A Case of Life-Threatening Abdominal Wall Hematoma Formation in a Patient on Warfarin Therapy with Concurrent Influenza Infection

Warfarin therapy provides extensive antithrombotic benefits and, thus, is widely used in the general population. However, as with most medications, there are also risks associated with warfarin use. Specifically, because of the narrow therapeutic window of this drug, patients taking it are at a much higher risk of accidental bleeding. Additionally, patients may also present with bleeding complications when infected with illnesses with coughing as a symptom, such as influenza or COVID-19. These patients have the potential to suffer hemorrhagic morbidities related to the increased intra-abdominal and intra-thoracic pressures that are generated from coughing. Moreover, a synergistic effect is seen when patients find themselves in a situation where they are taking anticoagulation therapy and become infected with illnesses such as influenza or COVID-19. We present a case in which an individual on warfarin therapy was infected with Influenza A. This combination of factors eventually led to massive hemorrhage and large abdominal wall hematoma formation. This case brings to light the importance of having a low threshold for considering the prospect of massive hemorrhage in any patient who is anticoagulated and develops a condition that is associated with increased abdominal pressure. Because these bleeding events can have devastating effects, raising awareness of this risk is increasingly important. Early detection of massive hemorrhage will lead to better outcomes and can ultimately be life-saving for these patients.

Pfizer-BioNTech (BNT162b2), Moderna (mRNA-1273) COVID-19 mRNA vaccines and hypersensitivity reactions

The SARS-CoV-2 Virus (COVID-19) is responsible for over 239 million cases and 4.8 million deaths globally (Data source WHO COVID-19 Dashboard accessed on October 14, 2021). It continues to surge and ravage countries, leaving healthcare systems in constant struggle and uncertainty. A variety of vaccines were developed to combat the spread of the COVID-19 Virus. Reports of possible allergic reactions with COVID-19 vaccines are a significant cause of public concern, especially among those with a known history of a severe allergic reaction (e.g., anaphylaxis). Here we review articles relevant to COVID-19 vaccines and their excipients (especially PEG (Polyethylene glycol) and hypersensitivity reactions associated with COVID-19 vaccines (including clinical features, pathophysiology, special populations receiving COVID-19 vaccinations, potential diagnostic tests, and preventive measures that can be taken to minimize the risks of hypersensitivity reactions with COVID-19 vaccines).

PSUN186 Comparison of Thyroid Function Test Screening in Patients with Diabetes Mellitus Type 2 versus Patients with Diabetes Mellitus Type 1

Diabetes mellitus (DM) and thyroid dysfunction (TD) are common endocrine diseases that often coexist in clinical practice. Prevalence of TD in individuals with DM type 2 ranges from 9.9 to 48%. There are no screening guidelines for thyroid function in patients with DM type 2 as there are in patients with DM type 1. Our previous electronic medical record (EMR) included an aid that imported diabetes metrics, but the current system does not. A previous study at our institution revealed TSH screening rate to be 86.2% in DM type 1 patients. We examined the rate of screening for TD in patients with DM type 2 versus DM type 1 based on the general population guidelines, and we evaluated the effect of EMR aid versus no aid on screening rate. We also analyzed the underlying etiology of thyroid dysfunction in patients with DM type 2 found to have an abnormal TSH.

We compared practice patterns with Centricity (EMR aid; from June 1, 2013 to May 30, 2016) and MedConnect (no EMR aid; from January 1, 2017 to December 31, 2019) in both primary care and endocrinology clinics in the MedStar hospital system in Baltimore, MD. A retrospective review was performed on 949 patient charts (MedConnect 498, Centricity 451). Inclusion criteria were DM type 2 diagnosis (ICD code E 11.0 to E 11.9) and age ≥18 years with at least one outpatient clinic visit.

Baseline TSH was done in 551 of overall 949 patients (58.1%), with 249 of 451 (55.2%) in Centricity and 302 of 498 (60.4%) in MedConnect. This difference was not significant (P = 0.5). Of the total 551 patients with baseline TSH, 48 (8.7%) had abnormal TSH, of which 35 patients (11.5%) were in MedConnect and 13 (5.2%) were in Centricity (P = 0.01). Of the overall abnormal results, 35 patients (6.3%) had hypothyroidism, 10 (1.8%) had hyperthyroidism, 2 (0.4%) had subclinical hyperthyroidism, and 1 (0. 2%) had subclinical hypothyroidism results. Logistic regression analysis found that the adjusted odds of baseline TSH screening with endocrinologists was 1.54 times higher than with primary care physicians.

No significant difference was found in TSH screening in patients with DM type 2 irrespective of EMR aid. A larger proportion of abnormal results were found in MedConnect than in Centricity. Endocrinologists ordered TSH screening more often than primary care physicians. The screening rate of TSH in patients with DM type 2 was lower than that found in our previous study of TSH screening in patients with DM type 1. This was expected as there are no current screening guidelines for TD specific to DM type 2 patients. Further studies are needed, and consideration should be given to screening all DM type 2 patients with symptoms.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

A Mysterious Case of Encephalitis: Diagnostic Challenge and Our Clinical Reasoning

Acute psychotic symptoms in young patients are frequently attributed to toxic or infectious causes. After ruling out the most common causes, obtaining a firm diagnosis becomes challenging. In this case report, we present the case of a young woman who presented with acute psychosis after returning from a five-day vacation in Mexico. We treated this as a case of cerebral spinal fluid (CSF)-negative anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, as testing for CSF-NMDA receptor IgG antibodies was negative, and the absence of anti-NMDAR IgG antibodies does not rule out this autoimmune encephalitis. Moreover, IV methylprednisolone remarkably improved our patient’s mental status and behavior. Anti-NMDAR encephalitis manifests itself in a variety of ways. As a result, providers must maintain a high level of suspicion based on their clinical assessment, as delays in labs or failure to diagnose early based on the clinical presentation can lead to delays in treatment with which this severe immune-mediated paraneoplastic condition can quickly escalate and have worse consequences. We describe our thought process behind our clinical judgment toward this atypical scenario to contribute to identifying this condition early on in the complex clinical presentation.

Monitoring Thyroid Function Tests in Patients With Type 1 Diabetes Mellitus: Adherence to Recommended Guidelines and Comparison of Practice Patterns in a Health Care System

Approximately 1.7 million people in the U.S. have type 1 diabetes mellitus. Autoimmune thyroid disease occurs in 17 to 30% of patients with type 1 diabetes. The American Diabetes Association recommends that thyroid function be assessed at diagnosis of type 1 diabetes and repeated every 1 to 2 years thereafter or sooner if clinically indicated. With Centricity, our former electronic medical records (EMR) system, an EMR aid automatically imported key diabetes metrics including the TSH test. Our new EMR system, MedConnect, does not have an EMR aid that imports these metrics. We hypothesized that the screening rate for thyroid dysfunction in type 1 diabetic patients would be higher with the previous EMR system than with the new EMR system. We also hypothesized that the screening rate in patients followed by an endocrinologist would be higher than in those followed by a primary care physician.

Methods: We compared practice patterns with Centricity (from June 1, 2013, to May 30, 2016) versus MedConnect (from January 1, 2017, to December 31, 2019) in both primary care and endocrinology clinics. A total of 502 patients (271 Centricity, 231 MedConnect) were identified by chart review with age ≥18 years and ICD 9/10 codes for type 1 diabetes mellitus in outpatient clinics in our multicenter system.

Results: Baseline TSH was done in 253 of 271 (93.4%) Centricity patients and in 181 of 231 (78.4%) MedConnect patients. The odds of baseline TSH with Centricity was 3.88 times higher compared to MedConnect (OR = 3.88, 95% CI=2.19,6.88). Of the 214 patients with normal baseline TSH, 135 (63.1%) had repeat TSH done in 1-2 years; and of the 136 MedConnect patients with normal baseline TSH, 86 (63.2%) had repeat TSH done in 1-2 years. Of 434 patients with baseline TSH, 81 (18.6%) had abnormal TSH. Of these patients, 67 (82.7%) had hypothyroidism, 1 (1.2%) had hyperthyroidism, 8 (9.8%) had subclinical hypothyroidism, and 5 (6.1%) had subclinical hyperthyroidism. Of the total 502 patients, 380 (75.7%) were followed by an endocrinologist and 122 (24.3%) were followed by a primary care provider. Among patients followed by an endocrinologist, 348 (91.6%) had a baseline TSH result. Only 86 of 122 (70.5 %) patients followed by a primary care physician had a baseline TSH. Endocrinologists had 4.6 times higher odds of TSH screening at baseline compared with primary care physicians (p <0.0001).

Conclusion: Thyroid function was not assessed at baseline in all patients with type 1 diabetes mellitus and was not followed at the recommended intervals per the guidelines. Higher screening rates were seen with an EMR aid. Endocrinologists screened significantly more patients than primary care physicians. Education of providers regarding the guidelines is needed, and addition of an EMR aid may help to improve detecting thyroid dysfunction in patients with type 1 diabetes mellitus.