Camel-Hump T-Wave, Tee-Pee Sign, and Wavy Triple Sign (Yasser’s Sign) with Hypocalcemia and Hyperkalemia in Covid-19 Pneumonia with Lacunar Infarction

Rationale: A novel COVID-19 is a multi-systemic critical worldwide pandemic infection. Certainly, associated multiple electrolytes imbalance in COVID-19 pneumonia is a remarkable decisive event. Camel-hump T-wave, Tee-Pee sign, and Wavy triple sign (Yasser’s sign)are novel highly significant descriptive electrocardiographic signs that are seen in calcium and potassium disturbance. There is an established and strong relationship between and electrocardiographic abnormalities and electrolytes imbalance. COVID-19 pneumonia and cerebrovascular stroke are commonly seen in a patient with Coronavirus infection. Patient concerns: A 69-year-old married worker Egyptian male patient was presented to the emergency department with COVID-19 pneumonia and cerebrovascular stroke. Diagnosis: COVID-19 pneumonia with lacunar infarction, hypocalcemia, and hyperkalemia. Interventions: Chest CT scan, brain CT scan, electrocardiography, oxygenation, and echocardiography. Outcomes: Initial bad and deterioration outcome but, the dramatic outcome had happened after later management. Lessons: The understanding of electrocardiographic signs regarding metabolic disorders such as electrolytes imbalance and other associated systemic diseases is very important. Elderly male sex, heavy smoker, COVID-19 pneumonia, cerebrovascular stroke, chronic renal impairment, ischemic heart disease, hypokalemia, hypocalcemia, and hypernatremia represent bad prognostic points and is indicating a high-risk condition.

Transcriptomic and Metabolomic Profiling in Helicobacter pylori–Induced Gastric Cancer Identified Prognosis- and Immunotherapy-Relevant Gene Signatures

Background: Chronic Helicobacter pylori (HP) infection is considered the major cause of non-cardia gastric cancer (GC). However, how HP infection influences the metabolism and further regulates the progression of GC remains unknown.Methods: We comprehensively evaluated the metabolic pattern of HP-positive (HP+) GC samples using transcriptomic data and correlated these patterns with tumor microenvironment (TME)–infiltrating characteristics. The metabolic score was constructed to quantify metabolic patterns of individual tumors using principal component analysis (PCA) algorithms. The expression alterations of key metabolism-related genes (MRGs) and downstream metabolites were validated by PCR and untargeted metabolomics analysis.Results: Two distinct metabolic patterns and differential metabolic scores were identified in HP+ GC, which had various biological pathways in common and were associated with clinical outcomes. TME-infiltrating profiles under both patterns were highly consistent with the immunophenotype. Furthermore, the analysis indicated that a low metabolic score was correlated with an increased EMT subtype, immunosuppression status, and worse survival. Importantly, we identified that the expression of five MRGs, GSS, GMPPA, OGDH, SGPP2, and PIK3CA, was remarkably correlated with HP infection, patient survival, and therapy response. Furthermore, the carbohydrate metabolism and citric acid may be downstream regulators of the function of metabolic genes in HP-induced GC.Conclusion: Our findings suggest that there is cross talk between metabolism and immune promotion during HP infection. MRG-specific transcriptional alterations may serve as predictive biomarkers of survival outcomes and potential targets for treatment of patients with HP-induced GC.

Perbedaan Indeks Trombosit (PDW, MPV, P-LCR, PCT) dan Jumlah Trombosit Antara Pasien Infeksi Dengue Primer dan Sekunder Di RSUD Dr. H. Abdul Moeloek Provinsi Lampung

Demam berdarah dengue termasuk penyakit endemik yang disebabkan oleh virus dengue. Manifestasi klinis ditandai oleh trombositopenia. Trombositopenia terjadi melalui mekanisme supresi sumsum tulang, destruksi dan pemendekan masa hidup trombosit. Selain jumlah trombosit, terdapat indeks trombosit yang diketahui sebagai aktivasi trombosit yaitu PDW, MPV, P-LCR dan PCT. Tujuan penelitian untuk mengetahui perbedaan indeks trombosit (PDW, MPV, P-LCR, PCT) dan jumlah trombosit pada pasien infeksi dengue primer dan sekunder di RSUD Dr. H. Abdul Moeloek Provinsi Lampung. Penelitian ini menggunakan metode analitik cross-sectional. Populasi yaitu pasien infeksi dengue primer dan sekunder menggunakan metode total sampling dengan jumlah sampel sebanyak 35 pasien. Data diperoleh dari rekam medis di RSUD Dr. H. Abdul Moeloek Provinsi Lampung. Analisis data dengan uji independent T test dan uji Mann Whitney. Dari 35 data didapatkan hasil yang terinfeksi dengue primer sebanyak 13 orang (37,1%) dan 22 orang (62,9%) terinfeksi dengue sekunder. Median PDW infeksi dengue primer 9,7±1,24% dan sekunder 10,75±1,87%. Median MPV infeksi dengue primer 9,7±2,25fL dan sekunder 10,087±0,84fL. Rerata P-LCR infeksi dengue primer 20,58±7,93% dan sekunder 25,33±6,84%. Median PCT infeksi dengue primer 0,17±1,07% dan sekunder 0,18±0,07%. Rerata jumlah trombosit infeksi dengue primer 169.523,08±57.590,713/µL dan sekunder 179.318,18±75.082,422/µL. Hasil uji statistik didapatkan nilai p; PDW nilai p=0,068, MPV nilai p=0,538, P-LCR nilai p=0,101, PCT nilai p=0,973 dan jumlah trombosit nilai p=0,393. Tidak terdapat perbedaan bermakna antara indeks trombosit (PDW, MPV, P-LCR, PCT) dan jumlah trombosit untuk infeksi dengue primer dengan sekunder. Dengue hemorrhagic fever is endemic disease caused by dengue virus.. Clinical symptomp marked by trombositopenia. Trombositopenia occurs through in mechanism of bone marrow suppresion, destruction and shortening of platelet life span. Morever platelet count, there are platelet index who known as platelet activator are PDW, MPV, P-LCR and PCT. This research to determine the difference platelet index (PDW, MPV, P-LCR, PCT) and platelet count between primary and secondary dengue infection patient at Regional General Hospital Dr. H. Abdul Moeloek Lampung Province. The research use analytic observational method with cross-sectional research design. Population are patient who diagnosed with primary and secondary dengue infection and using total sampling method for sampling with 35 patient. Data obtained from Regional General Hospital Dr. H. Abdul Moeloek Lampung Province. Data were analyzed by independent T test and Mann Whitney test. Based on 35 data from medical records, the patient who diagnosed as primary dengue infection are 13 people (37,1%) and 22 people (62,9%) who diagnosed as secondary dengue infection. Median of PDW primary dengue infection was 9,7±1,24% and secondary dengue infection was 10,75±1,87%. Median of MPV primary dengue infection was 9,7±2,25fL and secondary dengue infection was 10,087±0,84fL. Mean of P-LCR primary dengue infection was 20,58±7,93% and secondary dengue infection was 25,33±6,84%. Median of PCT primary dengue infection was 0,17±1,07% and secondary dengue infection was 0,18±0,07%. Mean of platelet count primary dengue infection was 169.523,08±57.590,713/µL and secondary dengue infection was 179.318,18±75.082,422/µL. Based on the result of statistical analyisis data, PDW p value =0,068, MPV p value=0,538, P-LCR p value=0,101, PCT p value=0,973 and platelet count p value=0,393.There are no significant differences platelet index (PDW, MPV, P-LCR, PCT) and platelet count in primary with secondary dengue infection.

AB0668 THE ONSET OF RHEUMATOID ARTHRITIS AFTER COVID-19 – COINCIDENCE OR CONNECTED?

Background:COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been suggested to induce autoimmune phenomena. Multiple studies have reported the presence of autoantibodies in patients with COVID-19. Also the presence of anti-citrullinated protein antibodies (ACPA) and flaring of rheumatoid arthritis (RA) after COVID-19 has been described.[1, 2] Furthermore, in rheumatology clinics patients may present with polyarthritis compatible with RA shortly after SARS-CoV-2 infection. However, it is unclear how often ACPA occur after COVID-19 and whether preceding COVID-19 impacts on disease presentation of RA and phenotype of the ACPA response.Objectives:This study aims to determine the seroprevalence of ACPA after COVID-19 and to investigate the association between preceding COVID-19 infection and disease presentation of new-onset RA, including clinical phenotype and autoantibody response.Methods:To estimate the prevalence of ACPA after COVID-19 we measured ACPA IgG in samples from 61 patients visiting the specialized post-COVID outpatient clinic of the LUMC 5 weeks after hospitalization, using routine tests or in-house ELISA. Furthermore, we identified 5 patients presenting with polyarthritis compatible with RA after SARS-CoV-2 infection. To study the impact of COVID-19 on disease presentation, we examined clinical phenotype, autoantibody isotype positivity and ACPA IgG variable domain (V-domain) glycosylation of these patients and compared these features to regular RA patients. Autoantibody isotypes, including rheumatoid factor (RF) IgM/IgA, anti-CCP2 IgG/ IgM/IgA and anti-carbamylated protein antibodies (anti-CarP) IgG were measured using in-house ELISA’s. The percentage of V-domain glycosylation of purified ACPA IgG was measured with UHPLC.Results:None of the 61 post-COVID patients tested positive for ACPA 5 weeks after hospitalization, except two patients previously diagnosed with ACPA-positive RA. Thus, we could not observe an increase in ACPA-positivity shortly after COVID-19. Of the 5 patients who developed polyarthritis compatible with RA after SARS-CoV-2 infection, the average age was 63.6 years and 2/5 were female. 4/5 patients had been hospitalized due to severe COVID-19. On average, joint complaints started 6.6 weeks after infection, although two patients reported symptoms before infection. 4/5 patients fulfilled the ACR 2010 criteria for RA. Three patients (patient 1, 4, 5) were phenotypically very similar to regular new-onset RA patients. Patient 3 had a history of seronegative RA and had been in DMARD-free remission for 5 years. She flared 6 weeks after SARS-CoV-2 infection. Patient 2 had a remarkably different presentation. He was admitted with a suspected septic polyarthritis or pneumonia with reactive polyarthritis 6 weeks after COVID-19. ACPA level was low positive. The patient died unexpectedly after two days and autopsy revealed dilating myocarditis of unclear underlying cause. No causative pathogen could be identified.Previous studies have shown that RA-patients are most often either seronegative or triple-positive for RF, ACPA and anti-CarP antibodies. Autoantibody measurements on sera of the post-COVID polyarthritis patients revealed a similar pattern (Figure 1A) with two patients being completely seronegative, and three patients positive for a range of autoantibodies. In all post-COVID samples, the percentage of ACPA IgG V-domain glycosylation was significantly increased compared to total IgG (Figure 1B), similar as in regular RA.Conclusion:In conclusion, we found that the seroprevalence of ACPA is not increased post-COVID and that most patients presenting with polyarthritis after COVID-19 resemble regular RA patients, both regarding clinical phenotype and autoantibody characteristics. Although sample size and follow-up was limited, it appears that RA post-COVID may be coincidence rather than connected.References:[1]Vlachoyiannopoulos et al. Ann Rheum Dis, 2020.[2]Perrot et al. The Lancet Rheumatology, 2020.Disclosure of Interests:None declared.

Case Report: Viral Pneumonia Could Prompt the Advancement of Immune-Mediated Liver Disease

Background: The impact of the influenza A (H1N1) and SARS-CoV-2 virus on the development of autoimmune hepatitis has not been described previously.Methods: In this case series, we evaluated the dynamic changes in liver function of three patients with autoimmune hepatitis who presented with viral infection (two with the H1N1 and one with the SARS-CoV-2 virus) during the recent COVID-19 outbreak.Result: Patient 1 was a 68-year-old woman with a history of hepatitis of unknown origin before being infected with the H1N1 virus. Autoimmune hepatitis with an exacerbation of liver injury was diagnosed during the infection. Patient 2 was a 48-year-old woman with pre-existing autoimmune hepatitis. Despite being on immunosuppressant therapy (using glucocorticoids), liver injury recurred with elevated total bilirubin and gamma-glutamyl transferase levels post H1N1 infection. Patient 3 was a 61-year-old woman with probable autoimmune hepatitis. Liver injury recurred with a flare in alanine transaminase/aspartate transaminase levels post SARS-CoV-2 infection, in spite of the patient being on liver protection therapy (using ursodeoxycholic acid).Conclusion: The case series raises the possibility that COVID-19 or influenza induced pneumonia triggers the progression of autoimmune hepatitis.

A Novel Case of Hyperinsulinemic Hypoglycemia in a Neonate With SARS-CoV-2 Infection

The Case: An 8 days old male, born at 40 wks, 2.8 kg (SGA) presented to local ED with lethargy, decreased PO intake and urine output, respiratory distress. No fever, URI sx, vomiting/diarrhea. His dad had URI symptoms and fever a week prior. He was found to have T=95.5F, glucose <10 mg/dL, improved to 125 after D10 boluses x2; and required supplemental O2 due to desats/cyanosis. CXR showed bilateral hazy opacities. Sepsis rule out was initiated, patient admitted to the PICU, started on antibiotics and dextrose. Patient became more alert over the next 3 days, but could not be weaned off from IV dextrose/continuous feeds, GIR up to 15 mg/kg/min. He was transferred to our institution. Critical sample at BG of 45 mg/dl showed high insulin level (6.9 uU/ml) and C-peptide (1.25 ng/dl); low beta-OH butyrate <0.2 mmol/L; and free fatty acids (0.25 mmol/L); all suggestive of hyerperinsulinemic hypoglycemia (HH). Cortisol and GH robust at 10.5 mcg/dl and 7.13 ng/ml. Nasopharyngeal swab for SARS-CoV-2 RT-PCR positive. Dad’s swab also positive. Mom was asymptomatic and not tested. ID was consulted, recommended supportive management and close observation. Pt was started on Diazoxide 10mg/kg/day divided q8h, and hydrochlorothiazide (HCT) 5mg/day. Patient’s status gradually improved - BG stabilized, feeds were compressed, IV fluids and O2 supplementation weaned off, and was discharged after 8 days with average BG in the 70-80’s range. Diazoxide and HCT were successfully weaned off in the following 3 mos. To this day patient remains well, no recurrence of hypoglycemia. Discussion/Conclusion: There is a dearth of information on SARS-CoV-2 infection in newborns. The few studies available show favorable outcomes in this population, with typical mild-moderate respiratory symptoms and fever, while some newborns are asymptomatic. Our patient required oxygen tx and developed HH requiring Diazoxide therapy. To our knowledge, this is the first reported case of HH in the newborn with SARS-CoV-2 infection. Hyerperinsulinism is the most common cause of hypoglycemia in infants. These newborns are at risk of developing significant neurologic morbidity, which can be dose dependent. Prompt diagnosis and aggressive management are important to reduce such risk. Perinatal stress is likely the underlying mechanism leading to HH in newborns with SARS-CoV-2 infection. Patient is also SGA. Both perinatal stress and SGA can lead to inappropriately elevated insulin levels and resultant hypoglycemia. HH in both of these conditions is effectively managed by Diazoxide. Our case illustrates that although most newborns do well with SARS-CoV-2 infection, a high index of suspicion for HH should be maintained in such newborns, particularly in those with at least one other risk factor for HH such as SGA. More studies are needed to elucidate underlying pathology and tease out actual incidence of hypoglycemia in neonates with SARS-CoV-2 infection.

Test dosing as an alternative treatment approach in urinary tract infection patient with Cefoperazone allergy

Drug hypersensitivity reaction (DHR) is classified as adverse reaction which is based on immunologic mediated reaction. Antibiotics are the most frequently prescribed drugs given to patients to treat bacterial infections, but also cause adverse drug reactions due to hypersensitivity in patients. We present here a case of cefoperazone drug allergy in a 75 years old patient with urinary tract infection requiring the test dosing approach.

Rare and interesting case of solitary peripheral pulmonary artery aneurysm

We report a rare case of solitary peripheral pulmonary artery aneurysm in a patient who was evaluated for haemoptysis. Incidentally, his total antibodies were positive for Coronavirus 2019 infection. Patient underwent right lower lobectomy uneventfully. Peripheral pulmonary artery aneurysms arising from segmental or intrapulmonary branches are extremely rare. Untreated, the majority end fatally due to sudden rupture and exsanguination. The purpose of this article is to report our rare case and review the pertinent literature.