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Introduction Adrenal insufficiency can happen because of decreased cortisol production as a result of negative feedback on the hypothalamic–pituitary–adrenal axis, caused by excess exogenous glucocorticoids (GC). The most common cause of adrenal insufficiency is, in fact, abrupt stoppage of exogenous GC. Patients with adrenal insufficiency are at risk of developing life-threatening adrenal crisis if GC is reduced or stopped abruptly, or if GC dose is not increased during periods of increased stress.The adrenal crises should be preventable with education of patients and healthcare professionals (HCPs) about “sick-day” rules, the importance of “steroid cards,” and the utility of parenteral steroids. Methods This study was aimed at assessing the knowledge of sick-day rules in patients on long-term GC as well as HCPs.Patients aged above 18 years on long-term GC presenting to the endocrinology clinic over 6 weeks were included after audit-committee approval. Results We assessed 18 consecutive patients in total, 61% (11/18) of whom said that they have received information about sick-day rules from an HCP. Only 38% (7/18) had access to emergency hydrocortisone-kit.We assessed 36 HCPs. Thirty-six (13/36) percent were aware of steroid emergency card and 50% (18/36) HCPs exhibited awareness regarding steroid dose during acute event and 27% of (10/36) HCPs were aware of accessible hospital intranet resources. Conclusion This study revealed significant lack of awareness of sick-day rules among patients and HCPs alike. Majority of patients failed to carry steroid emergency card or medic alert bracelet and majority of HCPs and patients lacked knowledge of sick-day rules.

Prevotella, a Gram-negative rod, is a normal commensal found on human mucosal surfaces. While infection with Prevotella spp. among immunocompromised individuals is common, among immunocompetent individuals, infection with this species is rare. We report an unusual case of a patient with Prevotella buccae bacteremia and we have conducted a short review of the literature on prior reports of P. buccae bacteremia.

Background Rocky mountain spotted fever (RMSF) is a rickettsial disease with incidence of 11 per million and is rarely associated with encephalopathy. Here we discuss a patient with RMSF encephalopathy, highlighting the natural course. Methods A 54 year old man with history of hypertension and chronic progressive external ophthalmoplegia, presented with waxing and waning confusion, headache, slurred speech, agitation and difficulty swallowing. He was afebrile and hemodynamically stable. Investigations showed leukocytosis of 15400 and mild transaminitis. Computed-tomography (CT) head was unremarkable. Lumbar puncture revealed normal pressure. Cerebrosopinal fluid (CSF) analysis was notable for WBC 7, glucose 76 and moderately elevated total protein 114. Urine drug screen was negative. Blood, fungal, and CSF cultures were sent and empiric therapy with vancomycin, ceftriaxone, ampicillin and acyclovir commenced, for suspected encephalitis. High dose solumedrol 1gm/day was given due to suspicion of autoimmune encephalitis. MRI brain showed cerebral atrophy. There was slight abnormal FLAIR/T2 signal within the medial aspect of the temporal lobes, right more than left. Results Occupational history revealed that he was a logger by profession, which steered our focus on tick borne diseases. Extensive serologic evaluation was requested and RMSF IgG titres came back positive at 1:512. Doxycycline was added, while ampicillin and ceftriaxone were discontinued. With doxycycline, patient made remarkable recovery and was discharged home well. However, he returned within 48 hours with recurring encephalopathy. His clinical presentation remained convincing for RMSF encephalitis, with the natural course of the illness spanning over weeks, with waxing and waning symptoms. Patient was managed with IV doxycycline for 72 hours following which he returned to his baseline mental status. Figure 1. MRI findings Figure 2. Serological investigations Figure 3. CSF studies Conclusion Patient’s occupation played a pivotal role in establishing diagnosis. In RMSF, IgM and IgG antibodies appear 7 to 10 days after the onset of the illness, and a fourfold rise in IgG is diagnostic of seroconversion and recent illness. Patient’s waxing and waning symptoms, persisting for weeks and remarkable response to doxycycline, are typical features of RMSF encephalitis. Disclosures All Authors: No reported disclosures

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: As we navigate through the Covid pandemic, there is emerging evidence of cardiac injury related to Covid-19 infection such as myocardial ischemia, arrhythmia and pericardial effusion. Studies have associated Covid-19 related cardiac injury with a 5-fold increase in the risk of mechanical ventilation and 14 times higher mortality rate(1). In the presence of cardiac co-morbidities, Covid-19 related all-cause mortality rate increases. We present a case of Covid-19 infection in a patient with Hypertrophic Obstructive Cardiomyopathy (HCM) intending to discuss its sequelae. CASE PRESENTATION: A 72-year old male presented to ER with 2 days history of non-productive cough and dyspnea. Six months ago, he was hospitalized for 8 days with respiratory failure secondary to Covid-19 pneumonia. He was treated with remdesivir, ceftriaxone, azithromycin and dexamethasone. His past history was significant for HCM status post AICD placement, chronic diastolic heart failure with ejection fraction of 55% and hypertension.On presentation, he was hypotensive at 83/50, with a heart rate of 58 and saturation of 94% on room air. His WBC count was elevated at 12.2. Chest x-ray revealed right basal infiltrate with bilateral small pleural effusions. His presentation ECG revealed new onset atrial fibrillation (AF). Covid PCR test was negative. He was admitted to intensive care unit for vasopressor support for management of septic shock secondary to pneumonia.Therapeutic dose of enoxaparin was initiated in view of AF with CHA2DS2VASC score of 3. Echocardiogram showed mild concentric left ventricular hypertrophy with ejection fraction of 55-60%. Significant left ventricular outflow tract gradient consistent with HCM was noted. Due to worsening of bilateral pleural effusions, bilateral thoracocentesis was performed separately draining 650ml of hemorrhagic fluid on the left and 800ml of hemorrhagic fluid on the right. Pleural fluid (PF) analysis was exudative and cytology was negative. Re-accumulation of PF warranted bilateral chest drain placement. PF culture remained negative. Unfortunately, patient had recurrent hypovolemic shock and he opted for comfort care measures. DISCUSSION: ACE2 receptor in the respiratory epithelium serves as the entry portal for the SARS-CoV-2 virus. In patients with HCM, there is up-regulation of ACE2 expression causing a 5-fold increase in ACE2 protein in sarcomeres, thereby increasing susceptibility to cardiac complications (2). Our patient in discussion had new onset AF, on the background of HCM. CONCLUSIONS: Reports indicate an increased incidence of cardiac complications in HCM patients with Covid-19 infection such as arrhythmia, as in our patient. AF in the setting of underlying HCM, can be explained by ACE2 protein up-regulation. Physicians managing HCM patients should well be aware of increased risk of such complications. REFERENCE #1: Toloui A, Moshrefiaraghi D, Madani Neishaboori A, Yousefifard M, Haji Aghajani M. Cardiac Complications and Pertaining Mortality Rate in COVID-19 Patients;a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2021 Feb 13;9(1):e18. doi: 10.22037/aaem.v9i1.1071. PMID: 33870205;PMCID: PMC8035700. REFERENCE #2: Bos JM, Hebl VB, Oberg AL, Sun Z, Herman DS, Teekakirikul P, Seidman JG, Seidman CE, Dos Remedios CG, Maleszewski JJ, Schaff HV, Dearani JA, Noseworthy PA, Friedman PA, Ommen SR, Brozovich FV, Ackerman MJ. Marked Up-Regulation of ACE2 in Hearts of Patients With Obstructive Hypertrophic Cardiomyopathy: Implications for SARS-CoV-2-Mediated COVID-19. Mayo Clin Proc. 2020 Jul;95(7):1354-1368. doi: 10.1016/j.mayocp.2020.04.028. Epub 2020 Apr 28. PMID: 32448590;PMCID: PMC7186205. DISCLOSURES: No relevant relationships by Khushdeep Chahal, source=Web Response No relevant relationships by Sangeetha Isaac, source=Web Response No relevant relationships by Kavitha Juvvala, source=Web Response No relevant relationships by Eileen Montalvan, source=Web Response No relevant relationships by Utibe Ndebbio, source=Web Response No relevant relationships by Mohammed Afraz Pasha, source=Web Response

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary cryptococcosis (PC) is an opportunistic invasive mycosis common in immunocompromised patients, presenting as dyspnea and cough(1). Studies have shown opportunistic infections such as pulmonary aspergillosis, candida and pneumocystis pneumonia in critically ill patients with COVID-19. However data on incidence of PC in this subset of patients is sparse(2). We discuss a patient with post-COVID-19 pulmonary fibrosis(PF) who developed PC. CASE PRESENTATION: A 62-year-old lifelong non-smoker male presented with worsening dyspnea and cough. One month prior to this, he was treated for new hypoxic respiratory failure secondary to COVID-19 pneumonia and pulmonary embolism and was on baseline oxygen therapy 4L/min since. On presentation, he was noted to be afebrile, tachycardic HR of 114/min, tachypneic with RR 24/min, and saturating 93% on 6L O2. He had bilateral crackles on chest auscultation. Initial labs were unremarkable except ABG showing normal pH of 7.38, with hypoxia pO2 58 and hypercarbia pCo2 65. COVID-19 PCR remained positive. Chest X-ray was suggestive of multifocal pneumonia. Chest CT revealed severe multifocal pneumonia with interval development of bronchiectasis. Patient was initiated on IV linezolid, meropenem, remdesivir and dexamethasone;he required BiPAP support due to respiratory failure. Worsening respiratory failure despite completion of antibiotic course, prompted initiation of ceftazidime. He was also started on trial of IV methylprednisolone 125mg every six hourly in view of suspected post-COVID-19 PF, administered for two weeks. Patient's hospitalization was further complicated by critical illness myopathy, atrial fibrillation and flutter. Subsequently fungal serology returned positive for cryptococcal antigen and fluconazole therapy was initiated. He had no history of immunocompromise such as HIV, Diabetes, ESRF etc. CSF analysis was deferred since he had no CNS manifestations. Patient showed clinical improvement into second week of hospitalization and repeat CT scan done 18 days after starting fluconazole showed interval improvement of multifocal infiltrate. DISCUSSION: Post-COVID-19 pulmonary fibrosis is increasingly identified with evolving clinical data. Dysregulated release of matrix metalloproteinases, epithelial injury, and fibroproliferation are all implicated in the pathogenesis of post infective PF(3). CONCLUSIONS: High dose steroids used in the management of PF pose serious risk of complications related to immunosuppression and subsequent opportunistic infections such as pulmonary cryptococcosis and pneumocystis pneumonia. As the pandemic is still evolving, it will be interesting to see if PF and opportunistic infections become an established post-COVID-19 sequela. REFERENCE #1: Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol. 2019 Feb 1;57(2):133-150. doi: 10.1093/mmy/myy086. PMID: 30329097. REFERENCE #2: Salehi M, Ahmadikia K, Badali H, Khodavaisy S. Opportunistic Fungal Infections in the Epidemic Area of COVID-19-19: A Clinical and Diagnostic Perspective from Iran. Mycopathologia. 2020;185(4):607-611. doi:10.1007/s11046-020-00472-7 REFERENCE #3: Tale S, Ghosh S, Meitei SP, Kolli M, Garbhapu AK, Pudi S. Post-COVID-19-19 pneumonia pulmonary fibrosis. QJM. 2020;113(11):837-838. doi:10.1093/qjmed/hcaa255 DISCLOSURES: No relevant relationships by Sangeetha Isaac, source=Web Response No relevant relationships by Shalom Isaac, source=Web Response No relevant relationships by Evans Kyei-Nimako, source=Admin input No relevant relationships by Amos Lal, source=Web Response No relevant relationships by Mohammed Afraz Pasha, source=Web Response