ABSTRACT
Humanistic geographers distinguish between space and place: "What begins as undifferentiated space becomes place as we get to know it better and endow it with value" [19, page 6]. In this essay, we seek to demonstrate how mathematics education researchers and mathematics instructors may find space and place il-luminating for understanding important aspects of students' learning experiences during the coronavirus pandemic - and possibly beyond. Specifically, after in-tro ducing the terms and relating them to the context of a university mathematics class, we exemplify how home and class places collided for three undergraduate mathematics students forced to deal with the abrupt transition to online educa-tion. We conclude by discussing implications of attending to space and place for designers and researchers of (pandemic) online instruction and make connections to how the pandemic and attending to space and place can serve as a catalyst for reshaping undergraduate mathematics education.
ABSTRACT
Unexplained hypoxia in a pregnant patient is an alarming finding for patient and provider. The differential for hypoxia is broad, and many imaging techniques and procedures are contraindicated in pregnancy. Transient pulmonary arteriovenous malformations (AVMs) are a rare and relatively poorly studied cause of hypoxia in pregnancy. Our patient is a 27-year-old G1P0 female with a remote history of asthma who presented to clinic with slowly progressive exertional dyspnea, exertional tachycardia, and paroxysmal nocturnal dyspnea. She reported use of a home oximeter which read in the high 80s% during exertion. Prior to presentation, the patient was evaluated in the Emergency Department and noted to have an oxygen saturation of 86% on room air. A transthoracic echocardiogram, computed tomography angiography of chest, and basic laboratories including B-type natriuretic peptide, troponin, COVID-19, and hemoglobin were unremarkable. Her clinical timeline is presented in Figure 1. Further testing was obtained, including pulmonary function testing, bubble echocardiogram, nocturnal oximetry, and shunt study. Work-up revealed a 15-20% shunt, depending on calculation, and insignificant desaturations during nocturnal oximetry. Her symptoms progressed, and repeat nocturnal oximetry showed marked overnight desaturations requiring supplemental oxygen for the remainder of her pregnancy. She delivered a healthy baby girl via cesarean section without serious complication. Repeat testing in the post-partum period showed resolution of nocturnal desaturations and decreased shunt, and her exertional dyspnea and desaturations resolved spontaneously. This case illustrates the challenging diagnosis of transient pulmonary AVM in pregnancy. Case reports of this phenomenon have been published, but as in our case, no definitive diagnosis was made secondary to testing limitations in pregnancy and quick resolution of symptoms in the post-partum period. Some reports describe pre-existing pulmonary AVM becoming worse during pregnancy causing hemothorax, fetal demise and even death. While the mechanism is not known, theories include the vasodilatory effects of progesterone on vascular smooth muscle as well as other physiologic changes in pregnancy such as increased plasma volume. These AVM are thought to be like those seen in hepatopulmonary syndrome. Similar to our case, increasing positional hypoxia has been reported as the pregnancy progresses. Further research dedicated to early and accurate detection of pulmonary AVMs in pregnancy is necessary. (Figure Presented).
ABSTRACT
Introduction: Sarcoidosis is a systemic granulomatous disease which may involve the liver in ∼11.5% of cases. Coronavirus disease 2019 (COVID-19) can induce a systemic, pro-inflammatory state but the development of systemic sarcoidosis after COVID-19 has not been described. We present the case of a newly diagnosed systemic sarcoidosis after COVID-19 infection. Case Description/Methods: A 50 year old male patient was evaluated for increased liver enzymes. He had a history of familial hypercholesterolemia, fatty liver disease, and diabetes mellitus. Seven months prior he was admitted to the hospital with shortness of breath, cough, lightheadedness, nausea and was diagnosed with COVID-19. After recovery, he developed pleurisy. CT scan showed mediastinal lymphadenopathy and scattered nodules. PET scan showed uptake concerning for reactive nodes, chronic granulomatous disease or lymphoproliferative disease. Subsequent lymph node aspirate found noncaseating granulomas consistent with sarcoidosis. He was referred to hepatology for abnormal liver enzymes (ALT 104, AST 81, Alkaline Phosphatase 216, Total Bilirubin 1.1). Tests for viral/autoimmune hepatitis, AMA, ANA, hemochromatosis, A1AT and ceruloplasmin were negative. Liver US showed steatosis and no evidence of obstruction. Transient elastography by FibroScan confirmed steatosis, CAP score of 347 and stiffness of 28kPa consistent with cirrhosis or infiltrating disease. Liver biopsy (Figure 1) revealed marked granulomatous inflammation with 10- 20% macro/micro-steatosis and stage 2-3 portal fibrosis. AFB stains were negative. Given the marked inflammation and fibrosis, the patient was started on prednisone 40mg daily with 4 week labs showing liver enzyme improvement (ALT 80, AST 31, Alk Phos 149, T Bili 0.6). Prednisone resulted in hyperglycemia requiring insulin, so azathioprine was started as steroid sparing treatment with budesonide added which he tolerated well. Discussion: Multisystem inflammatory syndrome in adults (MIS-A) is a rare complication of COVID-19. This case represents a unique type of MIS-A with hepatic sarcoidosis. The liver may be affected during COVID-19 with liver enzymes elevation reported in 20-30% of those with acute infection. After recovery, persistent elevation in hepatic transaminases and alkaline phosphatase should alert the clinicians to investigate for MIS-A triggered diseases such as sarcoidosis.