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Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mainly present with upper and lower respiratory tract symptoms, with complications related to cytokine storm syndrome and acute respiratory distress syndrome. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding thrombosis in coronavirus disease 2019 (COVID-19). Here we are presenting a case of arterial thrombosis in a patient with COVID-19 and a systematic review on coagulopathy associated with COVID-19.

Bilateral diffuse infiltrates on chest imaging can present a diagnostic challenge due to a broader differential diagnosis which includes pulmonary and non-pulmonary causes. Malignancy is generally not considered under differential diagnosis at the time of initial presentation. Here we present a case of primary adenocarcinoma of lung manifesting as diffuse bilateral infiltrates on imaging. Our case is unique in regards to its acute presentation, rapid progression to respiratory failure, ultimately leading to the demise of the patient. This indicates the aggressive nature of this malignancy and its variable presentation, like male gender and young age, thus emphasizing the importance of entertaining malignancy in such presentations, especially if there is no response to conventional antibiotic therapy.

Hepatocellular carcinoma (HCC) is ranked the fifth-most common cancer in men and ninth most common cancer in women. Immunotherapy has been shown effective in malignancies refractory to chemotherapy and has been used as a second-line therapies in many advanced cancers, including HCC. The advent of immunotherapy has resulted in a brand-new set of side effects, and it has been proposed that it was related to over activated immune system. Herein, we presented the case of 59-year-old African American gentlemen who was diagnosed with HCC caused by Hepatitis C virus, for which he was started on chemotherapy and immunotherapy. However, the patient developed cryoglobulinemia that prompted stopping both therapies and giving rituximab and steroids. We believe that the mixed cryoglobulinemia was unmasked by immunotherapy in our patient. To our knowledge, this is one of the few first cases to describe such adverse effect from immune checkpoint inhibitors.

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: COVID-19 is a major public health emergency with increasing mortality since the first case in December 2019. COVID-19 has multifaceted presentation and only about 15-20% required hospitalizations and a quarter of those required management in an intensive care unit (ICU). Herein, we reviewed the demographics, clinical outcomes, and identified the potential prognostic indicators in patients with COVID-19 who were admitted to our ICU. METHODS: A retrospective cohort study was conducted on patients ≥ 18 years old with confirmed COVID-19, who were admitted to our ICU between 03/17/2020 and 05/14/2020. Demographic, clinical, and laboratory data were reviewed and retrieved. Data was expressed as counts and percentages. T-test and chi-square (χ) were used for continuous and categorical variables respectively. Univariate analysis was also performed to identify the prognostic indicators associated with mortality. GraphPad PRISM was used for data analysis. RESULTS: Seventy-five patients were identified during the study period with an average age of 60.8 (ranged from 19-89), of which males were 99 (71%) and females were 41 (29%). Majority were Hispanic (45%) and African Americans (34%). The average body mass index was 30.6. Hypertension (47.9%) and chronic kidney disease (47.1%) were the most common comorbidities. Mechanical ventilation was required in 99 (70.7%) of the patients. Of those 99, 75 (76%) expired. There was no statistically significant difference between the survival and expired groups in term of age, gender, ethnicities and number of comorbidities. Need of mechanical ventilation (MV) and renal replacement therapy (RRT) were significantly associated with mortality (p

Background The first reported case of COVID-19 in the United States was in January 2020 and has since become a pandemic spreading rapidly worldwide. There is limited data on the epidemiology and prognosis of COVID-19 in end stage renal disease (ESRD) patients on hemodialysis (HD). In this study we describe our experience with 39 such patients who contracted COVID-19 disease. Methods We conducted a retrospective hospital cohort study on patients ≥ 18 years old with ESRD on HD and confirmed COVID-19, who were admitted to our hospital between 03/15/2020 and 05/25/2020. Study individuals were recruited if they had a well-defined clinical outcome (discharged alive or expired). Demographic, clinical and laboratory data were reviewed and retrieved. Descriptive analysis, univariate and multivariate logistic regression methods were employed to describe the demographic and to identify prognostic markers associated with mortality. Results Out of the 427 confirmed COVID-19 hospitalized patients during the study period, 39 ESRD patients on HD were included in this study, 19 (49%) expired, and 20 (51%) were discharged alive. Demographic analysis was tabulated in Table 1. The non-parametric analysis showed a significant difference in ethnicity, history of COPD, need of mechanical ventilation, ferritin, LDH, lymphocyte-ferritin ratio (LFR), lymphocyte-CRP ratio (LCR) and AST/ALT ratio between survival and non-survival groups (Table 1, 2). Mechanical ventilation is independently associated with mortality in ESRD patients with COVID-19 (odds ratio [OR] 21.11; 95% confidence interval [CI], 3.00–238.9). In addition, low AST/ALT ratio has an odd of survival in this group of patients (OR 0.45; 95% CI, 0.19–0.88). Table 1: Demographic Analysis of all ESRD patients with COVID-19. (HTN – Hypertension, DM – Diabetes mellitus, CAD – Coronary artery disease, CHF – Congestive heart failure, COPD – Chronic obstructive pulmonary disease) Table 2: Non-parametric analysis of all prognostic markers. (WBC – White blood count, ANC - Absolute neutrophil count, ALC - Absolute lymphocyte count, MPV – mean platelet volume, CRP – C-reactive protein, LDH – Lactate dehydrogenase, LFR – Lymphocyte-ferritin ratio, LDR - Lymphocyte-D-dimer ratio, LCR – Lymphocyte-CRP ratio, LLR - Lymphocyte-LDH ratio, AST – Aspartate transferase, ALT – Alanine transferase, BNP – Brain natriuretic peptide, NLR – Neutrophil-lymphocyte ratio, PLR – Platelet-lymphocyte ratio) Conclusion Our observation of COVID-19 disease in patients with ESRD on HD confirms that this population is at the highest risk for mortality from SARS-CoV-2 infection, and that a low AST/ALT ratio is independently associated with decreased mortality, while mechanical ventilation had an increased mortality. Larger prospective studies in this population may help us understand better those prognostic markers and suggest how to intervene in order to decrease this catastrophic rate of mortality Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

Background One of the risk factors for poor outcome with SARS-CoV-2 infection is diabetes mellitus; diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most serious complications of diabetes mellitus. We aimed to explore the clinical characteristics and outcomes of COVID-19 patients presenting with isolated DKA or combined DKA/HHS to our institution. Methods A retrospective, hospital based observation case series was performed on patients with SARS-CoV-2 admitted to Intensive Care Unit between 03/20/20 and 04/20/20. Inclusion criteria were: 1) Blood Glucose >250mg/dL; 2) Serum bicarbonate < 18 mmol/L; 3) Anion Gap >10; 4) serum pH < 7.3; 4) ketonemia or ketonuria; and 5) positive SARS-CoV-2 RT-PCR. Hyperosmolality, on the other hand, was defined as an effective/calculated plasma osmolality >304 mOsm/kg. Results A total of 87 patients with COVID-19 were admitted to the ICU during the study period, 12 of them had either isolated DKA or DKA/HHS. Baseline demographics, lab values and outcome are summarized in Table 1. Six of the patients had isolated DKA and six had combined DKA and HHS. The median age for the patient was 49.5 years old (range from 19 to 62 years old). The male to female ratio was 5:1. Of the 12 patients, 10 patients (83%) had a history of DM, nine were type 2 and only one type 1; two patients were newly diagnosed DM, presenting as DKA, presumptively precipitated by COVID-19. Five patients (42%) had a BMI >30 kg/m2. As for ethnicity; seven were Hispanic (59%), four African American (33%), and one Caucasian (8%). Patients with combined DKA/HHS, higher BMI, higher HbA1c, severe acidosis tended to have higher mortality. The striking feature was that isolated DKA or combined DKA/HHS was the initial presentation for COVID-19 for most of the cases. Table 1: Demographic characteristic, inflammatory markers and outcome. Conclusion Our observational retrospective case series reinforces the need to watch for new onset DM and monitor blood sugar closely in those with known diabetes mellitus during SARS-CoV-2 infection, in order to avoid such serious complications as DKA and HHS. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

The emergence of immune checkpoint inhibitors (ICIs) in recent years has transformed the landscape of the management of solid tumors. The advancement of immunotherapy has resulted in a brand new set of adverse outcomes not previously seen in classical chemotherapy. One such adverse effect has been termed as hyperprogressive disease (HPD), a phenomenon characterized by rapid tumor progression, which often leads to devastating outcomes. In this report, we present a unique case of a 48-year-old African American female who initially presented with abdominal pain, fatigue, and weight loss. Subsequent CT scan showed extensive irregular wall and luminal narrowing with an eccentric mass and adenopathy along the portacaval space. Tumor markers were found to be elevated and genetic testing was done. The patient was diagnosed with stage IIIC colon cancer with K-RAS wild type, associated with Lynch syndrome. The patient underwent surgical resection, chemotherapy, and targeted therapy for progressive/stage IV disease. In light of the progression of the disease, pembrolizumab was introduced into the treatment regimen. One month after the treatment, a repeat CT scan showed enlargement of the metastatic lesion with almost double the size. The progression of the disease was so rapid and, ultimately, pembrolizumab administration was withheld and the patient passed away after about two months on pembrolizumab. To our knowledge, this is one of the few cases of HPD reported in patients with advanced colon cancer, particularly in one with Lynch syndrome. Further studies are warranted to understand why some individuals benefit from immunotherapy, whereas others experience grave outcomes.

Starvation-induced ketoacidosis in non-diabetic and non-pregnant, otherwise healthy patients is not common. In an otherwise normal healthy individual, short-term starving will only result in mild ketosis. Nonetheless, the effects of ketosis can become more severe if there is stress and insulin resistance, such as in pregnant or lactating woman or in very young individual such as neonates. We report a case of severe starvation-induced ketoacidosis in a non-diabetic and non-pregnant 37-year-old African American female patient with a history of multiple recurrent pancreatitis. The patient was initially presented to the emergency department with abdominal pain, nausea and vomiting over two days. The patient also reported starving for two days prior to admission. Biological findings, however, showed a severe degree of metabolic acidosis with an increased anion gap. Serum glucose was normal and 3+ ketonuria were present. Lactic acid was 1.7 mmol/L with no uremia. Salicylate acid, acetaminophen and ethanol level were normal. The patient’s beta-hydroxybutyrate level elevated with ketonuria, suggestive of ketoacidosis as the cause of metabolic acidosis. To our knowledge, the presenting case was novel as no case reports or case series have been reported in these groups of patients. Short-term starvation, if it occurs during periods of stress and medication, may result in life-threatening ketoacidosis, even among non-diabetic women and non-pregnant patients. Awareness of this condition may facilitate prompt recognition and proactive treatment for dietary and stress control.

Background A few COVID-19 related retrospective studies have established that older age, elevated neutrophil-lymphocyte ratio (NLR), and decreased lymphocyte-CRP ratio (LCR) were associated with worse outcome. Herein, we aim to identify new prognostic markers associated with mortality. Methods We conducted a retrospective hospital cohort study on patients ≥ 18 years old with confirmed COVID-19, who were admitted to our hospital between 03/15/2020 and 05/25/2020. Study individuals were recruited if they had a complete CBC profile and inflammatory markers such as CRP, ferritin, D-dimer and LDH, as well as a well-defined clinical outcomes (discharged alive or expired). Demographic, clinical and laboratory data were reviewed and retrieved. Univariate and multivariate logistic regression methods were employed to identify prognostic markers associated with mortality. Results Out of the 344 confirmed COVID-19 hospitalized patients during the study period, 31 who did not have a complete blood profile were excluded; 303 patients were included in the study, 89 (29%) expired, and 214 (71%) were discharged alive. Demographic analysis was tabulated in Table 1. The univariate analysis showed a significant association of death with absolute neutrophil count (ANC, p=0.022), NLR (p=002), neutrophil-monocyte ratio (NMR, p=< 0.0001), LCR (p=0.007), lymphocyte-LDH ratio (LLR, p=< 0.0001), lymphocyte-D-dimer ratio (LDR, p=< 0.0001), lymphocyte-ferritin ratio (LFR, p=< 0.0001), and platelets (p=0.037) with mortality. With multivariable logistic regression analysis, the only values that had an odds of survival were high LDR (odds ratio [OR] 1.763; 95% confidence interval [CI], 1.20–2.69), and a high LFR (OR 1.136, CI 1.01–1.34). We further build up a model which can predict >85% mortality in our cohorts with the utilization of D-dimer (>500 ng/ml), Ferritin (>200 ng/ml), LDR (< 1.6), LFR (< 4) and ANC (>2.5). This new model has a ROC of 0.68 (p< 0.0001). Conclusion This retrospective cohort study of hospitalized patients with COVID-19 suggests LDR and LFR as potential independent prognostic indicators. A new model with combination of D-dimer, Ferritin, LDR, LFR and ANC, was able to predict >85% mortality in our cohort with ROC of 0.68, it will need to be validated in a prospective cohort study. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

Cholangiocarcinoma (CCA) is a rare cancer of the bile duct epithelial cells and it commonly spreads to the regional lymph nodes, liver, and lungs. Bone metastasis has been reported in patients with CCA, involving both the axial and appendicular skeleton. Herein, we report a case of extrahepatic CCA with extensive bone metastases involving the calvarium, sternum, bilateral ribs and scapulae, entire spine, pelvis, and bilateral femur. To our knowledge, this is the first case report on sternum metastasis in CCA. The case presentation and review of literature highlighted the rarity of this metastasis, and health-care providers should be aware of the rare presentation of CCA.

Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericardial fluid. There are multiple risk factors for cardiac tamponade, nephrotic syndrome is an uncommon one, especially in adults. Herein, we are reporting a 35-year-old African American woman with membranoproliferative glomerulonephritis secondary to human immunodeficiency virus-associated immune complex kidney disease (HIVICK), who presented with cardiac tamponade. The patient had pericardiocentesis and was discharged, with outpatient follow-up with cardiology, nephrology, and infectious disease. To the best of our knowledge, this is the first report of HIVICK nephrotic syndrome associated with cardiac tamponade.

Aim One of the risk factors for poor outcome with SARS-CoV-2 infection is diabetes mellitus; diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most serious complications of diabetes mellitus. We aimed to explore the clinical characteristics and outcomes of COVID-19 patients presenting with combined DKA/HHS to our institution. Methods A retrospective, hospital based observation case series was performed on patients with SARS-CoV-2 admitted to Intensive Care Unit between 3/20/2020 and 4/20/2020. Inclusion criteria were: (1) Blood Glucose >250 mg/dL; (2) Serum bicarbonate 10; (4) serum pH 304 mOsm/kg and (7) positive SARS-CoV-2 RT-PCR. Results We reported 6 patients who presented during this period with combined DKA/HHS. Their median age was 50 years, all males, three Hispanic, and three African American. Hispanic patients, had more severe acidosis, and multiple comorbidities, with a higher mortality. The striking feature was that combined DKA/HHS was the initial presentation for COVID-19 for most of the cases. Discussion Our observational retrospective case series shows that diabetic patients are at risk of developing combined DKA/ HHS associated with COVID-19 and a substantial mortality. To our knowledge, we are first to report the clinical characteristics and outcome in this group of patients.