Acute Pancreatitis as a Rare and Unusual Manifestation of COVID-19 in a Child with Acute Lymphoblastic Leukemia

Introduction: The coronavirus disease 2019 (COVID-19) mainly causes pulmonary disease. However, extrapulmonary manifesta-tions, which affect the gastrointestinal tract and hepatobiliary system, have been reported. Case Presentation: Here we reported a 4-year-old boy with acute lymphoblastic leukemia and abdominal pain who had acute necrotic pancreatitis secondary to COVID-19. Conclusion(s): According to the COVID-19 epidemic, if drug-induced pancreatitis is ruled out, viral causes, especially COVID-19, should be considered.Copyright © 2023, Author(s).

Repeated COVID-19 infection in recipients of post-living donor liver transplantation: Two real-life cases

COVID-19 is an emerging pandemic. The course and management of the disease in the liver transplant setting may be difficult due to a long-standing immunosuppressive state. In Egypt, the only available option is living donor liver transplantation (LDLT). In our centre, we have transplanted 440 livers since 2008. In this study, we report a single-centre experience with COVID-19 infection in long-term liver transplant recipients. A total of 25 recipients (5.7 %) had COVID-19 infections since March 2020. Among these recipients, two developed COVID-19 infections twice, approximately three and two months apart, respectively.Copyright © 2021 The Author(s)

METABOLIC SUPPORT FOR PATIENTS WITH MILD COGNITIVE (DODECAMENTAL) IMPAIRMENT IN THE OUTCOME OF COVID-19.

An open comparative study was conducted to assess the efficacy and safety of cytoflavin in the treatment of 50 patients who underwent SARS-CoV-2 infection, with subsequently developed mild cognitive impairment after leaving an infectious disease hospital. The survey was carried out using the Montreal Cognitive Assessment Scale (MoCA test) for the study of cognitive status, as well as the SF-36 questionnaire to determine parameters of the quality of life of patients and to assess the level of asthenia, anxiety and depression during follow-up (at the beginning of study and after 10 days of fluid therapy). Patients of the main group received intravenous infusion of cytoflavin for 10 days at a dose of 10 mL per 100 mL of 0.9% sodium chloride solution, while the comparison group received "active placebo" (100.0 mL of 0.9 sodium chloride solution) also for 10 days. During observation, the main test group patients showed significant discrepancies in the amount of complaints such as dizziness, headache, and decreased cognitive performance versus placebo group. According to the MoCA test results, patients of the main group showed higher total score on the background of improved cognitive functions: attention improved by 13.2%, p < 0.05 (subtest "repetition" of the number series in forward and reverse order and the "cotton" subtest with letter "A");regulatory skills improved by 9.8%, p < 0.05 (speaking "fluency" subtest);visual-constructive skills improved by 11.4%, p < 0.05 ("clock drawing" subtest);phrase repetition improved by 11.3%, p < 0.05, and literature associations improved by 11.3%, p < 0,05. Based on the results of the SF-36 questionnaire, the life quality was also significantly improved, by 19.5%, p < 0.05 on the average (including physical functioning and condition, pain intensity, general condition, vitality and mental health indicators). The tolerance of cytoflavin in all patients was good and there were no side effects related to the drug. Thus, the use of cytoflavin in the complex treatment of SARS-CoV-2 patients, who suffered from the infection with encephalopathy/mild cognitive impairment developed as part of the postvoid syndrome, reduces neurological deficit and helps to restore neurocognitive functions.Copyright © 2021 Eieeaeoea aaoiia

Novel Coronavirus is the Only Virus Causing Childhood Invasive Diarrhea: A Case Series

Introduction: Typical manifestations of Coronavirus disease 2019 (COVID-19) include respiratory involvement. Gastrointestinal (GI) symptoms have also been reported as early clinical manifestations. The GI involvement can represent with diarrhea, vomiting, and abdominal pain. The present research aimed to identify dysentery as one of the signs of GI involvement in the novel coronavirus infection in children. Case Presentation: We report twelve patients with COVID-19 and dysentery. All these children had positive reverse transcriptionpolymerase chain reaction (RT-PCR) results. None had underlying illnesses or recent travel history. However, all children had contact with a first-degree relative affected by non-digestive COVID-19. In three patients, obvious dysentery was observed, and in the rest, red and white blood cells were evident in the stool exam. Stool exams were negative for bacterial infections, parasites, and the toxin of Clostridium difficile. Abdominal ultrasonography and echocardiographic evaluations to rule out multisystem inflammatory syndrome in children were normal. Supportive treatment, such as zinc supplementation and probiotics, was prescribed. They also received intravenous fluid therapy based on their dehydration percentage. In the end, they were discharged in good general condition without any complications. No GI complications were found in the follow-up series. Conclusion(s): Dysentery in children can be one of the GI manifestations of COVID-19, which is usually self-limiting. It does not require invasive diagnostic measures and antiviral treatments. This symptom is in contrast to other viral infections of the GI tract.Copyright © 2022, Author(s).

Mucormycosis, Acute Necrotising Pancreatitis and Haemorrhagic Stroke Occuring Simultaneously in an Immunocompetent Male: The Unwarned Apocalypse

Mucormycosis or zygomycosis is a life threatening invasive fungal infection, usually seen in patients with alteration of their immune system. It is a lethal and an aggressive fungal infection caused by the fungi of the order Mucorales. The angioinvasive property of mucormycosis can lead to fatal complications such as intracranial bleed. Acute pancreatitis refers to inflammation of the pancreas which presents mainly as acute pain in the abdomen and is a potentially fatal condition. The association of mucormycosis with acute pancreatitis is rare but dangerous. This case report highlights a case of 32-year-old male patient, with no co-morbidities, who was admitted to an rural central Indian hospital with four days of abdominal pain and two days of headache. Patient appeared to be in good health prior to this event. He was ultimately diagnosed with mucormycosis of paranasal sinus with acute pancreatitis. The patient was treated with intravenous antifungals, antibiotics and fluid therapy along with other supportive measures. Patient later developed intracranial bleed five days after admission, and ultimately succumbed on day seven of admission. After an extensive review of literature it was found that this is the first article to report mucormycosis, acute pancreatitis and intracranial bleed all occurring at once in an immunocompetent male.

Focused Ultrasound in Critical Care Outreach for acutely ill and deteriorating patients on the wards

Introduction: Focused Ultrasound in Intensive Care (FUSIC) refers to the use of ultrasound by a trained bedside clinician to guide patient management in real-time. Ultrasound is widely applied in practice and there is growing consensus that it is an essential tool for managing acutely ill patients in the intensive care unit (ICU). The Critical Care Outreach Team uses FUSIC as an additional assessment tool to guide management and decision-making plan for deteriorating patients on the wards. Objectives: To investigate whether how often information gained fromFUSICimaging had an impact on patient care and management decisions in a critical care outreach setting. Methods: A single-centre observational study at an academic tertiary referral institution. We included all patients reviewed by critical care outreach who were assessed by ultrasound during a 12-month period. Routine procedures for teaching purposes were not included. Results: Forty-six patients were assessed and supported by a combined focused lung and heart ultrasound performed at the patient bedside on the wards. In 46 patients FUSIC was instrumental in the differential diagnostic workup and in guiding the clinical management. In 32 (70%) patients FUSIC aided fluid therapy or diuresis (in case of pulmonary oedema) and helped targeting fluid balance. In three patients though to have consolidation on chest x-ray we were able to identify significant pleural effusions without needing an additional CT scan. In four patients with hypotension, an additional CT-PA was warranted due to dilated right ventricle (RV) with abnormal septal motion and decreased left ventricle (LV) size ratio (i.e. sign of right heart strain) as highly suspicious of pulmonary embolus. In two young patients with Coronavirus disease 2019 (COVID-19), using FUSIC we identified severe LV dysfunction which was subsequentially diagnosed as myocarditis and Angiotensin-converting enzyme (ACE) inhibitors therapy was commenced within 24 hours. Further diagnosis included cardiac tamponade (n = 2) requiring pericardiocentesis and pneumothorax (n =1). In all cases, the use of ultrasound helped in promptly referring patients to the specialist team (i.e. respiratory or cardiology) and to the ICU consultant. Conclusions: In our critical care outreach practice, FUSIC is considered an indispensable tool for safe and accurate management of acutely ill and deteriorating patients on the wards.

Multisystem Inflammatory Syndrome in Indian Children Associated with SARS-CoV-2 Infection: A Case Series ABS0026)

Introduction: The coronavirus disease 2019 pandemic has affected all the countries and age groups alike. However, during the initial part of a pandemic, COVID-19 affected children with a milder form of the disease and had better clinical outcomes than adults.1 Subsequently, a rising number of previously well children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) induced hyperinflammatory states resembling macrophage activation syndrome, toxic shock syndrome, and Kawasaki disease were reported.2 Here, we describe four children with COVID-19-associated MIS-C presenting to a tertiary care center between May 17 and June 17, 2021. They had distinct clinical features, but similar laboratory and radiological findings. However, none of them were positive for SARS-CoV-2 nucleic acid on real-time polymerase chain reaction but all of them had elevated immunoglobulin G titers against SARS-CoV-2. Case description: Four previously well children, aged 13-14 years, including equal number of males and females, presented to us with complaints of fever with rash, abdominal pain for 5-6 days. None of the patients had comorbidities, except patient 2, who was a known case of type 1 diabetes mellitus and was receiving huminsulin. At presentation, patients 1 and 4 had hypovolemic shock and dyspnea. There was mild global hypokinesia with mild tricuspid and mitral regurgitation in patient 3 and biventricular dysfunction (ejection fraction: 54%) with mild pericardial effusion in patient 4. Laboratory investigations revealed negative for malaria, dengue, scrub typhus, and leptospira in all the patients. Neutrophilia and lymphocytosis were observed in every patient. All, except patient 2, had thrombocytopenia. The international normalization ratio was raised in patients 1 and 2. All patients had negative RT-PCR for SARS-CoV-2. While, the levels of COVID-19 IgG antibody, C-reactive protein, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate. They were managed in the medicine intensive care unit (MICU). The shock and hypoxia was managed with fluids and inotropes and 6-8 L O2 through bag-mask-ventilation (BMV). Additionally, in all the patients, MIS-C was suspected and intravenous immunoglobulin (IVIG, 2 mg/kg), intravenous methylprednisolone, low molecular weight heparin, broad spectrum antibiotics, fluid therapy, and supportive care was initiated. One of them developed cardiorespiratory arrest. Resuscitation was done but the patient could not be revived back. While other patients responded well over the next 48-72 hours with a gradual decrease in titers of inflammatory markers. Steroids were slowly tapered off and patients were discharged. Conclusion: The findings of our series suggest that COVID-19 can trigger a hyperinflammatory state resulting in shock and pulmonary involvement, in some of the patients. The patients presented with distinct clinical features, with some mimicking atypical KD, the underlying mechanism for which still remain unclear. The physicians should be suspicious of MIS-C in children presenting with fever, rash, and gastrointestinal symptoms.

An Unusual Case of Autoantibody-Negative KetosisProne Diabetes (KPD) Secondary to Marked Insulin Resistance

KPD is classically regarded as an atypical form of diabetes caused by near-complete beta-cell failure. A 37-year-old Egyptian man (BMI: 27.7 Kg/m2) presented with hyperglycemia (362 mg/dL) and DKA (arterial pH 7.20, ketonemia 5.0 mmol/L, ketonuria 80 mg/dL) . He was afebrile, with recent polyuria, polydipsia and weight loss. HbA1c was 107 mmol/mol (11.9%) and blood tests excluded diabetes secondary to endocrinopathies. SARS-CoV-2 RT-PCR test was negative. IV insulin infusion (0.1 IU/kg/h) and IV fluid therapy were started. He was shortly transitioned to a sc basal-bolus insulin regimen (0.7 IU/kg/day) . Mixed-meal tolerance test (MMTT) revealed a peak 120-min stimulated C-peptide of 12.3 ng/mL, suggesting marked insulin resistance. Islet autoantibodies (ICA, IAA, GADA, IA-2A, ZnT8A) and insulin receptor autoantibodies (IgG/IgM) were negative. HLA genotyping detected the following haplotypes: DRB1∗01, ∗04;DQA1∗01:01P, ∗03:01P;DQB1∗03:02P, ∗05:01P. Insulin dose was gradually reduced and insulin therapy was discontinued after 4 months in favor of metformin (2550 mg/day) plus sc semaglutide (up to 1 mg/week) . After one year, MMTT revealed a peak 60-min stimulated C-peptide of 8.25 ng/mL. During the 18-month follow-up period, fasting capillary beta-hydroxybutyrate values were <0.2 mmol/L and HbA1c remained <48 mmol/mol (<6.5%) , indicating disease remission. This case suggests the existence of an autoantibody-negative KPD subtype driven by marked insulin resistance rather than by insulinopenia.

Severe hypernatremia in soft drink ketoacidosis and hyperglycemic hyperosmolar state at the onset of type 2 diabetes mellitus: a case series of three adolescents

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies. Some patients with a hyperglycemic crisis can present with an overlap of DKA and HHS. The coexistence of DKA and HHS is associated with higher mortality than in isolated DKA and HHS. In addition, electrolyte derangements caused by global electrolyte imbalance are associated with potentially life-threatening complications. Here, we describe three cases of mixed DKA and HHS with severe hypernatremia at the onset of type 2 diabetes mellitus. All patients had extreme hyperglycemia and hyperosmolarity with acidosis at the onset of diabetes mellitus. They consumed 2 to 3 L/d of high-carbohydrate drinks prior to admission to relieve thirst. They showed severe hypernatremia with renal impairment. Two patients recovered completely without any complications, while one died. Severe hypernatremia with mixed DKA and HHS is rare. However, it may be associated with excess carbohydrate beverage consumption. Reduced physical activity during the COVID19 pandemic and unhealthy eating behaviors worsened the initial presentation of diabetes mellitus. We highlight the impact of lifestyle factors on mixed DKA and HHS.

Effect of Fluid Therapy on Coagulation in COVID-19 Patients in the Intensive Care Unit

Study Objectives: Several studies have evaluated CT pulmonary angiography of COVID-19 patients and reported a 7%-30% increase in the incidence of pulmonary embolism. In this study, it was aimed to investigate the effect of fluid therapy on coagulation in COVID-19 patients in the intensive care unit. Methods: This retrospective study included 120 patients hospitalized in the COVID-19 Intensive Care Unit for more than one week, between August 2020 and February 2021. Blood prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, troponin, D-dimer levels, platelet count measured at the time of admission (T1, baseline) and one week after admission (T2), and the fluid treatments administered during this period were recorded. Patients were divided into the saline solution (SS) group (n=75), 0.45% saline solution group (0.45%, n=30), and combined fluid therapy group (SS+0.45%, n=15). Results: The change in PT was statistically significant for the SS group (p = 0.005), but not for the 0.45% and SS+0.45% groups (p = 0.625, p = 0.262, respectively). In the SS group, the aPTT levels increased posttreatment (p = 0.005). INR levels were significantly different between SS and SS+0.45% groups (p = 0.008). In the SS group, the INR levels increased between T1 and T2 (p = 0.014). In the SS group, the D-dimer levels significantly increased posttreatment. Conclusion: The D-dimer levels were prominent in the follow-up of the COVID-19 patients. Accordingly, using SS for fluid therapy may increase hypercoagulation and the risk of an embolism when compared to the SS, 0.45%, and combined (SS+0.45%) treatment.

Multicenter Evaluation of Superinfection Occurrence and Impact on Clinical Outcomes in Patients with COVID-19

Background. The coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spread globally throughout late 2019. During this pandemic, concern for bacterial and fungal superinfections has been present during the treatment of these patients. Methods. Hospitalized, adult patients with laboratory confirmed and symptomatic COVID-19 disease admitted between March 12, 2020 and May 31, 2020 were eligible for inclusion in this study. Data was obtained from electronic medical records and the hospital system's clinical surveillance program including demographics, comorbidities, hospitalization dates, laboratory values, mechanical ventilation, positive blood and respiratory cultures, treatment administration for COVID-19 as defined by the system's fluid treatment algorithm, and discharge disposition. Outcomes of this analysis include overall bacterial and fungal superinfection occurrence rate within 28 days of admission, patient characteristics that correlate with a higher risk of a superinfection, and the effect on 28-day mortality. Results. A total of 404 patients were included in the study analyses of which 56 (13.9%) had a documented superinfection within 28-days from admission. The most common superinfection organisms observed were Staphylococcus spp. (36.9%), Candida spp. (16.7%), and Klebsiella spp. (13.1%). Mortality was significantly higher in patients with superinfections (12.1% vs 5.8%, p < 0.001). To best assess characteristics that place patients at a higher risk of superinfection, a backwards, stepwise, multivariable logistic regression was performed. Black ethnicity, chronic kidney disease, intensive care unit (ICU) upon admission, lymphocytopenia, and receipt of tocilizumab were found to more likely have a superinfection within 28-days from admission. Comparison and analysis of baseline characteristics in patients with or without superinfection present. Day-28 mortality comparison in patients with or without superinfection. Mortality was observed in 7/58 patients with a superinfection versus 20/346 patients without superinfection present (p < 0.001). Multivariable analysis results for increased superinfection risk. All baseline characteristics with univariate analysis resulting in a p value of < 0.2 were included in the backwards, stepwise logistic regression model. Conclusion. In conclusion, our retrospective cohort study reports a superinfection rate of 13.9%. Presence of a superinfection significantly increases the likelihood of mortality within 28-days from admission. Characteristics that have a significant correlation to increased risk of superinfections include Black ethnicity, chronic kidney disease, ICU upon admission, and receipt of tocilizumab.

Recommendations on fluid therapy and pharmacological management of hemodynamic dysfunction and septic shock in COVID-19. (Pautas nacionales para la atenci..n de pacientes adultos con COVID-19.) [Spanish]

The aim of the article was to discuss haemodynamics and septic shock for COVID-19. Recommendations for the management of acute kidney injury and liver dysfunctionManagement of acute kidney injury associated with COVID-19. The etiology of acute kidney injury (AKI) associated with COVID-19 is multifactorial, involving factors specific to the disease itself (viral tropism, proinflammatory cytokines, coagulopathy with thrombotic microangiopathy, rhabdomyolysis), and nonspecific, linked to the treatment of critically ill patients. The diagnosis of AKI is made using the diagnostic criteria of the KDIGO definition, through frequent monitoring of creatinine and urinary output in order to carry out early detection of renal involvement. There are no specific measures for prevention and treatment of acute kidney injury associated with CO-VID-19, but immunomodulatory treatment (corticosteroids) and coagulopathy (heparin) could contribute to reducing its incidence and magnitude. Some of the measures to treat the non-specific factors involved in the development of acute kidney injury are also discussed in this study.

Case Report of 78-Year-Old Man With Meningitis, Pulmonary Thromboembolism and SARS-Coronavirus-2 Infection

The novel coronavirus infection involves both the Central and Peripheral Nervous systems. Some of the presentations include acute cerebrovascular disease, impaired consciousness, transverse myelitis, encephalopathy, encephalitis, and epilepsy. Our patient was a 78-year-old man with dementia and diabetic nephropathy who was admitted two times for possibly COVID-19 infection. At the first hospitalization, the patient is treated with hydroxychloroquine and Kaletra based on clinical symptoms and initial laboratory findings due to suspicion of COVID-19. After the negative RT-PCR test of the nasopharyngeal sample for COVID-19 and evidence of aspiration pneumonia in CT scan, the patient was discharged with oral antibiotics. Five weeks later, he was rehospitalized with loss of consciousness, fever, and hypoxemia in the physical exam;he had neck stiffness in all directions, So the central nervous system (CNS) infection was suspected, the cerebrospinal fluid (CSF) sample was in favor of aseptic meningitis and second RT-PCR test of nasopharyngeal sample for COVID-19 was positive, but Brain MRI just showed small vessel disease without evidence of encephalitis. In the second hospitalization, he had acute renal failure, which was treated with supportive care, and also suffered from pulmonary embolism with cavitary lesions in his lungs. Meningitis with pulmonary embolism and acute renal failure have not yet been reported. Our patient is the first one, so we decided to share it. This case showed a different presentation of COVID-19 without typical lung involvement. So, we must pay attention to any signs and symptoms in a patient suspected of having a COVID-19.

An early complication in patient with CoViD19 pneumonia

Background: In December 2019, many cases of atypical pneumonia with unknown etiology were reported in China. Later on, a new coronavirus was identified, named SARS-CoV-2. We present a case of SARS-CoV-2 pneumonia complicated by spontaneous pneumomediastinum (SPM), pneumothorax (PNX) and subcutaneous emphysema (SCE) without the use of an invasive or noninvasive positive pressure ventilator. Presentation of the case: A 42-year-old man with moderate dyspnea arrived at the DEA. He reported infection with SARS-CoV-2 from a week. He reported no medical history. At the entrance the patient was lucid, oriented and cooperative. The B.P. was 125/75 with sinus rhythm with pulse 75 bpm, apyretic, SpO2 88% on A.A. To DEA showed examinations: D-Dimer 549, fibrinogen 850, VES 75, PCR 8.33, LDH 295. The EGA (Reservoir 90%) detected: pO2 60.7 mmHg, pCO2 36.3, pH 7.47, SpO2 92% and P/F 67,4. The Rx thorax showed multiple hazy parenchymal opacities in the lower lobar seat bilaterally. He was submitted to therapy based on dexamethasone, fluid therapy, antibiotics, enoxaparin. After 36 hours, he presented progressive deterioration of respiratory function and chest CT showed: SPM, PNX, SCE. After two days he died. Conclusions: In many CoViD-19 studies the incidence of SPM, PNX, SCE is rare. The peculiarity of this case report is given by the serious SPM, PNX, SCE as an early complication in the absence of lung comorbidities, cough, consume alcohol, smoke tobacco or use recreational drugs. This suggests that others processes related to CoViD-19 might be the mechanism of air leak that progress to SPM, PNX, SCE.

Severe thrombocytopenia in patient with SARS-CoV-2 infection

Background: SARS-CoV-2 disease (CoViD-19) is an important pandemic respiratory disease that emerged in China on December 2019 and quickly spread around the world. Many studies on SARSCoV- 2 infection demonstrate its association with an increased incidence of coagulopathy. In this case-report we describe a serious thrombocytopenia as an early manifestation of CoViD-19. Description of the case: A 59-year-old male with moderate dyspnea and rare petechiae spread to the trunk arrived at the DEA. He reported infection with SARS-CoV-2 from a week with the appearance of petechiae 24 hours before the discovery of positivity. He also reported COPD history and hypertension. At the entrance the patient was lucid, oriented and cooperative. The B.P. was 110/75 with sinus rhythm with pulse of 110 bpm, apyretic, SpO2 85% in A.A. To DEA showed examinations: thrombocytopenia (8,000), leukocytosis (15,560), D-Dimer 11727, VES 74, PCR 10.53, ferritin 1592, LDH 365. The EGA (Reservoir 90%) detected pO2 70.0 mmHg, pCO2 36.5 mmHg, pH7.44, SpO2 94% and P/F 78. The X-ray chest showed multiple thickening at the lower lobar seat bilaterally and moderately spread interstitial thickening. He was admitted to the CPAP cycle (FiO2 90% PEEP 7.5 cm H2O) and therapy based on dexamethasone, fluid therapy, cholecalciferol, antibiotics and multiple platelet transfusions. After 12 days the patient died. Conclusions: In many CoViD-19 studies the incidence of thrombocytopenia is about 36%. The peculiarity of this case-report is given by the serious thrombocytopenia as an initial manifestation in the absence of clinical bleeding.

Severe hypernatriemia refractory to therapy in patient with SARS-CoV2 infection

Background: In December 2019, pneumonia-like syndrome with unknown etiology was observed in China. Later on, a new coronavirus was identified, named SARS-CoV-2. We present a case of SARS-CoV-2 pneumonia complicated by severe hypernatriemia refractory to therapy. Description of the case: A 60-year-old man with mild dyspnea came at the DEA. He reported infection with SARS-CoV-2 from a week. He reported no medical history except for prostatic hypertrophy. At the entrance the patient was lucid, oriented and cooperative. The B.P. was 130/75 with pulse 75 bpm, apyretic, SpO2 88% on A.A. To DEA showed examinations: D-Dimer 291, fibrinogen 744, VES 84, PCR 21.4, Ferritin 17347, LDH 532, normal electrolytes. The EGA (Reservoir 60%) detected: pO2 61.8 mmHg, pCO2 42.7, pH 7.45, SpO2 89% and P/F 103. The Rx thorax showed multiple hazy parenchymal opacities in the lower lobar seat bilaterally. He was submitted to therapy based on dexamethasone, fluid therapy, antibiotics, enoxaparin. After 36 hours, he presented progressive deterioration of the cognitive state and blood tests showed hypernatriemia (154 mmol). He undergoing therapy, sodium (168 mmol) worsened . After six days he died. Conclusions: While the multisystem impact of SARS-CoV-2 has been well established only recently been described the incidence of the disruption of sodium homeostasis in patients with CoViD- 19. The peculiarity of this case-report is given by the early and serious hypernatriemia as an uncommon complication. This suggests that others processes related to CoViD-19 might be the mechanism of dysnatremias in hospitalized patients.

Comprehensive meta-analysis of randomized controlled trials of Lactated Ringer's versus Normal Saline for acute pancreatitis.

INTRODUCTION: Fluid resuscitation is the keystone of treatment for acute pancreatitis. Though clinical guidelines and expert opinions agree on large volume resuscitation, debate remains on the optimal fluid type. The most commonly used fluids are Lactated Ringer's (LR) and Normal Saline (NS), but the studies published to date comparing LR vs NS yield conflicting results. We aimed to identify and quantitatively synthesize existing high quality data of the topic of fluid type or acute pancreatitis resuscitation. METHODS: In collaboration with the study team, an information specialist performed a comprehensive literature review to identify reports addressing type of fluid resuscitation. Studies were screened using the Covidence system by two independent reviewers in order to identify Randomized controlled trials comparing LR versus NS. The main outcome was the development of moderately severe or severe pancreatitis and additional outcomes included local complications, ICU admission, and length of stay. Pooled odds ratios were estimated using the random effects model and standardized mean difference to compare continuous variables. RESULTS: We reviewed 7964 abstracts and 57 full text documents. Four randomized controlled trials were identified and included in our meta-analyses. There were a total of 122 patients resuscitated with LR versus 126 with NS. Patients resuscitated with LR were less likely to develop moderately severe/severe pancreatitis (OR 0.49; 95 % CI 0.25-0.97). There was no difference in development of SIRS at 24 or 48 h or development of organ failure between the two groups. Patients resuscitated with LR were less likely to require ICU admission (OR 0.33; 95 % CI 0.13-0.81) and local complications (OR 0.42; 95 % CI 0.2-0.88). While there was a trend towards shorter hospitalizations for LR (SMD -0.18, 99 % CI -0.44-0.07), it was not statistically significant. CONCLUSION: Resuscitation with LR reduces the development of moderately severe-severe pancreatitis relative to NS. Nevertheless, no difference in SIRS development or organ failure underscores the need for further studies to verify this finding and define its mechanism.

Update on Canine Parvoviral Enteritis.

Canine parvoviral enteritis is one of the most common causes of morbidity and mortality in dogs worldwide. Tests can detect viral antigen in feces, and characteristic decreases in total leukocyte, neutrophil, and lymphocyte counts can increase the index of suspicion in affected cases and can be used to prognosticate morbidity and mortality. The standard of care for infected animals includes IV crystalloid and sometimes colloid fluids, antiemetics, broad-spectrum antibiotics, and early enteral nutrition. Vaccination induces protective immunity in most dogs. Vaccination, along with limiting exposure in young puppies, is the most effective means of preventing parvoviral enteritis in dogs.