Lactic acidosis is an extremely rare paraneoplastic manifestation of hematological malignancies, and often carries an extremely poor prognosis. Mantle cell lymphoma is an aggressive and rare form of non-Hodgkin lymphoma. To the best of our knowledge, it is extremely rare to have severe lactic acidosis in patients with mantle cell lymphoma. In this article, we are reporting a rare case of mantle cell lymphoma diagnosed with typical cluster differentiation (CD markers) in bone marrow examination with persistent lactic acidosis refractory to intravenous hydration that responded well to chemotherapy. Malignant lactic acidosis is a medical emergency that needs rapid evaluation and identification that shows improved prognosis after the introduction of chemotherapy.

Hyperacute cardio-cerebral Infarction with simultaneous acute myocardial infarction and acute ischemic stroke (2), is an extremely rare and deadly condition with management dilemma. To date, there were no clear consensus guideline in terms of managing this group of patients. Herein, we are presenting a challenging case of hyperacute cardio-cerebral infarction as well as its diagnostic and management dilemma. CASE PRESENTATION:A 77-year-old gentleman with no known past medical history was brought to the hospital for altered mental status, slurred speech and right sided weakness that started acutely when the patient woke up. According to the patient's daughter, patient also complained of chest tightness and dyspnea on exertion, progressively worsening for the past 3-days. Initial vital signs showed a temperature 98.9, heart rate 126, respiratory rate 25 and oxygen saturation 89%. Pulmonary exam decreased air entry to the lungs bilaterally with diffuse crackles heard. Cardiovascular exam showed tachycardia, regular and normal heart rhythm with no murmurs. Neurological examination was significant for right sided weakness with muscle strength 3/5 on upper and lower right extremity with hyper-tonic and hyper-reflexia. Electrocardiogram displayed inferolateral ST elevations with an elevated troponin of 93. Code STEMI was called. Patient was intubated in light of GCS < 8 with incapable of protecting his own airway. In light of neurological signs on physical examination, computed tomography (CT) of the head was ordered which showed acute to subacute infarct at left middle cerebral artery territory with possible hemorrhagic conversion. CT angiogram of the chest otherwise ruled out aortic dissection. Patient was placed on mechanical ventilation for ventilatory support and in light of the possible hemorrhagic conversion, antiplatelets and anticoagulation were held. Cardiac catheterization was also not possible in light of ischemic stroke with hemorrhagic conversion which limit the use of antiplatelets. Patient was on mechanical ventilation for 21 days and ultimately expired due to cardiorespiratory arrest secondary to ventricular arrythmia. DISCUSSION:The purpose of this case is to examine and understand the potential benefits of implementing future guidelines for cases of hyperactive cardio-cerebral Infraction. Although very rare, the potential benefits of having a clear understanding of which pathology to treat first, by implementing proper guidelines, would help to further understand both pathologies, prevent severe complications and to reduce the morbidity and mortality.CONCLUSIONS: Whether to treat the brain and heart first is always a challenging management dilemma, in this case, if the patient has no acute contraindication for antiplatelets/anticoagulation, patient may benefit from cardiac catherization after 48 hours of stabilization of acute stroke.

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INTRODUCTION: Emphysematous pyelonephritis (EPN) is an uncommon acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The clinical course of EPN can be life threatening if not managed astutely. The primary organisms responsible include Escherichia coli and Klebsiella Pneumoniae. We present a rare and uncommon case of severe EPN that was managed conservatively with good outcome. CASE PRESENTATION:A 63-year-old Hispanic female with a past medical history of uncontrolled diabetes and hypertension presented with a four-day history of abdominal pain, nausea, vomiting and diarrhea. Vital signs showed T 38.2 C, HR 99, BP 103/ 58 mmHg and saturating 100% on RA. Palpation and percussion of the left flank region elicited pain. Lab findings were significant for hyponatremia (132), hypochloremia (95), elevated BUN and Creatinine (43/2.4), hyperglycemia (264), elevated CRP 36.5. Initial lactic acid was found to be 2.8. Urinalysis showed findings suggestive of a UTI. Patient also was incidentally found to have COVID-19 Ag and PCR positive. Chest X-ray showed mild interstitial prominence. Emergent renal ultrasound reported scattered foci of air in the left renal upper pole calyces and proximal ureter. CT Abdomen Pelvis with contrast showed air in the bladder and left ureter and kidney. Despite adequate initial resuscitation with IV fluids and IV piperacillin-tazobactam, her lactic acid increased peaking at 8.5 and she was promptly moved to MICU for hemodynamic monitoring. With a working diagnosis of EPN and SARS-CoV-2 infection, she was switched to Meropenem, placed on IV fluids and her pain was managed supportively. Urology was consulted who recommended close monitoring and plan for emergent intervention if condition worsened. However, since patient started to recover, she did not undergo intervention. Antibiotics were de-escalated to Ceftriaxone after blood cultures grew sensitive Escherichia coli. Patient's condition improved and she was discharged with outpatient follow-up with urology.DISCUSSION: Based on CT findings, emphysematous UTI's are characterized into Class I to IV with increasing mortality associated as you move towards class IV. Our patient initially presented with Class I and as a result was promptly started on antibiotics. If EPN had progressed anymore, she would have needed a percutaneous drainage, or even nephrectomy in refractory cases, in addition to antibiotic therapy. However, due to prompt care and aggressive monitoring provided to her, she was able to improve without further interventions. The rarity of the condition and the decision-making involved while managing the disease makes this case unique.CONCLUSIONS: Emphysematous pyelonephritis is an uncommon severe infection of the renal parenchyma, which with early diagnosis can be managed conservatively.

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=&lt; 0.0001), LCR (p=0.007), lymphocyte-LDH ratio (LLR, p=&lt; 0.0001), lymphocyte-D-dimer ratio (LDR, p=&lt; 0.0001), lymphocyte-ferritin ratio (LFR, p=&lt; 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 &gt;85% mortality in our cohorts with the utilization of D-dimer (&gt;500 ng/ml), Ferritin (&gt;200 ng/ml), LDR (&lt; 1.6), LFR (&lt; 4) and ANC (&gt;2.5). This new model has a ROC of 0.68 (p&lt; 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 &gt;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)

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