Delaying escalation of care for a COVID-19 patient

Background: Since being reported on December 31st 2019, COVID-19 has become a pandemic. In Detroit, there are 1075 cases and 23 deaths, as of March 28th, 2020. Rapid identification of the disease is vital as preliminary reports show that multiple ED and clinic visits are associated with worse outcomes, likely due to delayed treatment. Our report describes the course of a COVID-19 patient who required multiple visits prior to diagnosis, and rapidly deteriorated.Case Report: A 63-year old African American man presented to his PCP with sore throat, cough, and body aches. Patient endorsed symptoms for 4 days, no sick contacts, and flu swab was negative. Patient was diagnosed with a viral syndrome and prescribed rest and symptomatic care. The following day he went to the ED with worsening symptoms and hypotension and was sent home. The next day, patient went for a CXR, where he developed SOB. Due to his distress and presence of bilateral pneumonia, he was sent to the ED rule out COVID. At the ED, patient endorsed a fever, SOB, and chills. Patient’s past medical history included asthma, hypertension, and diabetes. On exam, he was febrile but hemodynamically stable. Patient was ill-appearing, with decreased breath sounds on the left. Labs showed leukopenia, lymphopenia, and an AKI. COVID testing was sent. Patient was admitted, with airborne plus precautions, and antibiotics were started.On hospital day 3, patient became persistently febrile and hypoxic. ABG was done which showed a PaO2 of 55.9. Due to worsening respiratory status, patient was intubated and transferred to the MICU. CXR was repeated and showed worsening airspace opacities bilaterally, and small pleural effusions. COVID test came back positive and treatment began with Hydroxychloroquine, and use of remdesivir pending. On hospitalization day 7, patient received remdesivir and tocilizumab, with hopes that reduced systemic inflammation would lead to improvement of his ARDS. Overnight, patient was hypotensive and nonresponsive to fluids. Levophed was begun, and vent settings were increased. On days 9 and 10, due to worsening hypoxia and inability to follow commands, patient was paralyzed to allow for more time to improve inflammation. Patient was placed on max vent settings, and his PaO2 sat was 57. CXR was repeated due to worsening vent requirements and showed no change. Subsequently, patient became tachycardic in the 120s, and hypotensive to the 80s. D-dimer was elevated, and patient desaturated when turned or repositioned. On day 11, patient was found to be hyperkalemic. Nephrology was consulted and determined the hyperkalemia was due to hemolysis secondary to DIC, but the patient was not a candidate for ultrafiltration or intermittent dialysis. Due to absence of clinical improvement, patient was transferred to comfort care, and expired.Discussion: Our report elucidates the importance of rapid identification of a patient with COVID. Our patient had a standard presentation with cough, fever, body aches and sore throat, indicating that the possibility of COVID as the cause for the patient’s presentation should have been considered. During a pandemic it is vital to practice with a high of index of suspicion. The importance of prompt identification of the illness becomes even more salient considering that current treatment approach is primarily symptomatic management, due to lack of clinically effective curative treatments. It may seem overly simplified, but the sooner a patient is able to receive these services, the more likely they are to recover. While our patient had multiple risk factors for deterioration due to COVID, such as HTN, and T2DM, our patient had two opportunities for escalation of care and identification of his underlying pathology that could have improved his prognosis. Further, our report is in line with preliminary findings that African Americans and patientshttps://scholarlycommons.henryford.com/merf2020caserpt/1103/thumbnail.jp

Severe COVID 19 Case with Atypical Presentation

Introduction: COVID-19 was brought to the attention of the WHO on December 31st, 2019 and classified a global pandemic on March 11th. As of March 26th, there were 2,856 cases and 60 deaths in Michigan, with 851 cases and 15 deaths in Detroit. Efforts to characterize risk factors for severe disease may improve clinical outcomes and inform resource allocation. Better understanding of the epidemiological and clinical characteristics of COVID-19 are essential to slowing transmission and treating patients. Below we detail the clinical features of a COVID-19 positive patient seen in early March, 2020. Case Report: An 80-year-old female presented to the ED with fevers. She endorsed worsening fevers, watery diarrhea, abdominal pain, and myalgias of one week. She was lethargic and presyncopal for one day prior to presentation. She endorsed contact with sick members at home and denied travel history. Her past medical history was significant for resected colon cancer, T2DM, COPD, HTN, and CAD. She was a former smoker. On exam she was febrile and had lower abdominal tenderness. Her labs showed lymphopenia, thrombocytopenia, and mild hyponatremia. Influenza swab, viral panel, and legionella urine antigen were negative, prompting COVID-19 testing. Chest x-ray showed diffuse reticular opacities. Antibiotics were started and she was admitted on hospital day 2. She developed dyspnea, rales, and increasing oxygen demand through her hospitalization. COVID-19 testing resulted positive by day 4. Infectious disease recommended ribavirin and lopinavir-ritonavir. Her son was informed, and all contacts were advised to isolate for two weeks. On days 5 and 6 she improved clinically, though was not discharged due to concern she would not abide by self-isolation recommendations. Overnight, she had increasing oxygen demand and repeat chest x-ray revealed worsening infiltrates. She was intubated and transferred to the MICU on day 7. Inflammatory markers including LDH, CRP, procalcitonin, lactate, anion gap, aPTT, INR, and D-dimer were elevated. ABG revealed low PaO2 and low pH. Her IL-6 and fibrinogen levels were normal. She continued to decompensate with concern for septic shock, and had worsening bradycardia and hypotension, unresponsive to three vasopressors. On day 7, she expired. Discussion: Our report of a COVID-19 patient that ended in their mortality provides important lessons for providers. The transmission mode was local spread, reflecting high transmissibility among family groups. Fevers are reliably present over the illness course, though seen in under half on presentation. Fatigue is common and was observed in our patient. Cough is common, though was absent here. Diarrhea is an uncommon presenting symptom, reducing initial clinical suspicion and potentially delaying diagnosis. Other characteristics seen in our patient reflect a growing body of evidence supporting high rate of morbidity and mortality in patients with COVID-19. Such populations, including critically ill elderly population, require ICU level care, with marked lymphopenia on admission labs, and elevated inflammatory markers across their hospitalization. Also, investigative treatments including Lopinavir-ritonavir, ribavirin, hydroxychloroquine, and azithromycin have yet to demonstrate clinical efficacy in large randomized controlled trials.https://scholarlycommons.henryford.com/merf2020caserpt/1105/thumbnail.jp

A Case of Alcohol Withdrawal-Induced Central and Extrapontine Myelinolysis

A 40-year-old female with a history of chronic alcohol use disorder presented with an acute intractable left-sided headache for three days and progressively worsening unsteady gait requiring a wheelchair to ambulate. The patient had a history of chronic alcoholism since 2019 but reported abstinence since September 2021. One month after quitting alcohol, she experienced a sudden deterioration in bilateral extremity neuropathy, forgetfulness, difficulty writing, and severe mood swings, which continued to worsen until her presentation in July 2022. Laboratory tests, including complete blood count and electrolyte levels, were within normal ranges. A previous MRI performed during the investigation for alcoholic neuropathy a few months before she quit drinking showed no abnormalities. However, a subsequent MRI during work-up for the current acute symptoms revealed significant signal abnormalities involving the central pons, bilateral cerebral peduncles, and medullary pyramids, consistent with chronic central pontine myelinolysis (CPM) with extrapontine myelinolysis (EPM) extending into the peduncles. The patient received treatment with folate and multivitamins and was scheduled for outpatient follow-up with physical therapy for rehabilitation. This case highlights CPM as a consequence of alcohol withdrawal and emphasizes the importance of timely diagnosis and appropriate management in such patients

COVID-19 Presenting with Neurological Symptoms

Introduction: Healthcare officials of Wuhan City in China became aware of several pneumonia cases with an unknown etiology in December 2019. A novel coronavirus, SARS-CoV-2, was identified as cause of the disease named Coronavirus disease-19 (COVID-19). SARS-CoV-2 enters cells through a receptor found on pneumocytes, and there is also evidence this receptor is located on neurons and glial cells. Recently, the neurological manifestations of COVID-19 have been described. However, to our knowledge, there are currently no known cases of COVID-19 presenting as cerebellar dysfunction and essential tremor, which we describe here. Case: A 77-year-old obese man with a past medical history of hypertension and essential tremor presented with decreased mentation, episodes of blank staring, bradykinesia, and worsening bilateral hand tremors. He also reported shortness of breath with a cough productive of clear sputum. Physical exam was within normal limits except for tachypnea requiring 4 liters of oxygen, a bilateral essential tremor and dysmetria. All labs were within normal limits. A chest x-ray suggested multifocal pneumonia. A Computed Tomography (CT) scan demonstrated scattered ground glass opacities and multi-lobar pneumonia, while a CT scan of the head was negative. Treatment was initiated for community acquired pneumonia with azithromycin and ceftriaxone. Upon admission, the patient continued to be orientated only to person and place. Subsequent laboratory investigation demonstrated elevated ferritin (1,200 ng/mL), Lactate Dehydrogenase (613 IU/L), C-Reactive Protein (13.2 mg/dL), and low procalcitonin ( Discussion: The respiratory systems – cough, sputum production, and dyspnea – and imaging findings of COVID-19 are well described.7–11 The presented case is unique because, while the patient did display the established symptoms of COVID-19, he also had encephalopathy, bilateral essential tremor, and cerebellar dysfunction. Neurological imaging was negative, and patients with these symptoms would traditionally receive further investigation. Patients with neurological dysfunction secondary to COVID-19 can demonstrate some significant findings on magnetic resonance imaging (MRI) such as enhancement in the leptomeningeal region and bilateral frontotemporal hypoperfusion on perfusion imaging.5However, because of his concomitant respiratory symptoms, and in context of the ongoing COVID-19 pandemic, our patient did not receive further neurological imaging as there was a high index of suspicion. The central and peripheral nervous system manifestations of COVID-19 are documented, but this case demonstrates that COVID-19 can result in cerebellar dysfunction as well. Conclusion: COVID-19 is caused by SARS-CoV-2, a virus that enters host cells via a receptor primarily found on pneumocytes but also neurons and glial cells. As such, the most common presenting symptoms are respiratory. Here we present a case of a patient presenting with neurological dysfunction in addition to the established respiratory symptoms. Highlights: Our patient presented with encephalopathy, worsened essential tremor, and cerebellar dysfunction, which is an unusual presentation of COVID-19.-In an ongoing pandemic, it is important to have a high index of suspicion, even when patients present with atypical symptoms -It is unclear at this time if hydroxychloroquine and azithromycin should be the treatment of choice for COVID-19, but the regimen was successful in this patient.https://scholarlycommons.henryford.com/merf2020caserpt/1049/thumbnail.jp

Pandemic Emergency Department Triage Screening: Symptoms Increase Sensitivity

INTRODUCTION: In the weeks following the January 20, 2020, announcement of the first confirmed case of COVID-19 in the United States, valuable data was published on the clinical characteristics, including the most common presenting symptoms of individuals affected with the disease. One study in Wuhan, China, identified fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%) as common symptoms. A second study in Washington State identified shortness of breath as an initial symptom in 76% of patients. This case highlights the importance of rapid incorporation of updated data on the symptomatology of diseases into triage screening questionnaires during pandemics. CASE REPORT: Days after the World Health Organization’s March 11, 2020 declaration of a pandemic, a 37-year-old female presented to our Emergency Department (ED) with a 4-day history of cough, shortness of breath, myalgias, and fever. In triage, the patient was asked if she had traveled outside of the United States and if she had close contact with any person that had laboratory-confirmed COVID-19, for which she answered no. While waiting to be evaluated, the patient spent approximately 40 minutes in triage and an ED hallway before the possibility of COVID-19 was considered. At that point, airborne isolation precautions were ordered. Upon further questioning, the patient revealed she had taken a public bus trip to Florida, 6 days prior. She stated that several passengers on the bus were complaining of flu-like symptoms and were coughing. Upon arrival in Florida, the patient began developing a cough. As her symptoms progressed she also developed headache, nausea, and diarrhea, prompting her to return to Detroit to seek medical attention. The patient had multiple chronic health conditions, including hypertension, insulin-dependent type 2 diabetes, and obesity with a BMI of 48. The patient was subsequently admitted and was later confirmed to be positive for COVID-19. DISCUSSION: Historically, beta-coronaviruses have high rates of transmissibility in healthcare settings. A review of a 2014 MERS outbreak in Saudi Arabia classified 43.5% of all cases as nosocomial infections, while other outbreaks in Saudi Arabia in 2013 and South Korea in 2015 linked 100% to healthcare settings. Studies of the 2002-2003 SARS outbreak found that 21% of all cases occurred in healthcare workers and that the admission of a single index patient in one hospital led to a disastrous superspreading that infected 76 individuals. Data for COVID-19 is still limited, but one series in Wuhan, China presumed that 29% of hospitalized patients with COVID-19 pneumonia acquired the disease in a healthcare setting. It is important to maximize the utility of any tool that has the potential to reduce exposure of a contagious disease to healthcare workers and hospital patrons. Containment and isolation practices are significantly less effective during pandemics that have asymptomatic carriers and lengthy pre-symptomatic states, hence we should not lose opportunities to immediately isolate individuals who are showing symptoms. Another important consideration is that all SARS superspreaders were symptomatic. This case highlights the importance of rapid incorporation of updated data on the symptomatology of a disease into triage screening questionnaires in the setting of an evolving pandemic. This patient presented to our emergency department with a constellation of symptoms that were associated with COVID-19. She had close contact with individuals with the same symptoms while traveling. However, the triage screening questions utilized were not sensitive enough. Shortly after this incident, our institution modified the questionnaire to include specific symptoms associated with the disease, including fever, cough, shortness of breath, and myalgias, which would have potentially identified this patient earlier and expedited the placement of isolation orders.https://scholarlycommons.henryford.com/merf2020caserpt/1115/thumbnail.jp

Role of diagnostic stewardship in reducing healthcare-facility-onset Clostridioides difficile infections

We describe the implementation of an electronic medical record hard stop to decrease inappropriate Clostridioides difficile testing across a 5-hospital health system, effectively reducing the rates of healthcare-facility-onset C. difficile infection. This novel approach included expert consultation with medical director of infection prevention and control for test-order override

Outcomes associated with SARS-CoV-2 reinfection in individuals with natural and hybrid immunity

BACKGROUND: Studies comparing SARS-CoV-2 reinfection outcomes among individuals with previous infection (natural immunity) and previous infection plus vaccination (hybrid immunity) are limited. METHODS: Retrospective cohort study comparing SARS-CoV-2 reinfection among patients with hybrid immunity (cases) and natural immunity (controls) from March 2020 to February 2022. Reinfection was defined as positive PCR\u3e 90 days after initial laboratory-confirmed SARS-CoV-2 infection. Outcomes included time to reinfection, symptom severity, COVID-19-related hospitalization, critical COVID-19 illness (need for intensive care unit, invasive mechanical ventilation, or death), length of stay (LOS). RESULTS: A total of 773 (42%) vaccinated and 1073 (58%) unvaccinated patients with reinfection were included. Most patients (62.7%) were asymptomatic. Median time to reinfection was longer with hybrid immunity (391 [311-440] vs 294 [229-406] days, p \u3c 0.001). Cases were less likely to be symptomatic (34.1% vs 39.6%, p = 0.001) or develop critical COVID-19 (2.3% vs 4.3%, p = 0.023). However, there was no significant difference in rates of COVID-19-related hospitalization (2.6% vs 3.8%, p = 0.142) or LOS (5 [2-9] vs 5 [3-10] days, p = 0.446). Boosted patients had longer time to reinfection (439 [IQR 372-467] vs 324 [IQR 256-414] days, p \u3c 0.001) and were less likely to be symptomatic (26.8% vs 38%, p = 0.002) compared to unboosted patients. Rates of hospitalization, progression to critical illness and LOS were not significantly different between the two groups. CONCLUSIONS: Natural and hybrid immunity provided protection against SARS-CoV-2 reinfection and hospitalization. However, hybrid immunity conferred stronger protection against symptomatic disease and progression to critical illness and was associated with longer time to reinfection. The stronger protection conferred by hybrid immunity against severe outcomes due to COVID-19 should be emphasized with the public to further the vaccination effort, especially in high-risk individuals

Risk Factors Associated With Hospitalization and Death in COVID-19 Breakthrough Infections

BACKGROUND: Characterizations of coronavirus disease 2019 (COVID-19) vaccine breakthrough infections are limited. We aim to characterize breakthrough infections and identify risk factors associated with outcomes. METHODS: This was a retrospective case series of consecutive fully vaccinated patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a multicenter academic center in Southeast Michigan, between December 30, 2020, and September 15, 2021. RESULTS: A total of 982 patients were identified; the mean age was 57.9 years, 565 (59%) were female, 774 (79%) were White, and 255 (26%) were health care workers (HCWs). The median number of comorbidities was 2; 225 (23%) were immunocompromised. BNT162b2 was administered to 737 (75%) individuals. The mean time to SARS-CoV-2 detection was 135 days. The majority were asymptomatic or exhibited mild to moderate disease, 154 (16%) required hospitalization, 127 (13%) had severe-critical illness, and 19 (2%) died. Age (odds ratio [OR], 1.14; 95% CI, 1.04-1.07; P \u3c .001), cardiovascular disease (OR, 3.02; 95% CI, 1.55-5.89; P = .001), and immunocompromised status (OR, 2.57; 95% CI, 1.70-3.90; P \u3c .001) were independent risk factors for hospitalization. Additionally, age (OR, 1.06; 95% CI, 1.02-1.11; P = .006) was significantly associated with mortality. HCWs (OR, 0.15; 95% CI, 0.05-0.50; P = .002) were less likely to be hospitalized, and prior receipt of BNT162b2 was associated with lower odds of hospitalization (OR, 0.436; 95% CI, 0.303-0.626; P \u3c .001) and/or death (OR, 0.360; 95% CI, 0.145-0.898; P = .029). CONCLUSIONS: COVID-19 vaccines remain effective at attenuating disease severity. However, patients with breakthrough infections necessitating hospitalization may benefit from early treatment modalities and COVID-19-mitigating strategies, especially in areas with substantial or high transmission rates

Addressing COVID-19 in the surgical ICU: Incidence of antibodies in healthcare personnel at a quaternary care center

Background: There is concern that frontline healthcare personnel (HCP) are at increased risk of exposure to COVID-19 compared to the general population. Multiple studies have demonstrated significant seroprevalence of COVID-19 antibodies in HCP. Increased seropositivity has been associated with reduced use of personal protective equipment (PPE) along with reported PPE shortages. This investigation aims to determine the seroprevalence of COVID-19 in frontline HCP working at a quaternary care center that was heavily impacted by the initial surge of COVID-19, while also identifying underlying factors associated with increased seropositivity. Methods & Materials: HCP who participated in the management of COVID-19 patients were recruited from April 27 to May 13 of 2020. Unidentifiable demographic data was collected, including a questionnaire to identify potential exposure, symptoms, medical comorbidities, and adherence to PPE usage on a scale of 1 to 5 (1 being always, 5 being never). Serological testing was performed using CMC-19D SARS-CoV-2 (COVID-19) Rapid Antibody Test manufactured by Audacia Bioscience. Seropositivity was captured by formation of a dark band at the G (IgG) and C (control) positions on the test device, while IgM alone was considered a false positive. Pearson chi-squared and Fisher exact tests were performed to analyze categorical variables. SPSS version 27.0 was used for statistical analysis (SPSS, Armonk, NY). Conclusion: Overall seropositivity of IgG antibodies was 10.6%. Non-ICU personnel showed higher seroprevalence compared to ICU personnel, this may be attributed to decreased reported adherence to strict PPE usage in non-ICU areas compared to ICU areas during patient contact. Compared to MICU, SICU personnel appeared to be less compliant with frequency of PPE use outside patient rooms. Adherence to PPE usage outside patient contact was a predictor of seropositivity, and non-ICU personnel had a tendency toward high seroprevalence.https://scholarlycommons.henryford.com/sarcd2021/1003/thumbnail.jp

Liax Is a Surrogate Marker For Cell Envelope Stress and Daptomycin Non-Susceptibility in Enterococcus Faecium

Daptomycin (DAP) is often used as a first-line therapy to treat vancomycin-resistan