Changes in Kawasaki disease incidence and phenotype during the COVID-19 pandemic

INTRODUCTION. The aetiology of Kawasaki disease (KD) remains unknown. Changes in infectious exposure during the COVID-19 pandemic owing to infection prevention measures may have affected the incidence of KD, supporting the pathogenic role of an infectious trigger. The purpose of this study was to evaluate the incidence, phenotype and outcome of KD before and during the COVID-19 pandemic in Denmark. METHODS. This was a retrospective cohort study based on patients diagnosed with KD at a Danish paediatric tertiary referral centre from 1 January 2008 to 1 September 2021. RESULTS. A total of 74 patients met the KD criteria of whom ten were observed during the COVID-19 pandemic in Denmark. Alof these patients were negative for SARS-CoV-2 DNA and antibodies. A high KD incidence was observed during the first six months of the pandemic, but no patients were diagnosed during the following 12 months. Clinical KD criteria were equally met in both groups. The fraction of intravenous immunoglobulin (IVIG) non-responders was higher in the pandemic group (60%) than in the in the pre-pandemic group (28.3%), although the rate of timely administered IVIG treatment was the same in both groups (>= 80%). Coronary artery dilation was observed in 21.9% in the pre-pandemic group compared with 0% in KD patients diagnosed during the pandemic. CONCLUSION. Changes in KD incidence and phenotype were seen during the COVID-19 pandemic. Patients diagnosed with KD during the pandemic had complete KD, higher liver transaminases and significant IVIG resistance but no coronary artery involvement.Copyright © 2023, Almindelige Danske Laegeforening. All rights reserved.

Acute myeloid leukemia complicated by post COVID-19 multi-system inflammatory syndrome-children

Corona Virus disease 2019 (COVID-19) pandemic has presented a huge challenge to the health care system in terms of magnitude of cases and to pediatric oncology units with varied clinical presentations. Acute myeloid leukemia(AML) is a rare heterogenous cancer of childhood with an induction mortality around 15% in our country due to neutropenic sepsis. Multisystem inflammatory syndrome in children(MIS-C) is an hyperinflammatory syndrome seen 4–6 weeks after COVID-19 infection. COVID infection in some of these children would have gone unnoticed. Here we report a two year eight months old boy diagnosed with AML on induction chemotherapy developed post COVID MIS-C. © 2022

Evaluation of cardiovascular autonomic dysfunction in symptomatic post COVID-19 patients

Background: The COVID-19 disease is known for its severe respiratory complications, however it was found to have some cardiovascular complication in post COVID-19 patients. The heart rate variability (HRV) is a non invasive, objective and reliable method for assessment of autonomic dysfunction in those recovered patients. Purpose(s): We aimed to evaluate the cardiac autonomic function by using valid HRV indices in subjects who recovered from mild to moderate acute COVID-19 but still symptomatic. Method(s): The study Group composed of 50 subjects with confirmed history of mild to moderate post COVID 19. All subjects underwent routine 2D echocardiography assessment in addition to 2D speckle tracking and 24 hours Holter monitoring for HRV analysis. Result(s): The mean age of the study population was 42+/-18 years, symptoms were reported as follows 27 (54%) had Dyspnea, 17 (34%) had palpitations, 7 (14%) had dizziness. Time domain parameters SDNN, SDANN and rMSSD were diminished with mean SDNN value being markedly impaired in 12 (24%) patient, while frequency domain parameters as assessed by LF/HF ratio with mean of 1.837 with 8% of patients being impaired. SDNN was significantly reduced in elderly patients (p=0.001), smokers (p=0.019) and hypertensive (p=0.016) and those complaining mainly of palpitation (p=0.006). SDNN was significantly reduced in patient with impaired LV diastolic function (p=0.009), in patients with reduced MAPSE (p=0.047), reduced TAPSE (p=0.00) and impaired Global longitudinal strain (0.000). Conclusion(s): Patients with post COVID-19 syndrome have abnormalities in the HRV which indicates some degree of dysfunction in the autonomic nervous system and consequently impaired parasympathetic function in this population, however this have been also correlating with subtle impairment of the left ventricular systolic function.We believe that this preliminary research can serve a starting point for future research in this direction.

Case series of acute pulmonary thrombo-embolism following endourological proceedures in COVID era: A serious threat to patients life and urologist!

Introduction and Objectives: In late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged as the cause of a cluster of pneumonia cases in China, and the corresponding disease was designated as Coronavirus Disease 2019 (COVID-19), spreading quickly around the world resulting in a pandemic. COVID-19 is associated with a set of coagulation abnormalities that increase the risk of thromboembolic events. Material(s) and Method(s): We report series of five cases of acute pulmonary thromboembolism following endourological procedures, treated in our tertiary care center, which after an apparent clinical improvement, developed acute pulmonary thrombo-embolism between second and third post-op day. Results and Observations: Among five cases, three were post PCNL and two post URSL. All Patients presented with dyspnoea, tachycardia, desaturation and hypotension. Further investigated with E.C.G, D-dimer, 2D-echo and CT-pulmonary angiogram, all suggestive of PTE. Hence patients were managed sucessfully in CCU with cardiologist advice and timely intrevention. Among five, three were managed with IV thrombolytic and anticoagulant therapy and two managed with IV anticoagulation alone , dose monitored with periodic coagulation profile. All patients discharged with oral newer anticoagulants and periodic follow up for 6 months. All patients on follow up and doing well. Conclusion(s): Thromboembolic events are potential complication of COVID-19 and can manifest later. Although very rare after endourological procedures, it requires high index of suspicion so as not to be missed as diagnosis, especially in hemodynamically unstable patients with respiratory distress. Early diagnosis and proper therapeutic actions is crucial for patients.

Multisystem inflammatory syndrome: A case report

Background: Multisystem inflammatory syndrome is a rare but severe complication of Coronavirus 19 infection (COVID-19) occurring about 2-12 weeks after the initial infection. It was initially reported in children (MIS-C) but later identified in adults (MIS-A). We report a case of MIS-A in a patient presenting with myocarditis.\ Method: Case report Results: A 36 years old female admitted due to 3 days history of fever and severe epigastric pain. She had exposure to a relative with COVID-19 3 weeks prior to symptoms and antigen test done was negative. On the day of admission, she started to experience shortness of breath and easy fatigability during activities of daily living. Upon examination, she was hypotensive requiring vasopressors. 12 lead ECG showed acute anteroseptal wall myocardial infarction and 2D echocardiography revealed hypokinesia of the entire interventricular septum and inferior left ventricular free wall, and reduced ejection fraction (EF) at 43.3%. Coronary angiogram showed normal findings. On work-up, she had mild normochromic, normocytic anemia, normal serum lipase, elevated AST 222 (<34 U/L), ALT 250 (<49 U/L), Troponin T > 2000 ng/L, CPK-Total 669 (<192 U/L), Ferritin 456.90 (<204 ng/ml), ESR 13 mm/hr, CRP 24 (<6 mg/L) and procalcitonin 0.35 (<0.5 ng/ml). Infectious workup revealed negative results and PCR for COVID-19 was negative. However, further workup revealed COVID-19 Enzyme Linked Fluorescent Assay (ELFA) IgG positive at 44.75 (>1.00) and IgM negative. The patient was managed as a case of MIS-A and was started on intravenous immunoglobulin (IVIg) and short course steroids with significant improvement in symptoms. On the 10th day of hospitalization, follow-up 2D echocardiography showed improvement in previously noted ventricular wall hypokinesia and normalization of EF to 55.8%. The patient was discharged well and improved. Conclusion(s): Diagnosis of MIS-A is challenging in patients without a previously known COVID-19. A positive serology result is required to fulfill the case definition of MIS-A. Determining a history of COVID-19 and its relationship to a patient's clinical course is important for making diagnosis and determining subsequent management.

LATE ONSET PRIMARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS in AN INDIAN ADOLESCENT BOY during A PEAK of POST COVID-19 MULTISYSTEM INFLAMMATORY SYNDROME

Background: Familial Hemophagocytic lymphohistiocytosis (fHLH) categorized as FHL2 (PRF1), FHL3 (UNC13D), FHL4 (STX11), and FHL5 (STXBP2) encoding for Perforin, Munc13-4, Syntaxin11, and Syntaxin binding protein 2, respectively. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. Objectives: To delineate clinical and laboratory features of late onset familial Hemophagocytic Lymphohistiocytosis. Methods: A 12-years-old well nourished sick looking boy, born to a non-consanguineous parents with normal birth, development and immunization history with uneventful past presented to us with 6 days history of high fever, cough, breathing difficulty and severe headache. He had occasional vomiting, abdominal pain, polyarthragia & chest pain from last 10 days. Mother also had given history of throat pain, backache & some non-specifc papular rashes over face before the onset of fever. His vitals were normal. Examination revealed faint diffuse fxed erythematous rash all over the body, pallor, icterus and hepatos-plenomegaly. Musculoskeletal examination was unremarkable. Lab evaluation revealed HB 8.9gm%, TLC 4700/cumm with neutrophils 40% and lymphocytes 56% with 8-9% activated lympocytes. Further evaluation showed low ESR 6mm/hr, fbrinogen 97mg% and albumin 2.2 gm% with elevated CRP 40mg/L, ferritin 2000ng/ml, LDH 658IU/L, SGPT 110IU/L, SGOT 221 IU/L, total bilirubin 6mg%, D-dimer 4355 ng:EFU/ml and Triglycerides 441mg%. His blood, urine, CSF and bone marrow cultures were sterile for endemic bacterial and viral infections in our area. His EBV PCR, CoVID RT PCR and CoVID antibody (Total & IgG) test were negative. His immunoglobulin leves were normal. HRCT Chest showed bilateral mild-moderate plural effusions, mild interstitial thickening in both the lower lobes, few fbrotic opacities & old areas of consolidation bilaterally. 2D echo showed mild pericardial effusion. Bone marrow examination showed Hypercellular marrow with iron depletion and occasional hemophagocytosis with CD8 T lymphocytes proliferation (55.2%) and double positive CD4 & CD8 (1.2%). He was initially commenced on supportive therapy, oxygen & intravenous antibiotics. In view of most probable non-infectious, non-malignant hemophagocytic lymphohistiocytosis, he was fnally given intravenous immunoglobulin (2gm/kg) and intravenous pulse methylprednisolone (30mg/kg). He responded well to above regimen within 3 days. He was discharged with tapering steroids over few weeks. Clinical exome by NGS revealed Homozygous Mutation in STXBP2 gene Intron 14, c.1280-1G>C (3' Splice Site) His parents has been counselled for hematopoietic stem cell transplantation and their decision is still pending. Results: We compared our patietnt with a reference to the largest Indian series of pediatric HLH1. Conclusion: Primary HLH type 5 can present frst time during childhood and adolescence. Any child presenting with unexplained HLH features should undergo genetic analysis irrespective of person's past and family history.

Coronavirus-2019 Disease with Pancytopenia with Leptospirosis and Herpes Simplex Virus Co-infection

Aim and background: COVID-19 pandemic has affected the whole world. Besides COVID, many infections may emerge during the course of the disease. Lymphopenia, use of immunosuppressants underlying comorbidities, and immune dysregulation secondary to SARS-CoV-2 could be the likely cause of the emergence such infections. We hereby describe a case of COVID-19 disease which presented with pancytopenia and was found to have Leptospirosis and Herpes Simplex Virus co-infection. Case summary: A 23-yearold postpartum female with no comorbidities and uneventful obstetric history was referred to our hospital 2 weeks after a full-term normal vaginal delivery. She developed generalized convulsive status epilepticus on the 10th day of her delivery, which was managed elsewhere with anti-epileptic drugs (AEDs). During her hospital stay, RTPCR for COVID-19 turned out to be positive but she remained asymptomatic throughout the course of her illness and seizures remained well-controlled on AEDs. On admission to our hospital, she was fully conscious, alert with no focal neurological deficits. Notable findings on evaluation were pancytopenia with megaloblastic features, bilateral pedal edema, and hepatosplenomegaly. NCCT brain was done which was suggestive of subarachnoid hemorrhage (SAH) along bilateral parietooccipital region for which conservative management was planned. 2D echocardiography was normal. Ultrasonography of abdomen revealed gross splenomegaly and mild hepatomegaly with mesenteric lymphadenopathy. NCCT thorax and abdomen were unremarkable apart from hepatosplenomegaly. In the panel sent for pancytopenia workup, IgM anti-HSV 1 antibodies turned out to be positive in blood. In addition, tropical workup was suggestive of Leptospirosis (IgM antibodies were positive). Workup for tuberculosis was negative. Bone marrow workup revealed features of trilineage hematopoiesis with micronormoblastic maturation consistent with iron deficiency anemia with no evidence of hemophagocytosis. Subsequently, IV acyclovir, IV doxycycline, and iron replacement were added. She improved clinically after these therapies and was subsequently discharged in a stable condition. MRI brain with MR angiography and venography done before discharge showed T1 sulcal hyperintensities along bilateral parietooccipital regions suggestive of SAH which was not progressing (as compared to NCCT brain scan done at admission). On day 60 of telephonic follow-up, patient was doing well and leading normal life without any persistence or emergence of symptoms.

A study of NT PRO-BNP and ETCO2 in Patients Presenting with Acute Dyspnea

Introduction: Common diagnoses amongst patients presenting with acute dyspnoea in Emergency Department are Decompensated Heart Failure, Chronic Obstructive Pulmonary Disease, ARDS, and others like pulmonary embolism, etc. Differentiating these is essential for proper management. Objectives: 1. To measure NT-PRO-BNP and ETCO2 in patients presenting with dyspnea. 2. To evaluate the levels of NT-PRO-BNP and ETCO2 in patients with Heart Failure, COPD, and ARDS. Materials and methods: This is a cross-sectional, observational study in patients admitted to the Medicine ICU with Dyspnoea. A total of 72 hypoxic (COVID Negative) patients requiring ventilatory support were evaluated and further categorized into three groups: 1. Heart failure (n = 44). 2. Pulmonary (COPD-13 and PE-2). 3. Sepsis with ARDS (n = 13). All patients were evaluated clinically and NT pro-BNP, ETCO2, ABG, Chest X-ray, Lung Ultrasound, 2D Echocardiography, and other basic laboratory testing were carried out. Results: The mean NT Pro-BNP and ETCO2 in the study subjects was 9872.69 pg/mL ± 10223.83 and 31.52 +13.83 mm Hg, respectively. Mean NT pro-BNP value was found to be more in cardiac group (13,835.04 pg/mL + 9868.87, CI 10,834.63 to 16,835.45) as compared to respiratory group (785.92 pg/mL + 1129.16, CI 103.6 to 1468.24) and sepsis with ARDS group (4890.6 pg/mL ± 9583.78, CI 900.81 to 10,682.03). This result was statistically significant with p value < 0.05. The difference between mean values of NT pro-BNP in the respiratory and sepsis group was NOT statistically significant (p value > 0.05). Mean ETCO2 value was found to be maximum in respiratory group (49.89 ± 7.26 mm Hg, CI 45.5 to 54.28), followed by the cardiac group (30.88 ± 10.78 mm Hg, CI 27.61 to 34.17) followed by sepsis group (19.46 ± 12.15 mm Hg, CI 12.12 to 26.8) and all three were statistically significant (p value < 0.05). Two patients with pulmonary embolism had mean NT pro-BNP value of 13,649 pg/mL and mean ETCO2 value of 29 mm Hg. Mean PaCO2-ETCO2 value was found to be maximum in sepsis group (16.78 ± 6.97 mm Hg, CI 12.57 to 21) followed by the respiratory group (8.15± 3.32 mm Hg, CI 6.14 to 10.16) followed by cardiac group (5.55 ± 2.04 mm Hg, CI 4.93 to 6.17). This was found to be statistically significant. The difference between mean values of PaCO2-ETCO2 in the respiratory and cardiac group was NOT statistically significant. The lung ultrasound comet-tail sign had 93.02% sensitivity, 100% specificity, 90.62% negative predictive value (NPV), 100% positive predictive value (PPV), and 95.83% accuracy for the diagnosis of heart failure. Conclusion: High NT-pro BNP and lower ETCO2 were found in acute HF-related dyspnea as compared to COPD. Mean PaCO2-ETCO2 value was found significantly higher in patients of ARDS. Hence, NT pro-BNP, ETCO2, and PaCO2-ETCO2 can be used together in evaluating patients presenting with acute dyspnea in emergency settings.

A Case Report of Coronavirus (COVID-19) Disease and Herpesviridae Viral Co-Infections: A Lethal Combination? ABS0138)

Introduction: COVID-19 pandemic has affected the whole world. Besides COVID, other viral infections may emerge during the course of the disease owing to lymphopenia, use of immunosuppressants, underlying comorbidities, and immune dysregulation, which may pose additional threats.1 We hereby describe two cases of COVID- 19 with viral co-infections belonging to the Herpesviridae family with undulating clinical course. Case 1: Cytomegalovirus (CMV) Co-infection: A 55-year-old male, COVID unvaccinated, chronic smoker, overweight and hypertensive was admitted to our ICU with a 1-week history of fever, cough, and breathlessness. SARSCoV- 2 reverse transcriptase-polymerase chain reaction (RT-PCR) test was positive. At admission, he had hypoxaemia (SpO2 86%on room air), respiratory rate 35-40/minute, and ground-glass opacities in chest X-ray involving 50% of bilateral lung parenchyma suggestive of severe COVID-19 pneumonia. He was managed with lung-protective invasive mechanical ventilation, restrictive fluid strategy, 16-18 hour/day proning sessions (4-5), intravenous (IV) remdesivir, IV dexamethasone 6 mg 12 hourly, and enoxaparin thromboprophylaxis. After 2 weeks of ICU stay, weaning was attempted but the weaning attempts failed due to underlying neuromuscular weakness. On examination, bilateral (B/L) cranial nerve palsies, areflexia, and motor power 0/5 in bilateral upper and lower limbs were noticed. possibility of Guillain-Barre syndrome (GBS) was kept and IV immunoglobulin therapy was empirically administered for 5 days with some improvement in power up to 1/5 in upper limbs. On day 35 of hospitalization, he developed pancytopenia along with features of deranged liver function and gut dysfunction. In evaluation, PCR for CMV turned out to be positive in blood. Bone marrow aspiration and biopsy showed hemopoiesis with viral inclusion bodies and hemophagocytosis (HLH) [Figs 1 and 2]. A diagnosis of secondary HLH related to CMV was contemplated and IV ganciclovir was initiated along with steroids. Histological evidence of CMV co-infection was present and moreover, the quantitative viral load of CMV showed a decreasing trend after initiating IV gancyclovir. However, the patient continued to deteriorate and succumbed to his illness in the 8th week of the ICU stay. Case 2: Herpes Simplex Virus (HSV) Co-infection: Twenty-three years postpartum female with no comorbidities and uneventful obstetric history was referred to our hospital two weeks after a full-term normal vaginal delivery. She developed generalized status epilepticus on the 10th day of delivery, which was managed with anti-epileptic drugs (AEDs). During the hospital stay, RTPCR for COVID-19 turned out to be positive but she remained asymptomatic and seizures were well-controlled on AEDs. On admission to our hospital, she was fully conscious and alert with no neurological deficits. Notable findings were pancytopenia with megaloblastic features, B/L pedal edema, and hepatosplenomegaly. NCCT brain revealed mild subarachnoid hemorrhage (SAH) along the bilateral parietooccipital region for which conservative management was planned. 2D echocardiography was normal. Ultrasonography of the abdomen showed gross splenomegaly and mild hepatomegaly with mesenteric lymphadenopathy. NCCT thorax and abdomen were unremarkable apart from hepatosplenomegaly. In pancytopenia workup, IgM anti-HSV-1 antibodies turned out to be positive in blood. In addition, tropical workup was suggestive of Leptospirosis (IgM antibodies positive). Serological evidence was suggestive of acute HSV-1 infection (based on antibody titers). Bone marrow workup had features of trilineage hematopoiesis with micronormoblastic maturation consistent with iron deficiency anemia without any evidence of hemophagocytosis. IV acyclovir, IV doxycycline, and iron replacement were added, after which she improved clinically and was discharged in stable condition. Tables 1 and 2 show a detailed description of these cases. Discussion: Herpesviridae family is the most important group of viruses responsible for persistent vi al infections in humans, of which CMV contributes to 60-90% of infections in adults, especially in developing countries.2 In healthy individuals, these viruses are kept dormant by the body's immune mechanisms but in an immunocompromised population, reactivation from the latent state can occur. SARS-CoV-2 infection predisposes patients to concomitant viral co-infections, owing to T-cell lymphopenia, decreased NK cell number, and use of immunosuppressive medications.3,4 The first case of CMV co-infection was first reported by D'Ardes and co-workers in 2020.5 Since then, many studies have been emerging in this area. In an observational study from France, 38 COVID-19 patients on >7 days of MV were studied for HSV and CMV pulmonary co-infections (by quantitative real-time PCR in tracheal samples) out of which 47% of patients had one of these infections (24% HSV, 5% CMV, 18% both).6 Another study looking for HSV-1 in patients on invasive MV found HSV-1 reactivation between days 11 and 40, which correlated with immunological markers of decreased innate immunity.7 A case series looking for CMV infection (by PCR in plasma or BAL) in COVID-19, also found CMV reactivation between day 7 and 45 of illness. Most of these patients were above 60 years of age and immunosuppressed (HIV, diabetes mellitus, medications).8 Although immunocompromised individuals are more vulnerable, healthy immunocompetent adults who are critically ill or on prolonged MV may also be susceptible to these infections.9-12 This may be explained by a state of immunoparalysis inherent to prolonged critical illness. In case 1, an ICU stay of around 9 weeks complicated with recurrent nosocomial infections, multiple blood product transfusions, and steroid usage could have the likely triggers. Whether viral co-infections are merely bystanders or truly pathogenic is difficult to comment but timely management is essential to avoid end-organ damage (EOD) which may occur directly (by enhanced viral load secondary to compromised host immunity) or indirectly (by inflammatory changes consequent to prolonged cell-mediated immunity required to maintain viral dormancy).2-4,13 It also seems imperative to study if a viral co-infection has a proclivity to develop more severe hematological anomalies (besides the inherent risk of HLH with COVID) as was seen in case 1, in which the patient had a downward spiral of illness with multiorgan dysfunction.14-15 Limitations: Dynamics of PCR trends and virology studies of samples from trachea, gut, and urine could not be analysed in our patients. Conclusion: Viral co-infections can occur in COVID-19 disease as these patients are often immunocompromised and critically ill. A high index of suspicion and prompt management is needed to improve the outcome of patients. Patients with organ dysfunctions especially hematologic abnormalities with bone marrow involvement should be worked up in detail to look for concomitant viral co-infections. In the future, large-scale research is needed to better elucidate the relationship between SARS-CoV-2 and other viral co-infections.

Multisystem Inflammatory Syndrome in an Adult Recovered from Mild COVID-19

Background: MIS-A, a hyperinflammatory condition in individual aged >21 years, is a rare condition seen in association with COVID-19 illness. Very few cases of MIS-A has been reported till date, and it still remains a box of mystery. Case Presentation: We report a case of 44 Year old male, with an evidence of prior COVID-19 illness, presented with 3 weeks of fever with polyarthralgia along with 3 days of palpitation, shortness of breath, conjunctivitis and soreness of mouth. Laboratory evidence of inflammation, features of myocarditis in 2D-Echocardiography was noted at the time of admission, with no evidence of any active infection and lung pathology. He was diagnosed as a case of MIS-A as per the CDC definition. Improvement in clinical and laboratory parameters and normalization of cardiac function was noted after treatment with IV methylprednisolone, and Intravenous Immunoglobulin. Conclusion: In adults presenting with fever and multisystem involvement, in Post-Covid period, with raised inflammatory markers, a high index of suspicion for MIS-A is required in order to start timely treatment and prevent potentially fatal outcome.

Rare and interesting case of solitary peripheral pulmonary artery aneurysm

Background: 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. Case Study: A 40-year-old man presented with an episode of haemoptysis. He had a history of intermittent mild grade fever, cough and dyspnea lasting for a month. He had no history of haemoptysis in the past. He had no pre-existing medical conditions or Coronavirus 2019 (COVID-19) infection. His clinical examination was unremarkable. Blood investigations were within normal limits. Reverse transcription polymerase chain reaction test was negative for COVID-19 infection, but his total antibodies test was elevated -117 (biologicalreference range <1.0). 2D Echocardiography was normal. Chest radiography showed a solitary pulmonary lesion in the right lower lung zone [Figure 1a].A computed tomography of the chest plain and contrast confirmed the presence of a 3.7 cm-3.6 cm, well-defined, circumscribed and densely enhancing lesion in apicoposterior segment of right lower lobe. It is seen along the course of descending branch of the right pulmonary artery. Areas of consolidation are also seen in apicoposterior segment. Postcontrast study shows heterogenous enhancement of this lesion suggestive of an aneurysm. The rest of lung parenchyma was normal [Figure 1b and c].The diagnosis of a solitary peripheral pulmonary artery aneurysm (PAA) was considered and right lower lobectomy was performed through posterolateral thoracotomy. Discussion: The estimated incidence of PAA is 1 in 14 000 autopsies, and these lesions can be central aneurysms and peripheral aneurysm. An aneurysm can be true or pseudo aneurysm. In this patient, an aneurysm is a true aneurysm and origin may be idiopathic or post-inflammatory with superadded fungal infection in thrombus, post-COVID-19 infection. Long-term follow up is required to observe the future course Conclusion: True solitary peripheral PAA is an extremely rare entity. A high degree of suspicion is needed for diagnosing PAAs on imaging. Intervention is mandatory as soon as the diagnosis is made, to prevent rupture and death. PAA has been managed most often by lobectomy but occasionally by pulmonary artery repair or endovascular approach.

Pleural aspergillosis with pulmonary artery thrombosis as a complication of Covid-19

Background: COVID-19 is associated with an increased risk of superimposed bacterial and fungal infections. Pleural aspergillosis is an uncommon manifestation of invasive aspergillosis. We report a case of pleural aspergillosis with pulmonary artery thrombosis after COVID-19 with favourable outcome. Case Study: A 67-year male, diabetic, IHD post CABG, with moderate COVID-19 disease 2 months ago, presented with 1 week history of productive cough, breathlessness and chest pain. Examination revealed hypoxia, tachycardia and diminished breath sounds on right side. Right hydropneumothorax was noted on imaging, tube thoracostomy was done. Pleural fluid investigations were suggestive of pyothorax. CECT-thorax showed cavitary consolidation in right lower lobe. Patient was treated with IV antibiotics. However, there was persistent air leak and tachycardia. 2D-ECHO showed mild PAH. D-Dimer was high, CTPA revealed partial thrombosis of right posterior basal pulmonary arteries. Pleural fluid fungal culture yielded Aspergillus fumigatus. Patient was initiated on oral voriconazole and anticoagulants. He showed marked improvement and in 5 days ICD was removed. Patient is on regular follow-up. Discussion: COVID-19 associated superimposed infections have been reported with high mortality rates. The use of corticosteroids and/or IL-6 antagonists have been implicated with the fungal infections. Pleural aspergillosis is rare. Diagnosis is usually based on clinical and microbiological evidence. A key finding in invasive aspergillosis is angioinvasion which leads to thrombosis and tissue infarction. Conclusion: Clinicians should have high index of suspicion for superimposed fungal infections in COVID-19. Early initiation of treatment brings down morbidity and mortality.

COVID-19 infection and incident myocarditis: A multi-site population-based propensity score-matched analysis

Background: COVID-19-infection manifestations range from asymptomatic infection to multi-organ failure and death. Cardiovascular complications from COVID -19 include myocarditis, acute myocardial infarction, heart failure. Population-level data is lacking on the relationship between COVID-19 and cardiovascular complications. Objectives: To examine the incidence of myocarditis, acute myocardial infarction (AMI), heart failure (HF) after COVID-19 infection. Methods: We used a retrospective cohort study using deidentified data from 50 health systems across the United States. Cohort groups were created using patients ≥18, who were admitted to hospitals for respiratory illness with COVID in 2020 and respiratory illness without COVID-19 for the years 2020 and 2019. There were 107,699 patients with COVID;77,499 patients with respiratory illness in 2020, and 112,898 patients with respiratory illness in 2019. The COVID group was matched to each of the respiratory illness groups by propensity score. Patients with prior specific cardiovascular events were excluded for the correspondent outcome analysis. Our outcomes were: myocarditis, AMI, HF. Results: In the COVID-19 group, 79 patients had new-onset myocarditis compared to 29 patients in the non-COVID-19 control (Pneumonia/flu) group (OR 2.73, CI 95%, 1.78-4.18). In the COVID- 19 group, 1512 patients developed HF compared to 2,659 patients in the non-COVID-19 group, (OR 0.49, CI 95%, 0.46-0.52). 1125 patients in COVID-19 group had AMI compared to 1243 patients in non-COVID-19 group (OR 0.87, CI 95 %, 0.80-0.94). Conclusion: COVID-19 was associated with a high risk of incident myocarditis but unexpectedly lower rates of HF diagnosis, suggesting possible under testing (e.g., 2-D ECHO) and underdiagnosis.

Congenital Portosystemic Shunts in Children: A Case Series From Single Centre

Background: Congenital portosystemic venous shunts (CPSS) are uncommon foetal vascular developmental anomalies where splanchnic venous flow bypasses liver. Four cases of CPSS are reported at our centre. Case Summary (1) Eight years old female child presented with Dengue with no features of chronic liver disease and normal liver function test (LFT). Ultrasonography (UGS) abdomen reported an incidental finding of abnormal vascular shunt in liver. Further imaging revealed an anastomosis between portal vein and intrahepatic part of inferior vena cava (IVC), hypoplastic portal vein and multiple nodules in bilateral liver lobes. Interventional Radiologist closed the anastomosis using vascular plug. Child sustained the procedure well. (2) Two months old female patient presented with high GGTP cholestasis, dysmorphism and deranged LFT. On USG abdomen there was intrahepatic portosystemic shunt. MDCT abdomen revealed 2 vascular shunts between left portal vein to middle hepatic vein and left portal vein. Cholestasis responded with symptomatic treatment, hence being followed-up for observation till 1year of age for complications and possibility of spontaneous closure. (3) Twenty-two days old, full term female child presented with convulsions and high GGTP cholestasis with multiple hematomas in brain. LFTs were deranged. 2D-ECHO showed small PFO. USG abdomen suggested a channel between left portal vein and hepatic vein. Patient tested COVID positive hence quarantined now and further evaluation is awaited. (4) One day old, late preterm male baby presented with respiratory distress and pulmonary hypertension with antenatal scan suggesting ductus venous agenesis with hepatic vascular malformation. Patient developed cholestasis with deranged LFT. 2D-ECHO showed PDA and ASD. MDCT abdomen revealed connection between main portal vein and intrahepatic IVC. Conclusions: CPSS has heterogeneous presentation. It can be diagnosed antenatal or postnatal, may be asymptomatic or may present as neonatal cholestasis and may be associated with anomalies. Management may vary from case to case and mainly depends on complications and age of presentation.

Incidence of Cardiovascular Events and Mortality in COVID-19 Patients Admitted in NIMS Intensive Care Unit during Second Wave

Prevalence of pulmonary thromboembolism (PTE) is very high when we compare the coronavirus disease 2019 positive patients with the other patients who are admitted in intensive care unit for other different infection. Thorough evaluation of the different causative factors for PTE should be better evaluated and prevention can be tried accordingly. Incidence of subclinical PTE that can give rise to future cardiac disease needs to be studied and plan of action can be done accordingly. Newer modalities of detecting PTE using non-invasive or simple invasive techniques need to be investigated to cope up in pandemic situation.

Covid-19 infection and incident myocarditis: A population-based propensity score-adjusted analysis

Introduction: COVID-19-infection caused by Severe Acute Respiratory Syndrome Coronavirus-2- has protean manifestations ranging from asymptomatic infection to multi-organ failure and death. Cardiovascular complications from COVID-19 include myocarditis, acute myocardial infarction (AMI), heart failure (HF). These complications-captured clinically and by tests (troponins, 2-D ECHO, MRI)-can occur either by direct injury to the myo-pericardium or by an inflammatory response and cytokine storm. Population-level data is lacking on the relationship between COVID19 and onset of Myocarditis, AMI, and HF. Therefore, we examined the incidence and correlations of Myocarditis, AMI, and HF after COVID-19 infection across the United States using a large nationwide database. Hypothesis: Infection with COVID-19 is associated with an increased risk of myocarditis. Methods: We used a retrospective cohort study using de-identified data from 35 health systems across the United States. Cohort groups were created using patients ≥18, who were admitted to hospitals for respiratory illness with COVID in 2020 and respiratory illness without COVID-19 for the years 2020 and 2019. Patients with prior cardiovascular events were excluded from the study. There were 103,187 patients with COVID;77,242 patients with respiratory illness in 2020, and 114,908 patients with respiratory illness in 2019. The COVID group was matched to each of the respiratory illness groups by propensity score. Three main cardiovascular outcomes were studied: myocarditis, AMI, HF. Results: In the COVID-19 group, 79 patients had new-onset myocarditis compared to 29 patients in the non-COVID-19 control group (Odds ratio [OR] 2.73, CI 95%, 1.78-4.18). In the COVID-19 group, 1512 patients developed HF compared to 2,659 patients in the non-COVID-19 group, (OR 0.49, CI 95%, 0.46-0.52). 1125 patients in COVID-19 group had AMI compared to 1243 patients in nonCOVID-19 group (OR 0.87, CI 95 %, 0.80-0.94). Conclusions: COVID-19 patients had 2 to 3 times the odds of incident myocarditis compared to non-COVID controls. Unexpected findings were the lower rates of HF diagnoses in the COVID-19 group, suggesting possible under testing (e.g., 2-D ECHO) and underdiagnosis in isolated COVID patients.

A case of recurrent pulmonary embolism

Background: Nephrotic syndrome is known to be associated with hypercoagulable status. Pulmonary artery thromboembolism is one of the life- threatening complications in patients with nephrotic syndrome but rarely occurs before the diagnosis of nephrotic syndrome. Methods and Results: A 33-year-old man without any co-morbidities presented to a primary care clinic with sudden onset shortness of breath. An electrocardiogram showed sinus tachycardia with S1Q3T3. ECHO and CTPA revealed thrombi of the bilateral pulmonary arteries and he was COVID-19 negative by PCR analysis. Anticoagulant therapy was initiated immediately. Hypercoagulability workup showed normal levels of protein C, protein S, and AT III. He was ANA- and APLA negative and his homocysteine levels were normal. Lower limb Doppler showed multiple deep venous system thrombi. Three months following this episode, he presented with recurrence of acute worsening of breathlessness with pedal edema and abdominal distention. He was referred to our Cardiology emergency care. 2D Echocardiography showed classic Mc Connells sign with akinesia of RV free wall and RV systolic pressure of 60 mm Hg. CT pulmonary angiography definitively proved fresh (recurrence of) pulmonary embolism with large clots in both LPA and RPA and CXR showed classical signs of pulmonary embolism (Fig. 1). USG abdomen showed ascites, normal kidneys and no renal vein thrombosis. Laboratory examination showed he was COVID-19 negative again by PCR analysis. They also revealed low serum albumin (2.2g/dl) and nephrotic-range proteinuria (>10 gm in 24 hours) with transudative ascitic fluid. Since patient was on anticoagulation renal biopsy was deferred by the consultant nephrologist in view of possible bleeding complications. In view of possible primary membranous nephropathy, Serum Anti-Pla2r antibody was done which was strongly positive. The constellation of nephrotic-range proteinuria, pulmonary thromboembolic complications and associated serum anti-Pla2R antibody suggested primary membranous nephropathy. Immunosuppression was started as per modified Ponticelli regimen. Proteinuria resolved after three weeks and patient continues to be doing well on anticoagulation on oral VKA [Formula presented] Conclusion: Previous case reports of pulmonary artery thromboembolism associated with nephrotic syndrome are very few, particularly in adults. In the rare cases where they do occur, the patients initially present with the symptoms derived from nephrotic syndrome, unlike in our patient where the presentation was extremely rare and the investigation of the thromboembolic event led us “backwards” to the diagnosis of nephrotic syndrome. Awareness regarding the potential complications of hypercoagulable in nephrotic syndrome is thus essential.

Echocardiographic features of patients with COVID-19 infection: a cross-sectional study.

COVID-19 patients with cardiac involvement have a high mortality rate. The aim of this study was to investigate the echocardiographic features in COVID-19 patients between severe and non-severe groups. For this single-center study, data from patients who were treated for COVID-19 between March 25, 2020 and April 15, 2020 were collected. Two-dimensional echocardiography (2DE) images were obtained for all patients. Patients were divided into two groups based on the severity of their COVID-19 infections. 2DE parameters indicating right ventricular (RV) and left ventricular (LV) functions were compared between the two groups. A total of 90 patients hospitalized for COVID-19 were included in this study. The mean age of the severe group (n = 44) was 63.3 ± 15.7 years, and 54% were male. The mean age of non-severe group (n = 46) was 49.7 ± 21.4 years, and 47% were male. In the severe group, RV and LV diameters were larger (RV, 36.6 ± 5.9 mm vs. 33.1 ± 4.8 mm, p = 0.003; LV 47.3 ± 5.8 mm vs. 44.9 ± 3.8 mm, p = 0.023), the LE ejection fraction (LVEF) and the RV fractional area change (RV-FAC) were lower (LVEF, 54.0 ± 9.8% vs. 61.9 ± 4.8%, p < 0.001; RV-FAC, 41.4 ± 4.1% vs. 45.5 ± 4.5%, p < 0.001), and pericardial effusions were more frequent (23% vs. 0%) compared to patients in the non-severe group. A multiple linear regression analysis determined that LVEF, right atrial diameter, high-sensitivity troponin I, d-dimer, and systolic pulmonary artery pressure, were independent predictors of RV dilatation. The results demonstrate that both right and left ventricular functions decreased due to COVID-19 infection in the severe group. 2DE is a valuable bedside tool and may yield valuable information about the clinical status of patients and their prognoses.