ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

Fixed Drug Eruption Secondary to Fluconazole Confirmed by Self-Challenge

Introduction: Fixed drug eruption (FDE) can have a wide array of culprits, especially in patients who use multiple medications. We present a patient with Fixed Drug Eruption (FDE) secondary to fluconazole. Case Description: A 36-year-old female was evaluated for recurrent pruritic and tender violaceous to hyperpigmented patches on her face (Figure 1A), neck, upper extremities, buttocks, flank, and genitals. Patches would blister after 2-3 days. These lesions occurred every 2-3 months for 1 year with Non-Steroidal Anti-inflammatory Drugs (NSAIDs) or fluconazole, and after her second Pfizer COVID-19 vaccine with acetaminophen as premedication. Punch biopsy showed focal dyskeratosis, papillary dermal eosinophils and neutrophils (Figure 1B). She was diagnosed with FDE and instructed to avoid NSAIDs, Polyethylene Glycol (PEG), over-the-counter medications, and fluconazole. Patch testing was performed for fluconazole (pet 5%), ibuprofen (pet 5%), celecoxib (pet 10%), povidone (pet 2% and liquid), and croscarmellose (pet 10% and liquid). All patch tests were negative at 48 hours, 72 hours, 5 days, and 7 days readings. Prior to performing a provocation test, the patient self-administered fluconazole for vaginal itching and the FDE recurred within 2 minutes on the same locations. She tolerated celecoxib and COVID19-vaccine booster without adverse reactions. The patient was instructed to avoid all azoles and use alternative agents. Discussion(s): When multiple possible agents are suspected in FDE, patch testing followed by provocation tests may be considered. In this case, the diagnosis was confirmed by self-administration of fluconazole. Copyright © 2022

Erythema multiforme-like lesions and COVID-19

A 27-year-old man presented to Accident and Emergency with an itchy rash over the thighs and buttocks. This followed 2 days of fever, headache and malaise. His past medical history was unremarkable and there was no regular medication use. He was unvaccinated. There was no history of previous erythema multiforme (EM) or herpes simplex virus (HSV) infection. He was febrile but otherwise haemodynamically stable. Clinically, over the thighs and buttocks there was a symmetrical rash consisting of striking urticated targetoid lesions. Some had a dusky centre and had coalesced over the thighs. There was no mucosal involvement. A SARS-CoV-2 polymerase chain reaction test was positive. Mycoplasma serology and swabs for HSV were negative. Other bloods were unremarkable. A skin biopsy from affected skin showed spongiosis and a mild dermal lymphocytic infiltrate. There was an absence of necrotic keratinocytes. He was treated with 5 days of prednisolone (30 mg) and potent topical steroids. There was complete clinical resolution of the rash in a week. In the published literature there are a small number of EM-like eruptions in the context of COVID-19 infection. Similar to our patient, skin biopsies often show features not typical of EM, including spongiosis and a lymphocytic perivascular and interstitial infiltrate (Torrelo A, Andina D, Santonja C et al. Erythema multiforme-like lesions in children and COVID-19.

Paediatric inflammatory multisystem syndrome (PIMS-TS): a novel condition

Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 infection (PIMS-TS) is a novel condition which has recently emerged during the COVID-19 pandemic, consisting of persistent fever, inflammation, and evidence of single- or multiorgan dysfunction, with additional features where any other microbial causes has been excluded (https://www.rcpch.ac.uk/resources/paediatric-multisysteminflammatory- syndrome-temporally-associated-covid-19-pimsguidance). A 16-year-old healthy male presented with a 48-h history of headache, fever, diarrhoea, vomiting and a widespread rash. One month prior he had contracted SARS-CoV-2 with no complications. On examination there was a maculopapular rash across the trunk and buttocks with petechiae present on the lower limbs and flexural folds in addition to an erythematous rash across the nasal dorsum and cheeks. Blood tests revealed lymphopaenia, thrombocytopenia, hypertriglyceridaemia and raised C-reactive protein and ferritin. Autoimmune screen and SARS-CoV-2 polymerase chain reaction tests were negative. A skin biopsy revealed features of a SARS-CoV-2 related urticarial reaction pattern. The patient was treated for myocarditis, fulfilling the diagnosis of PIMS-TS. He was transferred to a specialist intensive care unit and treated with intravenous immunoglobulins and steroids, infliximab, aspirin and topical steroids. He is currently undergoing investigations for encephalitis post admission. PIMS-TS is a rare syndrome that shares features with Kawasaki disease, toxic shock syndrome, macrophage activation syndrome and bacterial sepsis. Haemophagocytic lymphohistiocytosis has also been linked to SARS-CoV-2 (Retamozo S, Brito-Zerón P, Sisó- Almirall A et al. Haemophagocytic syndrome and COVID-19. Clin Rheumatol 2021;40: 1233-44). Clinicians should consider PIMS-TS as a differential in any child presenting with a fever, rash and evidence of systemic inflammation. Early recognition, involvement of a multidisciplinary team and prompt referral to critical care is essential in managing this life-threatening condition.

Determiners of pressure ulcers formation – analyses from hospital information system

Introductions: Pressure ulcers (PUs) represents an undesirable complication during hospitalization. Aim: Retrospective data analysis to verify the prevalence of PUs since 2015 (since the mandatory registration of the PUs an adverse event) by principal diagnosis, type of surgery and length of hospital stay in the period 2015–2021. Sample and methods: Retrospective analysis of data from the hospital information system (HIS), at 0.05 level of significance (T-Test) with the variables: age, number of pressure ulcers, principal diagnosis, operation, length of hospitalization and prevalence of COVID-19 to length of hospitalization. Results: A total of 2,350 PU cases in 1,539 patients (1.52 PUs/patient) were registered in the HIS, and 930 (40%) patients were admitted to hospital with PUs. The most common locations of PUs were: heel (33%), sacrum 6% less, buttocks (17%). Between 2015 and 2021;17,247 patients were operated on, of whom 289 had a Pus. The most common principal diagnosis in the occurrence of PUS was femoral neck fracture (14.35%) and neurological (9.09%) or oncological disease (12.03%). The incidence of PUs was surprising in patients with ileal conditions (11.57%). COVID-19 was found in 163 patients in 2020 and 2021, six of whom had PUs and prolonged hospitalization. Conclusion: It is important to view the health status of people with chronic wounds and PUs in a comprehensive manner and to develop an individualized care plan to improve patients‘ lives and chances of recovery.

NEWER CONTINUOUS GLUCOSE MONITORING SYSTEMS

“Newer Continuous Glucose Monitoring Systems” Satish K. Garg, MD Professor of Medicine and Pediatrics, Director of adult Diabetes program, University of Colorado Denver and Barbara Davis Center for Diabetes, Aurora, Colorado. Over the past decade there have been many advances in diabetes technologies, such as Continuous Glucose Monitoring devices/systems (CGMs), insulin-delivery devices, and hybrid closed-loop systems. There have been significant advances in CGMs in the past decade. In fact, ten years ago very few people use to believe in the use of CGMs, even though they had been available for the past two decades. Many providers used to question who, why, and when will patients ever use CGMs similar to the questions asked about Self-Monitoring of Blood Glucose (SMBG) about four decades ago. At the time of this writing, more than five million people world-wide are using a CGM for their diabetes management, especially those who require insulin (all patients with Type 1 diabetes (T1D) and about 20% of patients with Type 2 diabetes (T2D)). Total sales of all CGMs now exceeds more than $7 billion and the use of SMBG is going down every day. Most of the CGMs have improved their accuracy significantly in the past two decades. I still remember doing studies on the GlucoWatch and earlier versions of Dexcom STS where mean absolute relative difference (MARD) used to be in the range of 15-26%. Now most of the CGMs (Guardian by Medtronic, G6 by Dexcom, and Libre 2 by Abbott) have single-digit MARD. In addition, the majority of the new CGMs do not require calibrations and the newer CGMs last for 10-14 days. An implantable CGM by Senseonics (Eversense®) is approved in the USA for 3 months and a different version is approved in Europe for 6 months. FDA has still not approved the 6-month version of Eversense® implantable sensor in the USA, which also has single-digit accuracy. The newer CGMs that are likely to be launched in the next 3-6 months;hopefully around the ATTD Conference, include 10.5-day Dexcom G7 (60% smaller than the existing G6), 7-day Medtronic Guardian 4, 14-day Libre 3, and 6-month Eversense®. Most of the newer CGM data can be viewed on Android or iOS/iPhone smart devices, and in many instances they have several features like predictive alarms and alerts, easy insertion, automatic initialization (in some instances down to 27 mins, Dexcom G7) with single-digit MARDs. It has also been noticed that arm insertion site might have better accuracy than abdomen or other sites like the buttock for kids. Lag time between YSI and different sensors have been reported differently, sometimes it's down to 2-3 mins;however, in many instances, it's still 15-20 mins. Diabetes effects communities of color disproportionately higher. For example, the highest prevalence of diabetes in the USA is amongst Native Americans (14.7%), which is nearly two times higher than Caucasians. African Americans and Hispanics also have higher prevalence of diabetes in the USA. It's also known that LatinX, African Americans, and Native Americans are much less likely to be offered new technologies like continuous subcutaneous insulin infusion (CSII/insulin pumps) and CGMs. Use of technology, especially CGMs, is expected to remove many of the social barriers and disparities in care for people with diabetes. A large database during the COVID-19 pandemic recently reported better Time-in-Range (TIR) in patients with diabetes irrespective of their ethnic background. However, the baseline TIR was significantly lower for minorities as compared to Caucasians. I believe the future will bring a larger increase in the use of CGMs for people with insulin-requiring diabetes (estimated at more than 100 million people globally) and those with T2D on non-insulin therapies (estimated at more than 400 million people globally). I also envision an increase in the number of pre-diabetes patients (estimated at more than 200 million people globally) using CGMs so that early medical intervention for diabetes management can be entertained. The intermittent or continuou use of CGM would depend upon the clinical needs. Needless to say, healthy individuals without diabetes (who can afford CGMs) might even use these technologies for self-evaluation of their glucose profiles after meals.

Musculoskeletal Symptoms and its Associated Factors among Post Covid-19 hospitalized patients

Background: COVID-19 also called SARS-COVID-19 infects the respiratory system and affects multiple organ systems directly or indirectly, counting the musculoskeletal system. Individuals who are infected with COVID-19 indicate numerous musculoskeletal symptoms including myalgia, fatigue, osteoporosis, and osteonecrosis was communal in patients with moderate to severe intensity of disease. Aim: To discover the prevalence of MSK symptoms in COVID-19 recovered patients who were hospitalized and the association between these MSK symptoms and associated factors. Method: A descriptive type of cross-sectional study directed with 452 patients. Non-probability convenient sampling technique was used to select patients. Data was collected from patients who were diagnosed with COVID-19 test and received medical treatment, then had negative test results, presented with musculoskeletal symptoms within age range of 20-60 years. Results: Among 452 patients, with 294 (65%) of male and 158 (35%) were females and the mean age of the patients were 25 years. The data revealed 167 (36.95%) complained of pain in neck and 269 (59.51%) complained of shoulder pain, with 175 (38.71%) patients who had upper back ache after COVID-19, 188 (41.59%) had low back pain, 156 (35%) had pain in buttocks, thighs and hip, 166 (37%) had pain in thighs and feet. Conclusion: Our study concluded that COVID-19 was a significant cause of musculoskeletal impairments in COVID-19 recovered patients. The results of study exposed a significant association between different factors which would be cooperative in future for further researches.

Sweet syndrome induced by adenovirus vector CoViD-19 vaccine

Introduction: Sweet syndrome (SS) is a rare skin disease, characterized by rapid onset of plaques or nodules with extensive infiltration of neutrophils into epidermidis and dermis. Three main types of SS are known: classical or idiopathic, malignancy-associated, drug-induced. Case report: A 69 yo woman was admitted because of recent pirexya, painful and asymmetric erythematous plaques on legs and buttock, painful wrist and elbow tenderness for 6 days. History: hypertension and dyslipidemia. Eighteen days before she received Vaxzevria first dose. Physical examination revealed normal findings except of skin lesions. Biohumoral exams showed increased CRP, normal GB count;negative SARS-CoV-2 test, as well as HBV, HCV, CMV, EBV, Quantiferon, ANA, ANCA, LAC. C3 and C4 were normal. Blood and skin coltures were negative. Chest X-ray, ECG, ecocardiography, EGDS, colonscopy, PET TC were all normal. A broad spectrum antibiotic and anti-inflammatory therapy was initially set (vasculitis vs staphylococcus infection). Skin biopsy was performed: it showed a dense interstitial neutrophilic infiltrate of the dermis, according with SS. Corticosteroid therapy caused a prompt improvement of skin lesions. Conclusions: A classical SS induced by SARS-CoV-2 vaccine was diagnosed at the discharge. A vaccine-associated SS is well known: some post CoViD and post mRNA SARS-CoV-2 vaccine SS are described in literature. This is probably the first case of a SS induced by SARS-CoV-2 adenovirus vaccine. An alert was sent to AIFA.

A rare case of anti-tnf induced panniculitis

Case report-IntroductionPanniculitides comprise a heterogeneous group of inflammatory diseases involving the subcutaneous fat. They remain the most challenging areas for clinicians. Skin biopsy is commonly needed to confirm diagnosis. Because there are many underlying aetiologies for panniculitis, detailed history and thorough investigations are needed. We present a case of A 20-year male who was admitted with painful lumps treated initially as cellulitis/abscess but turned to be neutrophilic panniculitis on skin biopsy. Extensive workup failed to reveal underlying aetiology. Eventually Imradli (AntiTNF) was thought to be the culprit and therefore was kept on hold with no recurrence of panniculitis.Case report-Case descriptionA 20-year-old, Asian Malawian. Moved to the UK at the age of 6. He was diagnosed with Ankylosing spondylitis in November 2016. Initially received Naproxen followed by (Humira) with good clinical response. He was switched to biosimilar Imradli in Nov 2019. He was admitted with 2-3 weeks history of progressive right hip and buttock pain, 1 week of very tender erythematous swelling of the right buttock but without fever or weight loss. He reported mild weakness of lower limbs. Physical examination revealed 5x 8 cm swelling on Right buttock, Rest of examination was unremarkable. He was reviewed by neurology team who arranged MRI spine and brain, EMG and lumbar puncture which all came back as unremarkable excluding the possibilities of myelitis and myositis. Initially thought to be abscess/cellulitis but absence of fever/inflammatory response, abnormal CT finding and no response to antibiotics made it less likely. While the Right buttock erythema/swelling started to resolve, he developed two new migratory erythematous lesions appearing around the left buttock and lower lumbar spine. Working diagnosis of panniculitis was made which was confirmed on biopsy. Due to lack of response to NSAIDs, colchicine or oral steroids, a 3rd biopsy of the freshest lesion was performed to exclude deep-seated infection.Investigations-FBC, U&ES, LFT, CRP, CK, ACE-all were unremarkableASO titre <200, serology for Borrelia and TPHA negative.Viral, parasitic, and Autoimmune screen were unremarkable.CXR clear, MRI/CT: extensive subcutaneous inflammatory changes in the right buttock with sacral oedema.PET-CT-showed resolving inflammatory changes in the right flank, FDG intake in C6 and SI joints presumed secondary to ankylosing spondylitis and sacroiliitis.The underlying cause of panniculitis remains uncertain. Anti TNF was kept on hold and the patient was followed up with no evidence of recurrence of panniculitisCase report-DiscussionPanniculitis (inflammation of subcutaneous fat) is a relatively uncommon condition. It has various aetiologies including infection, trauma, inflammation, and malignancy. Skin biopsy can give valuable information including microbiological studies if infectious panniculitis was suspected. However, clinical correlation and careful consideration of the differential diagnosis is needed in many cases.The diagnosis can be quite challenging as in this case where all investigations and skin biopsy could not point towards the underlying aetiology. Although anti-TNF inhibitors are commonly used in treating a wide range of autoimmune conditions. But their use can lead to the development of secondary autoimmune diseases, such as cutaneous vasculitis, lupus-like syndrome, and interstitial lung disease, paradoxically induced by anti-TNF-a agents. Llamas-Velasco and Requena, reported the first case of panniculitis induced by etanercept injection in a 62-year-old woman with severe psoriasis who developed an erythematous, slightly painful nodule on the skin of the anterior abdominal wall.Adalimumab induced lupus panniculitis was reported in a Rhu-lupus patient. Although the lesions stopped progressing after cessation of adalimumab, they remained unchanged for two more years. The mechanism for adalimumab-induced CLE is uncertain.Although there is not enough data about autoimmunity with biosimilars, we think seco dary autoimmune conditions could similarly be induced by biosimilar as illustrated in this case. Anti-TNF induced cutaneous panniculitis is considered most likely although uncertain. If anti-TNF drug-induced, this should gradually resolve but can be slow (4-6 months). Corticosteroids have been added for an anti-inflammatory response, but there was little benefit which might point to a different pathogenetic mechanism.NSAIDs has helped to keep his AS relatively stable during the COVID-19pandemic. During the last review, the patient expressed his wishes to go back on biologic. But the question remains whether he will a have a recurrence of panniculitis or not?Case report-Key learning points1/Anti-TNF inhibitors sometimes cause secondary autoimmune conditions like cutaneous vasculitis, lupus-like syndrome, but there is not enough data regarding biosimilar induced autoimmunity.2/This case illustrates the high importance of having a tissue diagnosis. (whenever there is an issue, the diagnosis would be in the tissue).3/There is still uncertainty whether a recurrence of panniculitis might occur or not if the patient went again on biologics.