invasive or surgical approach using diversion or resection techniques. For high output fistulas, a diversion can be achieved by percutaneous duodenostomy, or transhepatic biliary or trans biliary approach. Alternatively, a more invasive open surgical diversion or resection and anastomosis can be performed.
Case Presentation:
A 19 year old male presented with sudden onset chest pain radiating to back. He was a smoker and denied using cocaine since his last hospitalization for cocaine-induced myocardial infarction 2 years ago. UDS was negative. EKG showed normal sinus rhythm with no ST-T wave changes. Initial troponin was 0.850. Potassium levels were low at 2.9 mmol/L but other labs were normal. Chest CT angiography ruled out aortic dissection. He was started on heparin drip. Stat Echocardiogram showed LVEF of 55-60% with no wall motion abnormalities. Repeat potassium levels normalized after replacement, however, his troponins were trending up from 3.9 and 11.5. He continued to complain of severe chest pain, so underwent cardiac catheterization which showed normal coronary arteries and LVEF 55-60%. Heparin drip was discontinued and NSAIDs and colchicine were started. Cardiac MRI
(see Figure)
was done that showed patchy mid-wall and epicardial delayed gadolinium enhancement involving the basal inferolateral wall, with mild hyperintense signal on the triple IR sequence, suggestive of myocarditis. On further probing, he reported receiving a second dose of Moderna COVID vaccine 3 days prior to presentation.
Discussion:
In December 2019, a novel RNA virus causing COVID-19 infection was reported, which quickly reached a pandemic level. COVID-19 vaccines were granted emergency use authorization by FDA. With millions of people receiving COVID-19 vaccinations worldwide, rare adverse effects are now being reported. The benefits of vaccination undoubtedly outweigh any minor side effects. However major adverse effects like this are potentially fatal. This case report warrants further investigation into the association of myocarditis with COVID-19 vaccinations and further recommendations regarding vaccination in younger adults.
Background: Antibiotic overuse leading to increasing antibiotic resistance has been a growing concern. Patients presenting with acute respiratory tract infections (RTI) are often started empirically on antibiotics and continued for days, unless confirmatory results are reported by microbiological testing. Procalcitonin is a serum inflammatory marker that increases in bacterial infections and is utilized as an adjunct to help differentiate viral versus bacterial pneumonia. Procalcitonin-guided management is associated with significantly lower antibiotic exposure and mortality. No studies exist in literature that assess the appropriate utilization of negative procalcitonin test for antibiotic discontinuation. This study assesses utilization of a negative PCT (<0.25 ng/ml) to guide antibiotic discontinuation in patients with pneumonia in a community hospital. Methods:Retrospective observational study including adult patients admitted to our community hospital in 1 year (July 2019-June 2020) with diagnosis of community acquired pneumonia and started on empiric antibiotic therapy and had procalcitonin levels checked. Our hypothesis was that PCT is not being appropriately used for discontinuation of antibiotics and that rate of discontinuation of antibiotics will be less despite a negative PCT. Statistical analysis was performed using XLSTAT. Categorical variables were represented by frequencies and proportions and compared using Chi-square and z test for two proportions. Results: 516 charts were reviewed. After excluding missing data, 176 patients were included. 100 patients had negative PCT. Antibiotics were discontinued in 16% of patients with negative PCT, compared to 58% (p<0.0001), in whom antibiotics were continued without any other indication (including UTI, severe COPD exacerbation, COVID pneumonia) despite a negative PCT. The difference between the percentage of antibiotic discontinuation in our PCT guided treatment sample (9%, n=16/176) was also found to be statistically significant (p< 0.001) compared to percentage of antibiotic discontinuation in population using data from a meta-analysis of 7 RCTs (42%, n=698/1658). 1 Conclusion:Previous studies have shown that procalcitonin guided treatment aids in decreasing antibiotic exposure. In lower respiratory tract infections, clinicians order PCT test to aid in differentiating viral versus bacterial etiology and ultimately help guide antibiotic therapy. Our data analysis reveals that despite negative PCT, thus indicating a likely viral etiology, clinicians are not consistently making changes to empiric antibiotic use. This study addresses need for further recommendations from antibiotic stewardship programs regarding procalcitonin-guided antibiotic use and prevent unnecessary ordering of PCT test. 1. Li H, Luo Y-F, Blackwell TS, Xie C-M. Procalcitonin-guided therapy in respiratory tract infections: a meta-analysis and systematic review. Antimicrob Agents Chemother
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.