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TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus Disease 2019 (COVID-19) continues to be a global pandemic with its management evolving as research continues to unveil innovative therapies. Dantrolene, approved in malignant hyperthermia, may have utility for hyperpyrexia in COVID-19 patients, given its cytoprotective effects (1). Here we present a COVID-19 case with persistent hyperpyrexia despite conventional antipyretic measures that abated after dantrolene administration. CASE PRESENTATION: A 57-year-old Hispanic male with no past medical history, presented with fever, palpitations, myalgias and worsening dyspnea. He denied other symptoms. His admission vitals were Temp 101.3F, BP 155/81, Pulse 106, Resp 22, SpO2 88% on RA and 98% on 50% Venturi Mask. Lung examination revealed decreased air entry throughout with scattered crackles. Laboratory investigations showed WBC of 5.61 with normal electrolytes. ABG showed pH 7.45, pCO2 36, pO2 59 with FiO2 0.35 which improved with increased oxygenation. CXR showed hallmark features for COVID-19 pneumonia. COVID-19 PCR was positive. Antibiotics and prophylactic anticoagulation were initiated. He was later admitted to the medical floor. His hospital course was unremarkable until day three when he developed acute hypoxic respiratory failure requiring high flow nasal cannula and intensive care transfer. Despite optimal oxygenation, PF ratio was 105F. Besides multiple positive COVID-19 tests, all other infectious investigations were negative. Antibiotics, antivirals and antifungals were started but pyrexia persisted. Intravenous dantrolene (2.5mg/kg then 1mg/kg) was given after which temperature abated. De-escalation of care ensued, with removal of antimicrobials, intubation and ECMO. Patient had an uneventful transfer from MICU and discharge from the hospital. DISCUSSION: Hyperpyrexia is an extreme elevation of core body temperature usually >106.7 °F due to an elevated hypothalamic thermo-regulatory threshold. It has been reported in COVID-19 patients and portends a poor outcome with up to 100% mortality. Proposed mechanisms include immune dysfunction, direct brain injury from SARS-CoV-2 and vascular thrombosis (2). Dantrolene has been shown to inhibit multiple cell damage induced by SARS-CoV-2 infection (1). In our index case, all conventional antipyretic measures failed, while dantrolene achieved normothermia. CONCLUSIONS: Our case had a favorable outcome juxtaposing those previously reported (1,2). The proposition that dantrolene can be repurposed in COVID-19 patients with hyperpyrexia is novel and hopefully will stimulate and unearth more research. REFERENCE #1: Jiang, B., Liang, S., Liang, G., & Wei, H. (2020). Could dantrolene be explored as a repurposed drug to treat COVID-19 patients by restoring intracellular calcium homeostasis?. European review for medical and pharmacological sciences, 24(19), 10228–10238. https://doi.org/10.26355/eurrev_202010_23247 REFERENCE #2: Suwanwongse, K., & Shabarek, N. (2020). Hyperpyrexia in patients with COVID-19. Journal of medical virology, 92(11), 2857–2862. https://doi.org/10.1002/jmv.26154 DISCLOSURES: No relevant relationships by Sneha Adidam, source=Web Response No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alicia Thomas, source=Web Response

SESSION TITLE: Medical Students/Residents' COVID-19 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: October 18-21, 2020 INTRODUCTION: The novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been detected in nasopharyngeal swabs (NPS), sputum, bronchoalveolar lavage, blood, feces and ocular fluid(1) To date, there are no reported cases of SARS-CoV-2 isolated in pleural fluid, that is associated with a life-threatening complication, empyema CASE PRESENTATION: He is a 64-year-old male with a known history of type 2 diabetes mellitus and hypertension who presented with a three-day history of progressive shortness of breath and generalized weakness which was preceded by a dry cough for a few weeks He otherwise had no complaints or ill-contacts On presentation, he was noted to be hypoxemic (saturation 93% on 4 liters of oxygen), tachycardic and afebrile Initial exam was significant for mild respiratory distress and bilateral crackles on lung auscultation Labs showed an elevated white blood cell count (11 6 x 10 6 ), troponin, D-dimer, ferritin and C-reactive protein Serum interleukin-6 was elevated at 17 26 pg/mL However, creatine phosphokinase, lactate dehydrogenase, transaminases and quantiferon gold were within normal limits A chest x-ray was done that showed bilateral patchy infiltrates and a follow-up computerized tomography (CT) of the chest showed diffuse ground glass opacity with a large thick-walled septated mass in the left lower thorax He was subsequently admitted for hypoxic respiratory failure likely secondary to COVID-19 pneumonia with superimposed bacterial infection complicated by possible empyema Nasopharyngeal swab for SARS-CoV-2 was positive Thoracentesis with chest tube placement revealed purulent material with pH of 6 5, that then later also tested positive for SARS-CoV-2 Final pleural fluid cultures grew pan sensitive Streptococcus pneumoniae Pleural adenosine deaminase was elevated, however acid-fast bacilli cultures were no growth He was treated with empiric antibiotics and the chest tube was removed after adequate drainage of empyema He was discharged on room air to complete a course of oral antibiotics, self-quarantine and to follow-up in the pulmonary clinic after two weeks DISCUSSION: Empyema is defined by the presence of bacteria or pus in the pleural space and is a well-documented sequela of pneumonia with mortality of up to 20%(2) The isolation of SARS-CoV-2 within the pleural fluid with a superimposed bacterial infection highlights the increased risk of self-quarantine and delayed treatment pose to the management of high-risk patients The MuLBSTA score, a 90-day mortality predictor for viral pneumonia, recognizes co-bacterial infection as an additional risk factor for mortality(3) CONCLUSIONS: The presence of SARS-CoV-2 in body fluids such as pleural fluid has not yet been reported, nor are the implications known in regard to shedding duration and prognostication Reference #1: Wang W, Xu Y, Gao R, et al Detection of SARS-CoV-2 in Different Types of Clinical Specimens JAMA 2020;323(18):1843-1844 doi:10 1001/jama 2020 3786 Reference #2: Morris DE, Cleary DW, Clarke SC Secondary Bacterial Infections Associated with Influenza Pandemics Front Microbiol 2017;8:1041 doi:10 3389/fmicb 2017 01041 Reference #3: Guo L, Wei D, Zhang X, et al Clinical Features Predicting Mortality Risk in Patients With Viral Pneumonia: The MuLBSTA Score Front Microbiol 2019;10 doi:10 3389/fmicb 2019 02752 DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Vishal Poddar, source=Web Response No relevant relationships by Lamiaa Rougui, source=Web Response

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A spontaneous pneumothorax is an abnormal atraumatic accumulation of air within the pleural space It is classified as primary or secondary pneumothorax with multiple associated precipitants or risk factors(1) Here we present a case of spontaneous pneumothorax following COVID-19 pneumonia CASE PRESENTATION: A 58-year-old Hispanic male, known to have hypertension, presented to the emergency room for dyspnea for one day This was associated with a non-productive cough, fever and pleuritic left-sided chest pain He denied any smoking history, recent travel, trauma or ill-contacts There was no known history of lung disease, autoimmune illnesses or family history of pneumothorax He reported only taking hydrochlorothiazide and amlodipine Initial vitals were normal, except a respiratory rate of 25 breaths per minute Pertinent examination findings were, he was of normal height with tachypnea and diminished air entry over the left hemithorax Laboratory results were positive for COVID-19 by nasopharyngeal swab, with mild leukocytosis, normal procalcitonin and lactic acid The interleukin-6 level (45 13 pg/mL), ferritin, CPK, LDH and ESR were elevated Initial chest x-ray and computer tomography (CT) chest showed 30-40% left pneumothorax with patchy bilateral and peripheral coalescing infiltrates, typical of COVID-19 of mild to moderate severity, with a CT severity score (CT-SS) of 12 out of 40 He subsequently had left pigtail placement and was admitted for COVID-19 pneumonia complicated by spontaneous pneumothorax He was started on antibiotics, hydroxychloroquine and placed on contact and droplet isolation Ultimately, influenza oropharyngeal swab, urine antigens for mycoplasma and legionella, HIV, collagen vascular screen and blood cultures were otherwise unremarkable After 8 days, he clinically improved with complete resolution of the pneumothorax post pigtail removal DISCUSSION: In the United States, the incidence of adult males with primary or secondary spontaneous pneumothorax is 7 4-18/100,000 or 6 3/100,000, respectively(2) There are several known risk factors for pneumothorax such as smoking, tall stature, family history and certain genetic disorders Our index case, with the exception of male gender, exhibited none of these precipitants and had no known history of lung disease or any other risk factors for spontaneous pneumothorax Sun et al,(3) proposed that diffuse alveolar injury due to COVID-19 may increase the risk of alveolar rupture resulting in pneumothoraces Another theory included a prolonged cough that is associated with COVID-19 pneumonia CONCLUSIONS: Healthcare providers should consider patients with COVID-19 pneumonia to be, directly or indirectly, predisposed to spontaneous pneumothoraces To the best of our knowledge this is the first reported local presentation of spontaneous pneumothorax in a patient with COVID-19 pneumonia Reference #1: McKnight CL, Burns B Pneumothorax [Updated 2020 Mar 25] In: StatPearls [Internet] Treasure Island (FL): StatPearls Publishing;2020 Jan- Available from: https://www ncbi nlm nih gov/books/NBK441885/ Reference #2: Costumbrado J, Ghassemzadeh S Pneumothorax, Spontaneous [Updated 2019 Dec 16] In: StatPearls [Internet] Treasure Island (FL): StatPearls Publishing;2020 Jan- Available from: https://www ncbi nlm nih gov/books/NBK459302 Reference #3: Sun R, Liu H, Wang X Mediastinal Emphysema, Giant Bulla, and Pneumothorax Developed during the Course of COVID-19 Pneumonia Korean J Radiol 2020;21(5):541-544 doi:10 3348/kjr 2020 0180 DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alicia Thomas, source=Web Response