Background Infection with the novel severe acute respiratory syndrome coronavirus 2 has been associated with a hypercoagulable state. Emerging data from China and Europe have consistently shown an increased incidence of venous thromboembolism (VTE). We aimed to identify the VTE incidence and early predictors of VTE at our high-volume tertiary care center. Methods We performed a retrospective cohort study of 147 patients who had been admitted to Temple University Hospital with coronavirus disease 2019 (COVID-19) from April 1, 2020 to April 27, 2020. We first identified the VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) incidence in our cohort. The VTE and no-VTE groups were compared by univariable analysis for demographics, comorbidities, laboratory data, and treatment outcomes. Subsequently, multivariable logistic regression analysis was performed to identify the early predictors of VTE. Results The 147 patients (20.9% of all admissions) admitted to a designated COVID-19 unit at Temple University Hospital with a high clinical suspicion of acute VTE had undergone testing for VTE using computed tomography pulmonary angiography and/or extremity venous duplex ultrasonography. The overall incidence of VTE was 17% (25 of 147). Of the 25 patients, 16 had had acute PE, 14 had had acute DVT, and 5 had had both PE and DVT. The need for invasive mechanical ventilation (adjusted odds ratio, 3.19; 95% confidence interval, 1.07-9.55) and the admission D-dimer level ≥1500 ng/mL (adjusted odds ratio, 3.55; 95% confidence interval, 1.29-9.78) were independent markers associated with VTE. The all-cause mortality in the VTE group was greater than that in the non-VTE group (48% vs 22%; P = .007). Conclusion Our study represents one of the earliest reported from the United States on the incidence rate of VTE in patients with COVID-19. Patients with a high clinical suspicion and the identified risk factors (invasive mechanical ventilation, admission D-dimer level ≥1500 ng/mL) should be considered for early VTE testing. We did not screen all patients admitted for VTE; therefore, the true incidence of VTE could have been underestimated. Our findings require confirmation in future prospective studies.

INTRODUCTION: Mycobacterium abscessus is a rapid growing NTM that rarely causes pulmonary disease in immunocompetent individuals. We present an unusual case of a young, immunocompetent woman with a protracted and complicated clinical course of pulmonary NTM infection. CASE PRESENTATION:A 39 years old female presented with a two month history of right sided pleuritic chest pain, cough and brown sputum, weight loss and night sweats. Chest imaging showed ground glass opacities with an apical cavity, and she was managed empirically for Community acquired pneumonia with vancomycin, ceftriaxone and metronidazole. To rule out tuberculosis, mycosis and malignancy, video bronchoscopy was performed and broncho alveolar lavage performed, that grew MSSA and it was negative for HIV and tuberculosis. She was treated with cefazolin and discharged on a month of cephalexin. 48 hours after discharge her Acid fast smear turned positive, and she was contacted by our infectious disease team and initiated on four drug regimen for pulmonary tuberculosis. While on treatment, her NAAT came back negative for tuberculosis and positive for mycobacterium abscessus. She started getting worse despite treatment, and came to the ER with worsening dyspnea and chest pain. New imaging revealed new bony erosions of the adjacent first and second ribs with pathological fractures and worsening bilateral infiltrates. The entire disease was attributable to the isolated Mycobacterium chelonae-abscessus group and she was urgently transferred to a tertiary care for multi-disciplinary treatment. On 2 months follow up, she is stable on outpatient IV antibiotic therapy with iminipenem, tigecycline and amikacin with a plan for prolonged therapy.DISCUSSION: Mycobacterium chelonae-abscessus group, a non-tuberculous mycobacterium (NTM), with prevalence across different regions of USA between 2% to 18%, naturally found in water and soil. It is known to cause outbreaks of skin and soft tissue infections in immunocompetent hosts. It is known to cause outbreaks of skin and soft tissue infections in immunocompetent hosts. Very rarely does this rapidly growing non-tuberculosis mycobacterium cause infection in an immunocompetent host. Furthermore, when it affects the lungs, results in bronchiectasis, nodules and consolidation.CONCLUSIONS: This case highlights the rapidly progressive course of Mycobacterium abscessus/chelonae complex in an unusual host-an immunocompetent female with no comorbidities, with the only pertinent history being that of smoking. Our case is atypical in presentation of its pulmonary involvement, as our patient had a cavitatory lesion, which is seen much less commonly. The British Thoracic Society recommends an aggressive multi-antibiotic approach, and treatment should be based on susceptibility panels, which should include clarithromycin, amikacin, cefoxitin amongst others.

INTRODUCTION:Kratom is an unregulated herb with psychogenic properties that can be ingested as a tablet, powder, or brewed tea. Patients use it for relief against a variety of ailments such as pain, gastrointestinal discomfort, opiate withdrawal and mood disorders. It has been associated with detrimental consequences such as seizures, cardiac arrest, and coma. [1,2] We present a rare case of a young healthy male who suffered cardiac arrest likely secondary to excessive Kratom use. CASE PRESENTATION:A 32-year-old male arrived at the Emergency Department after suffering a cardiac arrest at home. The patient called EMS with complaints of abdominal pain and feeling unwell, and he went into cardiac arrest shortly after EMS arrival. Following ROSC, a bedside FAST exam was negative and an EKG revealed ST elevations in the inferior leads. Preliminary laboratory results indicated that CBC and BMP were within normal limits. Lactic acid, troponin and cortisol were elevated. Urine chemistry and toxicology was devoid of common toxins. Serum alcohol, acetaminophen and salicylate levels were undetectable. Pan-cultures showed no growth. CTA of the chest, abdomen and pelvis confirmed the absence of a pulmonary embolism and aortic dissection, and showed no other abnormalities. He was taken to the cardiac catheterization lab which did not reveal any coronary disease, and echocardiogram showed a normal ejection fraction and left ventricular function. Subsequently, he was transferred to the ICU for targeted temperature management (TTM) per ACLS protocol.We contacted the family, who reported that the patient has schizophrenia on no medications, and confirmed that he was in his usual state of health until his arrest. The family also mentioned that he drinks Kratom tea multiple times per day, and there were dozens of boxes of Kratom tea found in his apartment. CT of the head showed anoxic brain injury, which was later confirmed with a brain MRI. Despite TTM, the patient never regained any significant neurologic response, and the family made the decision to withdraw care. DISCUSSION:The psychoactive compound in Kratom is mitragynine, an alpha and mu opioid agonist. It has been used increasingly for its properties to alleviate opioid withdrawal symptoms. [1] Studies have shown that Kratom causes QT prolongation and Torsade de Pointes by inhibiting rapid delayed rectifier potassium currents in cardiomyocytes.[3] As with our patient, this can potentiate ventricular fibrillation and cardiac arrest. CONCLUSIONS:We highlight the importance of considering Kratom when toxins are suspected as the possible etiology of cardiac arrest. This clinical vignette emphasizes the need for public education of the lethal adverse effects of this seemingly harmless supplement. Additionally, increased awareness amongst the healthcare community and the need to regulate herbal supplements can help prevent events like the one reported here.

INTRODUCTION: N-methyl-D-aspartate (NMDA) receptor antibody encephalitis, a type of autoimmune encephalitis, first described in 2007, is predominant in females with female to male ratio of 8:2 and about 37% patients being younger than 18 years at presentation. [1,2] It is considered a part of paraneoplastic syndrome, as more than half of the cases have an underlying malignancy, ovarian teratoma being the most common. [3,4] CASE PRESENTATION: A 20 year old male with asthma was brought into the Emergency Department for seizures. He checked himself into a behavioral health facility for bizarre behavior. He received chlorpromazine, causing generalized tonic clonic seizure. He received Lorazepam and Levetiracetam. Continuous electroencephalogram showed no further seizure activity and CT head was non-diagnostic for any structural abnormalities. He was afebrile and tachycardic on examination, along with him being, initially unrousable to verbal as well as tactile stimuli. Eventually he developed more aggressive mannerism, requiring 4 point tough restraints. Not being controlled with lorazepam and haloperidol, a Dexmedotomide drip was started.Laboratory data including urine drug screen was unremarkable except elevated CK (3127 U/L). MRI Brain and lumbar puncture revealed no acute abnormality. Meningitis panel consisting of E.coli, H.influenzae, Listeria monocytogene, N. meningitidis, Strep pneumoniae and agalactiae, Cytomegalovirus, Herpes simplex 1 and 2, Varicella zoster virus, Enterovirus and C.neo was non detectable. CSF gram stain showed no organisms. Staining for acid fast bacilli and PCR for west nile virus and Lyme were negative. Autoimmune encephalitis panel came back positive for NMDA receptor antibody encephalitis for which he received IV steroids and IVIG. DISCUSSION:The characteristic picture of NMDA receptor antibody encephalitis can be divided into 3 phases: I with respiratory symptoms and mild fever, II with psychiatric manifestations and III with development of neurological symptoms.[5] Psychiatric symptoms consist of delusions, hallucinations, anxiety and mania while neurological manifestations includes movement disorder, autonomic instability, central hypoventilation and coma. [3,5] It is difficult to differentiate from primary psychiatric disorder if a patient presents with psychiatric symptoms. Early suspicion and diagnosis are key to start treatment in the form of immunotherapy or removal of the tumor. [6] CONCLUSIONS: The differential of NMDA receptor antibody encephalitis must be considered in young patients with neuropsychiatric symptoms as they are often misdiagnosed with psychiatric disorders, which impedes early treatment.The removal of the tumor and immunotherapy generally carry a good prognosis with complete recovery.

We describe a case of a 27-year-old female without any prior underlying immunodeficiency syndromes who presented with hemoptysis secondary to subacute invasive pulmonary aspergillosis and subsequently diagnosed with lymphoid interstitial pneumonia (LIP). CT chest demonstrated bilateral interstitial disease with patchy opacities and multiple large cysts and bullae. Diagnosis was confirmed histologically after surgical lung resection of the mycetoma containing cavitation. Therefore, LIP should be suspected in patients presenting with opportunistic infections in the setting of cystic lung disease.