Clinical and biological heterogeneity of multisystem inflammatory syndrome in adults following SARS-CoV-2 infection: a case series

Importance

Multisystem inflammatory syndrome in adults (MIS-A) is a poorly understood complication of SARS-CoV-2 infection with significant morbidity and mortality.

Objective

Identify clinical, immunological, and histopathologic features of MIS-A to improve understanding of the pathophysiology and approach to treatment.

Design

Three cases of MIS-A following SARS-CoV-2 infection were clinically identified between October 2021 - March 2022 using the U.S. Centers for Disease Control and Prevention diagnostic criteria. Clinical, laboratory, imaging, and tissue data were assessed.

Findings

All three patients developed acute onset cardiogenic shock and demonstrated elevated inflammatory biomarkers at the time of hospital admission that resolved over time. One case co-occurred with new onset Type 1 diabetes and sepsis. Retrospective analysis of myocardial tissue from one case identified SARS-CoV-2 RNA. All three patients fully recovered with standard of care interventions plus immunomodulatory therapy that included intravenous immunoglobulin, corticosteroids, and in two cases, anakinra.

Conclusion

MIS-A is a severe post-acute sequela of COVID-19 characterized by systemic elevation of inflammatory biomarkers. In this series of three cases, we find that although clinical courses and co-existent diseases vary, even severe presentations have potential for full recovery with prompt recognition and treatment. In addition to cardiogenic shock, glucose intolerance, unmasking of autoimmune disease, and sepsis can be features of MIS-A, and SARS-CoV-2 myocarditis can lead to a similar clinical syndrome.

Evaluating an Oncology Video Curriculum Designed to Promote Asynchronous Subspecialty Learning for Internal Medicine Residents

Internal medicine (IM) residents frequently see patients in subspecialty clinics. However, there are few published core subspecialty curricula targeted to residents' learning and practical needs, and little guidance exists regarding delivery of core subspecialty content to residents rotating across multiple clinical sites. Our study objective was to evaluate a novel oncology video curriculum for IM residents as a model for asynchronous subspecialty resident learning. Using the cognitive theory of multimedia learning, we developed a five-part oncology video curriculum targeted specifically to the needs of IM residents. All second- and third-year residents rotating in oncology clinics from October 2018 to March 2019 at a single training program were invited to participate. We evaluated curricular demand, efficacy, and acceptability, using completion rates, knowledge tests, and a survey. Twenty-eight of 31 (90.3%) residents utilized the curriculum. Resident knowledge improved after utilizing the modules, by 36.9% from pre- to posttests (95% CI [31.3-42.5]; P<0.001) and 13.7% from pre- to delayed posttests (95% CI [7.5-20.0]; P<0.001). Twenty-four of 31 (77.4%) answered the survey. Most residents agreed or strongly agreed that the curriculum contributed to their knowledge (95.2%) and added educational value beyond the clinical rotation (93.1%). Our curriculum evaluation supports the asynchronous delivery of oncology education targeted to the learning needs of IM residents using a novel core video curriculum. These curricular methods provide a model for delivering subspecialty education to IM residents with complex and busy schedules.

Feasibility of implementing a resident oncology video curriculum

10500

Background: ACGME survey results consistently show that 40% of University of California, San Francisco (UCSF) internal medicine (IM) residents are dissatisfied with their oncology education—higher than the oncology national average and highest among UCSF IM subspecialties. A needs assessment revealed that UCSF residents desire online oncology resources for asynchronous learning. To address this need, we sought online oncology videos targeted to residents but found none. We thus used cognitive theory of multimedia learning principles to develop an oncology video curriculum and evaluated three feasibility components: demand (frequency of use), efficacy, and acceptability. Methods: We chose common cancers from the ABIM blueprint and filmed five 10-minute videos of UCSF oncologists discussing content they chose for residents. We created modules with pre/post tests derived from video content. After a pilot, we sent links to all IM residents on required oncology clinic rotations over four months (n = 25) and offered protected clinic time for optional completion. We compared pre/post test scores with a paired t test and surveyed residents. Results: Demand: 72% (18 of 25) completed ≥1 module; 32% completed all 5. Efficacy: The mean pre- vs. post-test score improved (50% vs. 87%, p = 0.002). Acceptability: 64% completed the survey. Of those who completed ≥1 module, 93% (13 of 14) felt strongly that the videos contributed to their knowledge. 93% recommended the videos to others. Residents praised the length, key points, and pre/post tests. Finding time for the modules was difficult; most did them at home. Suggestions included focusing on fundamentals and creating videos for all common cancers. Conclusions: We present demand, efficacy, and acceptability evidence supporting the feasibility of a resident oncology video curriculum. Formal protected time for module use is critical. We will focus on fundamentals for generalists as we make more videos. We will track ACGME survey results, examination scores, and clinical performance to study impact. We aim to publish the modules online for broader use and as a model solution to address similar needs across specialties and institutions, as complex resident schedules increasingly require asynchronous learning.

Abstract 4975: Tumor metabolism and cognitive dysfunction in CNS lymphoma

Background: The etiologic basis for neurocognitive and neuropsychological deficits in cancer patients and cancer survivors is poorly understood. Because of ongoing improvements in therapy and advances in survival, the problem of cancer-associated cognitive dysfunction is increasingly significant. While there is agreement that T2-weighted imaging abnormalities on MRI correlate with neurocognitive deficits, there has been limited insight into the neurochemical abnormalities associated with cognitive dysfunction in brain tumor patients. We are testing the hypothesis that tumor metabolism directly impairs neurotransmitter pathways and cognitive function, independent of anatomic extent of the cancer.

Methods: Our approach has been to focus on a type of brain tumor, CNS lymphoma, in which we are able to simultaneously monitor cognitive function, as assayed by repeat Mini-Mental Status Examinations (MMSE), tumor volume, as assessed by MRI, and dynamic changes in the tumor metabolic microenvironment, as characterized by quantitative measurement of tumor-associated metabolites in correlation with neurotransmitters that we hypothesize to be linked to normal cognitive function. Our initial study was to evaluate 14 subjects with CNS lymphoma that were treated on a phase I trial of the immunomodulatory agent lenalidomide. Volumetric analysis of CNS lymphomas was performed using Smartbrush Software (Brainlab) on pre-and post-therapy MRI's conducted at baseline and at monthly restaging. Metabolomic analysis of cerebrospinal fluid (CSF), using GC/MS, was conducted at baseline and at timepoints within 1 week of corresponding MRI. MMSE tests were conducted in all subjects at baseline and at corresponding monthly restaging examinations.

Results: Of 20 CSF metabolites analyzed, including 12 neurotransmitters, elevated CSF lactate correlated most strongly with impaired neurocognitive function as measured by MMSE score. (P=2.5e-6; rho= -0.66). Patients with high lactate had lower relative CSF concentration of the inhibitory neurotransmitter GABA, and higher concentrations of the excitotoxic glutamate. Notably, we determined that CSF lactate concentration more significantly correlated with lower MMSE score than size of the brain tumor, as quantified by volumetric analysis of tumor T2 hyperintensity and lesional contrast-enhancing volume.

Conclusions: To our knowledge, this is the first data linking cancer metabolism, neurotransmitter dysregulation, and neurocognitive deficits in a brain tumor patient population. We anticipate that elucidation of the mechanistic basis between tumor lactate metabolism, neurotransmitter imbalance, and neurocognitive deficits will provide potential opportunities for pharmacologic intervention to preserve neurologic function and potentially minimize cognitive and neuropsychological deficits in cancer patients.

Citation Format: Lakshmi Subbaraj, Huimin Geng, Jigyasa Sharma, Marisa LaFontaine, James L. Rubenstein. Tumor metabolism and cognitive dysfunction in CNS lymphoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4975.