Sphingomonas paucimobilis is a strictly aerobic, non-spore-forming Gram-negative bacillus, ubiquitous bacterium, thought to be an opportunistic pathogen and is rarely reported in clinical settings. Here in, is the first case report of Acute Sphingomonas phlebitis secondary to intravenous (IV) drug use. We present the case of a 39-year-old male who initially presented with pain in his right upper extremity, fevers and chills of three week duration. He admitted to regularly injecting heroin in his distal right upper extremity with visible erythema, tenderness and streaking along the path of vein along the injection site. Radiographic studies including X-ray of the right arm, ultrasound and a subsequent MRI of the right arm were not significant for any osteomyelitis, deep venous thrombus, abscess, cellulitis, osteomyelitis, or pyomyositis. Blood culture grew Sphingomonas paucimobilis. Patient was initially started on vancomycin and piperacillin/tazobactam and subsequently switched to levofloxacin to complete a 14 day course. Patient admitted to using toilet water to mix his heroin which we suspect may have been the source of his bacteremia. Since it was first reported in 1979, a wide variety of community-acquired and hospital-acquired infections have been attributed to this Sphingomonas. It is ubiquitous to natural environment. We believe that due to its widespread habitat and ability to survive in stress conditions it could be a potential future threat in the era of increasing antimicrobial resistance globally. More research needs to be done on early identification, pathogenesis, treatment and eradication of the organism.

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Traditionally sickle cell disease has been a disease of the young, and most sickle cell disease patients have previously been thin and undernourished. However with recent advances in sickle cell with the improvement in overall management due to groundbreaking medications such as hydroxyurea, sickle cell disease prognostics have improved along with a much increased life span compared to only a few decades ago. In the general population, the prevalence of being overweight and of obesity has exponentially increased causing an increasingly worse morbidity and mortality, and predisposing patients to increased heart disease, hypertension, stroke, and kidney disease. It is estimated that more than one-third of the US adults are obese. Sickle cell patients are prone to similar complications which are observed at an earlier age when compared to the general population due to constant hemolysis and increased stress on the various organ systems. The goal of this study was to examine the prevalence of obesity in sickle cell patients since there is very limited data on weight status and sickle cell disease. Also the nature of sickle cell complications in overweight and obese patients were compared to those of sickle cell patients with normal weight. Adult patients (>18yrs) with sickle cell disease were selected for a retrospective chart review to study their weight status. All the patients admitted over a three year period with the diagnosis of sickle cell disease at Franciscan St James, a 398 bed community hospital and health system were selected for this study. All patients were reviewed carefully to determine the sickle type and body mass index (BMI) and a total of 100 patients were reviewed for this particular study. Patients with sickle cell trait were eliminated from the study group. BMI weight status was defined as follows: <18.5: underweight, 18.5-24.9: normal weight, 25-29.9: overweight, >30: obese. Factors such as number of admissions over a three year period and comorbidities such as stroke, pulmonary disease, heart disease, Type 2 Diabetes Mellitus, renal dysfunction and liver disease were also included for analysis of weight related complications. Regression analysis along with the two tailed Fisher's exact test was used for statistical analysis. Upon data analysis the weight distribution among the 100 patients showed that 4 patients were underweight, 42 were normal weight, 26 were overweight, and 28 were obese. The overall average age of the patients was 34.3 and the average BMI was 26.3 with a standard deviation of 6.1. There were 34 males in the study and 64 females. Majority of the patients had the HbSS type sickle cell anemia. Comparisons of BMI, age, number of admissions was made based on weight status (Table 1). There is an overall inverse relationship (R² = 0.0343) between BMI and number of admissions (Figure 1). Obesity related variables were compared to evaluate if there was any significant difference between the normal and increased BMI group. The only significant result was that hypertension is more prevalent in sickle patients with increased BMI as compared to sickle patients with a normal BMI (p value=0.01). A larger sample would be useful to compare other variables such as cardiac, neurological, and diabetic complications. Based on this sample, there was no significant correlation found between increased BMI and the other comorbidities of obesity. From this retrospective chart review, it can be deduced that the incidence of obesity and overweight status is increasing among sickle cell patients similar to the general population. It can also be noted that patients who fall within the normal BMI range have fewer admissions overall. There is limited data on adult obese sickle cell patients and the complications associated with it. Further studies are needed to analyze how the trend in increased BMI has affected sickle cell outcomes. Our goal is to make clinicians aware of the rise in BMI in sickle cell patients and to improve patient care by addressing weight status in these patients. Table 1: comparison of weight weight status with variables such as age, BMI, and # of admissions Variables Underweight BMI<18.5 Normal weight BMI 18.5-24.9 Overweight BMI 25-29.9 Obese BMI >30 Average age (yrs) 40.75 28.4 38.7 39.2 Average BMI 16.7 21.9 26.3 33.2 Median # of admissions 51 4 3.5 3 Figure 1: inverse relationship between BMI and # of admissions over a 3 yr period. Figure 1:. inverse relationship between BMI and # of admissions over a 3 yr period. Figure 2: obesity related complications Figure 2:. obesity related complications Disclosures No relevant conflicts of interest to declare.

Neisseria meningitidis, a Gram-negative diplococcus, is an uncommon cause of pneumonia. There have been only about 344 cases reported worldwide from 1906 to 2015. To our knowledge, there have been only 3 cases reported in the USA in the past 2 decades. We present a case of a 72-year-old male with a past medical history of severe COPD, obstructive sleep apnea, and stage I lung cancer status post-stereotactic body radiation therapy 1 year ago, who was admitted with a 6-day history of productive cough with yellowish sputum, shortness of breath, extreme myalgias, and fatigue. Chest X-ray revealed an infiltrative process in the left lower lung field and left-sided pleural effusion. Blood cultures grew beta-lactamase-negative N. meningitidis after 24 hours. Our patient was initially treated with broad-spectrum antibiotics, which were later switched to amoxicillin to complete a total of 14 days of antibiotics. Diagnosing meningococcal pneumonia requires a high level of suspicion, as sputum cultures may be falsely positive due to asymptomatic carriage of the organism in the upper respiratory tract in up to 10% of outpatient population. We highlight this case as early recognition and treatment is critical. The case fatality rate for N. meningitidis pneumonia has been reported to be higher compared with meningococcal meningitis.

Background COVID-19 infection has become a pandemic and a global health issue since its origin in Wuhan, China in December 2019. The present systematic review and meta-analysis aim to assess hematological changes seen in COVID-19 infection and their association with the severity of the disease. Methods Pooled proportions were calculated using both fixed effects model and random effects model. Weighted mean difference and 95% CI were calculated and reported. Results Initial search identified 84 reference articles, 23 relevant articles were selected and reviewed. Compared to general population, the weighted mean difference of WBC count in all COVID-19 patients was lower by 0.97 × 10 9 mm 3 (95% CI = –1.29 to –0.66). In severe COVID-19 patients, the weighted mean difference of platelet count was lower by 23.85 × 10 9 /liter (95% CI = –35.18 to –9.53), as compared to general population. The weighted mean difference of prothrombin time, D-Dimer, and fibrinogen in severe COVID-19 patients was higher by 1.92 seconds (95% CI = 0.01 to 3.84), 6.23 mg/liter (95% CI = 0.11 to 12.36) and 1.88 g/liter (95% CI = 1.18 to 2.48) respectively, as compared to general population. Pooled proportion showed D-Dimer to be elevated in 80.00% (95 % CI = 50.00 to 99.00) of severe patients. Conclusions Our meta-analysis shows that patients with COVID-19 have significant thrombocytopenia, leukopenia along with elevated D-dimer, fibrinogen and prothrombin time. These laboratory findings are marked in severe COVID–19 infections and could be helpful in early recognition of severe infection.

Cystic fibrosis (CF) is a disease caused by a mutation in the cystic fibrosis transmembrane conductance regulator protein in the epithelial membrane, and affects at least 30,000 people in the USA. There are between 900 and 1000 new cases diagnosed every year. Traditionally, CF has been treated symptomatically with pancreatic enzymes, bronchodilators, hypertonic saline, and pulmozyme. In July 2015, the US Food and Drug Administration approved Orkambi (lumacaftor/ivacaftor), a combination drug that works on reversing the effects of the defective cystic fibrosis transmembrane conductance regulator protein. Orkambi and mucolytics decrease the viscosity of mucous secretions, leading to an accumulation of hypoviscous fluid in the alveoli, resulting in dyspnea. This presentation can be mistaken for an infective exacerbation. We present a case in which a young female with CF recently started on Orkambi therapy presented to her primary care physician with dyspnea and increased respiratory secretions and was admitted to the hospital for 2 weeks of intravenous and inhaled antibiotic therapy for a presumed CF exacerbation. We highlight this case to bring awareness and educate patients and clinicians of the side-effect profile of Orkambi therapy with an intent to avoid unnecessary hospitalizations, inpatient antibiotics, and other costly medical services.

The improving life expectancy for CF is known to be one of the biggest success stories in medicine. Life expectancy has increased from 6 months during the early 20th century to 42.7 years from in 2012–2016. As the life expectancy of CF patients has increased, it is important to consider other co-morbidities that these patients may encounter, and the impact this may have on their morbidity and mortality. We present a case of a 33-year-old male admitted to the hospital for a CF exacerbation who had an acute neurological decompensation due to an infarction of his right occipital and posterior temporal lobe.

Enteropathy-associated T-cell lymphoma (EATL) is a rare disease found in the small bowel and is seen most commonly in patients with refractory celiac disease (RCD). We present a case of an elderly male with celiac disease (CD) diagnosed in childhood with months of abdominal pain and diarrhea despite attempting to avoid gluten in his diet. After persistent symptoms for months, the patient was admitted for an acute abdomen and was found to have small bowel perforation due to a jejunal mass that was diagnosed as an EATL. In 2–5% of adult onset CD, serious complications such as RCD or malignancy develop. The clinical course for EATL is aggressive and generally has a poor prognosis. This case highlights the importance of early clinical suspicion for a small bowel malignancy in patients with a long-standing history of CD and acute worsening of symptoms. Early workup and diagnosis is vital in improving morbidity and mortality in patients with EATL.