A 78-Year-Old Man with a Pulmonary Embolism Who Developed Skin Necrosis 7 Days After Treatment with the Direct Oral Anticoagulant Factor Xa Inhibitor Apixaban

BACKGROUND Apixaban is one of the newer direct oral anticoagulants (DOACs) being used to manage venous thrombosis. Skin toxicities are recognized adverse effects of the new DOACs, but are rare and usually associated with vasculitis. This report is of a 78-year-old man admitted to the hospital with pulmonary thromboembolism, who developed severe and extensive skin necrosis of both forearms 7 days after treatment with apixaban. CASE REPORT A 78-year-old man was admitted for pulmonary embolism and congestive heart failure exacerbation. He was started on therapeutic enoxaparin and diuresis. Later on, enoxaparin was substituted with apixaban. Seven days after starting apixaban, he suddenly developed skin changes that developed into skin necrosis on both forearms and the abdominal wall. A skin biopsy was not performed due to the high risk of bleeding. Skin necrosis was diagnosed based on clinical findings. A review of clinical data and the patient's medication profile did not reveal any other possible etiology or culprit medication. Clinical presentation and lab values were not consistent with infections or autoimmune etiologies. Apixaban was discontinued as it was perceived to be the likely cause of skin necrosis. The skin changes gradually improved within 1 week with supportive wound care, and the patient did not require a skin graft. The patient was discharged safely with subcutaneous low-molecular-weight heparin therapy. CONCLUSIONS This report shows that skin toxicity can be associated with apixaban and that with the increasing use of these newer DOACs, clinicians should be aware of these potential adverse effects.

Abstract 559: Left Atrial Enlargement In Primary Cryptogenic Strokes Without Atrial Fibrillation

The relationship between left atrial enlargement (LAE) and primary cryptogenic stroke (PCS) remains a mystery. Previous literature found the severity of LAE to be an independent risk factor in cases of PCS, recurrent ischemic strokes, and paroxysmal atrial fibrillation. Our study seeks to further characterize potential risk factors for patients with PCS in the absence of atrial fibrillation. Our multi-center retrospective study constructed a database of 646 patients identified with a diagnosis of cerebral infarction over a three year period. Detailed chart review excluded all patients with known etiologies for PCS including: atrial fibrillation, atrial flutter, prior stroke, systolic heart failure, carotid artery stenosis, thromboembolic disease, previous anticoagulation, or an active cancer diagnosis. Diagnosis of LAE utilized a composite of criteria for transthoracic echocardiogram (TTE) measurements including left atrial diameter (LAD) and left atrial volume index (LAVI). All study criteria were met by 154 patients (24%) for analysis, where baseline characteristics included: 79 (51%) male, 104 (67.5%) Caucasian, 108 (70%) diagnosis of hypertension, 80 (52%) previous or current tobacco users, and 47 (31%) diagnosis of diabetes. Our preliminary analysis found 74 (48%) of patients met at least one criteria for LAE. The mean LAD for patients with and without LAE was 4.1cm and 3.4 cm, respectively (SD .87 vs .55, p<.0001). The mean LAVI for patients with and without LAE was 29.68 mL/m 2 and 18.44 mL/m 2 , respectively (SD 7.37 vs 5.13, p<.0001). Our findings support the significance of LAE as a risk factor for cases of PCS. Multiple risk factors were identified in our study population that reflect the importance of preventative counseling for patients with hypertension, hyperlipidemia, histories of tobacco use, and diabetes. Further research may elucidate whether LAE alone or in the setting of comorbidities warrant universal screening practices or prophylactic therapies to prevent cases of PCS.

Diabetic Ketoacidosis and Acute Pancreatitis in Covid-19 Setting

Introduction: Respiratory, kidney and gastrointestinal are some of the systems affected by COVID-19. Although COVID-19 has been studied as a lung pathogen, endocrine system involvement has rarely been studied. In this case report, we present a case of diabetic ketoacidosis (DKA) and acute pancreatitis in the setting of COVID-19.

Case Description: A 52-year-old female with a PMH of type 1 diabetes mellitus and hypothyroidism, presented to the ED with nausea, vomiting, fatigue and diffuse abdominal pain. She reports cosmetic surgery a few weeks prior and she started feeling these symptoms at the beginning of admission day of admission. On admission, WBC was 34.9, blood glucose was 496, lactic acid of 3.1. Arterial blood gas revealed pH of 6.96, PCO2 of 17 mEq/L, PO2 of 143, HCO3 of 5 and anion gap of 23. DKA protocol was initiated and was upgraded to ICU. She was found to be RT-PCR positive for SARS-CoV-2. She denied other symptoms, including melena, jaundice, hematochezia, hematemesis, cough, SOB or diarrhea. She also denied use of alcohol, tobacco or illicit drugs, prior hospitalizations, or family history of pancreatitis. The physical exam was significant for tenderness to palpation in epigastric region without guarding or rebound. Laboratory studies revealed lipase: > 4000U/L, AST: 64 U/L, ALT: 57 U/L, ALKPHOS: 152 U/L, and total bilirubin: 1.1 mg/dL. Serum triglycerides and calcium levels were within normal limits. CT abdomen showed a severe peripancreatic inflammation and edema, moderate non-organized fluid surrounds pancreas. An abdominal ultrasound showed no calcified gallstone or gallbladder wall thickening. The common bile duct was 3 mm, normal size. Over the course of 24 hours, anion gap was 7, pH was 7.28, blood glucose was 158. For sepsis, lactic acid was 0.7 after initiation of azithromycin. For acute pancreatitis, she was treated conservatively with intravenous fluids, bowel rest and analgesia. Patient denied any upper respiratory symptoms and did not require oxygen so steroids were not started for COVID PNA. Her symptoms improved and she was discharged home. Discussion: Here we report a case of a patient who presented with DKA, found to have severe acute pancreatitis as well as SARS-CoV2 PCR positive. Few case reports have reported an association of DKA and acute pancreatitis. Although the exact mechanism by which SARS-CoV-2 is evolving, it is thought to be mediated by the Angiotensin-Converting Enzyme-2 which is present in intestine, and on islet cells of the pancreas. This injury may be due to cytopathic effect of viral replication or indirectly caused by the inflammatory response induced by the virus. Further studies are needed to better understand the pathophysiology behind AP in the setting of COVID-19.

Conclusion: This case highlights DKA and AP as a possible initiating presenting manifestation of COVID-19 infection

A Case of Bilateral Thalamic Infarcts Involving the Artery of Percheron in the Setting of COVID-19

The artery of Percheron (AOP) is a rare anatomic variant, characterized by a single thalamoperforating artery arising from the P1 segment of the posterior cerebral artery that bifurcates to supply bilateral thalami with variable vascular supply to the midbrain. The occlusion of this artery is responsible for bilateral thalamic stroke with or without midbrain involvement. Since December 2019, coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to a worldwide pandemic. Acute ischemic stroke is a rare but known manifestation of COVID-19. There have only been a few reports of bilateral deep cerebral involvement in COVID-19 infection. In the absence of risk factors for such events, we suspect COVID-19 may have a contributory role. In this case report, we present a case of AOP infarction presenting as transient loss of consciousness, intermittent anisocoria, dysarthria, and right-sided weakness in the setting of COVID-19 infection. Given the degree of variation in clinical presentation for AOP infarcts and lack of evidence of ischemia on initial imaging studies, many patients may miss the time window for tissue plasminogen activator (tPA) administration. This case highlights the importance of timely neurological evaluation in patients presenting with COVID-19 and neurological complaints. Increased community awareness of neurological manifestations of AOP infarctions is of utmost importance as early detection and intervention improve clinical outcomes.

ODP151 Hypothyroidism and Cardiac Remodeling in Ischemic Strokes

Hypothyroidism has been shown to increase the risk of developing cardiovascular disease (CVD), yet the mechanism is not well described. Previous studies correlated hyperlipidemia, diastolic hypertension, and smoking with impaired thyroid function, which serve as independent risk factors for CVD. Our study seeks to understand the prevalence of hypothyroidism in ischemic strokes. We hypothesize that hypothyroidism may exacerbate the severity of co-morbidities accelerating cardiac remodeling and risk for ischemic strokes. Our multi-center retrospective study constructed a database of 646 patients who were admitted over a three year period for a primary diagnosis of ischemic stroke. Detailed chart review excluded patients with known risk factors for ischemic strokes including: atrial-fibrillation, atrial-flutter, prior stroke, carotid artery stenosis, thromboembolic disease, and an active cancer diagnosis. Cardiac remodeling was identified by the hallmark finding of left atrial enlargement (LAE) on transthoracic echocardiogram (TTE) with severity determined as a composite measurement of either left atrial diameter (LAD) or left atrial volume index (LAVI). Inclusion criteria were met by 482 patients (75%), where 349 (54%) were female, 435 (67%) were Caucasian, 390 (60%) had hypertension, 360 (56%) had hyperlipidemia, 291 (45%) were previous or current tobacco users, and 199 (31%) had diabetes. Our preliminary analysis found that 83 (13%) of patients had a diagnosis of hypothyroidism. Of note, TTE reports available for 225 (35%) of patients, wherein 74 (33%) of patients met at least one criteria for LAE. Our initial findings support further subgroup analysis to characterize the significance of hypothyroidism as a comorbidity in the development of ischemic strokes. Further research may identify the individual contribution of hypothyroidism to the severity of cardiac remodeling, as well as the impact of treatment for hypothyroidism in stroke risk reduction. Our preliminary analysis found 74 (48%) of patients met at least one criteria for LAE.

Presentation: No date and time listed

Coronary Air Embolism Secondary to Percutaneous Lung Biopsy: A Systematic Review

To determine mortality and morbidity associated with coronary air embolism (CAE) secondary to complications of percutaneous lung biopsy (PLB) and illicit-specific risk factor associated with this complication and overall mortality, we searched PubMed to identify reported cases of CAE secondary to PLB. After assessing inclusion eligibility, a total of 31 cases from 26 publications were included in our study. Data were analyzed using Fisher's exact test. In 31 reported cases, cardiac arrest was more common after left lower lobe (LLL) biopsies (n=4, 80%, p=0.001). Of these patients who suffered from cardiac arrest, CAE was found more frequently in the right coronary artery (RCA) than other locations but did not reach statistical significance (n=5, 62%, p=0.39). At the same time, intervention in the LLL was significantly associated with patient mortality (n=3, 60%, p=0.010). Of the patients who died, CAE was more likely to have occurred in the RCA, but this association was not statistically significant (n=4, 57%, p=0.33). LLL biopsies have a statistically significant correlation with cardiac arrest and patient death. More research is needed to examine the effect of the air location in the RCA on patient morbidity and mortality.