Iatrogenic immunodeficiency-associated lymphoproliferative disorder presenting as small bowel perforation

A woman in her late 50s on mycophenolate for limited systemic sclerosis presented with abdominal pain. Vital signs and investigative evaluations were normal. Cross-sectional imaging identified gastric and small bowel wall thickening, free fluid, and pneumoperitoneum. In the operating room, a small bowel perforation was found and resected. Postoperatively, immunosuppression was held and she completed a course of amoxicillin/clavulanate. She discharged home and re-presented on postoperative day 8 with seizures and was found to have a frontal brain mass which was biopsied. Pathology from both the resected bowel and brain biopsy demonstrated Epstein-Barr virus-positive B-cell lymphoproliferative disorder with polymorphic B-cell features. The patient's immunosuppression was discontinued, and she was enrolled in a clinical trial for chemotherapy. Lymphoproliferative disorder can present years after immunosuppression initiation with either spontaneous perforation or solid tumour. Pathological assessment determines treatment options. Heightened concern for atypical clinical presentations in immunosuppressed patients is always warranted.

A Review of Brooke Army Medical Center Chaplaincy Service During the SARS-COV2 Pandemic: Implications for Service Structure and Patient Needs

INTRODUCTION

We aimed to evaluate the effect of the SARS-COV2 pandemic on chaplain utilization at Brooke Army Medical Center. Our hypothesis was that multiple pandemic-related factors led to a care environment with increased mental and spiritual stress for patients and their families, leading to an increased need for adjunct services such as chaplaincy.

MATERIALS AND METHODS

This was a single-institution retrospective chart review study that evaluated the records of 10,698 patients admitted between July 1, 2019, and January 31, 2020, or between July 1, 2020, and January 31, 2021. Our primary study outcomes included the number of chaplain consultations, the number of visits per consultation, and the time of visits between the two study cohorts. Secondary outcomes included inpatient mortality and the number of end-of-life visits. We also isolated a subgroup of patients admitted with COVID-19 and compared their outcomes with the two larger cohorts. Statistical analysis included t-test or chi-squared test, based on the variable. This study was reviewed and approved by the Brooke Army Medical Center Institutional Review Board (IRB ID C.2021.010e).

RESULTS

Fewer consults were performed during the study period affected by the SARS-COV2 pandemic (4814 vs. 5884, P-value <.01). There were fewer individual visits per consult during the study period affected by the SARS-COV2 pandemic (1.44 vs. 1.64, P-value <.01), which led to fewer overall time spent per consult (37.41 vs. 41.19 minutes, P-value <.01). The 2020 cohort (without COVID-19 cases) demonstrated a higher mortality rate than the 2019 cohort (2.8% vs. 1.9%, P-value <.01). The COVID-19 diagnosis cohort demonstrated a much higher mortality rate compared to other patients in the 2020 cohort (19.3% vs. 2.8%, P-value <.01). We demonstrated the relative need for EOL consults by presenting the ratio of EOL consults to inpatient deaths. This ratio was highest for the COVID-19 diagnosis cohort (0.76) compared to the 2020 cohort (0.50) and the 2019 cohort (0.60).

CONCLUSIONS

This study demonstrates that factors related to the SARS-COV2 pandemic resulted in fewer chaplaincy consults in our inpatient setting. We did not find other reports of a change in the rate of chaplaincy consultation, but available reports suggest that many centers have had difficulty balancing the spiritual needs of patients with local exposure guidelines. Although fewer individual chaplain consults occurred during the SARS-COV2 pandemic, our chaplain service innovated by utilizing various phone, video, and web-based platforms to deliver spiritual support to our community. Our study also suggests that the patients most greatly affected by the pandemic have an increased need for spiritual support, especially at the end of life. Future studies in this subject should examine the effect of various types of chaplain services as they relate to the health and well-being of hospitalized patients.

2012. A Descriptive Study of Infections Complicating Extracorporeal Membrane Oxygenations in Trauma Patients

Background

Extracorporeal Membrane Oxygenation (ECMO) is a growing modality for respiratory and circulatory support in patients with traumatic injuries. There is limited data on the pathogens complicating a trauma patient’s ECMO course and thus empiric antibiotic choices are difficult in this cohort. We report the incidence and infection type in trauma patients receiving ECMO to potentially guide future empiric antibiotic treatment and improve outcomes.

Methods

A descriptive chart review was performed on all trauma patients at Brooke Army Medical Center receiving ECMO between February 2013 and July 2021. Charts were reviewed to identify pathogens by culture site as well as time to infection following cannulation. This protocol was approved by the 59th Medical Wing Institutional Review Board.

Results

Twenty-one trauma patients underwent ECMO during the study period. The majority of patients were men (n=19, 90%) with a median age of 30 years [IQR 27-38] with a median ECMO run of 227 hours [IQR 93-338]. Motor vehicle crashes (17, 81%) accounted for the majority of injuries, with gunshot wounds (2, 10%), blast injuries (1, 5%) and falls (1, 5%) accounting for the remainder. 16 (76%) patients survived to discharge, and infection was not associated with mortality (p=0.11). Of the 24 infections, the majority were respiratory (13, 58/1000 ECMO days) followed by skin and soft tissue (6, 26/1000 ECMO days), blood stream (4, 18/1000 ECMO days), and urinary tract (1, 5/1000 ECMO days). Gram-negatives were the most commonly isolated organism from all sites (Table 1) and at all time periods after cannulation (Table 2). Multi-drug resistant organisms accounted for 32% (n=9) of infections and were independent of time from cannulation.

Conclusion

This is the first study to describe infections in trauma patients requiring ECMO support. We observed majority Gram-negative infections regardless of culture site or time after cannulation. Determining empiric antibiotics will require a larger study of patients to identify trends in pathogens and ultimately improve antimicrobial stewardship in this unique population.

Disclosures

All Authors: No reported disclosures.

Delayed presentations of popliteal artery entrapment syndrome in a middle-aged military population

Popliteal artery entrapment syndrome (PAES) is a rare but significant cause of disability usually diagnosed in young, healthy adults. Advancements in diagnostic imaging modalities have prompted a current report of our recent experience with PAES in a middle-aged military population at the Walter Reed National Military Medical Center. The addition of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) permit accurate and facile diagnosis of this complex syndrome.