronary circulation and myocardial system.

183 The role of periodontal disease in coronary artery disease in a hispanic population (PUERTO RICO)

PI Altieri^1,2*

N Escobales¹

K Didriksen¹

R Sánchez¹

C Quiñones¹

HL Banchs^1,2

¹University of Puerto Rico Medical Sciences Campus, San Juan

²Cardiovascular Center of Puerto Rico and the Caribbean, San Juan

Purpose of Study

The purpose of this report is to describe the role of Periodontal Disease (PD) in Coronary Artery Disease (CAD) in a Hispanic country, Puerto Rico.

Methods Used

Literature and Puerto Rican experiences were reviewed and will be discussed.

Summary of Results

PD produces inflammatory disease by bacterial infection in the gingiva. This factor PD activates an inflammatory process affecting the CAD cascade inducing myocites and endothelial cells to be damage by this inflammatory process, producing damage to the endothelial lining. The incidence of gingival disease in the Puerto Rican population (P) in this group is around 40%; of this group 80% will develop periodontal disease, which include bacteria and Cytokines. The product of this process is severe damage to the gingiva, producing an active inflammatory disease, which will activate the cytokines system, reducing IL-10, producing CAD.

Conclusions

PD is related to an inflammatory process, which will activate the CAD process, producing tissue infarcts and inflammation. The daily use of resolving and Omega 3 applied to the gingival tissue is useful in the prevention of gingival and periodontal disease, reducing the incidence of CAD and other inflammatory problems. At present the dental and cardiology clinic is attacking aggressively this problem to keep a relatively low incidence of CAD in the Island. This incidence is 20–30% less than in the U.S.A. due to genetic factors and an aggressive program to reduce the inflammation in this population by local application of statins and the omega factors like omega 3 or 7 to the gingival tissue.

184 The use colchicine in ischemic heart disease

AK Butt¹*

B Cave²

M Maturana¹

RN Khouzam¹

¹The University of Tennessee Health Science Center Memphis, Memphis, TN

²Methodist Le Bonheur Healthcare, Memphis, Memphis, TN

Purpose of Study

To review the literature and summarize findings of clinical research studies investigating the use of colchicine in stable ischemic heart disease, acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI) with stenting.

Methods Used

We identified relevant literature by conducting a search of the databases from PubMed and United States National Library of Medicine clinical trial database (http://www.clinicaltrials.gov) using the terms ‘colchicine’ AND ‘cardiovascular disease’ OR ‘coronary artery disease’ OR ‘acute coronary syndrome’ OR ‘ischemic heart disease’.

Summary of Results

Inflammation is a major contributing factor leading to the development and progression of atherosclerosis and ischemic heart disease (IHD) and therefore represents a potential target for treatment with anti-inflammatory drugs. Colchicine is a well-known medication indicated for the treatment for inflammatory diseases such as acute gout and recurrent pericarditis. Various clinical and experimental trials have investigated the activity of colchicine in IHD. The LoDoCo and LoDoCo2 trials studied colchicine in chronic coronary disease and both demonstrated a significant reduction in cardiovascular events as compared to placebo. Studies such as the COLCOT trial showed that colchicine significantly decreased the incidence of future cardiovascular events in patients post ACS. For coronary angioplasty and PCI, colchicine has shown mixed results in trials so far. The encouraging results in recent clinical trials have generated considerable interest in further exploration of the potential indications of colchicine in treating and preventing IHD.

Conclusions

Current evidence shows that inflammation is a critical component in the pathogenesis of coronary atherosclerosis. Therapy with colchicine directed against inflammation may have a role in treating and preventing IHD. Future studies are highly anticipated to provide stronger evidence regarding the potential role of this low-cost drug in reducing morbidity and mortality associated with IHD.

185 The BCL-2 nineteen kilodalton interacting protein 3 modulates mitochondrial oxidative capacity and metabolism in rat systolic heart failure model

AH Chaanine*

P Delafontaine

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Previously we have shown that the Bcl-2 nineteen kilodalton interacting protein 3 (Bnip3) improved mitochondrial morphology and myocardial contractile function in a rat pressure overload systolic heart failure (SHF) model. BNIP3 expression increased in human SHF as well. The purpose of the study was to assess BNIP3 effect on myocardial proteome, focusing on changes in mitochondrial proteome.

Methods Used

Shotgun proteomic approach using tandem mass tags liquid chromatography mass spectrometry was performed in left ventricular myocardium tissue of Sham (n=3), SHF treated with control adeno-associated virus encoding for Luciferin ShRNA (AAV9.ShLuc, n=3), and SHF treated with AAV encoding for BNIP3 ShRNA (AAV9.ShBNIP3, n=4). Scaffold software was used for analysis of the proteomic data using the permutation test and Qlucore software was used for generation of heatmaps and data presentation. STRING database was used for protein networks and reactome pathways analysis. Some of the changes in reactome pathways were also verified by Western blotting.

Summary of Results

A total of 484 mitochondrial (mt)-proteins were identified, of which 12 (2.5%) increased and 348 (72%) decreased in abundance in SHF + ShLuc relative to Sham. 229/348 (66%) mt-proteins that decreased in SHF + ShLuc were related to reactome pathways involved in the citric acid (TCA) cycle and respiratory electron transport chain (ETC) system, Pyruvate, fatty acid and amino acid (AA) metabolism and branched chain amino acid (BCAA) catabolism. The remainder 119 (34%) belonged to reactome pathways related to mt-translation elongation and termination and mt-calcium entry and import. The gene delivery of AAV9.ShBNIP3 increased the abundance of 50/348 mt-proteins; 34 of which involved in TCA cycle, ETC system, pyruvate and AA metabolism and BCAA catabolism. Changes in expression of the ETC complexes were verified by Western blotting.

Conclusions

mt-proteins are predominantly decreased in abundance in SHF. The gene delivery of AAV9.ShBNIP3 in rat SHF model improved mt-oxidative capacity and metabolism as noted above. BNIP3 constitutes a potential therapeutic target for SHF.

186 Echocardiographic analysis of right heart disease in patients with pulmonary hypertension and cardiomegaly

B Daines*

O Hosseini

S Rao

SK Prieto

J Abdelmalek

M Elmassry

P Sethi

V Test

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Purpose of Study

Echocardiography is an imaging technique used as the preferred method for left ventricular evaluation in patients with heart failure. Echocardiography also provides information about the right heart which has both diagnostic and prognostic value. Measurement of ventricular strain provides information about myocardial muscle function even in patients with normal ejection fractions. Cardiomegaly in patients with pulmonary hypertension (PH) may have important clinical implications. We analyzed a cohort of patients with PH to determine the associations between cardiomegaly and right heart disease.

Methods Used

This cohort includes 131 patients referred to the pulmonary vascular disease clinic at Texas Tech University Health Sciences Center in Lubbock, Texas between January 1, 2019 and May 20, 2020. Patients with appropriate indications underwent right heart catheterization. Sixty patients had echocardiography prior to catheterizations. These echocardiograms were reevaluated to determine right heart strain. Information, including demographics, catheterization data, echocardiography data, and laboratory results, was analyzed.

Summary of Results

The mean patient age was 62.6 ± 14.8 with 58.3% women. Patients were grouped based on the presence of cardiomegaly on chest x-ray. The average right ventricular free wall strain was -18.0 ± 5.4 in patients with cardiomegaly and -18.5 ± 4.8 in patients without cardiomegaly. Patients with cardiomegaly had greater right ventricular (56.2 ± 28.4 ml/m² vs 47.6 ± 21.3 ml/m²) and atrial (42.9 ± 20.5 ml/m² vs. 34.4 ± 22.2 ml/m²) volume indices. Patients with cardiomegaly had increased right ventricular systolic pressures (67.6 ± 24.4 mmHg vs 50.8 ± 19.8 mmHg) and right atrial pressures (13.5 ± 6.9 mmHg vs. 8.5 ± 5.0 mmHg).

Conclusions

Patients with PH and cardiomegaly had slightly decreased right ventricular strain and had increased right heart pressures and volumes. These observations suggest that patients with PH and cardiomegaly are more likely to have right heart disease and that their evaluation should include comprehensive right heart assessment with echocardiography, including strain measurements.

187 Evaluating exercise response variables of children with pectus excavatum

C DeVol*

M Darwish

A Hyde

R Philip

¹LeBonheur Children’s Hospital, Memphis, TN

²The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Purpose of Study

Relationship between severity of pectus excavatum and cardiopulmonary changes during exercise.

Methods Used

Retrospective review of cardiopulmonary exercise testing of 121 patients aged 0 to 19 with pectus excavatum referred to the exercise physiology laboratory over a 5-year period. Baseline parameters were collected including Haller index and pulmonary function tests. Additional physiologic variables related to aerobic capacity, cardiovasular response, and ventilatory response were assessed with exercise stress testing. These parameters were then compared to the Haller index to see if there was any correlation between patient with a mild/moderate (2.0–3.5) and severe Haller Index (>3.5) using Two-Sample T-Test and Spearman Correlation.

Summary of Results

See tables.

Conclusions

There is a negative correlation between Haller index and FVC, FEV1, heart rate reserve, and vetilatory reserve. When comparing mild/moderate Haller index to severe there is no significant difference between FVC, FEV1, and heart rate reserve. However patients with a Severe Haller Index tended to have a statistically significant lower ventilatory reserve.

188 A rare case of seckel syndrome presenting with complete heart block

M Elmassry¹*

M Abohelwa¹

J Abdelmalek¹

E Elgwairi¹

M Elmassry²

G Del Rio-Pertuz¹

D Swaminath³

¹Texas Tech University Health Sciences Center, Lubbock, TX

²Leicester Royal Infirmary, Leicester, UK

³Texas Tech University System, Lubbock, TX

Introduction

Seckel syndrome is a rare (<1:10,000 live births) autosomal recessive disorder characterized by facial dysmorphic features and known as Bird-Headed Dwarfism. Only about 100 cases were reported in the literature. We present a case of Seckel syndrome presenting with Complete Heart Block (CHB).

Case presentation

A 21-year-old female with Seckel syndrome and epilepsy who presented with status epilepticus. She was hypotensive and bradycardic in the 20s. Labs showed AKI (Creat 0.8, baseline 0.5) with K 6.4. EKG showed CHB. She received IV Calcium chloride, IV Fluids, Dopamine drip, and placed on transcutaneous pacer with no response. A transvenous pacemaker was inserted prior to admission to the PICU given her very small size (57 lb). Electrolytes normalized with persistent CHB. Transthoracic Echo was unremarkable. A suitable permanent pacemaker (PPM) for her size was unavailable at our facility and she was transferred to UTSW Medical Center in Dallas where she got a PPM and was discharged home in stable condition.

Discussion

Seckel syndrome is a rare autosomal recessive disorder characterized by, dwarfism, intellectual disability, facial dysmorphic features, microcephaly, and ‘beak-like’ protrusion of the nose. Cardiovascular manifestations are very rare in this disease with less than 10 cases in the literature with cardiac manifestations. Congenital cardiac anomalies were reported in few cases (e.g. Tetralogy of Fallot, Tricuspid atresia, Atrioventricular canal defect, PDA, and ASD). Moyamoya-like Vasculopathy was reported in 1 case. Severe sinus bradycardia requiring a pacemaker was also reported in one case with an unclear mechanism. No arrhythmias or high degree AV block were reported. To our knowledge, our case is the first case of CHB to be reported in association with Seckel syndrome.

Conclusion

CHB may be a new association with Seckel syndrome. More cases need to be studied to further understand this potential association.

189 Shock without wires: a look at subcutaneous implantable cardioverter-defibrillator compared to transvenous implantable cardioverter-defibrillator for ventricular arrhythmias

KC Guice¹*

J Raja¹

M Oberoi²

R Khouzam¹

¹The University of Tennessee Health Science Center College of Medicine, Memphis, TN

²University of South Dakota Sanford School of Medicine, Sioux Falls, SD

Purpose of Study

Sudden cardiac death is a major cause of mortality in the US. Transvenous ICD is traditionally used for the prevention of ventricular arrhythmias. It is also associated with complications like pneumothorax and tamponade. This abstract aims to review subcutaneous ICD (S-ICD) as an alternative with reduced complications.

Methods Used

We conducted a Medline search of ‘Subcutaneous,’ ‘ICD,’ and ‘ventricular tachycardia or fibrillation (VT/VF)’ to identify trials published before October 5, 2020, for inclusion in this review. Major practice guidelines, trial bibliographies, and reviews were examined to ensure the inclusion of relevant trials. The following section reviews data from trials to review the efficacy of S-ICD for termination of VT/VF.

Summary of Results

The S-ICD system consists of a pulse generator positioned over the sixth rib between the midaxillary and anterior axillary line and a tripolar parasternal electrode with the proximal and distal sensing electrodes positioned adjacent to the xiphoid process and manubriosternal junction. The conversion of the efficacy of the S-ICD after the first shock is 88%-90.1% and 98.2%-100% after 5 shocks based on the current evidence. The device also has a 99% complication-free rate at 180 days. The PRAETORIAN trial showed non-inferiority of the S-ICD to transvenous ICD with device-related complications.

Conclusions

S-ICD advantages include no fluoroscopy and decreased complications. The limitations are a lack of pacing abnormalities, increase in inappropriate shocks, and non-reliability with baseline T wave abnormalities. Thus, S-ICD can be considered as an alternative to transvenous ICD in patients with a need for defibrillator therapy but with no need for pacing.

190 Cardiovascular safety reporting in breast cancer clinical trials

A Hamid¹*

J Ruckdeschel¹

MS Khan¹

A Tharwani²

AA Oshunbade¹

RK Kipchumba¹

C Thigpen¹

SD Anker³

GC Fonarow⁴

ME Hall¹

J Butler¹

¹University of Mississippi Medical Center, Jackson, MS

²Cleveland Clinic, Cleveland, OH

³Georg-August-Universitat Gottingen, Gottingen, Germany

⁴University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA

Purpose of Study

Several chemotherapies have been associated with cardiovascular (CV) harm in early phase clinical trials. However, some CV harms do not manifest until later phase (2 and 3) trials. To limit inter-disease variability, we focused on breast cancer. Thus, we assessed reporting of CV safety monitoring and outcomes in phase 2 and 3 contemporary breast cancer clinical trials.

Methods Used

We searched Embase and Medline records for phase 2 and 3 breast cancer pharmacotherapy trials. We examined exclusion criterion due to CV conditions, adverse CV event reporting, and whether CV safety was assessed through CV imaging, electrocardiogram, troponin, or brain natriuretic peptide (BNP). Fischer’s exact test was applied for comparisons in reporting amongst trial characteristics.

Summary of Results

50 clinical trials were included in our study. Patients were excluded due to CV conditions in 42 (84%) trials. Heart failure was a frequent exclusion criterion (n=31; 62% trials). Adverse CV events were reported in 41 (82%) trials. CV safety assessments were not reported in 23 (46%) trials; while BNP and troponin assessments were not reported in any trial. CV safety assessments were more frequently reported in pharmaceutically funded trials (p<0.001), and in trials administering targeted/immunotherapy agents compared to only hormonal/traditional chemotherapy (p<0.001).

Conclusions

Our findings demonstrate significant under-representation of patients with CV conditions or prevalent CV disease in contemporary later phase breast cancer trials. Additionally, CV safety is not routinely monitored in these trials. Therefore, contemporary breast cancer clinical trials may possibly underestimate the CV risks of cancer pharmacotherapy agents for use in clinical practice.

191 Incidence of acute myocardial infarction and hurricane katrina: fourteen years after the storm

D Harrison¹*

H Rawal¹

M Quan¹

A Ayoub¹

D Sangani¹

M La¹

M Kogan¹

R Subedi¹

AK Irimpen^1,2

S Srivastav¹

A Johnson¹

¹Tulane Medical Center, Tulane Medical Center, New Orleans, LA, US, New Orleans, LA

²Veterans Administration, New Orleans, LA

Purpose of Study

We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the fourteen years since Hurricane Katrina

Methods Used

This was a single-center retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years before Hurricane Katrina and fourteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data

Summary of Results

In the fourteen-year post-Katrina period, there were 3469 admissions for AMI out of a total census of 114,795 (3.0%) compared to 150 admissions out of a census of 21,079 (0.7%) in the 2-year, pre-Katrina group (p<0.001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (45.9% vs. 30.7%, p<0.001), diabetes mellitus (40.6% vs. 28.7%, p=0.002), hypertension (80.3% vs. 74.0%, p=0.028), hyperlipidemia (56.7% vs. 44.7%, p=0.001), smoking (54.0% vs. 39.3%, p<0.001), drug abuse (18.2% vs. 6.7%, p<0.001), and psychiatric disease (15.6% vs. 6.7%, p<0.001). The post-Katrina group was more often prescribed aspirin (50.1% vs. 31.3%, p<0.001), beta-blocker (47.3% vs. 34.0%, p=0.002), ACE inhibitor or ARB (52.5% vs. 36.0%, p<0.001), and statin (52.8% vs. 28.0%, p<0.001) but with higher medication non-adherence (15.9% vs. 7.3%, p<0.001). The post-Katrina patients were more likely to be unemployed (41.3% vs 22.7%, p<0.001) and non-married (56.3% vs. 52.7%, p<0.001). Rates of STEMI were lower in the post-Katrina group (28.8% vs 42.0%, p=0.001). There was no significant difference between the two groups in terms of sex, being uninsured, or prior coronary artery bypass grafting

Conclusions

There was a 4-fold increase in the incidence of AMI fourteen years following Hurricane Katrina. Prevalent psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post-Katrina group. These findings add to the growing body of literature demonstrating adverse cardiovascular outcomes after a natural disaster. Further research is needed to elucidate underlying mechanisms to help mitigate future cardiac morbidity

192 Prevalence of abnormal spect myocardial perfusion imaging during the COVID-19 pandemic

UA Hasnie*

P Bhambhvani

A Iskandrian

FG Hage

University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

There has been a decline in the rate of abnormal MPI studies reported over several decades. The COVID-19 pandemic resulted in restrictions that reduced the volume of cardiovascular procedures and imaging. It is not clear if the restriction on performing MPIs caused by the pandemic impacted the rate of abnormal MPI studies.

The aim of this study is to evaluate the rate of abnormal myocardial perfusion imaging (MPI) studies at a single medical center during the COVID-19 pandemic compared to its rate prior to the pandemic.

Methods Used

We retrospectively studied MPI studies performed during the peak of COVID-19 restrictions at the University of Alabama Medical Center in comparison to the same time period in 2019.

Summary of Results

The MPI volume was reduced from 553 per month in 2019 to 105 per month in 2020 (i.e. to 19% of pre-pandemic utilization). The proportion of abnormal MPI for the 2020 cohort (61±13 years, 48% men, 41% black) was not different from the 2019 cohort (62±12 years, 48% men, 42% black) (31% vs. 27%, p=0.4). Similar proportion of patients in the 2 cohorts had abnormal myocardial perfusion, moderate-large perfusion defects, myocardial ischemia, myocardial scar, and abnormal left ventricular ejection fraction. The proportion of MPIs that were abnormal was not different based on whether patients were evaluated face-to-face or by tele-medicine (28% vs. 27%, p>0.9) but was higher for cardiology providers (40% vs. 20%, p<0.001).

Conclusions

There was a significant reduction in the number of MPI studies performed during the peak restrictions from the pandemic. Despite this restriction, the rate of abnormal studies remained stable. Our study suggests that it remains difficult to predict which patients will have abnormal MPI even when providers and stress laboratories are forced to prioritize the performance of studies to high-yield patients.

193 Hyperaldosteronism secondary to renin-angiotensin-aldosterone system activation in heart failure

A Jain¹*

EW Reynolds²

S Jain¹

¹The University of Texas Medical Branch at Galveston, Galveston, TX

²The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX

Purpose of Study

Congenital heart defects can lead to heart failure (HF). HF decreases renal perfusion resulting in activation of the renin-angiotensin-aldosterone system (RAAS) leading to hyperaldosteronism. This leads to sodium (Na) and water retention and urinary potassium (K) loss, evident by low urinary Na:K ratio. Chronic use of furosemide also activates the RAAS and sympathetic nervous system with persistent hyperaldosteronism leading to a poor prognosis. The objective of this study is to investigate RAAS activation in HF by measuring serum aldosterone and renin and urine Na and K levels before and after medical treatment.

Methods Used

This is an observational study of infants with VSD who developed HF requiring treatment with furosemide and captopril. Infants with lethal anomalies were excluded. Blood and urine were collected before initiation and 2 weeks after starting treatment. Serum aldosterone, renin, and NT-proBNP along with urine Na and K were measured.

Summary of Results

This is an interim analysis of the first 5 patients. The mean gestational age was 35.3 ±3.3 weeks and mean birth weight of 2768 ±916 g. Mean pretreatment NT-proBNP was 10532 ±10177 pg/mL (normal <125 pg/mL), renin 58 ±40 ng/mL/hr (normal 2–35 ng/mL/hr), aldosterone 232 ±201 ng/dL (normal <16 ng/dL), urine Na 6.2 ±1.6 mmol/L (normal >20 mmol/L), and urine K 68.6 ±44.8 mmol/L (normal 5–10 mmol/L). Mean posttreatment BNP was 6500 ± 2718 pg/mL, renin 58 ±15 mg/mL/hr, aldosterone 182 ±138 ng/dL, urine Na 12.4 ±9.4 mmol/L, and urine K 27.7 ±15.3 mmol/L.

Conclusions

Our study demonstrates that HF leads to persistent hyperaldosteronism secondary to RAAS activation despite 2 weeks of medical treatment. This pilot data can be used to guide a multicenter study to further investigate the role of RAAS activation in HF.

194 Effects of sex and race on guideline directed medical therapy for heart failure with reduced ejection fraction

S Kancharla*

AA Oshunbade

RC Long

G Hernandez

B Lennep

L Papadimitriou

C Moore

J Butler

ME Hall

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

Recent evidence from the Change the Management of Patients with Heart Failure (CHAMP-HF) registry suggests there are opportunities for initiation/optimization of guideline directed medical therapies (GDMT) including beta blockers (BBs); angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or angiotensin receptor neprilysin inhibitors (ARNIs); and mineralocorticoid antagonists (MRAs) in patients with heart failure with reduced ejection fraction (HFrEF). We examined HF GDMT prescription patterns in a large, tertiary-care medical center to determine whether sex and race affect prescription of these important medications.

Methods Used

This analysis included data from 10,812 adult patients with HFrEF from 2013–2019 from the University of Mississippi Medical Center. All data was extracted from the electronic medical record Patient Cohort Explorer. We examined prescription patterns of GDMT for HFrEF patients by sex and race, including ACEIs/ARBs, ARNIs, HF BBs, and MRAs.

Summary of Results

Among included HFrEF patients, 41.3% were women and 59.6% were black. These patients were insured primarily by Medicare/Medicaid (62.2%) and private insurance (13.8%), while 21.8% had no insurance coverage. Overall, we found suboptimal rates of HF GDMT prescriptions: 53.2% on ACEIs/ARBs, 9.6% on ARNIs, 62.2% on BBs, and 24.8% on MRAs. We noted higher percentages of black patients with HFrEF were on BBs (66%) and MRAs (28%) in comparison to white patients with HFrEF (56.7% and 20.2%, respectively). Men with HFrEF had higher prescription rates of HF GDMT. This difference was most pronounced with BB prescriptions – 64.3% in men versus 59.2% in women.

Conclusions

Our institution appears to have significant opportunities for initiation of Class I indicated GDMT for HFrEF. Despite some differences noted with regard to sex and race, the overall prescription rates are lower than 70%. Suboptimal prescriptions rates were especially pronounced with ARNIs and MRAs. While some patients could have contraindications to some of these therapies, there is likely a large proportion without contraindications not on GDMT for HFrEF.

195 Predictors for 30-day readmission for recurrent syncope

S Khan*

R Kamoga

D Nair

N Mehta

White River Medical Center, Batesville, AR

Purpose of Study

Syncope is a common medical problem with 18.1–39.7 episodes per 1000 patients.¹ Prior analyses have estimated the 30-day readmission to be at 9.3%.² The causes and predictors for recurrent syncope readmission are unclear. Since recurrent syncope is the most common cause of readmission, we sought to determine the factors that predict these readmissions.

Methods Used

We utilized the Nationwide Readmission Database to identify admissions with a principal diagnosis of Syncope (ICD-9 780.2). Applicable admissions were all adults (age ≥ 18) from January 1 to November 30, 2014. All-causes including syncope readmissions (either as principal or secondary diagnosis) within 30-days of an index syncope admission were analyzed. Readmission predictors were determined using a multivariate logistic regression model following sequential step-wise elimination of covariates.

Summary of Results

A total of 63,282 patients were admitted for syncope. There were 6,320 readmissions (9.99%) within 30-days of index admission. Of readmissions, 17.53% were readmitted for recurrent syncope. The Length Of Stay (LOS) for those readmitted was 2.97 days (Confidence Interval, CI 2.81–3.13) while those not readmitted was 2.67 days (CI 2.65–2.69) which was statistically significant (p<0.001). The statistically significant predictors of recurrent syncope readmission were leaving Against Medical Advice (Odds Ratio [OR] 2.11, 95% CI 1.63–2.76), discharge to short term hospital (OR 3.75, CI 2.49–5.64), Age 18–35 (OR 1.89, CI 1.33–2.68), metropolitan (> 1 mill.) hospitals (OR 0.75, CI 0.63–0.90), female gender (OR 0.85, CI 0.75–0.96) and private payers (OR 0.78, CI 0.63–0.97). Income quartile and the presence of comorbidities such as obesity or Chronic Kidney Disease (CKD) did not influence readmission.

Conclusions

While syncope has a 10% 30-day readmission rate, 1/6 patients will be readmitted for recurrent syncope. Provider awareness of predictors of recurrent syncope may allow for the development of interventions to decrease the rate of readmissions.

196 The rapid evolution of invasive strategies for the management of pulmonary embolism to-date

M Maturana¹*

M Seitz²

I Pour-Ghaz³

UN Ibebuogu³

RN Khouzam³

¹The University of Tennessee Health Science Center College of Medicine, Memphis, TN

²Lenox Hill Hospital, New York, NY

³The University of Tennessee Health Science Center, Memphis, TN

Purpose of Study

This abstract aims to outline the current major interventional treatments for pulmonary embolism through 2020.

Methods Used

We conducted a Medline search of ‘interventional pulmonary embolism treatment’ to identify pivotal trials published before May 15, 2020 for this review of the latest modalities for treatment of pulmonary embolism (PE).

Summary of Results

While the cornerstone of treatment for PE is anticoagulation, more aggressive therapies are increasingly being developed and used to treat high-risk PEs, including systemic thrombolysis, catheter-directed thrombolysis (CDL), ultrasound-assisted thrombolysis (USAT) and mechanical thrombectomy (MT). Systemic thrombolysis is effective but has increased risk of major bleeding. Conversely, CDL, USAT, and MT use alternative devices for treating for high-risk PEs. CDL and USAT involve catheter-directed injection of a thrombolytic drug, and MT uses catheter-directed aspiration of thrombus. Our study provides an in-depth overview of all devices in use, their research trials, and each device’s indications, advantages, and disadvantages.

Conclusions

Interventional devices have shown promising results in treatment of high-risk PE’s. In particular, the EXTRACT-PE trial and subsequent FDA approval of the Indigo Thrombectomy System is a major recent development. Its small size, ease of delivery to pulmonary arteries and low adverse event rate make it arguably the best overall device to date. However, clinical trials for catheter-based devices so far have been limited to mostly single-arm studies measuring short-term surrogate outcomes. These studies offer a preliminary evaluation of the safety and efficacy of devices but are not sufficient to stratify risk and guide clinical practice. Large RCTs are needed to fully examine these risks and long-term outcomes and to create a more clear and specific set of guidelines for use of these devices.

197 Machine learning-based prediction of positive-culture sepsis after the norwood operation in children with single ventricle lesions

AG Moreira^1,2*

K Chorath³

A Moreira⁴

¹Texas Children’s Hospital, Houston, TX

²Baylor College of Medicine, Houston, TX

³The University of Pennsylvania, Philadelphia, PA

⁴The University of Texas Health Science Center at San Antonio, San Antonio, TX

Purpose of Study

The Norwood operation for single ventricle lesions is one of the most complex congenital heart surgeries with a mortality of 22% postoperatively, and 75% of children having at least 1 post-operative complication. Acquiring sepsis after the Norwood operation increases mortality by 13%. The aim of this study was to examine the performance of machine learning approaches to predict positive-culture sepsis in children with a single ventricle lesion.

Methods Used

A secondary data analysis of children from the Pediatric Heart Network Single Ventricle Reconstruction Trial. A total of 549 individuals from multiple cardiac intensive care units around the country were included. The outcome was culture-proven sepsis evaluated between the Norwood and Glenn procedure. In the training set (70% random sample), using demographic, clinical, and surgical predictors, we derived three machine learning models: logistic regression, extreme gradient-boosted decision tree, and k-nearest neighbors. We measured the models’ prediction performance by computing C statistics in the remaining test set (30% random sample).

Summary of Results

Fourteen percent (n=78) of children were diagnosed with sepsis [mean (SD) gestational age, 38.1 (1.6) weeks; 61.9% male; mean (SD) age at Norwood, 6.8 (4.1) days]. Extreme gradient-boosted decision tree had the best C-statistic for predicting sepsis at 81.6% (CI 0.718 - 0.914). Logistic regression and k-nearest neighbors had a C-statistic of 59.1% and 74.0%, respectively. Age at discharge was the top predictor followed by echocardiographic measures of right ventricular function, intraoperative variables, and demographic features.

Conclusions

Machine learning-based predictors can help clinicians determine which children with single ventricle lesions are at highest risk of developing sepsis after the Norwood operation.

198 Increased covid-19 mortality in American Indians and those with prevalent atherosclerotic cardiovascular disease

H Nannapaneni*

A Oshunbade

ME Hall

MR McMullan

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

The coronavirus disease-2019 (COVID-19) pandemic has been associated with varying mortality. Racial disparities and underlying medical conditions appear to play a role.

Methods Used

We retrospectively analyzed data from a large academic medical center in Mississippi using the electronic health record Patient Cohort Explorer. We evaluated differences in mortality rates among racial groups, between sexes, and based on a diagnosis of prevalent atherosclerotic cardiovascular disease (ASCVD). Multivariable regression models were performed to assess the differences and odds of dying due to COVID-19 by race and ASCVD status.

Summary of Results

Among 804 adults aged ≥19 years admitted to the University of Mississippi Medical Center with COVID-19 from 3/14/2020 to 9/14/2020, 521 (65%) were Black, 153 (19.1%) were White and 54 (6.7%) were American Indian or Alaska Native (AI), and 151 (19.8%) patients had ASCVD. In patients without ASCVD, mortality rates were similar between Black and White patients (13.2 vs 15.1%, respectively), but were higher in AIs (37.8%). Mortality rates were also similar between Black and White patients with ASCVD (33.7 and 37.8%, respectively) but higher in AIs with ASCVD (55.6%). Patients with ASCVD had higher mortality rates compared to those without ASCVD (36.4 vs 14.9%, respectively). After adjustment for age and sex, the odds of dying was significantly higher among AIs (OR 4.93 p<0.001). ASCVD was also associated with increased likelihood of mortality in patients with COVID-19 (OR 3.36 p<0.001), irrespective of race.

Conclusions

In a large academic medical center, AIs had about 5-fold increased risk of dying from COVID-19 and a diagnosis of ASCVD also presaged increased mortality in patients with COVID-19. Based on our findings, physicians should have a heightened awareness of risk of dying from COVID-19 in AIs and those with underlying ASCVD.

199 Evaluation of glucose tolerance test in guanylyl cyclase/natriuretic peptide receptor-a gene-targeted mutant mice

K Neelamegam*

C Ramasamy

KN Pandey

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Atrial natriuretic peptide (ANP) acting through the guanylyl cyclase/natriuretic peptide receptor-A (GC-A/NPRA), plays pivotal roles in the regulation of blood pressure and cardiac homeostasis. The disruption of the Npr1 (encoding GC-A/NPRA) in mice exhibits hypertension and provokes renal and congestive heart failure; however, the underlying mechanisms are not yet precisely determined. The objective of present study was to investigate whether Npr1 gene plays a critical role in regulating glucose homeostasis in Npr1 gene-disrupted haplotype and gene-duplicated mice.

Methods Used

The adult male (14–18 wks) Npr1 gene-knockout haplotype (Npr1^±, 1-copy), wild-type (Npr1^+/+, 2-copy), and gene-duplicated (Npr1^{+ +/+ +}, 4-copy) mice were fasted overnight (16 h) and given free access to water. The mice were administrated with glucose both orally and intraperitoneally (2 g/kg body weight) to determine oral glucose tolerance test (OGTT) and intraperitoneal glucose tolerance test (IPGTT). Blood glucose levels were determined by performing tail bleeds at 0, 15, 30, 60, 90, and 120 min using the AlphaTRAK blood glucose monitoring system.

Summary of Results

The results showed that administration of glucose resulted in a greater increase in blood glucose levels at 120 mins in 1-copy mice (OGTT: 237 ± 5 mg/dL, IPGT: 246 ± 6 mg/dL) than 2-copy male (OGTT: 131 ± 3 mg/dL, IPGT: 126 ± 6 mg/dL), respectively. The blood glucose was also significantly lower in 4-copy mice (OGTT: 113 ± 5 mg/dL, IPGT: 108 ± 7 mg/dL) compared with 2-copy mice. Systolic blood pressure (SBP) was determined by non-invasive tail-cuff method (Visitech 2000). SBP was significantly greater in 1-copy mice (130 ± 4 mmHg) than 2-copy mice (100 ± 3 mmHg). Similarly, SBP was also significantly lower in 4-copy mice (90 ± 2) than 2-copy mice. The increase in plasma glucose levels were significantly lower in OGTT than IPGTT.

Conclusions

These results revealed that Npr1 gene markedly prevented a steep rise of blood glucose levels after glucose challenge and ameliorated glucose intolerance in wild-type 2-copy and gene-duplicated 4-copy mice than haplotype 1-copy mice, suggesting that glucose homeostasis might be regulated by Npr1 gene.

200 Race is not a predictor of major cardiovascular events or mortality in COVID-19 patients

H Nguyen*

F Ikram

N Nguyen

C Patel

P Acharya

A Dhillon

M Sidhu

Methodist Health System, Dallas, TX

Purpose of Study

To determine if race is linked with higher rates of MACE and/or mortality in patients hospitalized for COVID-19.

Methods Used

Our retrospective observation cohort study analyzed 496 hospitalized patients to determine if race was a predictor for poorer outcomes (MACE or death). Data was obtained from review of the electronic medical records of de-identified patients that tested positive for COVID-19. Statistical analysis using Pearson’s chi square test was used to compare race with incidence of MACE or death.

Summary of Results

Out of the 484 patients that had data available on race, 132 (37.39%) were Black or African American, 87 (24.65%) were white or Caucasian and 134 (37.96%) were other ethnicities. No significant association was observed between race and higher risk for MACE or death in COVID-19 patients (p-value = 0.878).

Conclusions

While African Americans make up a larger demographic of hospitalized COVID-19 patients, they are just as likely as any other race to have MACE or death. Our study shows that race does not affect the rate of MACE or death.

201 Elevated body mass index is not associated with incidence of major adverse cardiovascular events or death in covid-19 patients

H Nguyen*

F Ikram

N Nguyen

C Patel

P Acharya

A Dhillon

M Sidhu

Methodist Health System, Dallas, TX

Purpose of Study

To determine if elevated BMI is associated with higher rates of major adverse cardiovascular events (MACE) and/or mortality in patients hospitalized for COVID-19.

Methods Used

Our retrospective observation cohort study analyzed 496 hospitalized COVID-19 patients to determine if elevated BMI is associated with MACE and/or mortality. Data was obtained from review of the electronic medical records of hospitalized COVID-19 patients. A two-sample Wilcoxon rank-sum (Mann-Whitney test) was used to compare BMI to worse outcomes. The Fisher’s exact test was used to compare the BMI categories with worse outcomes. MACE was defined as a composite of myocardial infarction, deep venous thrombosis pulmonary embolism, stroke or shock requiring vasopressor support. BMI categories were as follows: Underweight (BMI<18.5), Normal (BMI 18.5 to <25), Overweight (BMI 25 to <30), and Obese (BMI>30).

Summary of Results

Of the 495 patients with BMI data available, 358 (72%) did not have MACE or death and 137 (28%) had MACE or death (p = 0.5126). Examination of outcomes based on BMI category found that 0.56% of underweight patients did not have MACE or mortality versus 2.19% with worse outcomes, 19.55% of normal BMI patients did not have worse outcomes versus 21.17% with MACE or mortality. 32.68% of overweight patients did not have worse outcomes versus 29.93% with worse outcomes, and 47.21% of obese patients did not have worse outcomes versus 46.72% with worse outcomes (p = 0.392).

Conclusions

Our study shows that obese patients were not as likely to develop MACE or death compared to patients with normal or low BMIs. Furthermore, patients in higher BMI categories were not as likely to experience MACE compared to those in lower BMI categories. In conclusion, the incidence of MACE and mortality in COVID-19 positive patients is independent of obesity and BMI.

202 Hypertensive diseases in pregnancy and kidney function later in life

AA Oshunbade¹*

ST Lirette¹

B Windham¹

T Shafi²

A Hamid¹

S Gbadamosi³

W Yimer¹

D Clark¹

D Kamimura¹

R Mentz⁴

ER Fox¹

J Butler¹

K Butler¹

V Garovic⁵

S Turner⁵

T Mosley¹

ME Hall¹

¹University of Mississippi Medical Center, Jackson, MS

²University of Mississippi Medical Center, University of Mississippi Medical Center, Jackson, MS

³Florida International University, Miami, FL

⁴Duke University, Durham, NC

⁵Mayo Clinic Minnesota, Rochester, MN

Purpose of Study

Hypertension in pregnancy has been associated with increased risk for end-stage kidney disease; however, there are limited data assessing the relationship between hypertensive diseases in pregnancy and kidney function later in life.

Methods Used

We evaluated kidney function in 725 women of the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Women were classified by self-report as nulliparous (n=62), a history of normotensive pregnancies (n=544), a history of hypertensive pregnancies (n=102), or a history of preeclampsia (n= 17). We compared adjusted associations among these 4 groups with measured (iothalamate clearance) and estimated (Cystatin C) GFR measurements of kidney function using generalized estimating equations to account for familial clustering.

Summary of Results

Among women with renal function measurements (mean age 59 ± 9 years, 53% African American). Those with a history of hypertensive pregnancy had lower GFR (iothalamate urinary clearance: β-coefficient,-4.66 ml/min/1.73 m², 95% CI -9.12, -0.20) compared to women with a history of normotensive pregnancies. Compared to women with a history of normotensive pregnancies, women with a history of hypertensive pregnancy had higher odds of GFR < 60 ml/min/1.73 m² by iothalamate urinary clearance (OR 2.09, 95% CI 1.21,3.60). Additionally, women with a history of hypertensive pregnancy had greater odds for chronic kidney disease (OR 4.89, 95% CI 1.55, 15.44), after adjusting for risk factors.

Conclusions

A history of hypertension in pregnancy is an important prognostic risk factor for kidney disease several years later.

203 Smoke and heart should stay apart: e cigarettes and other alternatives to conventional cigarettes’ impact on cardiovascular health

J Raja*

A Khouzam

N Khouzam

R Khouzam

UTHSC, Memphis, TN

Purpose of Study

This abstract aims to review alternatives to conventional cigarettes, and their impact on cardiovascular health.

Methods Used

We conducted a Medline search of ‘E cigarettes,’ ‘Smokeless tobacco,’ ‘hookah’, and ‘cardiovascular risk’ to identify pivotal trials published before May 10, 2020, for inclusion in this review. Major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. The following section reviews data from pivotal trials to review the effects of E cigarettes, smokeless tobacco, hookah, nicotine replacement therapy on cardiovascular health.

Summary of Results

E cigarettes are associated with increased risk of atherosclerosis leading to myocardial infarction, stroke as well as arrhytmogenic property of the cigarettes have been noted. E cigarettes also lead to vaping associated illness which can culminate into acute respiratory distress syndrome. Hookah use leads to increased smoke inhalation even compared to cigarettes. Evidence points towards higher risk of CAD among hookah users. Though initial evidence for smokeless tobacco products like ‘snuff’, ‘snus’, or chewable tobacco did not show any association, recent and emerging research shows increased in MI and cardiovascular mortality. The only cigarette alternative that remains safe from a cardiovascular perspective are nicotine Replacement therapy.

Conclusions

The abundance of evidence regarding alternatives to conventional cigarette’s impact on cardiovascular mortality and morbidity does not position it as a safe alternative, but an alternative means of smoking nicotine. The humongous rise in popularity and its gain in favor among the younger population poses a serious threat to the cardiovascular well- being of the exposed. Thus, E cigs and other alternatives of cigarette smoking do impart differing risks in cardiovascular mortality and morbidity, with the possible exception of nicotine replacement therapy.

204 The prevalence of pathologic q waves in pediatric patients with confirmed hypertrophic cardiomyopathy: a systemic review of the literature

K Singhapakdi*

L Mellick

University of South Alabama, Mobile, AL

Purpose of Study

The electrocardiogram (ECG) of patients with hypertrophic cardiomyopathy (HCM) ranges from normal to exhibiting evidence of ventricular hypertrophy, a classic finding being deep Q waves in the inferior and lateral leads. However the prevalence of this finding in pediatric HCM patients is not well-established. The purpose of this review is to describe the prevalence of pathologic Q waves in pediatric patients with echocardiogram proven HCM.

Methods Used

PubMed, Web of Science, Scopus and CINAHL were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. The Rayyan Systemic Review Software was used to screen for final review. The initial search (Search 1) consisted of the following terms: ‘dagger Q wave’, ‘dagger-like Q waves’, ‘dagger shape Q waves’, ‘deep Q wave’ ‘narrow Q wave’, ‘Q wave elevation’ and ‘hypertrophic cardiomyopathy’. A broader search (Search 2) was conducted using the same terms except ‘hypertrophic cardiomyopathy’. The authors then reviewed the articles these searches yielded as well as the references of the articles.

Summary of Results

This yielded 9 articles that specifically addressed the prevalence of pathological Q waves in pediatric HCM patients. The articles described a total of 845 pediatric patients with hypertrophic cardiomyopathy. Of these, 258 (30.5%) demonstrated pathological Q waves on their electrocardiograms. The range of percentages reported for pathological Q waves was 12.5–66.7%.

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Abstract 204 Figure 1

Conclusions

Our systematic review confirmed that pathologic Q waves are a common and early finding in children with HCM and may sometimes be the only ECG finding.

205 Incidence of major adverse cardiovascular events in covid-19 infected patients at a major southwest metropolitan quaternary care hospital

CD Ukoha*

M Sidhu

FG Ikram

C Patel

N Nguyen

H Nguyen

L Hoang

P Acharya

Methodist Dallas Medical Center, Dallas, TX

Purpose of Study

The world reached over eight million cases of COVID-19 in June 2020. There are several unknown cardiovascular manifestations of COVID-19, specifically major adverse cardiovascular events (MACE). The purpose of this study is to identify the incidence of MACE within the COVID-19 infected patient population hospitalized in a major Southwest metropolitan quaternary care hospital.

Methods Used

A total of 496 patients tested positive for COVID-19 from March 2020 to June 2020 at a major Southwest metropolitan quaternary care hospital. Electronic medical records of these cases were reviewed to identify any evidence of MACE. MACE was defined as a composite of myocardial infarction, stroke, deep venous thrombosis/pulmonary embolism or shock requiring vasopressor support.

Summary of Results

In this single-center retrospective study, all 496 patients who tested positive for COVID-19 and were hospitalized were included. The mean age of the patients was 58.2 (SD=14.5) years, with 39% of the patients between 40 and 60 years of age. More than 70% of the patients were African American or a race other than White. Overall, 122 of the 496 patients developed a MACE during hospitalization. 493 patients had at least one of the following comorbidities: hypertension, diabetes, chronic obstructive pulmonary disease (COPD), asthma, or obesity (BMI>30). 82 patients had hypertension, 20 patients had COPD or asthma, and 59 patients had a BMI greater than 30. Of the 122 patients who developed a MACE, 83.2% did not have COPD or asthma. Forty-nine (40.1%) of the COVID-19 infected patients had a MACE or expired during hospitalization.

Conclusions

This study revealed that a substantial percentage of COVID-19 patients developed a MACE during admission, and most of these patients did not have an underlying lung condition including COPD or asthma. Despite studies indicating a higher risk of complications in obese patients with COVID-19, only half of the COVID-19 population with MACE had a BMI >30.

206 Angiotensin II type 2 receptor regulates skeletal muscle stem (satellite) cell differentiation and potentiates muscle regenerative capacity via GSK-3β/β-catenin pathway: implications for treatment of cachexia and skeletal muscle wasting

T Yoshida*

P Delafontaine

Tulane University, New Orleans, MO

Purpose of Study

Patients with advanced congestive heart failure (CHF) or chronic kidney disease (CKD) often have increased angiotensin II (Ang II) levels and cachexia. We previously demonstrated that Ang II type 2 receptor (AT2R) potentiates skeletal muscle stem (satellite) cell (SC) differentiation. However, AT2R expression is suppressed in Ang II-mediated muscle atrophy, suggesting the involvement of AT2R signaling. We aimed to identify the downstream signaling of AT2R in SCs, and to assess its role in skeletal muscle regeneration and atrophy.

Methods Used

AT2R downstream signaling pathways were analyzed in AT2R knockdown cells by phosphoprotein array. The identified signaling pathway was pharmacologically and genetically manipulated both in vitro and in vivo, and the skeletal muscle regenerative capacity was analyzed by qRT-PCR, western blotting and immunohistochemistry. Also, AT2R-overexpressing transgenic animal was generated and the changes in SC signaling was analyzed.

Summary of Results

We found that 20 phosphoproteins were upregulated (>1.4 fold change) and 28 were downregulated (<0.7 fold change) in SCs after AT2R knockdown. The analysis indicated an involvement of Akt/GSK-3β/β-catenin pathway, and β-catenin TCF/LEF reporter (TOPFlash) assay showed an increase in β-catenin activity both in vitro and in vivo during SC differentiation. AT2R knockdown in cultured SCs significantly inhibited Akt/GSK-3β/β-catenin pathway, and importantly, decreased SC differentiation. In transgenic mice that overexpress AT2R specifically in SCs, muscle regeneration is potentiated in association with increased Akt/GSK-3β/β-catenin pathway. Furthermore, pharmacological activation of Akt/GSK-3β/β-catenin pathway restored SC regenerative capacity both in vitro and in vivo after AT2R knockdown. Importantly, Ang II-induced decline in muscle regenerative capacity and muscle atrophy development were both prevented by AT2R overexpression and activation of Akt/GSK-3β/β-catenin pathway in vivo.

Conclusions

These data indicate that AT2R/Akt/GSK-3β/β-catenin pathway plays a critical role in regulating SC differentiation and muscle regeneration, and could be a novel therapeutic target in wasting disorders such as CHF and CKD.

207 Paradoxical hypotension and pulmonary edema after surgical pericardiotomy for cardiac tamponade: an under-reported complication to anticipate

J Abdelmalek*

M Abohelwa

M Elmassry

E Elgwairi

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Pericardial decompression syndrome (PDS) is a rare and serious complication that ensues after often-initially-uncomplicated pericardial drainage in patients with pericardial effusion and tamponade physiology.

Here we report a case of PDS in a 70-year-old male with end stage renal disease (ESRD) who underwent surgical pericardial window for drainage of a moderate pericardial effusion with tamponade physiology. After presenting with severe dyspnea, hypoxia and hypotension, his vital signs initially improved after drainage of pericardial fluid.

Few hours after surgery patient developed pulmonary edema and hemodynamic instability requiring intubation, mechanical ventilation and vasopressor support.

Compared to his normal Echocardiogram 2 months prior to this hospitalization, an Echocardiogram done in the ICU postoperatively showed moderately reduced left ventricular ejection fraction 30–34%, with apical, lateral and inferior wall hypokinesis, significant right ventricular systolic dysfunction, and paradoxical ventricular septal wall motion.

EKG showed no acute ischemic changes, cardiac biomarkers were only mildly elevated in the setting of ESRD.

A diagnosis of pericardial decompression syndrome was made.

Vasopressors were weaned gradually over a duration of 5 days, patient was extubated, his fluid status improved with continuous renal replacement therapy, he was transferred to the stepdown unit and later discharged 13 days after admission.

A follow-up Echocardiogram 6 months after discharge showed normalization of his left ventricular systolic function with ejection fraction estimated at 50–54%.

This case provides further evidence that rapid pericardial decompression, notably with pericardiotomy, can lead to acute life-threatening low cardiac output heart failure, particularly in patients with underlying cardiac risk factors. Early recognition, diagnosis and supportive treatment in the intensive care unit is crucial for improving survival.

208 A case of pembrolizumab induced complete heart block

M Abohelwa¹*

M Elmassry¹

M Ali Hassan²

E Elgwairi¹

J Abdelmalek¹

K Nugent¹

¹Texas Tech University Health Sciences Center, Lubbock, TX

²American University of Beirut, Beirut, Lebanon

Case Report

Introduction

Pembrolizumab is a monoclonal antibody directed towards programmed cell death protein 1 (PD-1).It is commonly used in the treatment of non-small cell lung cancer. It’s associated with multiple immune-related side effects. Here, we present a case of complete heart block (CHB) 14 days after pembrolizumab administration.

Case Presentation

A 57-year-old female patient known to have metastatic non-small cell lung cancer presented with syncope. She was started on treatment for non-small cell lung cancer nine months before the presentation to the ED. Initially, she received induction with cisplatin and pemetrexed, then pemetrexed as maintenance therapy with a good partial response. However, her disease progressed. Only three percent of the patient’s tumor cells expressed PDL-1. Therefore, the patient was started on pembrolizumab 14 days before her presentation. Upon presentation to the ED, her electrocardiogram (EKG) showed a CHB. Her previous EKG was normal sinus. The troponin level was trended, and it was normal. A temporary pacemaker was inserted. Coronary angiography was done, and it showed normal coronary vessels. The patient was started on high dose corticosteroids. However, after seven days, she was still in CHB. Therefore, a permanent pacemaker was inserted.

Discussion

Pembrolizumab immune-related side effects have commonly been reported in the literature e.g., thyroiditis, hepatitis, hypophysitis, pneumonitis, etc. Although it is rare, cardiovascular complications have been reported as a side effect of pembrolizumab therapy. It might cause arrhythmias, pericarditis, myocarditis, pericardial effusion, and tamponade. CHB is a rare complication following pembrolizumab therapy. Various proposed mechanisms have attempted to explain immune checkpoint inhibitor-mediated arrhythmias. Some of these theories include ventricular myocarditis with inflammation and fibrosis or inflammation of the His-Purkinje conduction system, leading to re-entry arrhythmia. Atrial or ventricular arrhythmias secondary to inflammation without myocarditis and atrial and ventricular arrhythmias from functional cardiotoxicity without inflammation are other possibilities.

209 Concurrent acute corianry syndrome and acue infection: a case report

M Abohelwa¹*

A Gharamti²

M Elmassry¹

J Abdelmalek¹

TE Whisenant¹

P Sethi¹

¹Texas Tech University Health Science Center, Lubbock, TX

²American University of Beirut, Beirut, Lebanon

Case Report

Introduction

An increase in the short- and long-term risk of myocardial infarction (MI) in the setting of acute infections is well described in the literature. We present a case of concomitant acute MI and acute cholecystitis. The latter was diagnosed following the persistence of abdominal pain after successful stenting.

Case presentation

A 41-year-old man with hypertension and recently diagnosed Inflammatory Bowel Syndrome presented with severe epigastric pain radiating to the interscapular area of 3 hours duration, associated with diaphoresis, nausea, and vomiting. His vital signs were normal, except for a heart rate of 49. EKG showed sinus bradycardia and ST-segment elevation in leads II, III, and a-VF. He was rushed to the cardiac catheterization lab and was found to have an 80% lesion with a high thrombus burden in the proximal RCA. A stent was successfully placed. Following the procedure, he reported persistence of the abdominal pain. Murphey’s sign was positive. Repeat EKG showed resolution of the ST-segment elevations with no new changes. A gallbladder ultrasound showed acute calculous cholecystitis. Since the patient was on dual antiplatelet therapy, surgical management was not possible, and he was medically managed with antibiotics. He was given seven days of intravenous piperacillin-tazobactam, followed by seven days of oral amoxicillin-clavulanate. The patient was last seen three months following discharge, and he was doing well and pain-free.

Discussion

The patient presented with acute MI and cholecystitis. It is essential to stay vigilant of the association between acute infections and MI. This is thought to be related to the prothrombotic and procoagulant states triggered by infections, such as enhanced platelet activation. Additionally, atherosclerotic plaques contain inflammatory cells, which can get activated by circulating cytokines such as Tumor Necrosis Factor (TNF)-α, produced by infections. Finally, infections increase the metabolic demands of the body, though inflammation and fever. This can increase the heart rate, shorten the diastolic filling time, and compromise coronary perfusion.

210 Subtle pre-excitation a wolf in sheep’s clothing

N Albrecht*

UF COM, Jacksonville, FL

Case Report

17-year-old presented with palpitations and chest pain with otherwise normal physical exam. Work-up with 12 lead ECG and echocardiogram was normal apart from a finding of an anomalous origin of the right coronary artery (ARCA) from the left sinus. CT angiography revealed an ARCA with a 1.5 mm interatrial course between the descending aorta and the right ventricular outflow tract. A stress echo was unremarkable for ischemia however the patient complained of worsening symptoms and underwent surgical unroofing of the right coronary ostium. At follow up the patient continued to report sporadic palpitations followed by chest pain with sudden onset and termination. Follow-up ECGs showed manifest pre-excitation. A review of ECGs, stress tests and perioperative tracings showed subtle pre-excitation at all heart rates. An Electrophysiology Study revealed an accessory pathway mapped to the left lateral mitral annulus with a Shortest Pre-excited RR Interval during atrial fibrillation of 250 msec and inducible antidromic reentrant tachycardia that was successfully ablated. On follow up patient is asymptomatic with no evidence of pre-excitation.

In conclusion, we stress the importance of a good history to elicit symptomatology. Palpitations due to ischemia typically follow chest pain whereas chest pain following palpitations indicate an arrhythmogenic etiology. Subtle pre-excitation due to a far-left lateral pathway may be difficult to discern in patients with a robust AV node tone.

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Abstract 210 Figure 1

12 lead ECG demonstrating a) subtle preexcitation b) obvious preexcitation e) post ablation

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Abstract 210 Figure 2

MRI image demonstrating the anomalous origin of the right coronary artery from the left sinus

211 Mins: cardiac arrest during laparoscopic appendectomy

AA Ali*

J Ruiz-Morales

W Kogler

K Esmail

University of Florida College of Medicine – Jacksonville, Jacksonville, FL

Case Report

A 47-year-old male diagnosed with acute appendicitis was planned for laparoscopic appendectomy. Intraoperatively at the time of intra-abdominal insufflation, the patient had an asystolic cardiac arrest with return of spontaneous circulation after cardiopulmonary resuscitation with epinephrine. EKG revealed ST-segment elevation in leads I, aVL, V5-V6. Emergent left heart catherization revealed angiographically normal coronary arteries with possible high anterolateral and mid-inferior hypokinesis. Troponin T resulted at 0.55 (0.00–0.03 ng/ml). Echocardiogram revealed an ejection fraction of 50–55% with all segments contracting normally. The patient was admitted to the coronary care unit and underwent urgent appendectomy within twenty-four hours.

Laparoscopy requires intrabdominal insufflation which results in elevated intrabdominal pressure with consequent inferior vena cava and aortic compression thus affecting cardiac hemodynamics resulting in decreased cardiac output. The patient‘s intraoperative cardiac arrest was likely due to the rapid changes in cardiac hemodynamics essentially from under-perfusion.

Coronary angiography revealed angiographically normal coronary vessels with anterolateral and mid-inferior hypokinesis likely as a result of under-perfusion and stunning of the left circumflex during intrabdominal insufflation. The patient was admitted for management of myocardial injury after non-cardiac surgery (MINS).

MINS is a clinically and prognostically relevant diagnosis due to myocardial ischemia either from supply demand mismatch. Diagnosis requires the presence of elevated cardiac biomarkers within 30 days of non-cardiac surgery without symptoms or EKG changes. The prevalence of MINS can be as high as 8% and carries with it a significant increase in 30-day mortality. Patients with MINS has a greater risk for vascular complications, recurrent myocardial injury/infarction, congestive heart failure, and life-threatening arrhythmias.

Carbon dioxide insufflation during laparoscopic procedures directly affects cardiac hemodynamics and can result in bradycardia, hypotension and cardiac arrest. Patients with myocardial injury after non cardiac surgery should be risk stratified and closely followed as they are at increased risk of future cardiac events.

212 Case of spontaneous coronary artery dissection

Q Aziz*

JA Cavo

J Fanning

The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL

Introduction

Spontaneous Coronary Artery Dissection (SCAD) is a rare life-threatening condition that occurs due to separation of the coronary vessel layers leading to ischemia and chest pain. It is associated with connective tissue and rheumatological diseases. It is commonly seen in females and in younger population. SCAD commonly involves the left main coronary vessel.

Case

A 31-year-old female with medical history of primary biliary cholangitis and rheumatoid arthritis (RA) comes to the emergency room with intermittent retrosternal chest pain and palpitations that started one day ago. The pain is stabbing, non-radiating and lasts a few minutes. She denies radiation, diaphoresis, dyspnea, nausea and vomiting. She had similar pain 2 weeks ago, which resolved. Denies any tobacco, alcohol, or illicit drug use. She takes prednisone and ursodiol. Physical exam findings include stable vital signs, chronically ill appearance, jaundice, scleral icterus, normal cardiac exam, clear lungs, and pitting edema in lower extremities. ECG negative for ischemic changes. Troponin level is 265. ECHO shows normal wall motion and ejection fraction. Left heart catheterization is highly suspicious for SCAD. An optical coherence tomography (OCT) to confirm the diagnosis was unsuccessful due to severe vessel spasm. She is treated with beta-blocker, aspirin, statin, amlodipine, and nitroglycerin.

Discussion

In SCAD an intimal tear leads to an intramural hematoma which reduces lumen size and distal blood supply. It can lead to myocardial infarction, arrhythmias and sudden death. Coronary angiography shows long and diffuse narrowing due to intramural hematoma. It is recommended to confirm diagnosis with OCT, intravascular ultrasound, or cardiac magnetic resonance imaging. Workup includes assessing for underlying inflammatory or autoimmune conditions, connective tissue disorders, hormone levels and fibromuscular dysplasia. Most common associations are RA, systemic lupus erythematosus, Crohn’s disease, Marfan syndrome, and Ehlers-Danlos syndrome. Management includes aspirin, beta blockers, clopidogrel, statin and treatment of underlying associated condition. If patient is hemodynamically unstable or has ischemic symptoms, percutaneous intervention or coronary artery bypass graft are considered.

213 The classic octopus trap

AD Brown*

D Busby

A Hamid

B Deere

University of Mississippi Medical Center, Canton, MS

Case Report

A 68-year-old female with end-stage renal disease and hypertension presented with a middle cerebral artery stroke. Two weeks prior, she had both a normal transthoracic echocardiogram (TTE) and coronary angiography. On arrival, she was hypotensive with low voltage on electrocardiogram (ECG), and had a normal troponin T and TTE. Later, brain imaging showed hemorrhagic conversion. Her proBNP peaked at 17,487 pg/mL and troponin T peaked at 0.41 ng/mL. Repeat TTE revealed a left ventricular ejection fraction (LVEF) 25% and apical hypokinesis with LVOT obstruction. She improved with a vasopressin infusion. A TTE four days later showed improvement of apical hypokinesis and LVEF 40%.

Takotsubo syndrome (TTS) is characterized by transient regional wall motion abnormalities of the right or left ventricle that is often preceded by stress. These abnormalities do not correlate with a single coronary artery distribution and typically there is no atherosclerotic coronary artery disease, hypertrophic obstructive cardiomyopathy, or myocarditis. The presentation mimics an acute myocardial infarction with ST-elevation or depression on ECG, and elevated cardiac biomarkers, in particular, an increased brain natriuretic peptic (BNP) to troponin ratio. Lastly, there is recovery of systolic function within three to six months.

The pathogenesis of TTS is multifactorial from myocardial damage due to catecholamine surge, coronary artery spasm, neurally mediated stunning, and genetics. It often occurs in postmenopausal women. As in this case, TTS should be considered in patients presenting with neurological injury and cardiogenic shock.

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Abstract 213 Figure 1

Apical hypokinesis with preserved LV contraction at the base

214 A novel DLL4 intragenic deletion in an infant with adams-oliver syndrome and persistent truncus arteriosus with crossed pulmonary arteries

S Cheang*

H Meddaugh

S Samples

M Brumund

R Zambrano

T Kimball

Louisiana State University Health Sciences Center, New Orleans, LA

Introduction

Adams-Oliver syndrome (AOS) is a rare genetic disorder with an incidence of 1 in 225 000 individuals and is characterized by aplasia cutis congenita and terminal transverse limb defects. AOS is a clinically heterogenous disorder and cardiovascular malformations have been reported to occur in approximately 20% of these patients. To our knowledge, this is the first description of a newborn with AOS presenting with a DLL4 intragenic deletion and an unusual variant of truncus arteriosus.

Case Description

This female infant was born at term via a normal vaginal delivery. Physical exam was significant for cranial aplasia cutis congenita (ACC) with no other signs of dysmorphism or limb abnormalities. An echocardiogram done revealed a diagnosis of truncus arteriosus with both the pulmonary arteries arising anterolaterally and crossing one another as they coursed posteriorly. The echocardiogram also demonstrated a right aortic arch with an aberrant left subclavian artery. Pedigree analysis revealed that the patient’s father had tetralogy of Fallot (TOF) and absent fifth toenails bilaterally and the patient’s only sibling also had TOF with ACC and hypoplastic fifth toenails. The patient’s chromosome microarray and FISH for 22q11.2 deletion were negative. Whole exome sequencing identified a pathogenic deletion in DLL4 c.1857_1864delAGGGCCCC, p.P621AfsX12. This variant was also observed in the patient’s father and brother, consistent with a diagnosis of AOS type 6 in the proband and family.

Discussion

We present a case of AOS type 6 due to a novel intragenic deletion in DLL4, presenting with intrafamilial variability. 6 genes have been identified to be underlying AOS to date, including DLL4. Within the DLL4 gene, 14 pathogenic mutations have been identified prior to this novel intragenic deletion. Pathogenic variants in this gene are considered to affect the conotruncal musculature, likely contributing to the cardiovascular malformations seen in our patient’s family. Additionally, crossed pulmonary arteries are a rare vascular anatomic abnormality. This defect is known to be associated with various genetic syndromes but has not been reported in association with AOS.

215 Recalcitrant catecholaminergic polymorphic ventricular fibrillation

RD Coultas*

R Shukla

E Sadic

MB Omar

University of Florida Health Science Center Jacksonville, Jacksonville, FL

Case Report

A 50 year old male with a history of generalized anxiety disorder was admitted with an acute anterior STEMI. He underwent successful percutaneous coronary intervention to the left anterior descending artery. On day 5 post revascularization, he had a sudden ventricular fibrillation (VF) cardiac arrest. Successful return of spontaneous circulation was obtained after defibrillation, however, only briefly. He subsequently developed a further 12 episodes of VF, each resolving only temporarily with defibrillation. The episodes had been unyielding despite adjunctive therapies with amiodarone, lidocaine and mechanical circulatory support. Finally, propofol infusion was initiated with resolution of incessant VF. Over the ensuing days he did not tolerate propofol weaning due to recurrent VF and electrophysiological study did not identify an endocardial substrate. Thus, robotic sympathectomy with resection of left stellate ganglion was pursued. Propofol and mechanical support was then able to be weaned without further episodes of VF. He was eventually discharged with an intracardiac defibrillator.

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Abstract 215 Figure 1

Electrocardiogram captured during VT/VF storm showing degradation of sinus rhythm into polymorphic VT/VF

Discussion

Electrical storm is the phenomenon of incessant, episodic ventricular arrhythmias in a short time period. Catecholaminergic polymorphic ventricular tachycardia/fibrillation is a subtype that may be due to a congenital channelopathy or acquired by triggers such as acute myocardial ischemia. Episodes can be self-limited but termination of the storm often requires multiple antiarrhythmic drugs and/or defibrillation. In refractory cases like ours, salvage therapies with mechanical circulatory support, chemical sympathetic blockade with propofol or surgical stellate ganglion sympathectomy may be effective.

216 A case of recurrent spontaneous coronary artery dissection of the same vessel

D Daniels*

JD Pollard

University of Mississippi Medical Center, Brandon, MS

Case Report

Spontaneous coronary artery dissection is a very rare but increasingly more prevalent cause of acute coronary syndrome especially in young women < 60 years of age.¹ One review in British Colombia found the incidence of SCAD to be 0.15 new cases per 10,000 people per year.² Underlying inflammatory conditions such as systemic lupus erythematosus can certainly play a role in an increase incidence of SCAD. 38 year old African American female with history of systemic lupus erythematosus and lupus nephritis presented to the emergency room with ‘pressure-like’ left sided chest pain with radiation to the left arm and left side of her back. In the emergency room she was found to have a troponin of 0.25 and EKG with non-specific t wave abnormalities. Inflammatory markers were obtained and unremarkable at that time. She was taken for coronary angiography the next morning and found to have dissection of her distal RCA extending into the posterolateral branch. The decision was made to medically manage with dual antiplatelet therapy and follow up with repeat coronary angiography at a later date to track progression vs resolution. She underwent repeat coronary angiography about six months later and was found to have complete resolution of her dissection at that time. Around one year later, now at the age of 40 and one and a half years post her original episode of SCAD she presented to the emergency department with chest pain radiating down her left arm. EKG was consistent with inferior ST segment elevation consistent with acute myocardial infarction and she was loaded with aspirin and Brilinta, started on a heparin and nitroglycerin infusion and taken to the cath lab. In the cath lab she was found to have recurrent dissection of her right coronary artery in the mid-distal section of the vessel with active thrombosis present. The decision was made to medically manage with continued dual antiplatelet therapy and glycoprotein IIb/IIIa inhibitor post cath. This case is interesting as this patient did not only have recurrent SCAD but also there is documentation of complete resolution of previous dissection and then re-presentation with STEMI and further coronary dissection in same section of her RCA as her previous event

217 Right ventricular perforation in a patient with takotsubo cardiomyopathy: a case report

T Dixon¹*

M Elmassry¹

M Abohelwa¹

E Elgwairi¹

M Elmassry²

J Abdelmalek¹

K Nugent¹

¹Texas Tech University Health Sciences Center, Lubbock, TX

²Leicester Royal Infirmary, Leicester, UK

Case Report

Introduction

Takotsubo cardiomyopathy (TCM) is a development of apical ballooning of the left ventricle and is characterized by reversible left ventricular dysfunction. Cardiac free-wall rupture (CR) is a rare, but fatal complication of TCM. We present a case of TCM complicated by right ventricle (RV) perforation.

Case presentation

A 71-year-old female with hypertension who was admitted for C. difficile sepsis and rhabdomyolysis after she was found down on the ground for 18h. She developed atypical chest pain and was hemodynamically stable. EKG showed diffuse ST-Elevation and Troponin was elevated at 3,000. Bedside echo showed apical and septal akinesis. Coronary angiogram was negative for obstructive CAD and left ventriculogram showed mid to distal akinesis with apical ballooning consistent with TCM. A few hours later she became hypotensive and tachycardic. Repeat echo showed large pericardial effusion with tamponade physiology. The patient underwent an emergent pericardial window, was found to have hemopericardium and further exploration showed 0.5 cm tear in the RV side of LAD which was repaired. The patient did well and was discharged home 8 days later.

Discussion

TCM is a reversible disease precipitated by acute physical or emotional stress. It presents with chest pain and dyspnea associated with ST-elevation and elevated cardiac enzymes. It is diagnosed by apical ballooning on Left ventriculogram. TCM usually has a good prognosis. However, rarely life-threatening complications like CR may arise. Most reported cases of TCM-induced CR involved the LV wall. However, RV involvement occurs in about 20% of cases as in our case. We believe that our patient‘s acute illness led to TCM-induced RV perforation and tamponade. Early diagnosis and prompt surgical repair are critical for patient‘s survival as in our case.

Conclusion

Cardiologists should be aware of the rare and fatal TCM complications like ventricular wall rupture. Early diagnosis and prompt surgical intervention could be lifesaving.

218 Lung herniation after forceful coughing

MH El-Farra¹*

M Ali²

N Hasaniya^1,2

¹University of California Riverside, Riverside, CA

²Saint Bernardine Medical Center, San Bernardino, CA

Case Report

Introduction

Lung hernia is an abnormal protrusion of lung tissue through the boundaries of the thoracic cavity. It is commonly seen after chest trauma or thoracic surgery but rarely occurs spontaneously. We report a patient who presented with a lung herniation after vigorous coughing.

Case Presentation

A 70-year-old Hispanic male had a vigorous cough and shortness of breath for 15 days prior to admission. He presented with left chest pain aggravated by chest movement and breathing. Physical examination of the chest wall revealed large ecchymosis over the left anterior and lateral chest. Auscultation of the lungs revealed clear breath sounds bilaterally, but decreased air entry on the left lower side. The patient denied any popping sound or trauma to the left chest wall region. He was a former smoker but denied alcohol or drug abuse. Past medical history was significant for asthma, hypertension, and hyperlipidemia with no history of past chest surgery. Patient was morbidly obese with a BMI of 48.

Laboratory results showed white blood cell count was 14,800/mL, hemoglobin level of 10.7 gm/dL, hematocrit of 30.6%, prothrombin time of 12.7 seconds, and sodium level of 117 mmol/L.

A CT scan of the chest with contrast revealed a 4 cm left lung parenchyma herniation at the left 8^th intercostal space through the lateral chest wall without signs of strangulation.

The patient was admitted with normocytic normochromic anemia and partial herniation of the left lower lobe of the lung with left side chest ecchymosis. It was decided to proceed with conservative management of compressive pads and anti-tussive medications due to the lack of major symptoms in his current state and no signs of strangulation of the lung. The patient was discharged home in a stable condition. On follow-up the patient continued to be stable, partial resolution of the chest ecchymosis and significant improvement of his shortness of breath and wheezing.

Conclusion

With no set guidelines on treatment of lung herniations, symptoms, site of herniation, and presence of strangulation must be considered when deciding the course of treatment. Conservative management is for uncomplicated hernias while surgical intervention is for complicated hernias.

219 Chylothorax post-coronary artery bypass grafting: surgical ligation of the thoracic duct

MH El-Farra¹*

N Pham²

M Kajitani²

N Hasaniya^1,2

¹University of California Riverside, Riverside, CA

²Saint Bernardine Medical Center, Saint Bernardine Medical Center, San Bernardino, CA, US, hospital, San Bernardino, CA

Case Report

Introduction

Chylothorax post-coronary artery bypass grafting (CABG) is a rare complication. In CABG, the most common cause of thoracic duct injury is during the harvesting of the left internal mammary artery (LIMA). We present a case of chylothorax after coronary artery bypass grafting treated with surgical ligation.

Case Presentation

A 61-year-old female underwent a mitral valve repair and CABGx4 using a LIMA graft to the LAD artery. Initially, the patient did well postoperatively. However, on post-operative day 2, the patient began having a large amount of left pleural effusion drainage with chylous characteristics.

The patient was treated medically with fasting and total parenteral nutrition. On postoperative day three, the patient drained 2 L/day of continued chylous fluid. On postoperative day 4 the patient drained chylous milky colored fluid, and the patient’s serum triglyceride level dropped to 148. Conservative medical treatment was continued for two weeks without success. Surgical intervention was decided accordingly.

A redo sternotomy was preformed, and the mediastinum was explored. As suspected, there was a large amount of milky fluid gushing out from the top of the internal mammary artery (IMA) pedicle on the lateral edge adjacent to the left subclavian vein. The thoracic duct was carefully dissected along with isolation of the IMA pedicle from the left lung and mediastinal pleura. The leaking area was ligated with 5–0 Prolene pledgeted sutures, thus stopping any further chylous leakage. Doppler evaluation of the LIMA showed normal flow signal, ruling out injury to the LIMA. The sternum was closed in the standard fashion. The patient continued to be stable and drains were removed after 2 days. She had an uneventful recovery.

Conclusion

Clinicians should consider surgical ligation of the thoracic duct when there is a high chest tube output. Medical treatment has a high failure rate, and early embolization or surgical ligation of the thoracic should be considered to reduce hospital stay cost and morbidity.

220 A case of acute pericarditis due to covid-19 infection

AY Hammouda¹*

S Durganna¹

T Roca¹

L Barr²

¹University of Florida, Pensacola, FL

²Radiology Partners Inc, Pensacola, FL

Case Report

We present a case of a 3-year-old male with past history of VSD repair complicated by post-pericardiotomy syndrome and recurrent pericardial effusions who presented with pericarditis and pericardial effusion secondary to COVID-19 infection as the first presenting symptom.

Patient was brought to the ED for chest pain. Due to his history of pericardial effusion, CXR and ECHO were performed. A small pericardial effusion was found and patient was discharged on Ibuprofen and colchicine. Later that night the patient returned to ED after developing fever, chest pain and increased work of breathing.Repeat ECHO revealed the effusion to be larger and patient was admitted. COVID-19 screening was performed and was found to be positive. Patient was treated with toradol for 4 days till symptoms resolved and was discharged to follow up with his cardiologist.

The recent pandemic resulting from SARS-CoV2 (COVID-19) is a global concern. In children, a wide array of presenting symptoms are now documented. While the immune response to infection presents similarly to many other viral respiratory infections, there are increasing reports of other organ affection. The objective of this case report is to highlight the importance of considering COVID-19 infection in the differential diagnosis when a child presents with symptoms of viral illness in organs outside of the respiratory system so that the child is tested early, appropriate supportive care is initiated early and the number of unprotected contacts is minimized.

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Abstract 220 Figure 1

CXR revealing enlarged cardiac silhouette

221 Potential risk during catheter-directed thromboltyic therapy and how to avoid it

R Hazam¹*

A Hallak¹

D Murray²

R Murray¹

¹Texas tech university health science center, Amarillo, TX

²University College Dublin, Dublin, Ireland

Case Report

Introduction: Although rare, some patients may have atrial septal defect which may complicate this procedure like Cather-directed thrombolysis.

Case

A 41 year-old male, diagnosed with submassive PE. Right heart catheterization with two angled pigtail catheters manipulated through the right heart to reach the right and left pulmonary arteries, however on frontal fluoroscopy the catheters appeared slightly more caudal than expected. Lateral fluoroscopy didn’t show the catheter going through the expected anterior curvilinear course of the right ventricle and pulmonary trunk. Contrast was injected into each pigtail catheter showed retrograde flow of contrast back into the left atrium, confirming that the catheters were in the pulmonary veins, passed through an ASD. Upon review of CTA chest, there was a visible ASD.

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Abstract 221 Figure 1

Discussion

Congenital heart defects are rare but can complicate certain procedures and interventionalists need to be aware of this possibility.

Catheter position more caudal than the pulmonary artery silhouettes should alert the operator to the incorrect placement in the pulmonary veins via an ASD.

In these circumstances, lateral fluoroscopy will show no catheters along the expected anterior curvilinear route of the right ventricle and pulmonary trunk. Contrast injection will show flow back to the left atrium rather than the flow away from the heart. Other potential confirmatory methods include pressure monitoring and blood gas sampling. In addition, careful scrutiny of the CT angiogram for an ASD prior to the procedure may alert the operator to this potential pitfall.

222 Total anomalous pulmonary venous return in a neonate

SE Hudson*

UAB (University of Alabama at Birmingham), Birmingham, AL

Case Report

Infant female born at 32.6wga to 30yo P0101 via SVD 2/2 preterm labor was noted on prenatal US to have mild right atrial dilation. At birth patient immediately required positive pressure ventilation and later was intubated for poor respiratory effort. CXR demonstrated abnormal density in right lower lobe concerning for diaphragm eventration vs. congenital diaphragmatic hernia. Echocardiogram demonstrated unobstructed total anomalous pulmonary venous return (TAPVR) to confluence draining directly to right atrium posterior to the right superior vena cava (SVC), along with atrial septal defect (ASD) with right to left shunting, moderate perimembranous ventricular septal defect (VSD), and systemic venous abnormalities including bilateral SVC, left SVC to coronary sinus, interrupted inferior vena cava (IVC) with hemiazygos vein draining to left SVC, hepatic veins draining to right atrium. CT angiogram later obtained confirming anatomy. Given prematurity and unobstructed nature of TAPVR, patient monitored for weight gain prior to surgical repair.

Teaching Points include: Diagnosis of TAPVR and different types (supracardiac, infracardiac, cardiac). Differentiating obstructed vs. unobstructed. Typical management strategies (surgery; waiting in this case given prematurity/weight). Unusual case given additional systemic venous anomalies. Images will be utilized in poster/presentation from echocardiogram obtained during the neonate’s admission process.

223 E-L mitral inflow velocity masquerading as e/a pattern on echocardiography in a patient with atrial flutter

I Ifedili*

T Fan

The University of Tennessee Health Science Center, Memphis, TN

Case Report

Atrial flutter (AFL) carries an increased risk of stroke. Anticoagulation is indicated in patients with elevated CHA2DS2VASc risk score. Echocardiography (ECHO) is useful for distinguishing AFL from other atrial arrhythmias. Pulsed wave (PW) Doppler on ECHO showing an E/A mitral inflow pattern can exclude the diagnosis of AFL. A less known E-L mitral inflow pattern can occur in patients with AFL, leading to inaccurate atrial rhythm diagnosis and incorrect grading of diastolic dysfunction.

An 82-year-old male with history of coronary artery disease, heart failure, AFL and diabetes mellitus, came to the ECHO lab for chest pain workup. He had an EKG rhythm similar to when the diagnosis of AFL was made. PW Doppler of the mitral inflow velocities on ECHO (figure 1) gave the impression of an E/A pattern typical of sinus/atrial rhythm. Search for other features of AFL on ECHO, lead to the conclusion that the rhythm was indeed AFL. L wave masquerading as an A wave lead to an uncertainty in the diagnosis of his rhythm.

The E/A pattern is caused by the combination of the early passive filling of the left ventricle from left atrium (E) followed by an active filling from organized atrial contraction (A). This should be distinguished from an L wave which represents pulmonary vein mid diastolic flow through the left atrium into the left ventricle after early rapid filling.

A prominent L wave can masquerade as an A wave in patients with AFL, leading to inaccurate rhythm diagnosis. Careful observation of other parameters in ECHO is necessary to avoid this pitfall.

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Abstract 223 Figure 1

Pulsed wave Doppler showing an E-L pattern of mitral inflow velocity in a patient with atrial flutter

224 Congenital long qt syndrome masquerading as epilepsy

N Maaliki*

S Mikulic

W Kogler

MB Omar

University of Florida Health at Jacksonville General Medicine, Jacksonville, FL

Case Report

Introduction: Congenital Long QT Syndrome Type 3 is a cause of arrhythmias. While it can lead to sudden cardiac death, it may elusively present with neurologic symptoms.

Case

A 33-year-old man with a history of a ‘seizure disorder’ was admitted after a cardiac arrest. He had been found apneic during sleep, after which he was noted to be in pulseless polymorphic ventricular tachycardia that resolved after defibrillation. Subsequent Electrocardiogram (ECG) revealed a markedly prolonged QTc of 640/584 ms. Left heart catheterization and cardiac MRI were unremarkable. A subcutaneous ICD was placed, and he was started on Nadolol. The patient reported a history of random syncopal events since the age of 12, which occurred without prodromal symptoms and were immediately followed by tonic-clonic seizure activity. Genetic testing revealed an SCN5A mutation consistent with Long QT Syndrome Type 3 (LQT3)

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Abstract 224 Figure 1

Discussion

LQT3 is the third of congenital long QT syndromes. It is an autosomal dominant channelopathy identified by a mutation of the SCN5A gene, which encodes a cardiac sodium channel’s alpha-subunit. This results in a prolonged action potential, which leads to a long QTc interval. Clinically, this manifests as an increased risk of ventricular arrhythmias and sudden cardiac death that usually occur within the first three decades of life. LQT3 commonly presents with arrhythmogenic syncopal or seizure-like episodes during childhood, leading to multiple missed diagnoses. The QTc interval prolongation correlates with bradycardia, which explains the high proportion of arrhythmias during sleep. The diagnosis is made through a detailed history and 24-hour 12-lead ECG monitoring, followed by genetic testing. LQT3 can be treated with beta-blockers, class 1 agents, and an ICD in severe cases.

225 Paroxysmal supraventricular tachycardia in seronegative kawasaki disease like multi-system inflammatory syndrome in children

C Manjunath*

O Sanchez

University of South Alabama, Mobile, AL

Case Report

Multi-System Inflammatory Syndrome in Children (MIS-C) is the presence of persistent fever with elevated inflammatory markers with evidence of organ dysfunction. Its presentation is highly variable and overlaps with Kawasaki disease. Ventricular dysfunction is the most common cardiac manifestation in MIS-C. In a study in Italy, only 2 out of 10 patients who had MISC did not test positive for either IgG or IgM. Considering the temporal relationship with the current SARS-CoV-2 pandemic high index of suspicion is indicated to capture and report unusual presentations of it even in seronegative cases.

We present a rare case of an 8-month-old male child who was admitted for concerns of Kawasaki disease with continuous fever for two-weeks with diarrhea, cough, runny nose, edematous extremities, diffuse macular rash, bilateral erythematous conjunctiva, and oral mucosa. In a febrile event patient presented with supraventricular tachycardia (SVT) associated with desaturation that required transfer to the Pediatric Intensive Care Unit (PICU) for further care. Sinus rhythm was restored after 3 doses of adenosine and 1 synchronized cardioversion. Echocardiogram evidenced mild mitral regurgitation with small pericardial effusion without any coronary dilation or aneurysm. The patient met MIS-C criteria and he had exposure to SARS-CoV-2 infection in the past 3 wks. Multiple SARS-CoV-2 Protein Chain Reaction tests and antibody tests were negative. He was treated with immunoglobulin infusion and high dose aspirin. He did not require a second dose of immunoglobulin infusion or any second-line treatment. The patient recovered well and was discharged home with propranolol although no abnormal basal rhythm was identified.

Supraventricular tachycardia is an unusual presentation for either Kawasaki Disease or SARS-CoV-2 related MIS-C. Although both entities overlap, they are not mutually exclusive and treatment is similar if not the same. As pediatricians, prompt initiation of treatment and a higher level of monitoring should be considered with suspected Kawasaki disease or suspected MIS-C since we are still learning about its presentation. In our patient, the lack of laboratory confirmation of SARS-CoV-2 does not rule in or rule out any of the conditions.

226 Phantom tumor: ‘now you see me, now you don’t’

J Martinez*

JG Rodriguez Velez

Hospital Municipio de San Juan, San Juan

Case Report

An 89 year old female with pertinent medial history of hypertension who presented at the emergency clinic with complaint of shortness of breath which had progressive worsen in a 2 day period. She referred several months history of dyspnea on exertion with associated chest tightness, orthopnea, paroxysmal nocturnal dyspnea and leg swelling. Physical examination remarkable for jugular venous distention, weight loss, bibasilar crackles, and trace pitting edema.

Initial workup including chest X-Ray remarkable for right upper lobe space occupying mass and elevated BNP levels. Chest CT-scan significant for cardiomegaly, bilateral pleural effusion and low density mass at the interfissural region suggestive of tumor. 2D-ECHO consistent with heart failure with reduced ejection fraction. Patient was started on an aggressive diuretic regimen and restrictive fluid intake. After 5 days of inhospital management patient symptoms had significantly improved. Subsequent chest X-Ray were remarkable for almost complete resolution of tumor like right lung lesion.

Localized interlobular effusions (also known as phantom tumor) is a mass-like interlobular fluid collection rarely seen on imagine workup in patients presenting with decompensated congestive heart failure. This imagine findings vanishes after appropriate management. Disappearance of lesion after diuretic therapy tends to confirm the diagnosis. Due to its unease appearance but easily manageable treatment considering phantom tumor under the confounding presentation of a possible lung tumor in a decompensated heart failure patient may prevent unnecessary, expensive and possibly harmful diagnostic and treatment errors.

Although well-known phenomenon, Phantom Tumor is a condition that can be easily confuse and result in unnecessary hospital resource misuse and money expense. Not to mention increasing the risk of placing the patient to unnecessary radiation or invasive procedures. By making primary physician more aware of this diagnosis, we decrease the probability of missing this easily treated complication of decompensated congestive heart failure and avoid consulting or referring the patient to high cost subspecialties. Being said this; primary care physician can treat phantom tumor in a non-sophisticated facility with just x-ray equipment and loop diuretic therapy.

227 Large tricuspid vegetation in a previously healthy ten-year-old male

K McKnight*

K Singhapakdi

KP Sharma

C Gavrilita

USA Children’s and Women’s Hospital, Mobile, AL

Case Report

Infective endocarditis (IE) is relatively uncommon in children, especially in those with structurally normal hearts. When present, however, it is important to identify and treat IE promptly due to its ability to cause significant damage to the endocardial tissue and heart valves and its significant mortality rate. Here we will describe a previously healthy pediatric patient with a structurally normal heart who was found to have IE, with a very large vegetation on his native tricuspid valve. However, he did not exhibit any of the classic findings of IE (no Janeway lesions, Osler’s nodes, or splinter hemorrhages), and the vegetation formed on the right side of his structurally normal heart, in the absence of cardiac and social risk factors (e.g. no IV drug use). This case demonstrates that clinicians should always have a high index of suspicion for IE in the setting of bacteremia and fever, even in the absence of a classic history of physical exam.

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Abstract 227 Figure 1

A 10 × 24 mm vegetation is on the atrial side of the septal leaflet of the tricuspid valve

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Abstract 227 Figure 2

After treatment, there is no evidence of a vegetation on the tricuspid valve

228 A rare and mixed etiology of cardiac tamponade

S Mikulic*

P Dhruva

F Kandah

B Attarha

F Rollini

University of Florida Health at Jacksonville, Jacksonville, FL

Case Report

A 37-year-old female with pmh significant for Graves disease s/p ablation with resultant hypothyroidism was admitted at 20 weeks’ gestation for pre-eclampsia. The patient presented with abdominal pain and dyspnea. During evaluation she had significantly elevated TSH and undetectable free T4. She ruled in for pre-eclampsia with severe features due to blood pressure criteria and proteinuria. In addition, a TTE revealed moderate pericardial effusion. A pericardiocentesis removing 700cc of yellow fluid was performed, and the patient was started on levothyroxine. Analysis of serous fluid proved to be inconclusive. Further workup for etiologies of the effusion such as viral, bacterial, and autoimmune causes were negative. One week later, the patient had a recurrence of the pericardial effusion, along with hemodynamic compromise. A pericardial window was placed with 500cc of fluid removed. Due to worsening of symptoms the pregnancy was terminated. She was eventually discharged medically stable, and to date has experienced no recurrence of symptoms.

Our case presents a unique scenario in which two uncommon etiologies of pericardial effusions presented simultaneously to result in tamponade. Hypothyroidism can lead to a pericardial effusion in 3–6% of cases. The pathophysiology is suspected to be secondary to increased permeability of the pericardial capillaries to albumin, leading to increased colloid pressure within the pericardium, and therefore decreased colloid osmotic pressure gradient between the pericardial space and pericardium. Although hypothyroidism is a much more common etiology in leading to pericardial effusions, pre-eclampsia has also been reported as a cause in the medical literature, likely from generalized capillary leak due to endothelial cell dysfunction and reduced intravascular oncotic pressure.

This case highlights the importance of keeping a broad differential and performing a thorough investigation in determining the etiology of a pericardial effusion. In a patient with risk factors for developing a pericardial effusion, close observation with serial echocardiograms should be performed for early detection and prevention of cardiac tamponade, as the result may prove fatal.

229 Systemic inflammatory response syndrome after cardiac arrest

JR Padgett*

C Latour

JD Pollard

University of Mississippi Medical Center, Brandon, MS

Case Report

Introduction

Shock following sudden cardiac arrest due to myocardial infarction is usually thought to be cardiogenic in nature. However, systemic inflammatory response syndrome is possible after cardiac arrest. We present a case with MI and cardiac arrest and subsequent SIRS, discuss the proposed mechanism, and the importance of recognizing SIRS as a complication post cardiac arrest.

Case

A 72 yo female with pmh of CAD, T2DM and PAD presented to our hospital with chest pain and elevated troponin level. Coronary angiography revealed a thrombus with dissection in the right coronary artery. She received PCI x 4. After procedure, she had cardiac arrest with polymorphic VT requiring CPR and defibrillation with ROSC and no intubation. The next day she had short VT arrest with ROSC requirin intubation. Afterwards, she became hypotensive with vasopressor requirement and AKI. She developed 2:1 AV block with bradycardia requiring dopamine. Echocardiogram showed inferior wall motion abnormalities, LVEF 35% with RV dysfunction. Due to ventricular arrhythmias, AV block and shock, initial management was for cardiogenic shock secondary to RV infarction. She did not respond clinically to this management. Further workup later suggested distributive shock. Therapy was targeted for distributive shock and she made some improvement. Unfortunately, she had further refractory shock and expired. No clear source for sepsis was identified.

Discussion

Cardiac arrest with whole body ischemia and reperfusion syndrome can cause postresuscitation disease. Postresuscitation abnormalities after arrest can mimic severe sepsis. Both are characterized by high levels of circulating cytokines, plasma endotoxin and dysregulated leukocyte production of cytokines. [1] One study showed coagulation abnormalities after cardiac arrest where the thrombin-antithrombin complex was consistently elevated and protein C and S were decreased. [1]

Conclusion

Right ventricular infarcts may manifest as cardiogenic shock, and can be complicated by ventricular arrhythmias with cardiac arrest and high degree AV block. However, it is also important to note that patients with post cardiac arrest can have SIRS response due to whole body ischemia and reperfusion.

230 Takotsubo cardiomyopathy and qt-prolongation following a cerebrovascular accident

I Pour-Ghaz¹*

S Khan¹

T Fan^1,2

AB Katwal^1,2

RN Khouzam^1,3

AA Adeboye¹

¹The University of Tennessee Health Science Center, Memphis, TN

²Memphis VA Medical Center, Memphis, TN

³Methodist University Hospital, Memphis, TN

Case Report

Background: Takotsubo cardiomyopathy (TCM), or left ventricular (LV) ballooning syndrome, is a transient LV dysfunction in the apical or mid-ventricular segments usually provoked by physical or emotional stress seen on echocardiogram (ECHO). It is thought to be induced by catecholamine release and microvascular dysfunction. TCM can cause electrocardiographic (ECG) changes, chest pain, and myocardial enzyme release. Here we present a case of TCM with extreme QT prolongation following a cerebrovascular accident.

Case Presentation

The patient is a 72-year-old male with a past medical history of end-stage renal disease and hypertension who developed left-sided hemianopsia and neglect. Tissue plasminogen activator was administered after brain imaging. ECG showed prolongation of QT from 458 ms to 706 ms (figure 1). Same-day ECHO showed an ejection fraction of 55–60% with a moderate-sized akinetic apical wall motion abnormality, mostly resolved on the fourth day. Possible offending medications were stopped. Troponin levels were minimally elevated and peaked at 0.519 ng/mL. There were no significant electrolyte abnormalities.

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Abstract 230 Figure 1

ECG post tPA

Conclusion

Prolonged QT increases the risk of developing dysrhythmias; thus, timely recognition is critical. Here we presented a case of extreme QT prolongation after an acute stroke with ECHO findings of TCM. Appropriate care was provided by the utilization of ECG, ECHO, and timely studies. This is one of the few incidences of extreme QT prolongation in TCM with optimal outcomes through well-coordinated medical management.

231 Post maze and mitral valve annuloplasty atrial flutter ablation using three dimensional carto mapping system

K Sawalha*

D Nair

White River Health System, Batesville, AR

Case Report

Introduction

Over the past two decades Maze procedure has become the gold standard treatment for medically refractive atrial tachyarrhythmias (ATA) as it creates a functional myocardium for a proper depolarization of the atrium. Despite this, patients may still have recurrent atrial arrhythmias including AF, typical flutter, atypical atrial flutter and focal atrial tachycardias. Such patients may be candidates for electrophysiology study and catheter ablation. We present this case of atrial flutter post-Maze procedure in a repaired mitral valve with annuloplasty that was treated with catheter Radiofrequency Ablation (RFA) using three- dimensional CARTO mapping system.

Case Presentation

A 60-year-old male patient with a past medical history of paroxysmal atrial fibrillation status post cardioversion and Sick Sinus Syndrome with pacemaker presented for atrial tachycardia catheter ablation. He had a history of mitral valve regurgitation that was repaired with annuloplasty with subsequent MAZE procedure. Patient’s medications include Sotalol, Coreg, Xarelto and aspirin for anticoagulation. Device interrogation showed 100% atrial tachycardia. Intracardiac echocardiogram showed Ejection fraction of 60–65% with severely dilated left atrium and mitral annuloplasty in place. Patient had successful isolation of all four pulmonary vein and termination of his atrial flutter using 3D CARTO mapping system with no complications or return of the arrythmia on follow up visits.

Conclusion

Even though MAZE procedures designed to restore normal sinus rhythm, post-operative ATA including Atrial Fibrillation and Atrial Flutter may still occur. In most patients, these procedures are employed as adjunctive therapy in patients undergoing other cardiac surgeries such as mitral valve as seen in this case or coronary artery bypass surgery. Patients with recurrent ATA after surgical ablation may be candidates for electrophysiology study and catheter ablation using advanced mapping systems that uses 3D images for better outcomes.

232 Spontaneous coronary artery dissection in a postpartum female

J Sekhon*

B Rogers

S Siddiqui

Texas Tech Health Sciences Center, Lubbock, TX

Case Report

Spontaneous coronary artery dissection (SCAD) is an extremely uncommon cause of myocardial infarction, occurs predominantly in women during or after pregnancy. The exact etiology is unknown. Here we present a case of SCAD five days postpartum.

29-year-old Hispanic female G2P2 (gravida 2, para 2), was discharged home after an uneventful full-term vaginal delivery of a healthy baby boy, no prior medical history and no history of smoking. Five days postpartum she presented to emergency center (EC) with acute onset sharp chest pain radiating to bilateral arms and upper back at rest. Lab work showed elevated high sensitivity troponin T 6378 (normal high 19 ng/L), EKG with sinus tachycardia, ST elevation 1.5 mm V2-V3, 1 mm V4-V6, and Q wave in II, III, aVF, V1-V4. Transthoracic echocardiogram with ejection fraction (EF) 25–29% with severe hypokinesis. Taken to the catherization lab emergently for left heart catherization (LHC) showed type II SCAD involving proximal to distal left anterior descending (LAD) and proximal large D1 with TIMI III flow and severe mitral regurgitation. Started on medical management with aspirin 81 mg, lisinopril 5 mg twice daily, metoprolol succinate 25 mg daily, torsemide 5 mg daily, and rosuvastatin 40 mg daily. She was fitted for LifeVest secondary to low EF and discharged home with close follow up with cardiology along with counseling about future pregnancies.

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Abstract 232 Figure 1

EKG on admission

Spontaneous coronary artery dissection has been reported as a cause of myocardial infarction in females during pregnancy or postpartum. The left coronary artery is most commonly affected and typically arises within 2 cm of the aortic ostium. Multiple hypothesis have been proposed but the pathogenesis of coronary artery dissection is still unclear. However, multiparity and advancing age have been reported to be at increased risk. Management can vary patient to patient but can consist of intravenous heparin, nitroglycerin, aspirin, statin, and pain management. Thrombolytics are contraindicated in these patients.

233 Chasing the etiology of cardiac tamponade- when pericardial effusion is a red-herring

T Sharma*

F Habash

H Salah

A Lopez-Candales

University of Arkansas for Medical Sciences, Little Rock, AR

Case Report

We present the case of a 54-year-old lady with squamous cell carcinoma of the retromolar trigone with metastasis to mediastinal lymph nodes, who presented with hypotension and altered mental status. She had a recent history of bacterial pericarditis causing cardiac tamponade, for which she underwent pericardiocentesis and adequate treatment with antibiotics. On current presentation, bedside echocardiogram showed a large fluid collection anterior to the heart and decreased cardiac wall motion. CT scan of the chest was reported as nodular pericardium with surrounding low attenuating fluid collection and causing tamponade effect. Due to the acute presentation and hypotension, patient was taken to the cardiac surgery OR where a window was created, and a drain was placed into the fluid collection draining 350 cc of purulent fluid. On further review of the echocardiogram and CT scan, the fluid collection was recognized to be outside the pericardium and was indeed causing mass effect tamponade.

In this patient with recurrence of pericardial effusion causing tamponade, it is likely that tamponade could be due to recurrence of pericardial effusion. Yet, a necrotic mass in the anterior mediastinum may cause mass effect and tamponade. Identifying the cause of tamponade is crucial as it could signify a progression of the metastatic disease with poor prognosis for survival. In conclusion, anterior mediastinal masses can cause cardiac tamponade and should not be deemed as a by-stander in the presence of a pericardial effusion.

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Abstract 233 Figure 1

234 Diabetic ketoacidosis in covid-19 patients

K Ali*

S Rao

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Purpose of Study

Diabetic ketoacidosis (DKA) is a common condition causing hospitalization and mortality in patients with Type 1 and Type 2 diabetes. In the current COVID-19 pandemic, diabetes is a risk factor for poor outcomes in hospitalized patients. Early reports have indicated that COVID-19 patients with Type I Diabetes and DKA had longer lengths of stay, increased rates of ARDS, and higher mortality rates. This study explores those claims.

Methods Used

Our study includes 7 COVID-19 positive DKA patients and examines various demographic parameters, laboratory values, and outcomes.

Methods

The Infectious Disease and Control office at University Medical Center in Lubbock, Texas, provided a list of patients with a COVID-19 infection hospitalized between March 1 and July 20, 2020. The medical records were reviewed to collect information on age, gender, history of diabetes, laboratory tests pertinent to DKA, and outcomes.

Summary of Results

This study includes 7 patients with median age of 39. Three patients (42.9%) were males. The median admission BMI was 29.44 kg/m. Six patients (85.7%) had a history of diabetes mellitus; the median hemoglobin A1c was 12.8% (available in 5 patients). The median admission glucose level was 311 mg/dL with a median anion gap of 21 meq/L. The median pH was 7.25 (7 patients). All patients were managed with insulin infusions, and the median time until the anion gap closed twice was 48 hours. The median fluid balance during insulin infusion was 5,660 mls. Two patients (28. 6%) required mechanical ventilation during their hospitalization. No patients required vasopressors or renal replacement therapy. The median length of hospital stay was 4 days; the mortality rate was 14.3%.

Conclusions

Most patients with DKA and COVID-19 in this study had poorly controlled diabetes. They presented with typical laboratory results seen in other patients with DKA without COVID-19 and responded well to intravenous insulin and fluids. Except for one patient, the length of stay was relatively short. This study suggests that patients with diabetes admitted the hospital with COVID-19, especially patients with poorly controlled diabetes, should be screened for DKA and monitored for its development during hospitalization.

235 A case of high insulin resistance and shifting hhs to dka diagnoses

M Bell*

K Mentore

LS Engel

T DeSilva

LSU Health Sciences Center, New Orleans, LA

Case Report

Hyperglycemic crises, Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmotic State (HHS), are the most severe manifestations of Type 1 (T1DM) and Type 2 Diabetes Mellitus (T2DM), and can result in morbidity and mortality for patients.

Case

A 27 year old morbidly obese man presented to the hospital with polydipsia, polyuria, blurry vision and nausea and was found to have a blood glucose of 998 mg/dL and serum osmolality of 338 mOsm/kg and anion gap of 16, bicarbonate of 22 and beta-hydroxybutyrate of 1.9 mmol/L. After initial medical management for HHS with fluids and subcutaneous insulin, and apparent improvement, the patient developed altered mental status and was found to be in DKA, requiring the intensive care unit, insulin gtt and up to 870 units of insulin in one day. His metabolic encephalopathy resolved and he was able to resume an oral diet with blood glucose control.

Discussion

DKA and HHS are metabolic hyperglycemic crises that are managed with subtle differences, as the main driving force of morbidity/mortality for HHS is volume depletion secondary to hyperglycemia, volume repletion and close monitoring of electrolytes, specifically potassium, are the mainstays. Therapy for DKA, on the other hand, is focused on resolution of acidosis as the main force for damage, with insulin, volume repletion and close monitoring of electrolytes. The commonality is close monitoring of acidosis status and electrolytes. Our patient seemed to shift from an HHS presentation to DKA likely secondary to high insulin resistance in the presence of glucose toxicity. Had closer monitoring been enacted, the transition may have been avoided. This case illustrates the importance of understanding the pathophysiology of DKA vs HHS and close monitoring of blood glucose and electrolytes as patients can shift from one to the other without proper management.

236 Protocol based standardized endocrinological evaluation of children with traumatic brain injury: a qi initiative

J Bhat¹*

SC Schultz²

R Gomez¹

¹Louisiana State University Health Sciences Center, New Orleans, LA

²CHNOLA, New Orleans, LA

Purpose of Study

Traumatic brain injury (TBI) can disrupt the hypothalamo-pituitary axis, causing central neuroendocrine dysfunction and hormone abnormalities (HPAD). As one-third of children can develop post-traumatic HPAD, a longitudinal and thorough follow up may be required to exclude the transient or late-onset HPAD.

Objective

To implement a protocol for standardized evaluation of children with TBI for the diagnosis of HPAD and to effectively establish a regular inpatient endocrine consultation and outpatient longitudinal follow up.

Methods Used

The study is divided into pre-QI (baseline phase) and QI phase (post-intervention phase). During the pre-QI phase, retrospective data were collected on children admitted with TBI at our institution for 1 year. The prevalence of HPAD and the percentage of children longitudinally followed in endocrine clinic were estimated. A consensus-based protocol, detailing clinical and hormonal assay-based evaluation at presentation and during the follow up were formulated and implemented. Prospective data collection will be performed to estimate outcome measures (prevalence of HPAD, rate of initial endocrine consultation and endocrine outpatient follow up) and process measure (protocol adherence rate).

Summary of Results

During the pre-QI phase, a total of 27 children, aged ≤19 years were admitted in the year for TBI management. The median (IQR) age at TBI diagnosis was 9 (3, 15) years. Motor vehicle accident was the predominant cause, accounting for 60%. In 85% of patients, the TBI was classified as severe based on GCS. Overall, only 8 children (30%) underwent limited (non-consultation based) endocrine evaluation (7 for central DI and 1 for central hypothyroidism) and 1 patient had complete evaluation (endocrinologist consulted). During the baseline period, the prevalence of transient central DI was diagnosed in 1 patient (4%). Implementation of protocol and post-intervention data collection is pending.

Conclusions

The lower prevalence rate of HPAD in the current cohort of TBI patients may be due to under evaluation for endocrine dysfunction. QI initiative incorporating standardized evaluation using protocol will improve identification follow up rates of patients with endocrine dysfunction following TBI.

237 Symptomatic clinical variant galactosemia carrier in a 2-month-old girl with normal newborn screening

CI Chinchilla Putzeys*

F Al-Saygh

MR Roca Garcia

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Case Report

Galactosemia is an autosomal recessive disease caused by a mutation leading to decreased activity of Galactose-1-phosphate uridylyl transferase (GALT) enzyme. If not treated, can cause serious complications such as failure to thrive, hepatocellular damage, infantile cataracts, intellectual disability and is associated with E. coli infections.

An 8-week-old African-American female presented with fever, decreased appetite, vomiting, and diarrhea. On examination, the patient had increased work of breathing, tachycardia, and signs of dehydration. Inflammatory markers were elevated and coagulation profile was slightly prolonged requiring vitamin K. Urine and blood cultures grew E. coli requiring an antibiotic course. Lumbar puncture was normal.

Two weeks later the patient was re-admitted for E. coli bacteremia and urinary tract infection. Voiding cystourethrogram was remarkable for grade 3 vesicoureteral reflux. Immunoglobulin levels were unremarkable.

Recurrent E. coli sepsis prompted testing for galactosemia despite her negative newborn screen at 15 days old. Her GALT enzyme activity was reduced at 14.3µmol/g of hemoglobin (normal ≥19.4µmol/g of hemoglobin). GALT gene sequencing resulted in one copy of the pathogenic variant p.Ser135Leu. Therefore, this patient is a heterozygous carrier of clinical variant galactosemia. Homozygosity for p.Ser13Leu is a prevalent cause of symptomatic galactosemia in African Americans. There is limited data for galactosemia carriers presenting with symptomatic galactosemia; however, this patient shows symptomatic galactosemia with recurrent E. coli sepsis despite being heterozygous for p.Ser13Leu mutation.

238 A case of wernicke’s encephalopathy in the presence of thyrotoxicosis

C Cunningham*

K Oakden

D Matrana

LS Engel

S Walvekar

LSU Health Sciences Center, New Orleans, LA

Case Report

Wernicke’s encephalopathy, characterized by a classic triad of nystagmus, ataxia, and confusion, is a neurological condition resulting from thiamine deficiency.

Case

A 30-year-old woman with a history of hyperthyroidism presented to a rural hospital with lower extremity weakness, shortness of breath, and subjective fevers with diaphoresis. At that time she appeared alert, interactive, and oriented. She was notably tachycardic and labs demonstrated a TSH of less than 0.01 uiU/mlwith a an elevated free T4 of 4.35 mg/dl. Prior to transfer, she received beta blockers for her tachycardia and methimazole for presumed thyroid storm. Upon arrival to our hospital, she was febrile to 105° F and tachycardic to 162 beats per minute. She was disoriented and hallucinating. Exam revealed horizontal nystagmus. Labs again demonstrated an elevated free T4 but now showed a lactic acidosis. She received propranolol and PTU for her thyrotoxicosis. After hospital day 2, the patient was no longer hallucinating but remained disoriented despite her approaching euthyroid levels. The persistence of her altered mental status despite treatment of the thyrotoxicosis was concerning. EEG and MRI brain were both unrevealing. During her prolonged hospitalization, it became clear that the patient’s altered mental status was consistent with confabulation which paired with her persistent nystagmus was concerning for potential Wernicke’s encephalopathy. High dose thiamine was started and serum levels were collected. Her mental status and nystagmus improved slowly with supplementation. Suspicion for Wernicke’s was confirmed when her thiamine level returned low at 29 nmoles/L.

Discussion

Wenicke’s encephalopathy is frequently overlooked in the nonalcoholic patients presenting with altered mentation. Thyrotoxicosis induces the Krebs cycle to utilize thiamine. Once thiamine is no longer available, the body shifts to anaerobic metabolism resulting in the production of lactic acid as seen in this patient. Wernicke’s encephalopathy, a severe neurologic condition caused by the exhaustion of thiamine reserves, can result in debilitating neurological complications and death if not properly recognized and treated early.

239 Pediatric seizures in the setting of a febrile illness: an unexpected diagnosis of rickets

R Dean*

GB Maniam

P Pungwe

A Batson

S Tijani

A Lunsford

Texas Tech University Health Sciences Center, Fort Worth, TX

Case Report

Rickets is a childhood disease in which bony mineralization dysfunction occurs secondary to hyperparathyroidism due to a deficiency of vitamin D. The most common presentation includes skeletal findings and developmental delays. This case discusses a diagnosis of rickets presenting as hypocalcemic seizures in the setting of febrile illness.

A 12-month-old boy presented to his pediatrician after having had seizure activity the night before. He was born at 39 weeks of gestation with an unremarkable delivery and newborn screening tests. On the evening prior to presentation, the patient had become febrile – and that night, he had had a sudden-onset generalized tonic-clonic seizure before falling back asleep. The patient was brought to the outpatient clinic the next morning and diagnosed with otitis media and a simple febrile seizure. He was prescribed amoxicillin and supportive management, but on the way home had another seizure. He was rushed to the emergency department, where laboratory tests revealed critical hypocalcemia. Physical examination findings showed frontal bossing, craniotabes, enlargement of the bilateral wrists at the metacarpophalangeal joints, and mild anterior bowing of tibia bilaterally on weight-bearing. The CMP revealed an elevated alkaline phosphatase level, an elevated parathyroid hormone level, and a decreased level of 25-hydroxyvitamin D. Electrocardiography showed prolonged QT intervals. Emergent repletion of calcium was started with intravenous calcium gluconate; he was also started on oral cholecalciferol and oral calcium carbonate. Oral amoxicillin was continued for right otitis media. A radiologic skeletal survey demonstrated abnormal bone mineralization, fraying, splaying, and cupping of numerous sites bilaterally (femora, tibiae, fibulae, radii, ulnae). There was also mild anterior rib end expansion at the costochondral junction bilaterally. After three days of hospitalization, the patient was discharged on oral calcium carbonate with follow-up outpatient appointments.

While the initial presentation of rickets presenting as hypocalcemic seizures in the setting of a febrile illness is rare, previously reported cases suggest that febrile seizures warrant detailed physical examination for bony abnormalities.

240 Implementation of congenital hypothyroidism screening protocol in community hospital neonatal intensive care units

DR Dhoot*

TO Findley

A Shah

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, Houston, TX

Purpose of Study

Congenital hypothyroidism (CH) is a preventable cause of intellectual disability and detectable on newborn screening (NBS). Preterm infants have a high rate of inaccurate results on NBS compared to term infants due to thyroid dysmaturity, underlying illness and delayed TSH surge. A screening protocol for preterm infants was created at an academic institution and introduced to two community neonatal intensive care units (NICUs). Our aim is to evaluate the feasibility and adherence to the guideline in the community setting.

Methods Used

A retrospective review was conducted at two community NICUs including preterm infants (≥23 to <35 weeks’ gestation) admitted between June 2018 and June 2020 in Houston, Texas (n=575). Data collected included associated genetic conditions, NBS results, free thyroxine and TSH levels. The protocol recommends obtaining thyroid function tests (TFTs) at ~30 days of life with monitoring and/or endocrine consult based on results and corrected gestational age (GA).

Summary of Results

The cohort of neonates had a median GA of 33 ^2/7 weeks with interquartile range (IQR) 31 ^1/7-34 ^2/7 and median birth weight of 1950 g with IQR 1470–2290. TFTs were collected at ~30 days of life in 206 out of 274 (75%) preterm infants that were admitted for at least 21 days. The median number of TFTs done per baby was 1 with a range of 1–5. 38 out of 274 infants (14%) and 31 out of 274 (11%) had abnormal first and second NBS for CH, respectively. In infants less than 28 weeks GA, incidence of abnormal first and second NBS for CH was 50% and 46%, respectively. Subsequent initial TSH levels obtained for those infants were normal (0.5–6 uIU/mL). Hypothyroidism was detected by the screening protocol in one neonate who was started on levothyroxine for medical treatment. This infant was born at 25 ^6/7 weeks GA and was diagnosed with an atrial septal defect. Results of the first and second NBS were abnormal for CH (reported as ‘TSH slightly elevated’).

Conclusions

Implementation of this protocol in community hospitals affiliated with an academic institution demonstrates its practicality. Many community NICUs have limited access to pediatric endocrinologists, so this protocol may improve detection of hypothyroidism in premature infants.

241 Hypoglycemia unawareness and co-occurrence of thyroid autoimmunity as features to help distinguish between type 1 and type 2 diabetes in an adult patient

SM Ford*

DM Borne

AM McClean

LS Engel

GL Cosentino

LSU Health Sciences Center, New Orleans, LA

Case Report

Type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) can share many features, including presenting symptoms polydipsia, polyuria, and polyphagia as well as lab abnormalities of hyperglycemia and ketosis. However, care to make the correct diagnosis can make an important impact on patient outcomes, ease of medication administration, and limit dangerous adverse events such as hypoglycemia.

Case

A 49 year-old man with history of T2DM (diagnosed at age 31) and acquired hypothyroidism s/p neck irradiation to treat T-cell lymphoma endorsed episodes of tremors and sweating over the previous three months. During these episodes his blood sugar ranged between 40–60 mg/dL. For management of presumed T2DM, he was on a regimen of insulin glargine 30 units nightly. Chart review indicated that the patient previously tested positive for insulin antibodies. The clinical significance of the positive insulin antibodies was unclear given that the patient had been on insulin regimens for several years and may have generated an antibody response to insulin. Further testing revealed that Anti-GAD antibodies were > 250 IU/mL (normal range 0–5 IU/mL), confirming diagnosis of T1DM. Furthermore, his anti-thyroid peroxidase (TPO) antibody level was found to be elevated at 88.8 IU/mL (normal <9.0 IU/mL), confirming diagnosis of Hashimoto’s thyroiditis.

Discussion

T1DM occurs due to autoimmune destruction of the pancreatic islet cells, resulting in absolute insulin deficiency and subsequent hyperglycemia due to decreased endogenous insulin production. T2DM occurs due to impaired peripheral insulin responsiveness of insulin-sensitive tissues including skeletal muscle, adipose tissue, and liver, resulting in hyperglycemia due to inability of insulin to act at these tissues. Unlike T2DM, insulin sensitization of peripheral tissues is relatively preserved in T1DM, which leaves these patients more prone to experiencing frequent and/or severe hypoglycemic episodes. Practitioners should be especially suspicious of a missed diagnosis of T1DM in a thin patient with preserved insulin sensitivity and especially in any patients with other autoimmune conditions, thyroid disease being the most common.

242 Surgically treated resistant hypertension due to bilateral adrenal hyperplasia

K Ganesan*

AS Sallar

D James

University of Tennessee Health science center, Memphis, TN

Background

Treatment resistant hypertension (TRH) may affect about 15% of patients with hypertension. While primary hyperaldosteronism is a known etiology of TRH, clinicians must consider the possibility of elevations of other adrenal hormones. Early identification of an etiology may prevent or delay the onset of complications.

Case Report

Endocrinology was consulted on a 46 years-old man for evaluation of TRH. His past medical history is significant for TRH, congestive heart failure (Ejection Fraction 45–50%), and chronic kidney disease. Physical examination was unremarkable except for a blood pressure of 193/124 mmHg while on furosemide, isosorbide mononitrate, hydralazine, carvedilol, spironolactone, and clonidine. Chart review revealed mild hypokalemia. Computed tomography of the abdomen without contrast showed bilateral enlarged nodular adrenal glands with an increase in size over the last three years (left adrenal gland: 6.3 cm, right adrenal gland: 5.6 cm). Initial workup showed normal free plasma metanephrine, normetanephrine, aldosterone renin ratio, 17-hydroxyprogesterone, and undetectable random adrenocorticotropic hormone (ACTH) with random cortisol of 29 mcg/dl. Subsequent evaluation revealed elevated deoxycorticosterone (3030 ng/dL), 11-deoxycorticosterone (42 ng/d) and 18-Hydroxycorticosterone (640 ng/dL). He subsequently developed Cushing’s syndrome and diabetes mellitus.

The patient underwent laparoscopic left adrenalectomy and subtotal right adrenalectomy. Pathology showed macro-nodular adrenal cortical hyperplasia. He was started on hydrocortisone for postoperative adrenal insufficiency. On his most recent follow-up, his blood pressure was well controlled on bumetanide, carvedilol, metolazone, and nifedipine. (Hydralazine, isosorbide mononitrate, spironolactone, and clonidine were stopped). After surgery, Corticosterone (92.10 ng/dL), 11-Deoxycorticosterone (<5.00 ng/dL) and ACTH (9 pg/mL) normalized.

Conclusion

Determining the etiology of TRH should not be stopped after ruling out the ‘usual suspects’ since malignant hypertension with end-organ dysfunction can develop, if not appropriately treated. In our patient, TRH was due to elevated 18-Hydroxycorticosterone (precursor of aldosterone), which improved after adrenalectomy.

243 Prolonged infant hypoglycemia

I Jacks*

R Bassali

Augusta University, Augusta, GA

Case Report

8 week old male presents with persistent hypoglycemia. He went to his pediatrician’s office where his glucose was found to be 28 mg/dL, he was then transferred to the hospital. Prior to the current episode he had no fever, cough, congestion, emesis, diarrhea, or other symptoms. He had two prior hospitalizations for hypoglycemia at an outside facility with no cause found. During prior stays he required dextrose fluids at a glucose infusion rate of 5.6 mg/kg/min then was discharged with strict oral feedings every 3 hours. He was born at 38.6 weeks via spontaneous vaginal delivery. Patient‘s mother was induced due to preeclampsia. Birth was complicated by broken clavicle and he had prolonged hospital stay for hyperbilirubinemia. Family history was negative for any endocrine or metabolic disorders. Upon arrival to the hospital patient was noted to be well appearing with mild jaundice but otherwise unremarkable physical exam. Glucose on arrival was 50 mg/dL, prior to the next feed the glucose was noted to be 33, so critical hypoglycemia labs were collected. The infant was continued on PO feeding and started on D10 fluids while awaiting lab results. Labs were significant for direct bilirubin of 3.4 mg/dL, beta-hydroxybutyrate of <0.1 mmol/L, insulin level of <0.5 mcIU/mL, cortisol of 0.63 mcg/dL, and growth hormone of 0.55 ng/mL. Interpretation of the labs revealed an appropriately low insulin level, inappropriatley low cortisol, and low growth hormone. An ACTH stimulation test showed an inappropriate response to stimulation as the cortisol did not rise above 18 mcg/dL. Based on the lab results a diagnosis of panhypopituitarism induced adrenal insufficiency leading to hypoglycemia was made. After the diagnosis was made he was started on somatropin, levothyroxine, and prednisolone for hormone replacement. His dextrose fluids were then weaned off. Neuroimaging and ophthalmology consult to evaluate for associated septo-optic dysplasia was deferred to outpatient setting. Neonatal hypoglycemia is a relatively common condition with a wide variety of potential causes. A thorough workup including lab results collected during the hypoglycemic episodes are crucial to obtaining the correct diagnosis. Hypopituitarism leading to adrenal insufficiency and hypoglycemia is a rare cause of neonatal hypoglycemia but is important to recognize early for proper hormone replacement therapy.

244 Déjà vu: recurrent abdominal mass and new paraspinal mass in a young adult

M Lago*

H Chachere

J Sansone

H Elaasar

J Taylor

R Gomez

C Straatman

Louisiana State University School of Medicine in New Orleans, New Orleans, LA

Case Report

Neuroendocrine tumors are an uncommon source of pediatric hypertension, but should be considered in cases of adrenergic storming. Pheochromocytomas (PCC) account for 1% of pediatric HTN diagnoses and are more likely to be related to genetic mutations at younger ages of presentation. Multiple genetic syndromes predispose patients to develop PCC, including VHL, MEN-2, NF-1, and FPS (Familial Paraganglioma Syndromes).

A 20-year-old female presented with four days of chest and abdominal pain, palpitations, urinary frequency, diarrhea, dizziness, blurry vision, and headaches. Her history was significant for a left suprarenal PCC, resected at age 12. Vitals were notable for labile hypertension. Labs were normal except for mild anemia. CT of the chest and abdomen revealed a 5.9 × 4.5 × 5.1 cm paraspinal posterior mediastinal mass at T5-T8 and a 3.8 × 5.4 × 4.5 cm left-sided suprarenal mass.

Maternal history was notable for PCC and subsequent paraganglioma. Consequently, genetic testing at the patient’s initial presentation revealed an SDHB p.R46X mutation. Due to risk of tumor recurrence with SDHB mutations, frequent surveillance with serologic testing and imaging is recommended, but this patient was lost to follow up.

Ultimately, the addition of an α-blocker, β-blocker, and CCB were required to control hyperadrenergic symptoms. NET labs showed elevated plasma epinephrine, dopamine, and chromogranin A. MIBG revealed intense radiouptake of the paraspinal mass and no uptake of the suprarenal mass, similar to the prior PCC. Due to concern for PCC recurrence, biopsy was contraindicated, but resection has been planned.

Several SDH gene mutations have been associated with FPS. SDHB mutations are autosomal dominant, associated with the development of extra-adrenal tumors with an increased risk of malignancy. This case demonstrates the importance of genetic testing and long-term surveillance in pediatric patients with PCC.

245 Myonectin is a marker of remission of type 2 diabetes in obese human subjects

D Lawson*

F Stentz

University of Tennessee Health Science Center, Memphis, TN

Purpose of Study

Obesity is a national epidemic and is a major component of metabolic syndrome. To prevent the progression to Type 2 Diabetes (T2D), patients are instructed to either lose weight or are put on a medication regimen. To date, diet and exercise are considered the gold standard in prevention and treatment, however no single diet has emerged as the optimal diet for remission in T2D patients.

We studied the effect of a High Protein(HP)(30% protein, 40% carbohydrate, 30% fat) diet vs High Carbohydrate(HC)(15% protein, 55% carbohydrate, 30% fat) diet in obese, T2D patients on remission of T2D to normal glucose tolerance(NGT), weight loss, body composition, and metabolic parameters in this randomized controlled clinical trial.

Methods Used

We recruited 24 women and men who were recently diagnosed with T2DM and they were randomized to a HP or HC for 6 months. All food was provided and designed for weight loss according to participants resting metabolic rate. Oral glucose tolerance (OGTT), weight loss, insulin sensitivity(IS), metabolic parameters, cardiovascular risk factors (blood pressure, lipids), inflammatory markers and DXA (to determine Lean Mass (LM) and Fat Mass (FM)) were measured at Baseline (Bl) and after 6 months on the diets. The novel myokine, myonectin, was of interest due to the possible implications of its use in clinical practice and measured at Bl and 6 months.

Summary of Results

12 patients completed the study. 100% (n=6) of the HP group had remission to NGT. 16.5% (n=6) of the HC group had remission to NGT. Although similar weight loss was obtained LM was gained in the HP group (+2.30%), but was lost in the HC group (-2.09%) along with FM loss in both groups. OGTT studies showed significant improvement in IS to NGT in the HP group compared to the HC group.The HP diet group had greater improvements in CVR and inflammatory markers than the HC diet group. Myonectin levels were significantly lower after 6 months on the HP group compared to the HC group.

Conclusions

These data suggest that a diet with a high protein content is optimal to the remission of T2DM. This could be explained by the gain or preservation of lean body mass in patients. The changes in myonectin levels could be used as a marker of remission of T2D.

246 The rate of detection of congenital hypothyroidism in patients with congenital heart disease via newborn screen

S Mahajan*

A Shah

TO Findley

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, New Braunfels, TX

Purpose of Study

Congenital hypothyroidism (CH) is the most common and preventable cause of intellectual disability in children, with a reported incidence of 1:2000–4000 in the general population. All newborns are screened for CH by newborn screening programs. Congenital heart defects (CHD) are the most common birth defect and may be associated with an increased risk for CH due to a common embryonic development pathway. We report a case series (n=12) of neonatal CHD treated for hypothyroidism and describe the rate of detection by newborn screening among CHD patients.

Methods Used

A single-center, retrospective review was conducted to identify CHD patients hospitalized in the neonatal intensive care unit (NICU) from January 2013 to March 2019 (n=413). Infants born before 32 weeks gestational age were excluded due to increased rates of hypothyroidism related to prematurity. Data collected included type of cardiac defect, birth parameters, newborn screen results, and duration of medical treatment for hypothyroidism with levothyroxine.

Summary of Results

Twelve patients were treated with levothyroxine during their hospitalization. Incidence of treatment for hypothyroidism among hospitalized CHD neonates was 1:34. The mean gestational age was 35 5/6 weeks and mean birth weight was 2408 g. Seven infants (58%) had a normal first newborn screening and five infants (42%) had a normal second newborn screening. The median age of initiation of levothyroxine was 41.5 (27 to 146) days of life. The incidence of permanent CH diagnosed at 3 years of age was 1:138 (n=3), one of which had Trisomy 21. Eight patients were lost to follow-up.

Conclusions

This case series demonstrates a higher rate of treatment of hypothyroidism in the neonatal period as well as permanent CH in CHD patients compared to the general population. The first and second newborn screens only accurately detected about half of patients who were required treatment with levothyroxine, suggesting the newborn screen may be an insufficient screen of CH for infants with CHD, making early identification of CH challenging in a high-risk population.

247 The cardiometabolic profile of a lean model of polycystic ovary syndrome

S McClung¹*

JG Morato¹

ED Torres Fernandez²

S Everman¹

J Pruett¹

D Romero^1,3

L Cardozo Yane^1,3

¹University of Mississippi Medical Center, Jackson, MS

²The University of Texas at Austin, Dell Medical School, Austin, TX

³Women’s Health Research Center, Jackson, MS

Purpose of Study

Polycystic Ovary Syndrome (PCOS) is the most common endocrinopathy in reproductive-age women. It is characterized by hyperandrogenemia and is associated with cardiometabolic abnormalities such as obesity, insulin resistance (IR), and increased blood pressure (BP). Obesity plays a major role in the clinical manifestations of PCOS, since weight loss is associated with reductions in metabolic derangements. Whether or not increased circulating androgens cause obesity and how these effects may occur remains poorly understood. We tested the hypothesis that obesity mediates the androgen-induced cardiometabolic abnormalities in PCOS.

Methods Used

Four-week-old female Sprague Dawley rats were randomized to either dihydrotestosterone (DHT, 7.5 mg/ 90 days) or control. DHT rats were assigned to ad libitum diet or daily pair-feeding schedule (PF-DHT) based on food intake (FI) of control (n=5–8 per group). Body composition (by EchoMRI), proteinuria, and IR were determined every 4 weeks. BP was measured by radiotelemetry.

Summary of Results

DHT rats have increased FI, body weight (BW), fat mass, proteinuria, IR, and BP than control. With pair-feeding, FI in PF-DHT was decreased to the same level as control. In PCOS, pair-feeding abolished the increase in fat mass (12.5 ± 1.7 vs 22 ± 2.5 g, p<0.001) and attenuated the increase in BW (269 ± 6 vs 308 ± 7 g, p<0.001). Pair-feeding normalized BP (103.8 ± 0.6 vs 109.6 ± 0.7 mmHg, p<0.0001) and ameliorated the androgen-induced increase in proteinuria. Pair-feeding worsened the Homeostatic Model Assessment of IR (5.4 ± 0.4 vs 3.4 ± 0.6, p<0.01).

Conclusions

In summary, pair feeding in PCOS decreases obesity which leads to a decrease in proteinuria and BP. Obesity appears to play a key role mediating the cardiometabolic derangements in women with PCOS. Though IR was not improved, weight loss is a promising therapeutic for the cardiometabolic abnormalities in PCOS. Funded by COBRE/MS CEPR P20GM121334.

248 Unusual adverse effect of commonly use antidiabetic agent

N Mon*

M Khan

RI Hazam

T Vo

Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX

Introduction

Euglycemic diabetic ketoacidosis (euDKA) due to sodium-glucose cotransporter 2 inhibitor (SGLT2 inhibitor) is a serious side effect that can be triggered by a very low carbohydrate diet with <1% incidence. It is vital to keep low threshold for diagnosis of euDKA in patients taking SGLT2 inhibitors to avoid delay management and to identify risk factors. We report a case of euDKA due to dapagliflozin with recent start of a very low carb diet.

Case

A 38 years old lady with type 2 diabetes mellitus, on Dapagliflozin for a year, presented to ED with 3 days of abdominal discomfort associated with intractable nausea and vomiting. She drank 6 packs of beer daily and started a very low carb diet 2 weeks ago. Admission vital signs and physical exam were unremarkable except mild epigastric tenderness. Labs: neutrophilic leukocytosis, glucose 185, HCO₃ 4, anion gap 20, BUN 8, creatinine 0.7, HbA1c 11.8; ABG pH 7, pCO₂ 8.6, HCO₃ 2, beta hydroxybutyrate 49 mg/dl, Lactic acid 0.8 and negative ethanol level. UA showed glucose3+,protein1+,ketone2+ & negative hCG. Once diagnosis of severe euDKA was confirmed, DKA protocol was initiated. She improved clinically and was discharged home with basal bolus insulin, discontinuation of dapagliflozin & diabetic education.

Discussion

Adverse effects of SGLT2 inhibitor should be considered in the presence of precipitants including strenuous physical activity, very low carbs/ketogenic diet, prolong starvation and heavy alcohol intake. It is contraindicated in eGFR<30. The mechanism of euDKA due to SGLT2 inhibitor is thought to be due to reduced insulin and increased glucagon secretion, which cause glucose metabolism shifting to fatty acid oxidation, leading to ketonemia and euDKA. By lowering the renal glucose excretion threshold, SGLT-2 inhibition may mimic starvation condition, leading to increased ketone and its renal re-absorption. It renders the body susceptible to ketonemia and continues to produce glycosuria, thereby causing euglycemia.

Conclusion

Early recognition of etiology of euDKA and precipitants are crucial to prevent metabolic consequences. Patients on SGLT2 inhibitor should be educated on signs and symptoms of DKA, precipitants and instructed to seek help when they are experiencing the symptoms.

249 Sarcoidosis presenting as hypoadrenalism

F Mubeen*

A Kamat

S Usala

Texas Tech University Health Sciences Center, Amarillo, TX

Case Report

Sarcoidosis is a multisystem granulomatous disorder that may present with lymphadenopathy, lung nodules, skin, joint and or eye lesions. Lung involvement is common but 30% may have extra-thoracic manifestations such as pituitary granulomas causing secondary adrenal insufficiency, but rarely presents as disease of the adrenal gland.

A 38-year-old athletic male was referred to endocrinology for possible hypoadrenalism. He had a past history of seasonal allergies, and had been recently seen by neurology for gradual onset of generalized muscle soreness, weakness and difficulty getting out of a chair. MRI of his brain was normal. He was nauseous and lightheaded on standing. In addition he had arthralgias. His father had sarcoidosis. Body mass index was 22.3 kg/m². On examination he did not have periorbital edema, conjunctival injection, exophthalmos, visual field defects or cushingoid features. He had a palpable, mobile, supraclavicular lymph node. A 250 mcg cosyntropin test was interpreted as possibly in the hypoadrenal range with 30 and 60 min cortisol level of 19.9 mcg/dl and 22.5 mcg/dl, respectively. Serum protein immunoelectrophoresis revealed high IgG Kappa. His CBC, ESR, comprehensive metabolic profile, vitamin D, B12, free T4 and TSH were normal. Lymphoma and sarcoidosis were in the differential diagnosis with concomitant hypoadrenalism. He was started on hydrocortisone 20 mg/day and at 2 weeks follow-up he had significant clinical improvement. Hematology, rheumatology, and surgery were consulted with the following results: C-reactive protein 32 elevated, Anti-CCP 0.6, Rheumatoid factor 15, Angiotensin converting enzyme 102 elevated, peripheral blood smear bone marrow were normal. Lymph node biopsy was negative for lymphoma or granulomas. CT scan of chest, abdomen, and pelvis was normal. Diagnosis of sarcoidosis was made, and the patient was started on hydroxychloroquine. A repeat 250 mcg cosyntropin test at 18 months was definitively in the hypoadrenal range, 10.0 mcg/dl and 11.6 mcg/dl.

Autoimmune endocrinopathies frequently coexist with sarcoidosis, and when Addison’s disease occurs in this context, the mechanism is usually autoimmune adrenalitis. Our patient did not have a tissue diagnosis of noncaseating granulomas, but the lymphadenopathy and elevated ACE levels made the diagnosis of sarcoidosis likely.

250 Hungry bone syndrome following parathyroidectomy in tertiary hyperparathyroidism

M Oye*

D Gidla

S Paglialonga

MB Omar

P Reddy

University of Florida Health Science Center Jacksonville, Jacksonville, FL

Case Report

A 51-year-old diabetic man with end stage renal disease on hemodialysis was admitted for total parathyroidectomy with autotransplantation. He had been on dialysis for the prior 16 years and developed secondary hyperparathyroidism 7 years ago, followed by tertiary hyperparathyroidism 7 months ago with a markedly higher parathyroid hormone (PTH) level. His asymptomatic hypercalcemia of approximately 11 mg/dL and average PTH of 2000 pg/ml had been refractory to medical therapy, thus parathyroidectomy was pursued. On day 1 postoperatively he developed diffuse paresthesias with Chovstek’s sign and a prolonged QTc on electrocardiogram. Investigations revealed a profound hypocalcemia and hypophosphatemia with a precipitous fall in PTH to 32 pg/ml. Over the ensuing week he required aggressive parenteral and oral calcium and vitamin D supplementation. He was discharged on substantial doses of oral supplementation and despite compliance, had to be readmitted 3 weeks later for symptomatic hypocalcemia. Parenteral calcium loading at dialysis sessions with high calcium baths are being planned.

Discussion

Hungry bone syndrome is the phenomenon of hyperdynamic bony reabsorption of calcium after parathyroidectomy. Although initially described with primary hyperparathyroidism (HPT), it has been shown to be more common and severe in HPT secondary to renal disease. In such cases, profound hypocalcemia, hypophosphatemia and hypomagnesemia are typical. Hyperkalemia may also be seen although the mechanism is yet uncertain. In this case of tertiary HPT, autotransplantation was performed in attempt to reduce the risk of postoperative hungry bone syndrome, although, it was unsuccessful as demonstrated. Preoperative calcium and calcitriol supplementation have been purported to reduce the risk of hungry bone syndrome and aggressive repletion is the mainstay of postoperative management. However, despite the prevalence of end stage renal disease, there is still a paucity of high quality data on effective prevention or management of this disease.

251 Hyperinsulinemic hypoglycemia in an infant with partial trisomy 13

A Pandhi*

M Drawdy

C Antonetti

Ascension Sacred Heart Hospital Pensacola, Pensacola, FL

Case Report

Hyperinsulinemic hypoglycemia is unregulated secretion of insulin from the pancreas in the presence of hypoglycemia. Hyperinsulinemia has been reported in patients with chromosomal abnormalities including Beckwith-Wiedemann and Turner syndromes, but rarely reported in trisomy 13. We present a case of an 8-week-old former 37 week male with a translocation of chromosome 13:17 admitted with feeding difficulty and apnea. History is significant for a brief NICU stay for hypoglycemia managed with orogastric feeds. No further evaluation for hypoglycemia was done at that time. On presentation, vital signs were normal for age. He was well-appearing with low-set ears and retrognathia. No clefts, no microphallus, or midline defects noted. He had normal muscle bulk and tone, no nystagmus, and present infant reflexes. Initial blood glucose level was 48 mg/dl. He was started on D5 containing IV fluids. Several hours later he developed hypoxia and seizure-like activity. Blood glucose level was 43 mg/dl, with an elevated insulin of 30.7 IU/mL, beta-hydroxybutarate 0.27 mmol/L, cortisol 12.77 mcg/dL, and growth hormone 1.84 ng/ml. He received three D10 fluid boluses which would transiently improve blood glucose before hypoglycemia recurred. He was diagnosed with hyperinsulinemic hypoglycemia, managed with continuous nasogastric feeds and diazoxide. Blood glucose levels normalized. He developed peripheral edema, a side effect of diazoxide, managed with furosemide. The diazoxide dose was weaned as an outpatient and blood glucoses have remained stable with bolus feeds. Hyperinsulinemic hypoglycemia is caused by inappropriate insulin secretion from pancreatic beta-cells, and can worsen with high dextrose concentration boluses, as the resulting hyperglycemia triggers more insulin secretion. The mechanism for inappropriate insulin secretion in patients with chromosomal abnormalities remains unknown, though several genes have been identified that may be involved. Hyperinsulinemic hypoglycemia could be considered in patients with chromosomal abnormalities and recurrent hypoglycemia, as it is managed with continuous glucose infusion rather than high concentration dextrose boluses.

252 Propylthiouracil induced hepatotoxicity

N Pant*

University of Tennessee, Memphis, TN

Introduction

Propylthiouracil (PTU) is one of the common antithyroid drugs used in treatment of hyperthyroidism. Common side effects includes rash, arthralgia, vasculitis, and agranulocytosis. Hepatotoxicity is a rare side effect of PTU therapy. We present an interesting case of PTU induced hepatotoxicity.

Case Description

A 39 year old AAM with history of Grave’s disease presented to hospital with complaint of weakness and fatigue. Vital signs were within normal limits. He was alert and oriented initially, but became more altered and was subsequently intubated to protect airway. His laboratory results showed TSH of 0.00 mIU/mL and Free T4 of 3.31 ng/dL. He was started on hydrocortisone, propranolol, Lugol’s iodine, and PTU. He had markedly elevated liver function test (LFTs) on day two of hospitalization [AST 3720 Units/L, ALT 2433 Units/L, ALP 139 Units/L and Total bilirubin of 2.8 mg/dL]. PTU was discontinued. His LFTs gradually improved off PTU, so he was started on methimazole. He progressively continued to improve. He was extubated to nasal cannula and was eventually discharged on Methimazole and Propanolol.

Discussion

Graves’ disease is the most common cause of hyperthyroidism in the United States. Treatment options include antithyroid drugs, radioactive iodine treatment and surgery. Drug induced liver injury has been reported in 0.03% to 0.5% of patients taking antithyroid drugs. Propylthiouracil is a thioamide and a thyroid hormone antagonist which acts by inhibiting the incorporation of iodine into tyrosyl residues of thyroglobulin and thus lowering thyroid hormone levels. Hepatotoxicity is a rare complication of thioamide therapy. The onset of hepatotoxicity is usually within 2 to 12 weeks of starting, and the pattern of enzyme elevations is typically hepatocellular. The severity of PTU induced liver injury varies from mild, transient serum aminotransferase elevations to severe hepatitis, hepatic failure, need for liver transplantation and even death. After medication discontinuation, liver function tests should be monitored weekly until normalization.

Conclusion

Although PTU-induced liver failure is rare in clinical practice, liver function should be appropriately monitored during treatment with PTU, especially in the first 6 months of therapy.

253 Hyperglycemic hyperosmoloar state: when SARS-CoV 2 turns down to be sweet

I Rivera-Nazario*

JL Ayala Rivera

A Nieves-Ortiz

K Hernandez Moya

MT Torres Torres

M Delgado

N Roman-Velez

HR Cintrón-Colón

Hospital Municipio de San Juan, Trujillo Alto, Puerto Rico

Case Report

Hyperglycemic emergencies such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) are commonly precipitated by infections. Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) is a Novel infectious process triggering hyperglycemic crisis. SARS-CoV-2 at the level of the lungs affect ACE2 functioning which in turns decrease the B cells proliferation at the pancreas and impede insulin secretion.

We present a 39-year-old woman with comorbidities of uterine fibroma, who presented with a complaint of general malaise, polyuria and polydipsia of 1 week of evolution. Associated with sore throat, subjective fever, dry cough, abdominal pain, nausea and vomiting. Physical examination remarkable for dry oral mucosa, decreased skin turgor, and prolonged capillary refills. Vital signs significant for hypertension, tachycardia and tachypnea. Laboratory work up remarkable for glucose of 1321 mg/dL, HCO3- of 16 mEq/L, serum osmolality of 333 mOsm/kg, serum ketones positive and HbA1C of 15%. ABG’s showed pH of 7.33, PCO2 of 29.8 and a PAO2 of 158.5 mmHg for a high anion gap metabolic acidosis, non-anion gap metabolic acidosis with respiratory alkalosis. Chest X-ray revealed bilateral perihilar, peribronchial cuffing. We get back positive PCR for SARS-CoV-2. Clinical and laboratory workup met criteria for the diagnosis of HHS and Diabetes Mellitus de Novo precipitated by SARS-CoV-2 infection. Patient was treated with IV fluids and insulin infusion with resolution of hyperglycemia, ketonemia and symptoms.

SARS-CoV-2 infection can precipitate acute metabolic complications in patients with diabetes or unknown diagnosis of diabetes. The effect of the virus could be direct on β-cell function and patient can develop DKA or HHS. To our knowledge, there are only a few cases reported of HHS precipitated by SARS-CoV-2 infection therefore medical awareness is important for early diagnosis, management and treatment in patients presenting with hyperglycemic emergencies de novo since SARS-CoV-2 infection must be ruled out.

254 The effect of metformin use on prevalence of varicose veins in the type 2 diabetic hispanic population- a retrospective study

FD Saenz^1,2*

F Dihowm^1,2

¹Texas Tech University Health Sciences Center El Paso, El Paso, TX

²Texas Tech University Health Sciences Center El Paso Paul L Foster School of Medicine, El Paso, TX

Purpose of Study

Several studies have been able to demonstrate that Metformin may reduce risk of cardiovascular disease in type 2 diabetes. This study focuses on verifying such association in the Hispanic population, who are adversely affected by type 2 diabetes. The aim of this retrospective cohort study is to analyze and confirm if there is reduced risk of varicose veins with Metformin use in the type 2 diabetic Hispanic population.

Methods Used

This comparative, retrospective chart review analysis, reviews 1765 patient medical charts. Patients who matched our inclusion criteria: type 2 diabetes, seen between 2008–2018, and above 18 years of age. Data was divided into various medication groups centered around Metformin to compare prevalence of varicose vein. All analyses were carried out using STATA V.15.

Summary of Results

The prevalence of varicose veins was high in the Metformin group 40 (3.1%) compared with other medications group 9 (1.9%) with P value of 0.19. The unadjusted association results demonstrated an increased risk of having varicose veins within the Metformin user population PR (95%) 1.6 (0.78, 3.28),yet the results between both groups did not have a significant P value (0.20) to confirm this finding. Unadjusted associations to increased risk of varicose veins with significant results were found in variables including age, hypertension, dyslipidemia, and statin use with P value of <0.001, 0.048, 0.029, and 0.026, respectively. Adjusted association in Metformin use found increased prevalence in varicose veins PR 1.25 (0.6, 2.6), but P value was 0.555. Metformin group was compared with 3 other groups (insulin group, sulfonylurea group and other hypoglycemic agents like sulfonyureas, meglitinides, acarbose, and thiazolidinedione), the results demonstrated an increased risk of having varicose veins within the Metformin group with PR 1.61, 1.18, 1.47 respectively, but it was not statistically significant.

Conclusions

The importance of these results is that Metformin may not have a protective effect against varicose veins in the Hispanic population. A more detailed and controlled study with individuals taking Metformin may need to be performed.

255 Dynamic course of normal TSH function after excision of a thyrotropin-secreting pituitary tumor (TSHoma) in a patient with thyroid cancer: review of the literature

G Sindi*

S Usala

Texas Tech University Health Science Center, Amarillo, TX

Case Report

Thyrotropin-secreting adenomas (TSHomas) are a relatively rare pituitary tumor and consequently there is limited information on both the time course of normal thyrotroph function after surgical cure and its association with thyroid cancer. A 53-old-man was incidentally found to have an inappropriately elevated TSH with biochemical hyperthyroidism during the evaluation of a goiter. He felt well and displayed only a mild finger tremor. His pre-treatment TSH was 6.43±0.78 (SE) uIU/ml (95%CI: 3.93, 8.94) (ref: 0.40 - 4.00 uIU/ml), Free Thyroxine 2.64±0.12(SE) ng/dl (95%CI:2.0, 3.2) (ref: 0.80 - 1.90 ng/dl), and Free Triiodothyronine 6.29±0.27(SE) pg/ml (95%CI:5.11, 7.48) (ref: 1.80 - 4.20 pg/ml). A thyroid ultrasound demonstrated multinodular goiter and a 5.1 cm dominant nodule revealed a follicular neoplasm by cytology with Afirma FNA thyroid analysis interpreted as suspicious for thyroid cancer. An MRI pituitary study showed a 1.0 cm x 0.9 cm x 0.8 cm pituitary tumor. Transsphenoidal adenomectomy was first performed with prompt reduction in TSH and subsequent hypothyroidism. The pre- operative TSH of 8.5 mIU/ml fell to 0.13 mIU/ml and 0.01 mIU/ml, two and six days post-excision, respectively. The TSH was still undetectable 27 days post- excision, but within normal limits at 0.6 mIU/ml 45 days post-excision. There was resolution of sleeplessness and tremor post adenomectomy. A thyroidectomy for thyroid cancer was performed 34 days after the transsphenoidal surgery and a 1.1 cm differentiated papillary thyroid cancer was found within the left dominant adenomatoid nodule with bilateral multi-foci of 0.8 cm and 0.3 cm papillary cancer. The TSH remained within normal limits for 14 months after TSHoma excision while the patient was on Levothyroxine replacement, until the Levothyroxine dose was increased for partial TSH suppression to treat the history of thyroid cancer. The serum Thyroglobulin was undetectable and the patient was negative for Thyroglobulin antibodies. In conclusion, normal TSH function was established within seven weeks of TSHoma excision with a subsequent thyroidectomy for multi-focal thyroid cancer.

256 Alterations in classical and non-classical intrarenal renin angiotensin system in polycystic ovary syndrome

SA Ye¹*

S Everman¹

ED Torres Fernandez²

J Pruett¹

D Romero^1,3

L Yanes Cardozo^1,3

¹University of Mississippi Medical Center, Jackson, MS

²The University of Texas at Austin, Austin, TX

³Women’s Health Research Center, Jackson, MS

Purpose of Study

Polycystic Ovary Syndrome (PCOS), the most common endocrinopathy in women, is characterized by androgen-excess, associated with obesity and hypertension (HTN). Therapeutic options to treat PCOS-associated cardiovascular risk factors are limited. We have previously characterized a rat model of PCOS in which chronic androgen-excess causes increased body weight, HTN, and activation of angiotensin converting enzyme/angiotensin 2 receptor type 1 (ACE/AT1R) axis of intrarenal Renin Angiotensin System (RAS) components. Still, the mechanisms responsible for HTN in PCOS remain unclear. In this study, we tested how chronic androgen-excess changes the renal mRNA expression profile of the RAS in a model of PCOS.

Methods Used

Four-week old female SD rats were randomized to either control or dihydrotestoterone (7.5 mg/90 days). BP was measured by radiotelemtry. After 85 days of DHT, renal cortices and medullas were collected. Renal mRNA expression was assessed separately by RT-qPCR.

Summary of Results

DHT rats were found to be hypertensive (116±1 vs 107±2 mmHg, p<0.001). In DHT rats, cortical mRNA expression of angiotensinogen, AT1R, renin receptor, dipeptidyl peptidase 3 (DPP3), neprilysin (MME), neurolysin (NLN), and prolylendopeptidase (PREP) were increased. In addition, medullary mRNA expression of ACE (4.89±1.12 vs 0.88±0.293 AU, p<0.01), ACE2 (3.00±0.78 vs 0.36±0.12 AU, p<0.05), angiotensinogen, AT1R, DPP3, kallikrein 1, MME, NLN, PREP, Mas 1 receptor (MAS) and thimet-oligopeptidase were increased. Medullary mRNA expression of renin and aminopeptidase B were decreased in DHT rats.

Conclusions

In summary, androgen-excess led to increase ACE/AT1R and ACE2/MAS axis components in both cortex and medulla. The increased ACE2/MAS axis could be a compensatory mechanism for the HTN in PCOS. This study highlights the effect of androgen-excess modulating the intrarenal RAS. Treatments focused on targeting RAS components may be promising therapeutic tools to ameliorate the cardiovascular abnormalities observed in PCOS. Funded by COBRE/MS P20 GM-121334.

257 Chronic diarrhea as a presentation of behcet disease

M Abohelwa¹*

M Elmassry²

S Shahbandar¹

J Abdelmalek¹

E Elgwairi¹

K Nugent¹

¹Texas Tech University Health Science Center, Lubbock, TX

²University of Leicester, Leicester, UK

Introduction

Behçet disease is a rare disease characterized by recurrent oral ulcers, genital ulcers, ocular disease, skin lesions, gastrointestinal involvement, vascular disease, and arthritis. The clinical symptoms are due to vasculitis.

Case presentation

A 32-year-old male patient presented for chronic diarrhea that has been present for four months. He described it as watery, occasionally bloody, 8–10 times a day associated with mucous. He reported 16 kg weight loss in 4 months, recurrent oral ulcers for a year, recurrent joint pains, and eye symptoms; he described right eye pain, redness, blurry vision, light sensitivity, and sometimes a skin rash. At the site of needle pricking for blood labs, he started to develop papule around it after 24 hours. CT abdomen showed thickening of the ileum and cecum. A colonoscopy was done to rule out inflammatory bowel disease (IBD); however, the biopsy showed focal ulceration, cryptitis, and crypt abscesses that were atypical for IBD. He was examined by an ophthalmologist, who documented evidence of uveitis in his right eye. The Rheumatology team was consulted and did a pathergy; it was positive after 48 hours. The patient met the criteria for the diagnosis of Behçet disease. The presence of recurrent large oral aphthae one year before presentation, evidence of uveitis, skin rash, and positive pathergy test confirmed the diagnosis. He was started on colchicine and reported improvement after three months of follow up.

Discussion

The diagnosis of Behçet disease is challenging. No pathognomonic test can be used for definitive diagnosis. The presence of recurrent oral aphthae at least three times in a year plus two of the following: recurrent genital aphthae, uveitis, skin lesions (pseudofolliculitis, papulopustular lesions, and erythema nodosum), and positive pathergy test defined by a papule of 2 mm or more developing after oblique insertion of a 20-gauge needle 5 mm into the skin of the forearm after 24–48 hours. Gastrointestinal involvement is rare and can be challenging to differentiate from inflammatory bowel disease. It causes ulceration, mostly in the terminal ileum, cecum, and the ascending colon like our patient.

258 Febrile neutropenia following infliximab

AA Ali*

B Bajric

J Calvert

P Reddy

University of Florida College of Medicine – Jacksonville, Jacksonville, FL

Case Report

A 24-year female with multisegment Crohn’s disease presented with fever, chills and myalgia. Six days prior to admission she received her first treatment dose of Infliximab. Admission CBC revealed a leukopenia 2.86 × 10⁹. The patient was started on Zosyn and admitted for management of febrile neutropenia. An infectious work-up was non-revealing. Subsequent labs revealed worsening leucopenia with nadir 0.71 × 10⁹ and an absolute neutrophil count of 0.15 × 10³. The patient responded to treatment with Granulocyte Colony Stimulating Factor (Filgrastim). The patient defervesced and was discharged with a WCC 7.41 × 10⁹ and absolute neutrophil count 4.75 × 10³.

Agranulocytosis is a rarely documented side effect of Infliximab therapy likely due to the formation of autoantibodies against granulocytes and neutrophils. Infliximab is a chimeric monoclonal antibody that targets TNF-α, which leads to a disruption of the inflammatory cascade. On the other hand, as TNF-α may regulate interleukin (IL)-1, IL-6, IL-8 and granulocyte and monocyte CSF (GMCSF), its blockage by Infliximab may interfere with bone marrow-derived cell proliferation and maturation.

Drug induced neutropenia is a rare complication of Infliximab and is associated with a high rate of infectious complications and an increased mortality rate. Blood cell parameters both pre- and post- Infliximab infusion should be monitored particularly in the early stages following initiation of anti-TNF agents.

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Abstract 258 Figure 1

White blood cell trend both pre- and post- infliximab infusion.

259 Uncommon case of achalasia in a patient with long standing dysphagia

FA Aponte Santos*

P Costas Caseres

I Padial Doble

Universidad de Puerto Rico Escuela de Medicina, Guaynabo, Puerto Rico

Case Report

Achalasia is characterized by lack of relaxation of the lower esophageal sphincter. The most common presenting symptom is dysphagia to solids and liquids. Since the disease is uncommon and patients may be able to compensate to early milder symptoms, the diagnosis may be delayed for years. We present a rare case of worsening dysphagia for more than a decade that highlights the importance of a high index suspicion and due diligence in the diagnosis and management of this disease.

71 years-old male presents to our institution with progressive esophageal dysphagia. The patient was initially referred in 2005 to a gastroenterologist due to dysphagia, chest pain, and regurgitation. At that time, imaging findings revealed a dilated esophagus. He was placed in PPI’s for symptomatic relief while workup was completed. Due to partial resolution of symptoms, the patient did not continue evaluation and was lost follow up. Fourteen years later, he presented to our institution with inability to ingest liquids or solids. Barium esophagogram brought from another institution showed the classic bird’s beak appearance of achalasia. Chest X-ray performed while in the ED showed severe widening of the mediastinum. Upper GI endoscopy was performed which demonstrated a long and tortuous esophagus. Subsequent high-resolution manometry showed absence of peristalsis and esophageal contractions with swallows. These findings were consistent with, but not diagnostic of, achalasia type 1 by Chicago classification v3.0 since the manometry catheter was unable to traverse the LES due to the altered esophageal anatomy. The diagnosis was made using radiological, clinical and available manometrical criteria. The patient underwent heller myotomy with partial anterior fundoplication with full resolution of the symptoms.

Achalasia is an uncommon disease with an annual incidence of 1.6 cases per 100,000 individuals. Given the rarity of the disease most primary care physicians will rarely encounter this disease in the daily practice. It is important to maintain a low threshold of suspicion in patients presenting with signs and symptoms of achalasia. Prompt identification and rapid treatment diminish the long term sequelae and potential complications. Finally improving outcomes and, more importantly, quality of life.

260 A case of recurrent pancreatitis secondary to pancreas divisum

HS Brar*

SJ Tang

UMMC, Flowood, MS

Case Report

Pancreas divisum is a common congenital anomaly of hepatobiliary system with an incidence of 5%-14%. It occurs due to failure of fusion of dorsal and ventral ducts of pancreas resulting in openings at abnormal positions causing pancreatitis. The diagnosis is challenging and if untreated can lead to pancreatic failure.

A 66 years old AAM with PMH of HTN, DM, CAD and recurrent pancreatitis presented with 4 days of epigastric pain. It was deep, aching without radiation and aggravated by food. He denied vomiting, diarrhea, fever or jaundice.

He had multiple admissions for similar complaints over last 4 years which were treated as acute pancreatitis. He reported anorexia and weight loss. He denied alcohol intake.

Physical exam revealed epigastric tenderness without any palpable mass.

Lab findings showed TLC 7300, T.bili 0.96, ALT 9, AST 10, ALP 82, lipase 47 and TG 71.

USG Abdomen showed cholelithiasis without cholecystitis or biliary dilatation. CT abdomen revealed interstitial edematous pancreatitis with peripancreatic fluid. MRI abdomen revealed pancreas divisum. The major pancreatic duct drained primarily into minor papilla but had a connection with minor pancreatic duct which emptied into major papilla.

ERCP confirmed major dorsal duct opening at minor papilla and minor duct opening at major papilla. He underwent minor papilla sphincterotomy with stent placement in dorsal pancreatic duct. He reported significant improvement and no recurrent episodes were reported.

Pancreatic divisum is a congenital anatomical anomaly characterized by the non-fusion of ventral and dorsal pancreas during fetal development. The major pancreatic duct(Wirsung) drains the majority of pancreas, and ends at major duodenal papilla(hepatopancreatic ampulla); the accessory pancreatic duct(Santorini) arises from head, crosses Wirsung’s duct and ends at minor duodenal papilla. In Pancreatic Divisum, the major pancreatic duct drains into the minor duodenal papilla and the accessory duct drains at the ampulla. This leads to insufficient drainage and symptoms of recurrent pancreatitis, bowel obstruction and even shock. CT abdomen is helpful but imaging of choice is cholangiography(ERCP or MRCP). The usual therapeutic solution is a sphincterotomy of the minor duodenal papilla, which decongests the duct. Some cases may need surgical sphincterotomy or even partial pancreatectomy.

261 A rare case of hepatocellular carcinoma with metastasis to the heart

HS Brar*

J Kang

H Daugherty

D Harkins

UMMC, Flowood, MS

Case Report

Hepatocellular carcinoma(HCC) is a common malignancy and the most frequent sites of metastasis include lungs, bone and brain. Intra-cardiac involvement rarely develops and has a poor prognosis. We discuss an unusual metastasis of HCC into the right atrium extending to the left atrium in patient with Hepatitis C.

A 66 year-old AAF with no known medical history, presented with epigastric pain for 1 week. She had decreased appetite and 10 lb weight loss in 2 months. She denied vomiting, melena, hematemesis, dysphagia, fever or cardiac symptoms like SOB, chest pain and orthopnea. The physical exam was unremarkable. Lab studies showed: WBC 12.6; Hb 12.5; Plt 155; ESR 76, PT 16; INR 1.4; total protein 8.6; albumin 3.0; AST 110; ALT 57; ALP 100; T.Bili 1.2 and direct 0.45. HepC Ab was positive. HepB sAg and Ab were negative. AFP: 227(N: 0–5.8). EKG was normal. CXR showed right lung nodule suggestive of metastasis. CT triple phase showed 7 cm heterogeneous liver mass concerning for HCC with extension to the IVC, SVC, right and left atrium along with non-calcified 11 × 19 mm pulmonary nodule. TTE showed 2.5 × 2.4 cm large mass in right atrium extending from IVC and abutting the atrial septum. TEE showed a well circumscribed mass protruding from IVC to right atrium and extending through atrial septum into left atrium through fossa ovalis. Patient was not deemed to be a surgical candidate and refused medical management considering the poor prognosis. 2 months later, she was diagnosed with COVID-19 and died of respiratory failure. No symptoms of CHF were present even at later stage.

Discussion

The prevalence of HCC is about 180 million worldwide with rising incidence. It is associated with poor prognosis with median survival of 4–7 months. The prognosis with cardiac involvement is worse with median survival of 1–4 months. The possible complications include HF, TR or TS, LVOT obstruction and SCD. The symptoms of dyspnea and edema are generally seen with cardiac involvement. The tumor invades IVC and reaches cardiac cavities. In spite of this, cardiac metastasis is still an unusual presentation of HCC. Our case is of a patient of HCC with intracardiac metastasis and with no cardiac symptoms. The case highlights that heart involvement should be suspected with HCC and screening TTE should be done even in absence of cardiac manifestations.

262 Cameron lesions: obscure gastrointestinal bleed presenting with iron deficiency anemia

HS Brar¹*

B Ross²

P Hosseini-Carroll¹

¹UMMC, Flowood, MS

²GV Montgomery VAMC, Jackson, MS

Case Report

Cameron lesions are erosive ulcers of the gastric mucosa associated with large hiatal hernia. Lesions occur due to sliding of the hernia through diaphragm. The relevance of the lesions pertains to their potential as a source of chronic, occult GIB and iron deficiency anemia(IDA).

A 71-year-old man was referred for GI consultation due to history of refractory IDA. There was no history of acute GI bleed. He presented with a symptomatic microcytic, hypochromic anemia (Hb 8.4 mg/dL, Hct 28.4%) and low serum ferritin (2.2 ng/mL). He was taking PPI for acid reflux and oral FeSo4 with ascorbic acid to treat IDA. However, his CBC, transferrin saturation, and TIBC failed to stabilize despite iv iron. An extensive workup for a positive FOBT failed to reveal any pathology. EGD did not show esophagitis, gastritis, duodenitis, or a PUD, colonoscopy did not show mucosal inflammation, polyps or mass, diverticulosis, or angiodysplasia, and capsule endoscopy was unremarkable. He denied melena, hematochezia, or loose stools; Celiac disease labs were negative. Though treated for HTN, there was no ischemic or valvular heart disease, and only a systolic flow murmur was noted. A CXR to evaluate his dyspnea revealed a double density overlying heart at level of diaphragmatic hiatus; a subsequent CT scan showed a large hiatal hernia containing gastric fundus and portion of gastric body. EGD was repeated, which revealed multiple linear erosions(10–15 mm) of gastric folds consistent with Cameron lesions, which were believed to be the source of chronic GI bleed. Esophageal manometry and pH testing are being conducted, prior to definitive surgical intervention.

Cameron lesions are a rare cause of obscure UGIB that are localized to the gastric body in patients with large hiatal hernias. The pathogenesis is ischemia of the gastric folds due to trauma to the riding hiatal sac by the diaphragm causing slow blood loss and IDA. The lesions are often missed on initial EGD, multiple endoscopies are required for diagnosis. Management is medical or surgical, but rarely endoscopic. Medical therapy includes PPI and iron supplements. The surgical options are ulcerectomy or fundoplication. This case highlights considering Cameron lesions as a possible cause of obscure GI bleed presenting as chronic or recurrent IDA.

263 Plummer-vinson syndrome presenting as sudden onset dysphagia in a young black woman

HS Brar*

B Brousse

D Schaefer

UMMC, Flowood, MS

Introduction

Plummer-Vinson Syndrome (PVS) is a triad of iron deficiency anemia(IDA), esophageal webs and dysphagia. The prevalence is around 1 in 1,000,000. It is found in middle aged women between 40 to 50 years and is rare before 30. It usually presents with fatigue, SOB or dysphagia.

Case Report

A 21-year-old AAF presented with difficulty swallowing solid food. The symptoms progressed gradually where she could take only a soft diet. She denied nausea, vomiting, hematemesis, heartburn or dark color stools. She had a similar episode 2 years back diagnosed as pill esophagitis. Her medical history was significant for IDA due to menorrhagia. She denied any history of alcohol, smoking, or illicit drug use. She denied any medication use. She had no history of PUD or collagen tissue disorder. Her family history was unremarkable. At presentation, the physical exam was significant for pale conjunctiva and flow murmur. Lab results showed Hb of 5.5 g/dl, Hct of 23 and Mentzer index of 15. PBF showed hypochromic and microcytic cells. Serum iron was 3 μg/dl, ferritin 3 ng/mL, TIBC 394 μg/dl, and transferrin saturation of 3%. LFT and RFT were unremarkable (AST 21 IU/L, ALT 5 IU/L, BUN 7 mg/dl, and creatinine 0.44 mg/dl). CXR was normal with no acute abnormality. Barium Esophagogram demonstrated contrast pooling in the piriform sinuses with no passage into the esophagus. EGD showed 3 moderate to severe stenosis in the esophagus. The patient underwent blood transfusion and balloon dilatations over the guidewire to a dilatation of 7 mm. She was given iron supplementation. After 1 month, she underwent repeat dilatation to 10 mm. She had symptomatic relief and her Hb improved to 8.2 g/dl at 1-month follow up.

Plummer-Vinson Syndrome is a precancerous condition with high potential for malignancy. The pathogenesis is speculated to be due to iron-deficiency as there has been improvement with iron supplementation. The early management is crucial as these webs can progress to SCC. The case emphasizes the importance of evaluating patients with dysphagia and be cautious of red flag signs. It highlights that although PVS is uncommon before the age of 30 years, it should be considered in the differentials of dysphagia. Early diagnosis is important and prognosis is usually good with iron supplementation alone or in combination with mechanical dilatation.

264 Chronic diarrhea due to homozygous diacylglycerol O-acyltransferase 1 mutation

CI Chinchilla Putzeys*

N Amritphale

MR Roca Garcia

AM Ponnambalam

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Case Report

A 4-week-old female, born at 38 weeks presented with 1 kg weight loss, fussiness, fever, vomiting, and diarrhea. Her diarrhea started at birth with 6 to 8 greenish large volume stools per day. Diarrhea resolved when not fed. She was breastfed and supplemented with peptide-based formula. On examination, she had no dysmorphic features and was dehydrated.

Laboratory tests revealed metabolic acidosis, hyponatremia, hypoalbuminemia, and normal cholesterol. Stool alpha-1-antitrypsin was elevated, fecal PCR multiplex, fat, reducing substances were negative and fecal elastase was normal. Attempts to continue amino acid-based formula were unsuccessful and she was transitioned to parenteral nutrition.

Upper endoscopic biopsies showed partial duodenal villous atrophy, stains were negative for microvillus inclusions by electron microscopy. Whole exome sequencing was positive for diacylglycerol O-acyltransferase 1 (DGAT1) gene mutation, variant c.751+2T>C homozygous. Her symptoms were resolved with a 3% fat formula and a low-fat diet.

DGAT1 is an enzyme that helps to catalyze the formation of triglycerides from diacylglycerol and fatty acyl-CoA. This is the final committed step of triglyceride digestion before they are packaged into chylomicrons. Toxic accumulations of DGAT1 lipid substrates in the epithelium can lead to the destruction of the enterocyte. Intestinal biopsies in DGAT 1 deficiency showed dermal fibroblasts and intestinal organoids with altered lipid metabolism and have increased susceptibility to lipid-induced cell death.

There are five different types of DGAT1 gene mutations. These patients have severe congenital diarrhea and protein-losing enteropathy. There has been a difference in phenotype presentation for DGAT1 deficiency with different laboratory findings and outcomes for patients with the same mutation. The key intervention is the introduction of a fat-restricted diet which prevents the development of a full-blown protein-losing enteropathy.

This child did well on the low-fat formula with the resolution of diarrhea and protein-losing enteropathy.

DGAT1 deficiency is a rare disorder and whole exome gene sequencing helps in identifying it sooner so that appropriate management can be instituted.

265 The inflammatory bowel disease conundrum: establishing a definitive diagnosis in cases with overlapping features

CI Chinchilla Putzeys*

L Thai

D Gremse

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Case Report

The differentiation of Crohn’s disease (CD) from ulcerative colitis (UC) can be challenging and establishing an exact diagnosis is essential for correct treatment.

Our patient was diagnosed with inflammatory bowel disease (IBD) at 10 years old after a 4-month history of painful bloody diarrhea and 15 pounds weight loss. Investigations showed iron deficiency anemia, elevated ESR, CRP, and p-ANCA. Endoscopy showed pancolitis with superficial erosions, shallow ulcerations, and exudates. Biopsy showed proctitis, colitis, diffuse enteritis without granulomas. Duodenal and stomach biopsies also showed enteritis with ulceration and gastritis. The patient met the criteria for phenotypic UC given no granulomas, perianal disease, segmental colitis, rectal sparing, cobblestoning or stricturing of the terminal ileum (TI), and normal growth parameters. She was treated with mesalamine, lansoprazole, azathioprine, and prednisone but had multiple flare-ups in the next two years despite treatment with infliximab, adalimumab, vedolizumab, and ustekinumab. Repeat colonoscopies at age 12 and 14 years showed left-sided colitis without granulomas with normal transverse, right colon, and TI. The next year she had an abdominal abscess and perforation requiring a subtotal colectomy. Biopsy showed severe diffuse chronic active intermediate colitis, superficial and deep perforating fissuring ulcers, transmural lymphoid aggregates, scattered transmural multinucleated giant cells, mild lymphoplasmacytosis, and occasional pseudopolyps. The rectal segment showed severe diffuse chronic active intermediate proctitis with peri-proctitis.

Although the patient‘s IBD was consistent with UC at the time of initial diagnosis, the presence of transmural inflammation, intra-abdominal abscesses, perforation was more consistent with a diagnosis of CD.

This case demonstrates we should always be cognizant of diseases with overlapping features and open to reevaluating our prior diagnoses. Multiple modalities help to distinguish CD from UC. p-ANCA is identified in 75% cases of UC and up to 20% in CD. Patients with CD limited to the colon have a higher prevalence of p-ANCA. Therefore p-ANCA is not useful in differentiating between UC and Crohn’s colitis.

266 Improving quality measures of hepatitis B care

MA Craig¹*

B Waters^1,2

¹University of Tennessee Health Science Center, Memphis, TN

²VA Medical Center, Memphis, TN

Purpose of Study

The Department of Veterans Affairs (VA) created a national database to optimize treatment and screening of Hepatitis B (HBV). A previous study at the Memphis VA Medical Center (VAMC) measured quality metrics of HBV patients on antiviral therapy. This study observed quality measures in HBV patients not receiving antiviral treatment.

Methods Used

The VA national database included all patients in the Memphis area with positive Hepatitis B surface Antigen (HBsAg) tests. The VA Computerized Patient Record System was utilized to measure: linkage to care; hepatocellular carcinoma (HCC) screening, Hepatitis A antibody (HAV) screening, and hepatitis D antibody (HDV) screening. HCC screening was defined as imaging every six months by ultrasound, computerized tomography or magnetic resonance imaging. Deficient patients were called or mailed letters. The rates of delinquency before and after intervention were recorded.

Summary of Results

44 patients received antiviral therapy. 74 patients with HBsAg were not on antiviral therapy. Of these 74, 10 were excluded due to false positive tests. False positive HBsAg tests were associated with recent influenza or HBV vaccinations. Of the remaining 64 patients, 44 were immune/vaccinated for HAV, 47 were screened for HDV, 36 had HCC screening, and 45 were linked to care. During the study, 6 more patients were excluded from the final results: 1 patient had a brief reactivation of HBV during Hepatitis C treatment which resolved; 3 were found to be Hepatitis B Core antibody negative; 1 was initiated on treatment; 1 refused follow-up. Of the 58 remaining patients, 48 were immune/vaccinated for HAV, 47 had been tested for HDV, 41 were up to date on HCC screening, and 49 were linked to care. 9 did not respond to telephone or letter.

Conclusions

Intervention improved the percentage of Hepatitis B patients linked to care and quality measures. This study shows the promise of utilizing a national database to guide quality improvement studies.

267 Splanchnic vein thrombosis in acute pancreatitis: is anticoagulation appropriate?

A Deb*

T Thongtan

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Splanchnic vein thrombosis (SVT) is a known complication of acute pancreatitis (AP) reported in about 10–16% cases. Anticoagulation therapy is commonly used to treat thrombosis, although current literature suggests that their use does not affect the clinical course but increases the risk of bleeding.

Case summary

A 36-year-old Hispanic man with a history of chronic severe alcoholism and hypertriglyceridemia presented with abdominal pain and vomiting for 1 day. He was found to have AP and hypovolemic shock requiring vasopressor support. His hospitalization was complicated by ARDS, respiratory failure requiring tracheostomy, abdominal compartment syndrome, and AKI needing dialysis.

On day 5 of admission, CT abdomen revealed fulminant necrotizing pancreatitis along with acute thrombosis of the portal vein, splenic vein, and superior mesenteric vein (figure 1). He was initially started on 40 mg enoxaparin for DVT prophylaxis and for SVT which was replaced with heparin drip (5000 U BID) due to imminent AKI. He developed upper GI bleeding from the ampulla along with hemorrhage in the pancreas. Heparin was discontinued and he underwent splenic artery embolization. Two weeks after the intervention, he developed significant GI bleeding requiring several units of blood transfusion shortly after low-dose enoxaparin (30 mg) was restarted. Enoxaparin was withheld during his subsequent course of hospital stay. A repeat CT abdomen 4 weeks later showed resolution of SVT.

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Abstract 267 Figure 1

CT scan abdomen showing portal vein thrombosis

Conclusion

High risks of bleeding and unclear clinical benefit preclude the use of anticoagulation for SVT in patients with AP.

268 The therapeutic effect of topical capsaicin in treating cannabinoid hyperemesis syndrome

K Delgado*

Philadelphia College of Osteopathic Medicine – Georgia Campus, Jacksonville, FL

Case Report

Cannabinoid Hyperemesis Syndrome (CHS) is a diagnosis occasionally seen with chronic marijuana users. It presents with nausea, vomiting, and abdominal pain that improves with cessation of marijuana and hot showers. Treatment involves the use of an antiemetic, a PPI, and a pain medication. This report presents a case of severe, refractory CHS with resolution of abdominal pain and nausea after treatment with topical capsaicin. Literature shows that refractory CHS is sometimes managed with antipsychotics such as haloperidol or olanzapine (Sontineni et al., 2009). Unfortunately, these antipsychotics are known to cause many unwarranted side-effects. This case report suggests that topical capsaicin may be an effective option for refractory CHS patients.

A 21-year-old man presented to the ED with abdominal pain, nausea, and vomiting. He was given Ciprofloxacin, Flagyl, and Phenergan and was discharged the same day. Three days later, the patient presents to the ED with the same complaints and was admitted. The patient’s physical exam was unremarkable. He was treated with Morphine, Oxycodone, Protonix, and Ondansetron. CT imaging of the abdomen and pelvis was unremarkable. The patient mentioned that ‘taking a hot shower’ provides relief. CHS was suspected and urine toxicology came back positive for cannabinoids. Topical capsaicin cream 0.075% was applied in his lower abdomen, with reapplication every 4 hours. The patient reported significant improvement in his symptoms. He was discharged home with a prescription and was encouraged to discontinue marijuana use.

Discussion

CHS is becoming more prevalent due the legalization of marijuana throughout the United States. The approach in treating this is with opioid analgesics and antiemetics, but unfortunately the percentage of symptomatic relief among patients isn’t impressive. This study showed that topical capsaicin provided significant relief, therefore highlighting a possible treatment solution. There is little data in literature pertaining to the efficacy of topical capsaicin for CHS treatment. Therefore, this case report hopes to bring awareness on this promising alternative for CHS treatment. Other advantages of topical capsaicin are that it’s inexpensive, has low risk for side-effects, and it is well tolerated.

269 Does high procalcitonin in acetaminophen-induced hepatotoxicity indicate mortality?

E Elgwairi¹*

A Abdalla²

N Eshak¹

G Bedanie¹

M Elmassry¹

M Abohelwa¹

J Abdelmalek¹

M Zitun¹

K Nugent¹

C Jumper¹

¹TTUHSC, Lubbock, TX

²University of Benghazi, Benghazi, Libya

Case Report

Procalcitonin (PCT) is a useful diagnostic biomarker of bacterial infection and also reported to be elevated in acute liver failure (ALF), especially if secondary to acetaminophen toxicity. We report a case of acetaminophen-induced hepatotoxicity and death found to have a high PCT level without evidence of infection.

A 49-year-old female presented to the ER after being found unresponsive. Examination revealed a GCS of 5, normotensive, tachycardic, tachypneic and afebrile women. Her initial workup revealed a severe anion gap metabolic acidosis, elevated liver enzymes, high PT and INR, acetaminophen level of 449 mcg/mL, and lactic acidosis. She was admitted to the ICU, intubated, placed on N-Acetylcysteine and supportive treatment. She later required vasopressors and CRRT for persistent acidosis. Laboratory results showed worsening of liver functions while the acetaminophen level declined. The PCT was greater than 100 ng/mL on day 2&3. The patient‘s condition continued to deteriorate, and she passed away on the third day of hospitalization.

Acetaminophen overdose accounts for about half of ALF cases in the US. Finding a laboratory prognostic indicator may help in decreasing morbidity and mortality. Acetaminophen-induced hepatotoxicity patients have much higher PCT levels than other causes of ALF. High levels of PCT correlate with the extent of liver damage. Acetaminophen toxicity induces an inflammatory response, macrophage activation, and cytokines release, which may explain the high PCT. A recent study showed that hepatic macrophages are the cell source of hepatic PCT. A few articles mentioned that PCT level positively correlates with MELD scores and mortality in cirrhotic patients.

Recently, another acetaminophen-induced hepatotoxicity case was reported, presented with a lower level of transaminases, acetaminophen, PCT (45 ng/ml), and the patient recovered. In contrast, PCT was above 100 ng/ml in our case and resulted in a death. This may suggest a promising use of PCT as a prognostic factor and indicator of mortality in ALF. Prospective cohort studies are needed to determine the predictive value of PCT in acetaminophen-induced ALF.

270 A preliminary report on the role of virtual reality as a treatment for patients with functional nausea, vomiting and abdominal pain

ML Esteban*

K Espino

R McCallum

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Purpose of Study

Virtual reality (VR) offers immersive, realistic, three-dimensional experiences that provides users with novel environments promoting distraction, relaxation and meditation. Multiple studies have proved its effectiveness in reducing pain of non-gastrointestinal etiologies and anxiety. This preliminary study investigates the utility of VR in patients with functional nausea and vomiting and abdominal pain.

Methods Used

Patients referred to an academic Neurogastroenterology and Motility Center at the Texas Tech University Health Sciences Center – El Paso from August to October 2020 with nausea, vomiting and/or abdominal pain not adequately responding to standard treatment were considered. After full disclosure and review of the VR programs, patients underwent a 30 minute to 1 hour VR session once or twice weekly and were coached regarding which programs to choose. Ongoing standard medical treatment was continued. A questionnaire grading symptoms as improved, same or worse was administered to the patients after each session.

Summary of Results

Four female patients aged 29 to 56 with nausea and abdominal pain were enrolled in this study with the following diagnoses: two rumination syndrome, one gastroparesis and one functional dyspepsia. All patients had at least one VR session during the study period. Results: Abdominal pain: three patients (75%) reported milder or no abdominal pain after the sessions compared to their baseline grading while one (25%) reported moderate abdominal pain. Nausea: three patients (75%) reported improvement in their nausea after the sessions compared to baseline while one (25%) with rumination syndrome noted worsening. Adverse effects reported were transient blurred vision, nausea and dizziness. All patients when questioned after completing the sessions and would consider this approach again and also recommend the treatment to other patients.

Conclusions

These preliminary results indicate that VR may be an effective as well as a safe adjunct in the management of patients with refractory functional nausea, vomiting and abdominal pain. A larger study with more treatment periods and longer follow-up to assess outcomes is being conducted.

271 Breaking the habit: resolution of cannibinoid hyperemesis syndrome with haloperidol

DS Gidla¹*

S Pagliolongase²

M Oye¹

MB Omar

P Reddy

¹University of Florida College of Medicine – Jacksonville, Jacksonville, FL

²Alabama College of Osteopathic Medicine, Dothan, AL

Case Report

An 18 year old female with a history of anxiety presented with intractable nausea and vomitting for 3 weeks duration. She had a history of multiple hospitalisations during this period without significant improvement. This was associated with worsening of anxiety and frequency of panic attacks. She had no prior medical history. Physcial exam was unremarkable. An extensive work up was unrevealing, including infectious, endocrine, pregnancy, heavy metal, porphyrin screening and CT abdomen. Upon further questioning she admitted to daily inhalational cannabis use for the past year and endorsed increased frequency of hot showers to alleviate symptoms. During this admission, symptoms remained refractory to aggressive therapy with multiple antiemetics. Salvage therapies were attempted with benzodiazepines and sumitriptan without relief. She was then administered a single intravenous dose of haloperidol 2 mg which succeeded in resolution of symptoms and significant decrease in patient anxiety.

As legislature changes the increasing incidence of Cannabinoid Hyperemesis Syndrome (CHS) may be seen. It is found is young adults who have a history of daily long term use. Though the mechanism of CHS is yet unknown, the clinical course is well described in the literature. It typically involves a Prodromal Phase, a Hyperemetic phase and a Recovery phase. Patients usually seek medical advice during the dramatic nausea and vomitting that occurs during the hyperemetic phase. Typically patients are found to have multiple emergency room admissions before diagnosis is made and suffer symptoms until diagnosis is made as first line anti-emetics which are commonly not effective in resolving symptoms. Salvage therapy with typical antipsychotics such as haldol has been demonstrated to show greater efficacy in management of CHS. In cases such as ours, its early use in patients with a suspicion of CHS whose symptoms are refractory to first-line treatment may allow earlier resolutions of patient symptoms, speed the formulation of a diagnosis and reduce the level of unnecessary testing in patients with CHS.

272 Gallbladder adenocarcinoma. The impact of tumor location and minimally invasive surgery on survival

M Hamdan¹*

F Maegawa²

S Joseph¹

M Ahmad¹

A Barrientes¹

S Chiba¹

A Philipovskiy¹

S Elhanafi¹

A Tyroch¹

I Konstantinidis¹

¹Texas Tech University Health Sciences Center, El Paso, TX

²University of Arizona, Tucson, AZ

Purpose of Study

There is evidence that T2 gallbladder adenocarcinoma (GBC) located on the peritoneal side has improved survival vs. on the liver side.

Methods Used

The National Cancer Database was queried for the location of GBC within the gallbladder, mode of surgery, and extent of hepatectomy from 2010 to 2016. Kaplan-Meier and log-rank test were used for survival comparisons.

Summary of Results

A total of 3308 patients with GBC were identified, of whom 1284 (38.8%) underwent a hepatectomy. Tumors occupied the hepatic and peritoneal sides in 19%, had the highest R1 margin, readmission, and 90-day mortality rates. In patients who underwent hepatectomy, peritoneal side tumors had improved survival compared to the liver or both sides (OS: 58mo vs.29mo vs.23mo; p<0.001). By T stage, tumors on the peritoneal vs. liver side had similar outcomes (T1: 72mo vs. 67mo; p=0.5, T2: 31.9mo vs. 32mo; p=0.9, T3: 11mo vs.14.6mo; p=0.1, T4: 10 mo vs. 9.4mo; p=0.3, respectively). Minimally invasive surgery (MIS) was increasingly utilized and is associated with shorter hospitalizations without a negative impact on survival.

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Abstract 272 Figure 1

Survival outcomes for 3308 patients who had GBC resected according to tumor location. Patients with peritoneal side tumors (n=737) had a significantly improved survival over patients with liver side tumors (n=1946) or both sides (n=625) (MedianOS:26.5mo vs. 21.3mo vs. 14mo; p<0.001)

Conclusions

GBC on the peritoneal and liver sides is associated with the worst outcomes. Peritoneal side tumors have similar survival to tumors located on the liver side for each T1-4 stage. MIS approaches do not have a negative impact on survival.

273 Pancreatic pseudocyst resulting from a jellyfish sting

B Jafar*

D Gremse

University of South Alabama, Mobile, AL

Case Report

Acute pancreatitis is a sudden inflammatory process of the pancreas leading to acinar cell death. One of the known complications is a pancreatic pseudocyst. We report the first case of pancreatic pseudocyst secondary to a jellyfish sting.

A previously healthy 10-year-old Caucasian developed crampy right lower quadrant and epigastric abdominal pain, along with multiple episodes of non-projectile emesis of gastric content, anorexia, and fatigue within 24 hours of being stung by a jellyfish. There was no history of trauma or medication use. Laboratory testing showed elevated lipase, leukocytosis with left shift, thrombocytosis, and elevated CRP. CT abdomen showed pancreatic phlegmon. CXR showed right lower lobe pneumonia. Treatment included IVF, Piperacillin/Tazobactam, and Vancomycin for the treatment of pneumonia. After 7 days of therapy, ongoing signs of inflammation led to the addition of Levofloxacin followed by Meropenem 2 days later. 12 days after onset, she developed a fever of 38.3C. Repeat testing showed worsening leukocytosis and CRP. A repeat CT abdomen and chest demonstrated a pseudocyst measuring 13.5 cm and pancreatic necrosis. Laboratory testing showed a serum lipase of 1300, metabolic acidosis, hypoalbuminemia, and mild transaminitis. The patient also had normocytic anemia, leukocytosis with a neutrophilic predominance, and elevated CRP. Lipase was repeated the next day and was found to be 1212. Amylase was 127. The urine and blood culture were negative.

CT abdomen showed acute pancreatitis and a pseudocyst measuring 13.5 cm. Laboratory results showed elevated lipase and inflammatory markers. The patient was started on IV antibiotics, kept NPO, and PPI. MRCP showed large simple appearing cystic structure arising from the distal body of the pancreas measuring up to 11.6 × 10.4 × 12.4 cm. which appeared to be arising from the pancreatic duct. The patient was extensively investigated, and all other causes of AP were ruled out. US Abdomen showed a large, lobulated low echogenic mass in the region of the pancreas consistent with a pancreatic pseudocyst, measuring at 12.7 × 7.5 × 7.7 cm. with noted internal echoes.

This demonstrates that acute pancreatitis may occur in association with a jellyfish sting. We conclude that acute pancreatitis should be considered in patients with abdominal pain and vomiting following a jellyfish sting.

274 Larger preterm infants do not show growth benefits from nutrient enriched post-discharge formula at 6 month follow up

J Julia¹*

J Davis¹

CL Blanco¹

S Abrams²

¹UT Health, San Antonio, San Antonio, TX

²UT Health, Austin, Austin, TX

Purpose of Study

Current recommendations to discharge infants on nutrient enriched feeding regimens are based on studies with limited benefit in the smallest infants. This study investigates if discharging preterm infants with birth weight (BW) >1500 g on nutrient enriched post-discharge formula shows improved growth parameters at 6 months (mo).

Methods Used

Charts of all infants admitted to the University Hospital (UH) NICU in 2018 with BW > 1500 g and GA < 37 0/7 were reviewed. Those with 6mo follow up at UH were included. Patients were analyzed in two groups (1) no fortification at discharge (DC) and (2) any fortification at DC. Primary outcomes were change in z-score for weight, length, and FOC from discharge to 6-month follow up.

Summary of Results

278 infants were admitted to the NICU with GA < 37 0/7 weeks and BW > 1500 g. 28 (10.1%) met exclusion criteria, 104 (37.4%) had follow up at 6mo, and 146 (52.5%) had no 6mo follow up. Baseline characteristics of included patients showed increased rates of BPD and lower mean GA and BW than those without follow up. Of those included, 16 (15.4%) received no fortification at DC and remained unfortified at 6mo follow up, 88 (84.6%) were discharged on fortification, but only 55 (52.9%) remained fortified at 6mo. Comparing those receiving any fortification to those unfortified at DC, there were no differences between groups in the primary outcomes of change in z-score for weight (p = 0.457, overall mean change Z-score +0.63), length (p = 0.236, mean +0.14), or FOC (p = 0.272, mean +0.672) at 6mo follow up. There was also no difference in change in z-score for weight, length, or FOC between infants that remained completely unfortified, those discharged on fortification but unfortified at 6 mo, and infants which remained fortified (p > 0.05 for all).

Conclusions

In preterm infants with BW > 1500 g admitted to the UH NICU in 2018 and followed until at least 6mo, feeding type at discharge does not affect growth outcomes at 6mo. Preterm infants discharged on unfortified feeds and those discharged on fortification but transitioned to unfortified feeds by 6mo showed similar growth to those who remained on fortified feeds.

275 Is gastroparesis always irreversible in a diabetic?

M Kalas*

GM Galura

I Sarosiek

R McCallum

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Introduction

Gastroparesis(GP) is a syndrome characterized by postprandial nausea, vomiting, abdominal pain, and fullness with a prevalence of approximately 10 million in the US and >70% of patients are females. The severity and persistence of symptoms often lead to poor quality of life, frequent hospitalizations, and increased economic burden. GP etiologies include diabetes mellitus (DM), post-surgical, drugs, systemic diseases or idiopathic.

Case

57 year old female with a 16 year history of type 2 DM presents to the clinic with a history of nausea, vomiting, early satiety, abdominal fullness and bloating of some years duration. Laboratory tests were remarkable for an HbA1C of 8.2%. Prior upper and lower endoscopy showed no obstruction and no previous gastric emptying study (GES) had been done. Upon further history taking, it was found that she started dulaglutide 1 year ago. A 4-hour GES was scheduled and showed 35% retention of isotope at 4 hours, indicating delayed gastric emptying (< 10% is normal). Dulaglutide was held for 4 weeks and symptoms resolved. A repeat GES showed 3% of isotope retained in the stomach at 4 hours, which is normal.

Discussion

The diagnosis of GP requires evidence of delayed gastric emptying (GE) in the absence of mechanical obstruction. Prolonged DM (> 5 years) can result in GP due to irreversible neuronal damage from poor glycemic control and is irreversible. Drugs such as PPIs, levodopa, calcium channel blockers, marijuana, opiates, and GLP-1 agonists are also associated with delayed GE. GLP-1 agonists such as Dulaglutide act by binding to incretin receptors resulting in insulin release and glucagon suppression. Moreover, GLP-1 agonists inhibit antral and duodenal motility and increase pyloric pressure which slows GE. GLP-1 agonists are growing in popularity due to their convenient subcutaneous weekly dosing and their favorable weight loss side effect.

This report highlights the under recognized role of gastroparesis induced by GLP-1 agonists and how a detailed history is crucial in differentiating drug induced GP which is reversible in contrast to diabetic GP.

276 Heparin, the savior for the acute management of hypertriglyceridemia

F Kandah*

R Shukla

J Ruiz

University of Florida Health Science Center Jacksonville, Jacksonville, FL

Case Report

A 52 year old male with past medical history of hypertension and Barrett’s esophagus presented for evaluation of hypertriglyceridemia at the request of his primary care physician. His symptoms included recent difficulty tolerating oral intake with associated watery diarrhea. Per labs from his primary care office two days prior, he had triglyceride levels of greater than 1800 and lipase of 121. Upon admission, his blood work was significant for a lipase level of 61 and triglyceride level further elevated to 2900. On bedside exam, the patient was resting comfortably and endorsed mild abdominal pain with deep palpation in the epigastric region. He was hemodynamically stable and admitted for further management and workup of possible pancreatitis. He was started on aggressive fluid resuscitation and pain control. As the patient remained a very low bleeding risk, he was also started on heparin drip. Less than twelve hours later, follow up triglyceride levels had decreased to 1200, and the patient denied any further symptoms. As he remained asymptomatic with downtrending triglyceride levels, the heparin drip was discontinued, and the patient was discharged on oral medications of atorvastatin and fenofibrate.

Discussion

This case illustrates the potential of rapid reduction of severe levels of triglyceridemia via monotherapy in a controlled setting. Oral medications including fibrates or statins are known to produce similar effects over longer settings of time. There are currently no established guidelines for the acute management of severe hypertriglyceridemia. Those that present with acute pancreatitis are treated with the standard management of nothing by mouth, intravenous fluids, and pain control. Hypertriglyceridemia-induced pancreatitis has several other effective treatment modalities that are seen in literature. Insulin and heparin are frequently used in these cases, mainly due to their effect on the LPL enzyme which assists in removing triglycerides from plasma.

Unfortunately, many cases of primary hypertriglyceridemia may present either spontaneously or in patients with poor medication compliance. Therefore, further investigation into insulin or heparin therapy to reduce severely elevated TG levels in the acute setting would prove beneficial.

277 Gluten-free diet ineffective in remission response of eosinophilic esophagitis in child also diagnosed with celiac disease

K Lemes¹*

K McGoogan²

¹University of Florida College of Medicine, Jacksonville, FL

²Nemours Children’s Specialty Care, Jacksonville, FL

Purpose of Study

Celiac Disease (CD) and Eosinophilic Esophagitis (EoE) are two distinct chronic immune mediated gastrointestinal disorders with unique differences in clinical and histopathological features. Numerous studies have indicated an association between these two diseases with increased prevalence of CD in patients diagnosed with EoE. The co-treatment of these diseases, however, has not been well described. The purpose of this report is to examine a case of a child diagnosed with both CD and EoE, placed on a gluten-free diet and proton-pump inhibitor (PPI) without remission of EoE on repeat endoscopy.

Methods Used

The case report included a patient diagnosed with both CD and EoE based on endoscopy and histopathological findings treated with a gluten-free diet and PPI. The patient’s presentation, laboratory results, and histopathology reports of esophageal and duodenal biopsies were reviewed.

Summary of Results

In this case report, we describe an 11-year old male who presented with esophageal food impaction. During endoscopic procedure, the patient was found to have EoE on visualization of the distal portion of the esophagus confirmed with histopathology report. The patient was also noted to have evidence of villous blunting in the duodenum consistent with CD which was confirmed by elevated celiac antibodies. While a strict gluten-free diet is the only effective therapy for CD, there are several therapeutic options, such as PPI, swallowed topical steroids, and dietary elimination therapy for EoE, one of which includes gluten containing foods. The patient’s parents opted to try a PPI and gluten-free diet for treatment of EoE and CD. This was continued for about 3 months at which point upper endoscopy was repeated. There was improvement in CD based on both lab work and histopathology of duodenal biopsies, but EoE did not show remission. This suggests that a gluten-free diet alone may not be adequate for the treatment of both EoE and CD.

Conclusions

This case report suggests that a gluten-free diet alone and/or PPI may not be enough to induce remission of EoE in patient also diagnosed with CD and that further food elimination diet or topical corticosteroids may be warranted.

278 A case of eosinophilic colitis and CMV positive menetrier disease

S Leon Paredes*

CI Chinchilla Putzeys

MR Roca Garcia

University of South Alabama, Mobile, AL

Case Report

Protein-losing enteropathy (PLE) is characterized by excessive loss of protein into the gastrointestinal tract due to impairment of the mucosa. This case report describes the clinical course of a patient diagnosed with eosinophilic colitis coexisting with Ménétrier disease.

A 5 year-old male presented with constipation, postprandial emesis and abdominal distention for 2 weeks. Physical exam findings were abdominal distention and tenderness. Blood workup revealed absolute eosinophilia. Administration of polyethylene glycol and milk of molasses enema resulted in worsening abdominal distention. Later, he developed scrotal and penile edema. Serum albumin decreased from 2.2 g/dL on admission to 1.1. Urinalysis, stool PCR multiplex, fecal elastase and anti-TTG, stool ova and parasites, HSV antigen and antibodies were negative. Fecal alpha-1-antitrypsin was elevated. Endoscopy showed candida esophagitis and erosive gastritis with rugal hypertrophy, suspicious for Menetrier disease. Cytologic evaluation reported eosinophilic infiltration of the esophagus, stomach, and ascending colon to rectum, sparing cecum and duodenum. No fungal hyphae or cytopathic changes of CMV were demonstrated. Further blood work revealed negative HIV and CMV IgM, elevated CMV IgG and low level CMV viremia on serum PCR. Specific IgE blood test positive to egg, wheat, and milk.

Intravenous albumin infusion and treatment for erosive gastritis, constipation and six-food elimination diet resulted in improvement of symptoms.

Ménétrier disease is characterized by irregular hypertrophic gastric folds and epithelial hyperplasia causing leakage of protein into the lumen.

The disease is idiopathic, associated to Helicobacter pylori in adults and CMV, HSV and rarely to H. pylori in children.

The differential diagnoses include inflammatory bowel disease, eosinophilic gastrointestinal disorders, celiac disease and lymphoma. The diagnosis requires an elevated stool alpha-1-antitrypsin and a full gastric mucosal biopsy.

PLE is rare, more so, the finding of two entities in a patient. This case report shows the importance of a thorough work up as different etiologies may explain the patient‘s presentation.

279 Total parenteral nutrition, cholestasis, and gallstones in infancy: a rare case

GB Maniam*

D Ukwade

S Tijani

GB Tardieu

R Mattamal

Texas Tech University Health Science Center, Amarillo, TX

Case Report

Cholelithiasis is rare in infancy, although the rates of diagnosis have increased as a result of the widespread use of ultrasonography in neonates. Most cases of neonatal cholelithiasis are due to hemolysis or an abnormality in the biliary tree or ileal tract; TPN administration is a lesser-known risk factor for the development of this condition. This case presents an infant who developed gallstones due to cholestasis secondary to TPN administration.

A 3-year-old girl presented to the emergency department with severe abdominal pain, which she rated as 8 of 10 in severity. The onset of the pain had occurred that morning during a long car ride. She described the pain as crampy and reported that it had begun in the right upper quadrant but had since become diffuse throughout the abdomen. Related symptoms included reduced activity and refusing to eat or drink; the mother also reported that the girl had foul-smelling urine. The patient denied fever, headache, nausea, vomiting, diarrhea, rash, or difficulty breathing. Her medical history was notable for gastroschisis (which had been surgically repaired on day 9 of life) that had been complicated by a 10-cm ventral hernia and cholestatic jaundice secondary to prolonged TPN administration in NICU. The cholestatic jaundice had resolved, but the hernia remained unresolved. The patient was admitted to the hospital and was ordered to have nothing by mouth with nasogastric tube placement. Laboratory studies were notable for an elevated white blood cell count. An ultrasonogram of the abdomen revealed cholelithiasis without bowel obstruction. One day following hospital admission, a surgical consultant recommended laparoscopic cholecystectomy and hernia repair. The procedure was performed the following day, during which cholesterol gallstones were found, but without any other complications. The patient was evaluated the next day, and discharge was recommended with a follow-up visit in 2 weeks.

Recognition and treatment of cholelithiasis secondary to TPN is rare in such young patients, clinicians should keep these causes in the list of differential diagnoses when presented with an infant with such symptoms and a history of prolonged TPN administration.

280 Gastrointestinal neuroendocrine tumors: a rare, indolent neoplasm on the rise

M Masood*

J Ertle

Augusta University, Augusta, GA

Introduction

Gastrointestinal neuroendocrine tumors (NETs) are a rare entity, but their incidence has vastly increased in recent years. The diagnosis is often delayed due to a variable presentation and an indolent course. Novel therapies have emerged which aid in the management of NETs.

Case presentation

A 77-year-old Caucasian male with a history of Alzheimer’s dementia and abdominal hernia repair who presented for abdominal pain of one-day duration. He denied nausea, vomiting, changes in stool, or dysuria. Vital signs were unremarkable. Examination was significant for lower abdominal tenderness. Laboratory studies were notable for a leukocyte count of 15,600/mm³, hemoglobin of 10.6 g/dl and a platelet count of 651,000/mm³. Contrast-enhanced, abdominopelvic computed tomography (CT) scan revealed a partial small bowel obstruction due to a 1.6 cm x 1.4 cm enhancing, intraluminal lesion near the ileum with mesenteric lymphadenopathy. The patient’s symptoms improved with conservative measures and he was discharged home. Resection of the lesion revealed two well-differentiated neuroendocrine tumors in the jejunum. Immunohistochemical staining of the lesions was positive for chromogranin A and synaptophysin with a Ki-67 index of 15%.

Discussion

While the incidence rate of gastrointestinal NETs has been reported to be 1.05 per 100,000, the incidence is steadily increasing, likely due to more frequent imaging and endoscopy. NETs are often slow-growing and have a non-specific presentation which can make the diagnosis challenging. Patients may be asymptomatic, have obstructive symptoms, such as in this case, or report symptoms related to tumor production of bioactive substances, as in carcinoid syndrome. NETs may secrete chromogranin A and synaptophysin which can be used for confirmation or surveillance of disease. Patients with localized disease are often treated with surgical resection. Somatostatin analogs and cytoreductive surgery are usually reserved for metastatic disease. Peptide receptor radionuclide therapy (PRRT) has emerged as the therapy of choice for progressive disease on somatostatin treatment. Given the increased incidence and often-delayed diagnosis of NETs, it is paramount that clinicians recognize and understand this disease. Early efforts should be made to diagnose and manage NETs using a multidisciplinary approach.

281 A root cause for dysphagia: vegetable food impaction mimicking esophageal malignancy

P Nethala*

A Edwards

University of Alabama at Birmingham, Birmingham, AL

Case Report

Food bolus impactions are medical emergencies that are usually meat associated, with vegetables making up less than 5% of documented cases. Structural abnormalities including reflux esophagitis may predispose to impactions, and edentulous patients or those with poorly fitting dentures are at increased risk for impaction due to ineffective chewing and decreased tactile sensation while swallowing. We present an 82 year old woman with dementia and edentulism presented with acute onset dysphagia to solids for 3 days. On examination she had normal vital signs. Her oropharyngeal exam showed loose fitting dentures, and her thyroid exam was normal. A barium esophagram showed a large, at least 3 cm well-defined round lesion within the distal esophagus (figure 1A), concerning for esophageal malignancy. Upper endoscopy showed a 3.5 cm diameter orange-brown disc-shaped foreign body in the distal esophagus (figure 1B) that was removed with a net retrieval basket. On inspection the foreign body was consistent with a slice of raw carrot (figure 1C). Two months after her upper endoscopy her weight was stable with no further dysphagia. A repeat esophagram showed a 2 cm hiatal hernia and no evidence of a distal stricture. We present this case to highlight a minority etiology for food bolus impaction and to highlight underlying structural complications that can predispose to impactions.

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Abstract 281 Figure 1A

Barium esophagram with arrow indicating a well-circumscribed lesion in distal esophagus concerning for malignancy

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Abstract 281 Figure 1B

Disc shaped foreign body seen on EGD in distal esophagus

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Abstract 281 Figure 1C

3.5 cm removed distal esophageal lesion, consistent with raw carrot slice

282 It’s complicated: monitoring after paracentesis

D Roman Colon*

M Ortiz

VA Caribbean Healthcare System, San Juan, Puerto Rico

Case Report

Abdominal paracentesis is a diagnostic and therapeutic procedure deemed safe. Complications are seen in 1% of cases, delayed hemoperitoneum from preceding large-volume paracentesis is extremely rare. Its presentation is subtle and confers motality rates >70%. High index of clinical suspicion for prompt diagnosis is possible with awareness. This is a case where delayed hemoperitoneum presenting 72 hours after large-volume paracentesis was succesfully managed with conservative measures.

A 60-year-old male with class B Child-Pugh cirrhosis secondary to alcohol abuse presented with 3-weeks of bilateral lower extremity edema extending to scrotum and increased abdominal girth. Physical examination revealed a globose, tense distended abdomen without tenderness to palpation, + fluid wave, and bilateral pitting edema. Ultrasound-guided paracentesis in the left lower quadrant yielded 5.6 L of clear, ascitic fluid compatible with portal hypertension. No hematomas were observed, rapid symptomatic relief was achieved, and albumin was replaced. Three days later the patient referred mild, diffuse abdominal discomfort with a hemoglobin drop to 6.5 g/dL from 10.3 g/dL without evidence of hematomas or bleeding. He was hemodynamically stable, 1 unit PRBC and 2 FFP transfused with resulting hemoglobin >7 g/dL. Abdominal imaging revealed large volume ascites and high-density fluid suggestive of hemoperitoneum. Serial hemoglobin levels remained stable and no further transfusions warranted. Given tense refractory ascites with associated shortness of breath, patient required two paracentesis which demonstrated blood-tinged, ascitic fluid and provided symptomatic relief. Patient was discharged home with spironolactone and furosemide in 5:2 ratio.

Delayed hemoperitoneum is believed to occur secondary to a rapid drop in intraperitoneal pressure following large fluid removal that cause mesenteric varices to rupture. Common symptoms include vague abdominal discomfort, distension, and shock. It may require aggressive transfusions, exploratory surgery, or transjugular intrahepatic portosystemic shunts. Prompt recognition of this complication can prevent invasive intervention and is critical due to its high mortality rate. Close surveillance in these patients, lower-volume paracentesis, and slower drainage of ascites is recommended.

283 Amber eyes: a tale of a choledochal cyst

J Sansone*

N Zeky

C LeBlanc

P Arias

Louisiana State University Health Sciences Center, New Orleans, LA

Case Report

Despite abdominal pain being a common pediatric complaint, choledochal cysts must be considered when a history includes jaundice and abdominal mass. Choledochal cysts are defined by biliary tree dilatation and obstruction. This disease presents most often in infancy and childhood with an incidence of around 1 in 100,000.

A previously healthy 10 year old girl presented to her doctor with 2 weeks of abdominal distension and scleral icterus. Her initial work up revealed a direct hyperbilirubinemia, Alkaline Phosphatase of 753 U/L, Aspartate Aminotransferase of 291 U/L, Alanine Aminotransferase of 222 U/L, and Gamma-Glutamyl Transferase of 633 U/L. Evidence of obstructive jaundice led to an abdominal ultrasound. This revealed dilatation of the common bile duct, gallbladder, and intrahepatic bile ducts. Magnetic Resonance Cholangiopancreatography confirmed a Type IVa choledochal cyst. She underwent Choledochal Cyst Excision and Hepaticojejunostomy.

Although a rare etiology in school age children, choledochal cysts need to be considered for this presentation. Choledochal Cysts should be recognized early with rapid intervention to prevent lifelong complications including liver failure and cholangiocarcinoma. An abdominal ultrasound is the preferred initial screening test, followed by an MRCP with Eovist to further characterize the lesion.

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Abstract 283 Figure 1

284 A mysterious case of chronic diarrhea not responsive to treatment

T Thongtan*

GD Bedanie

A Deb

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Introduction

Chronic diarrhea is a leading cause of health care utilization worldwide. While a specific diagnosis can be achieved in > 90% of patients, many do not have a conclusive diagnosis and more case reports are needed.

Case Report

A 47-year-old man with type 2 diabetes, hypertension, substance abuse, chronic kidney disease, old stroke, and untreated chronic hepatitis C infection presented with chronic diarrhea for 1 year. He endorsed lower abdominal pain and bloating. During a hospital stay, he had been having constant diarrhea up to 12 times/day and complete loss of bowel control with observed loose stool every day. Despite extensive workup undertaken, there was no known cause of his chronic diarrhea. The empiric treatment regimens used in sequence included low-carb/lactose-free diet, rifaximin, Welchol, cholestyramine, pancrelipase, albendazole, and loperamide failed to improve his secretory diarrhea. His hypovolemia from ongoing diarrhea led to end-stage renal disease with severe metabolic acidosis and hyperkalemia needing hemodialysis. He developed Enterobacter cloacae complex aspiration pneumonia and acute hypoxemic respiratory failure. The patient died on hospital day 64.

Discussion

Chronic diarrhea is a diagnostic challenge with hundreds of possible causes. Physicians should determine the category of diarrhea based on stool appearance into fatty, watery, or inflammatory. Empiric therapy is reasonable if a specific diagnosis was suspected. Life-threatening conditions should be excluded. We reported a case of a patient with chronic severe secretory diarrhea that remains unknown and unsolved for the etiology.

285 The mystery of analgesic refractory chest pain

H Yousuf*

RI Hazam

D Dave

KN Abdelmalek

I Ivyanskiy

N Elzubeir

N Rus

Texas Tech University of Health and Sciences, Amarillo, TX

Case Report

Chest pain has a wide differential diagnosis. It is important for clinicians to recognize the atypical presentations of esophageal carcinomas as chest pain. We report a case of a patient with esophageal carcinoma resistant to analgesics who presented with chest pain only.

A 61-year-old male presented with sudden onset, severe, non-radiating right-sided sharp chest pain for 8 days that increased on deep breathing. The exam was unremarkable but for a heart rate of 119 bpm. Lab findings, cardiac enzymes, and chest radiographs were unremarkable. ECG revealed sinus tachycardia. CT angiogram and the duplex US of the abdomen were unremarkable. Abdominal CT showed thickened gastroesophageal junction, concerning an underlying neoplasm with lymphadenopathy and invasion of the pancreatic body. EGD findings showed a large, ulcerated, non-circumferential mass just below the GE junction at 45 cm with no bleeding. Another large, partially obstructing, the noncircumferential ulcerating mass was found in the distal esophagus, extending from 39 cm to 45 cm cm from the incisors along with esophageal mucosal changes suspicious for long-segment, Barrett’s esophagus and moderately differentiated adenocarcinoma of the GE junction, clinically categorized as stage IV, T4 N3 MX. The patient opted for palliative chemotherapy.

Metastatic cancer can masquerade as retrosternal chest pain. About 74% of these patients present with dysphagia, 17% report odynophagia, 57% report weight loss, and 21% report long-standing GERD. But when the patient presents with retrosternal or right upper abdominal pain it usually reflects the presence of unresectable, extensive disease.

Physicians should recognize that persistent pain that is disproportionate to the exam findings is an important clue for possible unresectable extensive malignant disease

286 Gallbladder agenesis in a middle-aged female with nausea and right upper quadrant pain

H Yousuf*

MA Tanbir

RI Hazam

I Obokhare

T Naguib

Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX

Background

With an incidence of 1/6500 live births, gallbladder agenesis (GA) is a rare congenital condition. While majority of patients are asymptomatic, those who do develop symptoms present similarly to cholecystitis and have similar findings on ultrasound evaluation.

Case presentation

We present the case of a 35-year-old female with recurrent hospitalizations for 1 year due to postprandial nausea, vomiting and right upper quadrant pain. Vitals were stable except for tachypnea. Physical exam revealed epigastric and right upper quadrant abdominal tenderness on deep palpation. She had leukocytosis and right upper quadrant ultrasound showed contracted, thickened gallbladder with no ductal dilatation.

Patient underwent diagnostic laparoscopy with lysis of stomach/duodenal adhesions and ICG dye cholangiography. No gallbladder was noted during surgery. Post-operative CT scan (figure 1) confirmed absence of gallbladder. Subsequent Nuclear Medicine Hepatobiliary Duct System Imaging also confirmed it by nonvisualization of the gallbladder after 4 hours with a patent common bile duct.

Conclusion

Due to the similarity with biliary colic and rarity of the disease, GA is often diagnosed intraoperatively, and this was the case with our patient.

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Abstract 286 Figure 1

CT Abdomen

287 A little dili for your spider bite

K Zamora*

S Homra

B Lanoux

H Oddo Moise

V Thibodeaux

M Rees

LS Engel

S Walvekar

LSU Health Sciences Center, New Orleans, LA

Case Report

A 45-year-old woman with a history of gastric bypass surgery, recently treated hepatitis C, alcohol and cocaine abuse presented to the Emergency Department with two weeks of epigastric abdominal pain associated with fevers, chills, diffuse myalgias, fatigue, early satiety, nausea, and dark-colored urine. Further review of systems was notable for a recent spider bite which was treated with 3 days of amoxicillin, followed by 6 days of oral Trimethoprim-sulfamethoxazole (TMP-SMX) 40–200 mg/5 mL suspension BID about 3 weeks. She was concurrently on a course of doxycycline for presumed endometritis. On physical exam, she had a positive Murphy’s sign, jaundice and scleral icterus. Laboratory studies showed AST 137 U/L, ALT 136 U/L, ALP 688 U/L, total bilirubin 4.6 mg/dl, and GGT 306 U/L. RUQ ultrasound was significant for gallbladder wall thickening and increased vascularity in the wall of the gallbladder. CT abdomen showed no evidence of gallbladder obstruction or cholecystitis. MRCP confirmed no biliary obstruction. Work up for infectious, obstructive, autoimmune, and genetic etiologies was unremarkable. All potentially hepatotoxic medications were stopped but worsening of liver function continued, stabilized, and then began to decline over the course of her hospital stay. Liver biopsy revealed granulomatous hepatitis with irregular peri-granulomatous and background large-droplet steatosis that, in the setting of negative laboratory work-up, led to the diagnosis of TMP-SMX-induced granulomatous hepatitis with predominant cholestasis. She was started on ursodiol and discharged with outpatient follow-up.

Discussion

TMP-SMX-induced liver injury can range from mild liver enzyme elevations to acute liver injury. Most cases resolve quickly, within 2–8 weeks, but can last for months in cases of severe cholestasis. Some documented cases have resulted in the need for a liver transplant. In most cases sulfonamide is the causative agent, but trimethoprim also has associated cases of hepatotoxicity, so it is best to avoid switching to trimethoprim alone and identify the patient as allergic to TMP-SMX. Liver injury with the use of TMP-SMX is rare relative to the widespread use of this drug, and this case illustrates that even short courses may put a patient at risk.

288 The ripening process: finding the perfect balance between tuberculosis and ulcerative colitis

N Zeky*

E McDonough

R Zwiener

LSUHSC-Children’s Hospital of New Orleans, New Orleans, LA

Case Report

A 15-year-old previously healthy female presented to the emergency room for hematochezia, ultimately diagnosed with ulcerative colitis (UC) on colonoscopy. She was started on infliximab. Prior to initiating this therapy, she had a positive T spot however was having no respiratory symptoms, indicating latent tuberculosis (TB). Isoniazid and rifampin were started. Over the next five months, she was poorly compliant with her latent TB therapy. She was admitted to the hospital at this time, received methylprednisolone and had a documented calprotectin of >1,000 mcg/g, consistent with an UC flare. Shortly after this admission, she was readmitted for fever, cough, night sweats, pleuritic chest pain and diagnosed with active pulmonary TB. This admission included the discontinuation of infliximab and active pulmonary TB therapy, including rifampin, isoniazid, pyrazinamide, and ethambutol were started. At the conclusion of this admission, her calprotectin had trended down to a normal value of <16 mcg/g, despite no therapy for UC for two months.

Follow up from the hospital, she was asymptomatic. There were plans to repeat her colonoscopy. This got delayed and when she finally returned to for her follow up, ten months after stopping her infliximab she was now reporting some hematochezia, her calprotectin was now documented to be >3000 mcg/g, and her colonoscopy showed severe active colitis. Her TB therapy was in its final month to complete the course.

It is well documented that the use of tumor necrosis factor (TNF alpha) inhibitors increases the risk of reactivation of latent TB and it is why TB screening is done prior to induction therapy. When patients have latent TB, it is acceptable to start TNF alpha therapy with close monitoring for reactivation. It is unclear if this patient had reactivation from use of steroid taper during the flare up or was her underlying noncompliance playing more of a role. There is also a possibility that some of her TB therapy could have a played a role at controlling the inflammation of her UC.

289 Improved screening for sexually transmitted infections among hospitalized youth: a quality improvement project

F Abene*

R Chong

N Gordon

A Nasrazadani

S Patel

RM Beyda

The University of Texas Health Science Center at Houston, Houston, TX

Purpose of Study

Only 10% of adolescents admitted to the hospital receive the appropriate sexually transmitted infection (STI) screening recommended by the AAP. Lack of appropriate screening for STI in adolescents creates significant morbidity and elevates healthcare costs. Cases of gonorrhea, chlamydia (GC/CT) and syphilis have increased significantly since 2013. Youth often forego routine health visits and admission to the hospital may be their only interaction with healthcare providers. In our institution, screening is inconsistent and at the discretion of the physician. The aim of our quality improvement project was to increase screening among youth ages 16–18 years old admitted to the primary pediatric service in our children’s hospital.

Methods Used

Our study population included youth ages 16–18 years old admitted to Children’s Memorial Hermann Hospital from August 2019 to January 2020. A retrospective chart review from August to October 2019 determined baseline screening rates. The intervention took place in November 2019 and included 3 phases. First, residents were educated during their academic half-day and intern orientation regarding screening. Second, cue cards were placed on the mobile physician computer workstations, flyers were hung in the resident workroom and pocket reminder cards were handed out. Finally, our screening efforts were discussed with the hospitalists to emphasize compliance with the resident teams. When each patient was admitted, residents asked about sexual activity and offered screening during the social history which is conducted without the parents.

Summary of Results

A total of 167 patients were included in the study. 120 patients in the pre-intervention group and 47 patients in the post-intervention group. The screening rates for GC/CT, HIV, and syphilis prior to the intervention were 17.5%, 22%, and 21% respectively. The screening rates for GC/CT, HIV, and syphilis following the third PDSA cycle were 45% (p<0.05), 36%, and 36% respectively.

Conclusions

Cumulative efforts to increase education for physicians and posting of visual cues improved STI screening rates. We demonstrated through our quality improvement project that screening rates for STIs can be improved in the hospital setting through simple and targeted education.

290 Always ask why – preventing delayed diagnosis and treatment

A Ahuja*

P Yedla

University of Alabama at Birmingham, Huntsville, AL and University of Alabama at Birmingham, Huntsville, AL

Case Report

Patient is a 69-year-old retired professor admitted to service for evaluation of extensive rash with multiple blisters, who was ultimately diagnosed with bullous pemphigoid. Patient had been bed-bound for the last two years without the issue being addressed. He was told he had diabetic neuropathy several years ago and gradually became non-ambulatory over a year. His physician advised him to follow up with his neurologist, but patient never made it due to transportation issues and poor social support system: his kids live out of town and he was having issues with his caregiver. Not satisfied with a diagnosis of diabetic neuropathy, we consulted neurology. Lumbar puncture and nerve conduction study confirmed chronic inflammatory demyelinating polyneuropathy (CIDP) & MRI of the cervical spine showed severe myelopathy. Patient had laminectomy and was discharged to acute rehab. 6 weeks later, patient was still unable to walk and had not finished IVIG treatments due to transportation issues.

Discussion

1) Social determinants of health (SDH) are the conditions in which people are born, work, and reside that influence conditions of daily life. These factors include education, neighborhoods, social support networks, and access to health care. As patients present in the hospital, we often treat the medical diagnoses and look no further. However, it is ineffective to care for a patient without addressing SDH as these pose significant obstacles to treatments. For a true patient-centered approach, we must screen our patients for any underlying burdens as this influences health outcomes. 2) Independent patients who are capable of activities of daily living can gradually become non-ambulatory after a hospitalization, a fall, or without any obvious reason in the outpatient setting. Many times, patients nor their families question as to why they are not returning to baseline status. As medical providers, it is our responsibility to question this for them. Do not assume all patients have been evaluated to the fullest extent or have received diagnoses for each presenting ailment. Asking our patient why he had not walked in a year lead to further questioning and initiated the CIDP diagnosis after workup was delayed for over a year.

291 A national study on prevalence and racial disparities in lung cancer screening

MU Alsaggaf^1,2*

M Alghamdi³

M Anteet¹

K Sigel⁴

¹Ochsner Health System, New Orleans, LA

²King Abdulaziz University, Jeddah, Saudi Arabia

³Ministry of Health, Jeddah, Saudi Arabia

⁴Icahn School of Medicine at Mount Sinai, New York, NY

Purpose of Study

Evaluation and analysis of lung cancer screening uptake, and whether racial disparities exist using the 2017 survey of CDC Behavioral Risk Factor Surveillance System (BRFSS) for subjects who fit the US Preventive Services Task Force (USPSTF) criteria.

Methods Used

The BRFSS 2017 collected lung cancer screening data from ten US states (Florida, Georgia, Maryland, Missouri, Nevada, Oklahoma, Vermont, Wyoming, Kansas, and Maine). Individuals who fit the USPSTF lung cancer screening criteria were included in this study (smoke 30 pack/year, 55 to 80 years old, and current smokers or have quit within the past 15 years). The dependent variable is the computed-tomography lung cancer screening within the past year. Adjusted associations between the dependent variable and the independent variables were analyzed using multivariate logistic regression.

Summary of Results

A weighted total of 1,301,248 subjects who fit the USPSTF lung cancer screening criteria were included in the analysis. 18% of subjects were screened (see table 1), the percentage increased compared to the reported percentages (3–4%) in previous studies between 2010–2015. Racial disparities exist in lung cancer screening; the prevalence of screening in minorities was significantly less than Whites (Hispanic OR = 0.27, 95% CI 0.08–0.8) and Blacks OR = 0.28, 95% CI 0.09–0.84). Variables related to healthcare coverage showed a significant association with screenings, subjects without healthcare coverage had lesser odds of getting screening than those with coverage. Screening prevalence was different across included states; Florida had the highest uptake at 24%. On the other hand, Nevada had the lowest uptake at 11%.

Conclusions

The prevalence of lung cancer screening improved in 2017 compared to prior years, however, it is still low. Racial disparities exist among screened individuals, directed screening programs for racial minorities may be beneficial.

292 Key to becoming better antibiotic stewards for suspected urinary tract infections in children ≥2 years

ST Ansari¹*

L Bradley²

¹Children’s Hospital of Wisconsin, Brookfield, WI

²Children’s Hospital of Wisconsin, Milwaukee, WI

Purpose of Study

The American Academy of Pediatrics developed a guideline for the diagnosis and management of UTI in febrile infants in 2011.The age of majority of patients seen for suspected UTI at Children’s Wisconsin(CW) is >2 years.Also, a nitrite positive(NP) urinalysis(UA) is highly specific for UTI.Guidelines regarding initiation of empiric antibiotic(EA) therapy in children ≥2 years with a nitrite negative(NN) UA are not clear.Assess current state of EA prescribing practices for children ≥2 years of age with suspected UTI in NN and positive leukocyte esterase(LE) UA.

Methods Used

A retrospective chart review of patients aged 2–18 years who provided clean void urine specimens for suspected UTI from January to December 2019 and had paired UA & urine culture reports was performed.Patient demographics, documented/reported fever,UA results,urine culture report and EA therapy were obtained from electronic medical records.UTI was defined as urinary symptoms,pyuria on UA,and ≥50,000 colony forming units of uropathogen on urine culture report.Patients with a NP UA were excluded.

Summary of Results

1065 patients were included in the study(mean age 7.0 years, 89% female).135(12.7%)of all included patients met UTI criteria.349(32.8%)of 1065 patients had trace or 1+ LE on UA, of which 24(6.9%) met UTI criteria.116(33.2%)out of the 349 patients with trace or 1+ LE were started on EA for a suspected UTI,104(89.7%)of which did not meet UTI criteria.57(16.3%)of 349 patients had a temperature >38.0°C,of which 2(3.5%)met UTI criteria.

Conclusions

Initiating EA therapy for patients ≥2 years of age with trace or 1+ LE on UA resulted in overtreatment in 89.7% of cases.Fever was not a strong predictor of UTI in this group.Study findings suggest that providers can be better antibiotic stewards by waiting for the urine culture report prior to initiating EA therapy for patients with trace or 1+ LE and NN on UA.

293 Contribution of boarding time to emergency department overcrowding in an academic hospital

KE Anthony*

E Baus

Louisiana State University Health Sciences Center, New Orleans, LA

Purpose of Study

The Joint Commission recommends boarding time (defined as elapsed time between deciding to admit an ED patient and transferring said individual to an in-patient floor) should be limited to four hours. Prolonged boarding times contribute to ED overcrowding and decrease patient safety. Our study aimed to understand how University Medical Center’s ED boarding time compares to this recommendation and if encouraging ED physicians to submit an in-patient bed request prior to IM consult would expedite patient transfer to an inpatient floor.

Methods Used

The boarding time was calculated from the time that admission orders were entered into EMR to the time of transfer to an in-patient floor. Additional intervals were calculated based on other parameters noted: Time from Consultation to Transfer to In-patient Floor (1) and Hospital Bed Ready to Transfer to Inpatient Floor (2), and. Medical records of 1,185 patients were reviewed. 957 were placed in the control group. 228 patients had an in-patient bed request (IBPR) placed by the ED physicians.

Summary of Results

The average boarding was 4h 28m (95% CI 0h18m), exceeding the Joint Commission’s recommendation. There was no statistical difference between the boarding times of the IPBR and control group: 4h 24m (95% CI 0h26m) and 4h 29m (95% CI 0h22m), respectively. Despite this, the time interval designated (1) above was lower in patients with an IPBR than without (1h04m (06m) vs 1h36m (10m)). Though the IBPR aided in quicker admission of patients, this time-savings was not significant enough to affect the boarding time. Around 25% of the boarding time for all patients fell within the interval designated as (2) and was similar between the IPBR and control groups: 1h38m (08m) and 1h49m (17m).

Conclusions

We recommend further examination of the components contributing to UMCNO’s prolonged boarding times. While there should be continued collaboration between the IM and ED services, it is beneficial to account for the contribution of other ancillary staff (i.e. transportation, laboratory/radiology) to this time interval. Additionally, we plan to compare how boarding time varies with time of year. Similarly, since our original data collection, more hospital beds are available for inpatient use and we hope to quantify if there any impact on boarding time with this addition.

294 Racial injustice perceptions reawakened by the COVID-19 pandemic

MI Arrieta^1,2*

LL Parker¹

MD Carter¹

RS Hanks¹

ED Crook^1,2

¹University of South Alabama, Mobile, AL

²USA Health College of Medicine, Mobile, AL

Purpose of Study

Data shows minority communities experience profound impacts of disease severity and death if contracting COVID-19. We sought to understand the lived experience of the pandemic in an underserved, inner city minority community in Mobile County, AL.

Methods Used

This qualitative study gathered data via Focus Groups and Key Informant interviews with community members, leaders, or advocates. The analysis team implemented a deductive rapid analysis of scribe notes from eight data collection events. The data addressed twenty-six basic analysis questions.

Summary of Results

Issues of disparity, inequality, and racial bias were prominent in the discussions. Study participants stressed that African Americans have a long history of unequal and even harmful treatment from the healthcare system. This history means that many in the community are not surprised by the statistics of African Americans dying at a higher rate than whites. Community advocates are ‘curious’ about such reality and quizzical of why disparities persist in comorbidities that make the virus’ impact worse. Distrust and frustration may keep persons from going to the hospital (even if experiencing COVID-19 symptoms) for fear of receiving subpar treatment simply because they are Black.

The experiences of bias run deep in the African American communities’ understanding of the COVID-19 pandemic. Experiences of disparity, in particular health disparities, are a norm in the community, with one participant describing the situation as ‘another storm to be weathered.’

Throughout the research process, a few participants conveyed their sense of déjà vu. They had communicated the reality of their communities many times before. Where we focused the conversation on the COVID-19 pandemic, the issues of socioeconomic disadvantage, inequality, distrust, and structural racism would surface whatever the topic to be addressed.

Conclusions

Underserved African American communities experience sustained stress from inequality and injustice. The slow progression toward equity renders them vulnerable. It is necessary to address the fundamental drivers of inequity to foster resilience to any stressor, not just COVID-19.

295 Antivenom use or observation for patients with copperhead snake envenomation?

KS Baab¹*

F Ramirez-Cueva²

A Larsen¹

E Knowlton¹

R Rainey-Kiehl¹

A Hendrix¹

M Condren¹

M Woslager¹

¹The University of Oklahoma School of Community Medicine, Tulsa, OK

²Augusta University, Augusta, GA

Purpose of Study

Crotaline snake envenomation is a potentially serious medical condition affecting thousands of Americans each year. Snakes in the subfamily Crotalinae include, but are not limited to, copperheads, rattlesnakes, and cottonmouths. Variation in treatment of crotaline snakebites exists among physicians in the United States. In particular, managing copperhead snakebites is hypothesized to require minimal intervention, rarely requiring antivenom use and, even rarer, surgical intervention. This study assessed FabAV antivenom use and treatment outcomes for copperhead-envenomated patients in northeastern Oklahoma.

Methods Used

A retrospective cross-sectional review examined electronic medical records (EMR) of patients with venomous snake bites from July 1, 2014 to August 31, 2019. Patient demographics, snake species, clinical presentation and lab results were collected. Associations between patient variables and treatment were evaluated using the χ², Median tests, and binary logistic regression.

Summary of Results

Of 256 patients meeting inclusion criteria, 139 were envenomated by a copperhead. Compared to patients under observation (no antivenom, n=42), those treated with antivenom (n=97) were more likely to have ICU stays (χ²(1)=29.5, p<0.001). Few patients under observation experienced complications requiring intervention (n=3, 7%) or ICU stays (n=2, 5%). For FabAV-treated patients, 17% experienced complications (n=16) and the majority had an ICU stay (n=54, 56%). Comparing the antivenom administered vs. observation cohorts, there were no statistically significant differences in the proportion of patients who were hemotoxic (χ²(1)=0.91, p=0.34), or in the number of systemic symptoms (χ²(1)=0.78, p=0.38). Progression of venom effects across major joints was significantly associated with FabAV treatment.

Conclusions

Hospital policy of administering antivenom in the ICU for adult patients may contribute to the association between ICU stay and antivenom treatment. For those patients with a copperhead snakebite, treatment by observation had favorable patient outcomes, including reduced chance of an ICU stay and reduced overall length of hospital stay.

296 Impact on the fitness of n95 masks with extended use/limited reuse, and heat decontamination

BC Bunch¹*

M Zha^2,3

J Alsarraj²

¹Washington State University, Pullman, WA

²Columbia Basin Health Association, Othello, WA

³Mayo Clinic Research Minnesota, Othello, WA

Purpose of Study

To evaluate the respective and additive impact of extended use/limited reuse, and heat decontamination on the fitness of N95 masks, during the COVID-19 pandemic.

Methods Used

Twelve dental staff in a busy practice who recently passed the OSHA mandated fit test to wear the 3M^TM 9211 masks participated. Before each 10-hour shift, volunteers obtained a new mask. A used mask was collected and a new mask obtained if the 10-hour shift is finished and the count of don/doff is less than 5 (‘extended use group’), or before a shift ends and the don/doff count reaches 5 (‘limited reuse group’). The mask was discarded if there is any obvious hardware failure. Fit test was performed on collected masks. High velocity hot air (HVHA) decontamination was done using a CPAC^TM RH-N95 unit for a full cycle. Masks were fitted again.

Summary of Results

167 new masks are used. After a 10-hour shift, if the CDC recommended 5 don/doff rule is adopted, the retention rate of N95 masks was 30.5%. If not, the retention rate is 82.6%. 83.3% of masks after limited reuse group, and 85.4% after extended use group. This is not a statistically significant difference (p=0.807). After one cycle of decontamination, the mask fitness of the limited reuse group is significantly reduced (p=0.002), and the mask fitness of the extended use group is not (p = 0.191).

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Abstract 296 Figure 1

Conclusions

Extended use/limited reuse are reasonable ways to preserve N95 masks in healthcare setting, and it may be safe to extend the count limit of don/doff to beyond 5. The combination of extended use/limited reuse with heat decontamination significantly

297 Improving documentation in an academic general pediatrics clinic

J Dannenberg^1,2*

A Pope¹

J Yaun^1,2

¹University of Tennessee Health Science Center, Memphis, TN

²Le Bonheur Children’s Hospital, Memphis, TN

Purpose of Study

Well child care (WCC) is a cornerstone of pediatric care. In addition to teaching clinical skills, educators must also teach documentation, billing, and coding as part of resident education. For the Tennessee Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, certain components must be documented in WCC notes. Some of these requirements include important health screenings and portions of the physical exam. We hypothesized that all required components of the EPSDT WCC were not being completed in our resident teaching practice. Our objective was to conduct a quality improvement to improve documentation.

Methods Used

Baseline data was collected from December 2019 to May 2020. Twenty charts of children ages 0 to 15 months presenting for WCC were randomly selected and reviewed for completion of selected EPSDT components, including screening for anemia, lead, tuberculosis, and hyperlipidemia risk factors, food insecurity screening, and performance of a complete physical exam. Using the plan, do, study, act method, specific interventions were implemented, including a new note template. Follow up data was reviewed for the next 6 months. The percentage of required components documented was recorded.

Summary of Results

Baseline data demonstrated that 45.2% of all measured items were documented in WCC notes. We aimed to improve documentation to 60.2% over the next 6 months. While our first intervention led to an increase in documentation of the EPSDT screening questions, overall documentation decreased to 36.2%, in large part due to dramatic decreases in documentation of food insecurity questions and required physical exam components.

Conclusions

While the first intervention led to increased screening for anemia, lead, tuberculosis, and hyperlipidemia risk factors, overall documentation rates decreased. The new note template is a work in progress and further interventions will include methods designed to increase the documentation of food insecurity screening and required physical exam components. Education on documentation requirements is ongoing and other methods are being implemented for improvement. Documentation, billing, and coding are all an important part of resident education.

298 Incorporating a point of care ultrasound course in a new internal medicine residency program

TC Do*

S Ganti

J Depa

Appalachian Regional Healthcare, Whitesburg, KY

Purpose of Study

The goal of this study is to evaluate the competency of internal medicine residents after a formal course of POCUS during orientation. ACGME requires POCUS training in emergency medicine residents but not for internal medicine residents. This study will be part of an evaluation of whether or not POCUS needs to be taught during orientation in an IM program and what needs to be in the curriculum based on residents’ feedback.

Methods Used

This was a prospective cohort study with 7 incoming interns. A pre-course survey determined the residents’ previous exposure to ultrasound. A competency checklist covering the application of ultrasound was used on a student volunteer model prior to the course. The checklist involved heart and lung evaluations in addition to viewing the internal jugular vein and carotid artery. A total of 15 objective written multiple choice questions and 7 ultrasound videos questions were made. The course was broken down into 2 sessions due to the scheduling. It consisted of a didactic session taught by a critical care physician who uses POCUS and then a hands on session of the application of ultrasound with the same physician on a different student volunteer model. The interns were reevaluated 6 weeks after the course using the same written and video assessment and competency checklist on a different student model. A post survey was used to obtain feedback from the residents.

Summary of Results

At baseline, the average on the written part was 43% while the video portion was 50%. The average on the application of POCUS was only 12%. 6 weeks after the course, the averages did improve. Although they rarely practiced using the ultrasound on their inpatients, the average of the application of POCUS was 78%. This was a drastic improvement compared to the written and video part. With the written part, the average increased to 61% while the video portion increased to 69%.

Conclusions

The interns agreed that the course was helpful but wanted more hands on sessions with the physician. The course was successful due to the increased averages. In order to further determine competency, the interns will be reassessed in 6 months to determine retention of POCUS. Although they didn’t practice much within the 6 weeks, it will be interesting to see what the outcome will be in 6 months.

299 Comparing two facilitator debriefing rubrics to assess post-simulation debreifings

N Guimbarda*

M Tews

Augusta University Health System, North Augusta, SC

Purpose of Study

The use of simulation-based learning in medical education is essential. Arguably the most critical feature of simulation-based learning is proper debriefing. Many educators have adopted the PEARLS model to guide their debriefing sessions in an effort in facilitate more effective and consistent learning with their students. The aim of this study was to determine if a debriefing rubric could be used to effectively measure facilitator adherence to the PEARLS model by analyzing video recordings of the facilitator’s debriefings.

Methods Used

Approximately 130 hours of student debriefings were analyzed. During the video review, researchers evaluated facilitator adherence to the PEARLS debriefing model using two different debriefing rubrics for each video. The debriefing rubrics were the Pearls Debriefing Checklist (PDC) and the Pearls Debriefing Adherence Rubric (PDAR). Inter-rater reliability was established with an interclass correlation coefficient, and the reliability of the results of the two instruments were calculated using Cronbach’s alpha. Pearson’s correlation was calculated as evidence of convergent validity of the two instruments.

Summary of Results

The inter-rater reliability for the sum of scores for the PDC, PDAR, and total scores for both tools combined demonstrated an acceptable level of agreement. Measures of internal consistency for the PDAR and PDC were .515 and .714 respectively. A Pearson correlation of .648 was calculated for the convergent validity between sum of the debriefing scores tor both tools.

Conclusions

Since there was a lack of compelling evidence of both consistency and convergent validity for each of the instruments, this study demonstrates that there is additional work necessary in the evaluation of faculty debriefing behaviors. This study posed a difficult challenge, which was to find a way to operationalize and quantify observed behaviors. The two debriefing adherence rubrics used in this study were based on standardized facilitator behaviors that may not be applicable to all debriefings universally. The best use of the PDAR or PDC in their current iterations would be by simulation program administrators looking to provide formative feedback to novice facilitators in the effort to maximize student learning in the medical setting.

300 Standardization of maintenance intravenous fluids in pediatric inpatients

J He*

F Litra

CR Antonetti

University of Florida, Pensacola, FL

Purpose of Study

To locally implement the 2018 American Academy of Pediatrics (AAP) Clinical Practice Guidelines: Maintenance Intravenous (IV) Fluids in Children to increase proportion of patient hospital days with exclusive isotonic IV fluid use to ≥ 80%.

Methods Used

Our academic-affiliated, community-based children’s hospital participated in a national quality improvement project with the AAP Value in Inpatient Pediatrics Network, ‘Standardization of Fluids in Inpatient Settings.’ AAP IRB approval was obtained. Table 1 lists inclusion and exclusion criteria. 15 months of baseline type and duration of IV fluid use at our center was collected by retrospective chart review. A fluid management algorithm, lecture, and electronic medical record (EMR) order set were implemented in September 2019 (cycle 16). Nine months of post-intervention data were collected. Post-intervention isotonic IV fluid use was compared to baseline use via Z-test.

Summary of Results

206 baseline and 170 post-intervention charts were reviewed. Baseline isotonic IV fluid use varied from 47.62% to 100%, and became consistent between 82.14% to 100% following intervention (figure 1). Proportion of exclusive isotonic fluid use in the baseline group was 78% (95% CI 72–83%), compared to 93% (95% CI 89–97%) in the post-intervention group, p< 0.001.

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Abstract 300 Figure 1

Proportion of patient hospital days with exclusive isotonic IVF use at our hospital

Conclusions

This quality improvement project shows that educational and EMR interventions can standardize the use of isotonic fluids in pediatric inpatients in accordance with AAP guidelines.

301 A campus wellness inventory for students and employees

N Khorsandi*

S Embley

M Bishop-Baier

LSUHSC-New Orleans, New Orleans, LA

Purpose of Study

University wellness programs target health-related goals for staff and students such as physical activity, nutrition, and mental health. Programming improves individual health and wellness as well as improves productivity, campus morale, staff and student relationships, and decreases absences. To maximize utility of the Louisiana State University Health Sciences Center-New Orleans’ (LSUHSC-NO) current wellness programming, the Wellness Inventory for Students and Employees (WISE) was created. WISE assesses satisfaction and awareness of campus wellness initiatives and garners feedback on how programming can be improved.

Methods Used

WISE is a 23-question quantitative survey with qualitative components that targeted current LSUHSC-NO wellness programs: cafeteria, campus gym, on- and off-campus counseling, Tobacco-Free Campus Initiative, and campus lactation rooms. The quantitative aspect employed a 5-point Likert scale of agreement assessing respondent satisfaction and awareness levels. Qualitative data was analyzed to identify common themes in responses for improvement opportunities of campus wellness programming.

Summary of Results

939 of 7,000 (13%) LSUHSC-NO staff and students responded to the WISE. The three highest areas of agreement were: campus-wide tobacco policy awareness (97%), gym equipment availability (87%), and on-campus counseling assistance awareness (83%). The three lowest areas of agreement among participants were: on-campus lactation rooms satisfaction (9%), state tobacco quit-line awareness (18%), and off-campus counseling cost (25%). Qualitative results identified a total of nine areas of strengths and nineteen opportunities for improvement in programming.

Conclusions

The high response rate of 13% (compared to previous campus-wide surveys) for the WISE indicates a general interest of campus staff and students to improve wellness programs. Through this assessment, campus wellness staff have been able to highlight programs’ areas of strength and improve areas of weakness. There are also many areas identified from qualitative comments that will need further exploration by the wellness committee and staff. Continued iterations of the WISE will be necessary for LSUHSC-NO to optimize wellness programing for staff and students.

302 Flu vaccination rates of documentation during flu season

N Lalchandani^1,2*

C James^1,2

S Sarkar^1,2

¹LSU New Orleans, New Orleans, LA

²Children’s Hospital New Orleans, New Orleans, LA

Purpose of Study

Our aim is the increase the rate of influenza vaccination documentation during flu season by residents by 25% in the next 2 months, piloted on the 5th floor unit for general pediatrics patients.

Children under the age of 5 are particularly high risk of serious complications of influenza. Many children that are admitted to the hospital also have chronic conditions including asthma, diabetes or an immunocompromised state. The goal of this project is to assess documentation rates of the flu vaccination (FV) through nursing and medical provider notes. Every patient that is admitted to the hospital should be assessed if they have received the flu vaccination for that flu season. Residents and physicians should be knowledgeable and prepared to educate families especially common misconceptions about flu shots. If the patient has not received flu shot, they should receive flu vaccination prior to discharge.

Methods Used

Primary Outcome: Rate of documentation

Secondary Outcome: Flu vaccination rate

Process: Rate of documentation of those that did not document

Summary of Results

Rates of FV documentation were higher with nurses compared to residents in both the 2018–2019 and 2019–2020 flu season. After intervention #1, there was a small increase in documentation. A greater increase of documentation was seen after intervention #2. Although we saw improvement in the primary outcome, it is uncertain if those unvaccinated patients received the FV prior to discharge. We can look retrospectively to see if those patients that had been unvaccinated were vaccinated before discharge. Nurse driven protocol for FV administration or building the FV into a discharge order set are future considerations.

Conclusions

All children over the age of 6 months should receive the FV. This is the most effective way to protect them from having serious flu-related complications as well as protect our communities. We should ensure that every child who is eligible to receive the FV has the opportunity to do so.

303 Childhood obesity in primary care project – memphis site

MK McEwen*

A Walsh

MM Vickers

S Martinez

A Breithaupt

A Montague

A Broadnax

R Assfoura

J Yaun

N Bishop

M Hare

A Odulana

LBonheur Children’s Hospital, Memphis, TN

Purpose of Study

The ULPS General Pediatrics Clinic was a part of the Childhood Obesity in Primary Care Project (COPC), a quality improvement project intended to improve the implementation of comprehensive obesity-related health risk assessment in pediatric primary care practices. Aims were: 1) Assess obesity risk, including an assessment of growth, 50% of the time for patients < 2 years of age and 85% of the time for patients from 2 - 21 years of age; 2) Assess and counsel on healthy active living (HAL) behaviors 50% of the time for patients from 2 - 21 years of age; and 3) For overweight or obese patients, assess medical risk (through Family History (FH), obesity Review of Systems (ROS), and Physical Exam (PE)) 50% of the time and, when indicated, provide appropriate follow-up through lab orders and work-ups 50% of the time.

Methods Used

We conducted retrospective chart reviews (n=120) on Well Child Checks during three time periods in 2018 and 2019. Forty records were reviewed per cycle using a de-identified data collection sheet and then entered into the AAP’s Quality Improvement Data Aggregator, producing clinic reports on grouped data. After each cycle we used the clinic reports to assess how well our clinic performed compared to the aims and to identify areas for improvement. To improve our documentation of obesity-specific FH and ROS, we created a FH form for parents to fill out and updated our electronic ROS.

Summary of Results

The percentage of appropriate documentation of FH and ROS increased from 7% to 20% to 41% and 20% to 30% to 67%, respectively. Additionally, appropriate documentation of HAL rose from 43% to 64% to 72% and appropriate PE documentation rose from 20% to 70% to 67%.

Conclusions

The results of the ULPS General Pediatric Clinic’s data from participation in the COPC Project led to improvement in gathering obesity specific FH and ROS. Additionally, improvements were made in HAL and PE documentation. As a result of our findings, the clinic designed a new Healthy Weight Visit Note to assist in improving obesity relevant documentation during dedicated weight visits. In addition, our team is developing a new healthy weight curriculum to train residents about obesity management in the primary care setting.

304 Healthcare workforce diversity: pipeline programs’ role

R Nabaweesi*

K Blann

N Pettus

G Richard-Davis

University of Arkansas, Little Rock, AR

Purpose of Study

Assess summer pipeline programs performance in reaching and preparing under represented minority students for science, technology, engineering, mathematics and health careers.

Methods Used

Junior STEM Academy (JSA) targets K-3 and Senior STEM Academy grades 4–6. Scholars are immersed in health science while incorporating technology, engineering, and mathematics (STEM-H). Academy uses a combination of effective teaching pedagogies to design a culturally responsive and holistic curriculum, including didactic and hands on learning approaches.

Academy of Pre-Health Scholars (APHS): 5-week program pairs high school students with health care leaders to learn about biomedical sciences, research and public health. It also introduces them to career pathways in health care and helps them prepare for the ACT college entrance exam.

Pre-Medical Summer Scholars (PMSS) prepares undergraduate students interested in medical school for the MCAT entrance exam. The six-week program involves direct instruction, workshops to teach scientific knowledge and application in critical thinking and writing.

Summer Research Internship (SRI): Outstanding undergraduate and select high school URM students engage in in-depth faculty-mentored scientific research. Participants present research findings using posters.

Summary of Results

In FY 2020, 212 served students (200 Black and 12 Hispanic) from low social economic families, as determined by school lunch eligibility. Mean participation was 150, 25, 20 and 20 for STEM Academy, APHS, PMSS and SRI respectively. JSA and SSA participants reported high self-efficacy and confidence in pursuing Science, Technology, Engineering, Mathematics and Health (STEM-H) programs, better positioning them to pursue careers in health sciences.

98% APHS participants had a 2–4 year college attendance rate and, 100% CPR and First Aid certification. All APHS participants reported increased confidence in pursuing an undergraduate major in STEM-H with increased awareness of careers and educational opportunities beyond medical doctor. Mean pre-post MCAT change was 5.8. All SRI students complete and present a research project.

Conclusions

STEM academy and APHS are effective at supporting URM students. Formative evaluation will identify barriers and facilitators for URM students improved MCAT performance.

305 Community health programming models target influenza disparity reduction in African Americans in New Orleans, LA

S Nedunchezhian¹*

DP Ferdinand²

K Ferdinand²

¹Tulane University School of Medicine, New Orleans, LA

²Healthy Heart Community Prevention Project, New Orleans, LA

Purpose of Study

Healthy Heart Community Prevention Project, Inc. (HHCPP), a New Orleans community health organization, along with Sustainable Healthy Communities (SHC), LLC, organized an influenza education program during the 2019 and 2020 influenza seasons. The pilot program utilized community health programming in vulnerable New Orleans communities to disseminate culturally and clinically validated cardiovascular disease (CVD) information, emphasize social determinants of health on influenza and CVD, and educate on the benefits of flu vaccination.

Methods Used

Zip codes with predominantly African American populations and high prevalence of diabetes and CVD comorbidities were identified via geospatial analysis. Community and faith centers were chosen to bolster community-centered health education, improve participant self-efficacy, and increase accessibility. Two physicians, Keith C. Ferdinand, MD and Bo Nebolisa, MD, hosted health seminars on influenza disparities and distributed non-commercial clinical health materials. Pre and post-seminar surveys assessing education and retention of health information were administered. Primary data collected via sign-in sheets, surveys, and participant testimonials were analyzed using SPSS statistics and Microsoft Excel.

Summary of Results

Programs were completed at two community centers, five faith centers, two senior homes, and a local community hospital during both seasons. Data analysis demonstrated increased participant ability to identify multiple barriers to and health benefits of influenza vaccination. Moreover, increased engagement was noted when seminars were coupled with health materials and incentives.

Conclusions

The HHCPP demonstrated positive impact of utilizing community partners and local minority health advocates in trust building, action, and accountability towards reducing longstanding health disparities. Limitations include: COVID-19 pandemic restricted program completion during the 2019 season and participant hesitation to divulge personal residence zip codes. Future program directions include zip code-driven diabetes risk reduction, health belief model workshops to overcome belief barriers, and faith and community leader involvement to support influenza education initiatives.

306 Common sports injuries in children presenting to emergency department: a single institution retrospective review

J Nichols*

A Sorrentino

NP Shah

K Monroe

University of Alabama, Birmingham, AL

Purpose of Study

Participation in sports is popular among children and a common cause of pediatric injury. Understanding the epidemiology and trends of sports related injuries is an important component of injury prevention efforts.

Methods Used

A retrospective review of sports injuries presenting over one year (2019) to an Emergency Department (ED) of a large academic Children’s Hospital was performed. Inclusion criteria focused on patients ≤ 18 years whose ED visit resulted from active participation in a sport. Cases were identified using ICD-10 codes. Demographic data was collected on these patients and included gender, age, race, injury specifics. Descriptive statistics were performed and categorical variables were analyzed using chi-square test.

Summary of Results

A total of 1333 sports injuries were identified with the most common being football (43%); basketball (36%); soccer (11%),baseball (8%). The median age was 13 years (IQR: 4 years), 428 (32%) < 12 years and 905 (68%) ≥ 12 years; 1143 (86%) were males and 835 (63%) were black. School was the most common location for sports injuries (28%). When comparing injuries by age groups (<12 vs. ≥12), baseball and football injuries were more common in those < 12 years (14% vs.6% and 53% vs. 38% respectively) whereas basketball and soccer injuries were more common in those ≥12 (43% vs 22% and 11% vs 9% respectively); p<0.001. When comparing injuries by gender, baseball and football injuries were more common in males (9% vs. 2% and 49% vs. 6% respectively) whereas basketball and soccer injuries were more common in females (59% vs 32% and 27% vs 8% respectively); p<0.001.

Conclusions

Sports injuries that are commonly encountered in the emergency department differ in age and gender. Basketball and soccer injuries were more likely to be encountered in older females, while baseball and football injuries were more likely seen in younger males. This information can help guide future preventative efforts provided by primary physicians, schools, and coaches.

307 Recreational mobility vehicles and pediatric injuries

J Nichols¹*

A Sorrentino²

NP Shah²

K Monroe²

¹University of Alabama, Birmingham, AL

²University of Alabama School of Medicine, Birmingham, AL

Purpose of Study

Injuries are the number one cause of death in children and cause significant morbidity. Common scenarios for injury include vehicles that allow children to be mobile and independent (example ATV- all terrain vehicles, dirt bikes, bicycles, skateboards, and scooters). We present a case series review of these external causes of injury.

Methods Used

Following IRB approval, the electronic medical record was queried to identify all patients with an injury related to a recreational vehicle during a one year period (2019). Demographics with injury specific (body part injured, site where injury occurred, mechanism) and helmet usage were collected and analyzed using Excel. Patterns of injury and ages at risk are highlighted

Summary of Results

A total of 246 patients were identified (104 bicycle, 74 ATV, 25 dirt bike, 14 motorcycle, 16 scooter and 14 skateboard). Ages ranged from 2 y to 18 years with the greatest range noted for bicycles (2 to 17 years) and ATVs (2 to 16 years). The mean age was higher for motorcycle and skateboard (13 and 11.6 respectively) and lowest for bicycle (9). Many of the injuries were to passengers (most of which are not designed to carry passengers). The majority of (overall study (97%) and for each mode of transportation) patients were Caucasian which is in contrast to our overall ED population, ( 42% Caucasian). The majority were male (n=181 (74%)). 140 of the 246 (57%) were not wearing a helmet ( 60% of ATV riders andl 5 patients who reported their helmet came off). The lowest percentage of riders reporting appropriate helmet use was skateboarders with only 14% wearing helmets, and the highest percentage was dirt bike riders with 80% reporting helmet use.

Conclusions

Common scenarios for injury include vehicles that allow children to be mobile and independent. Most of these injuries were found in Caucasian males between the ages of 9–12 with low rates of helmet use. It is no surprise that the study found many pediatric patients to be injured on these vehicles because most are not designed to carry passengers.

308 Resident morbidity and mortality conference

E Poindexter*

L Bittles

SE Hudson

J Cassady

C Cordes

S Walley

University of Alabama at Birmingham, Homewood, AL

Purpose of Study

Medical errors are increasingly recognized as a significant cause of patient morbidity and mortality (M&M). Given the potential for systems-based improvements through discussion of patient safety events (PSE), a need was identified for a formal M&M conference system within the UAB/CoA Pediatric Residency Program in order to help promote resident involvement in these processes. From 7/1/2020 – 7/1/2021 we aim to decrease the number of patient safety events at CoA by 20% compared to the preceding 12 month period (7/1/2019 – 7/1/2020). Given there were 18 PSE from 7/1/2019 – 7/1/2020, our aim is less than 14.

Methods Used

Each quarter, an hour-long case presentation is completed during residency noon-conference. During this time, a safety event is reviewed, utilizing standard SBAR format (situation, background, assessment, recommendation). Patient history and preceding information is discussed, followed by completion of an analysis of contributing factors and literature review. Resident leaders will then identify potential interventions to pursue (i.e. policy changes, areas for improved communication, mock codes, etc.). We will analyze the number of PSEs distributed quarterly to determine effectiveness of the M&M model as a quality improvement initiative.

Summary of Results

There has been one quarterly M&M conference since 7/1/2020. The number of PSE for Q3 of 2020 has not been released. There were 18 PSE between 7/1/2019 – 7/1/2020. Over the past 6 months, there has been a 50% reduction in PSE in comparison to the preceding 6 months.

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Abstract 308 Figure 1

Conclusions

We are encouraged by the data from last year and hope through thoughtful M&M conferences we can continue to engage residents in identifying problems and improving systems.

309 Erythrodermic psoriasis: fatal psoriasis and urgent recognition

C Rodriguez Negron*

Hospital Municipio de San Juan, Guaynabo, Puerto Rico

Case Report

Psoriasis a chronic inflammatory condition of the skin that occurs in around 2–3% of the population. Erythrodermic psoriasis (EP) is an extremely rare variant been the clinical hallmark a generalized erythema of the skin involving 75% of body surface area. Despite the availability of multiple therapies, mortality rates still range from 9–64%. Therefore, prompt recognition of this life-threatening condition is crucial to ensure early therapy and disease control. We present an uncommon case of EP manifesting in a Hispanic patient, which has been rarely described in the literature.

73 yo male with a history of HTN, Psoriasis, and alcoholism presented with the complaint of severe skin tenderness and eruptions of two weeks of progression until it started compromising body movements and oral intake. He stated he has been following a poor diet and consuming excessive alcohol for three weeks before visiting the hospital. Physical examination evident for severe desquamative skin, hard plaques, erythrodermic thick scales, and skin exfoliation, involving 80% of the body surface area. Lesions spare mucosa but present in the rest of his body, palms, soles, and genitalia. Laboratory show elevated creatinine and low bicarbonate, suggestive of severe dehydration. Also, present fever, tachycardia, and minimal body motion with exquisite pain. Biopsy with pathological findings suggestive of a psoriatic form of dermatitis. Immediately managed with IV Fluids, Antibiotics, and topical triamcinolone. However, 48 hours after admission patient developed septic shock, resulting in fatality.

Erythrodermic Psoriasis‘ critical situation is the severe capillary leak that develops due to loss of skin integrity with progressive edema, hypotension, superimpose infections, and subsequently high risk of fatality. There may risk factors that can provoke this psoriasis exacerbation including infections smokers, alcohol abusers among others. Sudden development of this skin inflammatory exacerbation requires an emergent diagnosis due to a high risk of systematic compromise that can succumb to multiorgan failure and severe cardiovascular compromise. This case illustrates the possibility of the 3% of psoriasis that can develop life-threatening situations and need urgent recognition in order to provide immediate therapy and avoid undesired outcomes.

310 The prevelance of low back pain and evaluation of prevention strategies amnog the electrophysiology and catheterization laboratory community (physicians, nurses, technicians) in rural hospitals

K Sawalha¹*