Diabetic Ketoacidosis and Hypertriglyceridemiainduced Pancreatitis: Can the Perfect Storm Happen Twice?

This case report describes the recurrence of diabetic ketoacidosis (DKA) leading to hypertriglyceridemia-induced pancreatitis. Hypertriglyceridemia is present in 2-5% of patients with diabetic ketoacidosis. Hypertriglyceridemiainduced pancreatitis occurs in up to 4% of patients with diabetic ketoacidosis and is a well-reported complication. This is the first case report to the author's knowledge, where the same patient had two separate episodes of acute pancreatitis that have been attributed to diabetic ketoacidosis and resultant severe hypertriglyceridemia, etiology determined to be medication non-compliance. DKA and acute pancreatitis can co-exist, and hypertriglyceridemia has been the predominant pathogenetic link between the two conditions. We also describe the pathophysiology and treatment of hyper-triglyceridemia-induced pancreatitis in diabetic ketoacidosis.

Hypertension as an Independent Risk Factor for In-Patient Mortality in Hospitalized COVID-19 Patients: A Multicenter Study.

Despite the lack of direct evidence that hypertension increases the likelihood of new infections, hypertension is known to be the most common comorbid condition in COVID-19 patients and also a major risk factor for severe COVID-19 infection. The literature review suggests that data is heterogeneous in terms of the association of hypertension with mortality. Hence, it remains a topic of interest whether hypertension is associated with COVID-19 disease severity and mortality. Herein, we perform a multicenter retrospective analysis to study hypertension as an independent risk for in-hospital mortality in hospitalized COVID-19 patients. This multicenter retrospective analysis included 515 COVID-19 patients hospitalized from March 1, 2020 to May 31, 2020. Patients were divided into two groups: hypertensive and normotensive. Demographic characteristics and laboratory data were collected, and in-hospital mortality was calculated in both groups. The overall mortality of the study population was 25.3% (130 of 514 patients) with 96 (73.8%) being hypertensive and 34 (26.2%) being normotensive (p-value of 0.01, statistically non-significant association). The mortality rate among the hypertensive was higher as compared to non-hypertensive; however, hypertensive patients were more likely to be old and have underlying comorbidities including obesity, diabetes mellitus, coronary artery disease, congestive heart failure, stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and cancer. Therefore, multivariable logistic regression failed to show any significant association between hypertension and COVID-19 mortality. To our knowledge, few studies have shown an association between hypertension and COVID-19 mortality after adjusting confounding variables. Our study provides further evidence that hypertension is not an independent risk factor for in-hospital mortality when adjusted for other comorbidities in hospitalized COVID-19 patients.

Variation in clinical characteristics, outcomes, and mortality of hospitalized patients with COVID-19 during the second wave of the pandemic: a single-center experience.

As of February 2, 2021, the USA has 26,431,799 reported COVID-19 cases with 446,744 deaths. A high mortality rate (15%-40%) was reported among hospitalized patients with COVID-19 during the first wave of the pandemic. However, data regarding variation in COVID-19-related mortality and severity of illness among hospitalized patients with COVID-19 are heterogeneous. In this retrospective single-center study, we aimed to investigate the demographic characteristics, clinical presentations, disease severity, clinical outcomes, and in-hospital mortality of hospitalized patients with COVID-19 during the second wave of the pandemic. Adults with reverse transcription-PCR-confirmed SARS-CoV-2 infection were included. In-hospital mortality due to COVID-19 was the primary outcome, and intensive care unit admission, acute kidney injury, acute respiratory distress syndrome, respiratory failure requiring intubation, and septic shock were the secondary outcomes. A total of 101 adult patients were hospitalized with COVID-19 during the second wave study period. Of 101 patients, 8 were intubated and 6 died. The median duration of hospital stay was 6 days. Patients in the second wave were more likely to receive dexamethasone and remdesivir and less likely to require invasive mechanical ventilation. In-hospital mortality during the second wave was lower (5.9%) compared with the first wave (15.5%). At the last follow-up date, 86.1% were discharged alive from the hospital, 5.9% died and 7.9% were still in the hospital. Multivariate logistic regression showed higher odds of mortality were associated with higher age and elevated lactate dehydrogenase peak.

Four Distinct Cases of Multisystem Inflammatory Syndrome in Adults Associated With SARS-CoV-2 Infection at a Community Hospital in New Jersey.

Multisystem inflammatory syndrome (MIS) is a rare entity that usually presents with a constellation of symptoms such as fever, hypotension, gastrointestinal symptoms, cardiac dysfunction, or dermatological involvement, representing an inflammatory state. During the ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, several cases of multisystem inflammatory syndrome in children (MIS-C) have been described in the literature. The Centers for Disease Control and Prevention (CDC) has acknowledged the increasing incidence of the same entity in adults, referred to as multisystem inflammatory syndrome in adults (MIS-A). This case series describes four patients who presented to the Monmouth Medical Center in New Jersey with symptoms suggestive of MIS-A associated with SARS-CoV-2 infection and their clinical outcomes. All patients were within the age group of 20-40 years with no underlying medical condition. The period between SARS-CoV-2 infection and the development of MIS-A varied from 10 days through a month. Presentations ranged from a mild flu-like illness to shock requiring vasopressors. A positive SARS-CoV-2 antibody test was essential for the diagnosis. Inflammatory markers, such as ferritin, D-dimer, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and interleukin-6 (IL-6), were elevated on admission. The Use of immunomodulatory agents, namely steroids and intravenous immunoglobulin (IVIG), resulted in positive clinical outcomes. Inflammatory markers and imaging on admission did not appear to predict the disease course. A positive SARS-CoV-2 polymerase chain reaction (PCR) did not appear to influence the response to treatment. Given the high probability of MIS-A with negative viral testing, the use of both antibody and viral testing with the addition of inflammatory markers may be essential to diagnose this SARS-CoV-2-associated condition.

COVID-19 patients in a tertiary US hospital: Assessment of clinical course and predictors of the disease severity.

INTRODUCTION: Patients with severe COVID-19 can develop ventilator-dependent acute hypoxic respiratory failure (VDAHRF), which is associated with a higher mortality rate. We evaluated the clinical course of hospitalized COVID-19 patients and compared them with the patients who received invasive mechanical ventilation. Characteristics of intubated patients who were successfully weaned from the ventilator were compared with the patients who failed to be extubated or died in the hospital. OBJECTIVE: To investigate the clinical course of hospitalized COVID-19 patients, and assess the possible predictors of the disease severity leading to VDAHRF. METHODS: This is a single-center, retrospective study. The first 129 patients (18 years or older) with COVID-19 admitted to Monmouth Medical Center from March 1st to April 25th, 2020 were included. RESULTS: Out of 129 patients, 23.25% (n = 30) required invasive mechanical ventilation, and of those, six patients were successfully weaned from the ventilator. Multivariable logistic regression analysis showed increased odds of intubation associated with hypoxemia (odds ratio 17.23, 95% CI 5.206-57.088; p < 0.0001), elevated d-dimer by one unit mg/L of FEU (odds ratio 1.515, 95% CI 5.206-57.088; p = 0.0430) and elevated ferritin by one unit ng/ml (odds ratio 1.001, 95% CI 1.000-1.001, p = 0.0051) on admission, adjusted for other covariates. CONCLUSIONS: Patients who required invasive mechanical ventilation were more likely to have older age, male gender, coronary artery disease, diabetes, and obesity. The patients who were successfully weaned from the ventilator were more likely to be younger in age, and none of them had heart failure or CAD.

A case of tricuspid valve non-bacterial thrombotic endocarditis presenting as pulmonary embolism in a patient with antiphospholipid antibody syndrome.

A 47-year-old woman with a medical history of Raynaud's phenomenon presented with fever, cough and shortness of breath. She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia. During the hospital course, her respiratory status worsened, and she was intubated on the third hospital day. To investigate the high A-a gradient, a Computerized Tomographic Pulmonary Embolism (CTPE) study was done which identified a large left lower pulmonary artery embolism. She was also found to have a new murmur, and an echocardiogram demonstrated a large lesion on tricuspid valve. However, multiple sets of her blood cultures came back consistently negative. Alternative diagnoses for culture-negative endocarditis were considered, and a full set of rheumatological workup was done. Laboratory tests were suggestive of antiphospholipid syndrome, hence the diagnosis of tricuspid valve Libman-Sacks endocarditis was made.