Hospital Braga

Objectives The relevance of spinopelvic parameters in the patients' clinical and functional outcomes has been widely studied in long spinal fusion. Yet, the importance of the spinopelvic parameters in short-segment fusion surgeries needs further investigation. We analyzed the spinopelvic parameters and surgical outcomes of patients undergoing short-segment lumbar interbody fusion. Materials and Methods An observational, prospective study was conducted between January and June 2021. We selected 25 patients with lumbar stenosis, with or without concomitant spondylolisthesis, undergoing transforaminal lumbar interbody fusion. Variables related to the patient, diagnosis, and surgery were collected. The clinical and functional outcomes were assessed using the Visual Analogue Scale for low-back and leg pain and the Oswestry Disability Index (ODI). The surgical outcomes and spinopelvic parameters were analyzed pre- and postoperatively. Results There was a significant clinical and functional improvement after surgery ( p < 0.001), with a mean ODI decrease of 63.6%. The variables of obesity, concomitant spondylolisthesis, absence of osteotomy, and two-level fusion were all associated with lower levels of improvement after surgery ( p < 0.05). Pelvic incidence minus lumbar lordosis (PI-LL) was the only parameter that significantly changed regarding the pre- and postoperative periods ( p < 0.05). Before surgery, PI-LL < −10° correlates with less low-back pain after surgery (r = 0.435; p < 0.05). Postoperatively, no correlation was found between surgical outcomes and all the spinopelvic parameters analyzed. Conclusions The clinical and functional outcomes significantly improved with the surgical intervention but did not correlate with the change in spinopelvic parameters. Patients with preoperative PI-LL < −10° seem to benefit the most from surgery, showing greater improvement in back pain.

Introduction/Background Soft tissue tumors arising from peripheral nerve sheath tumors (PNSTs) may ocasionally be observed in the pelvic retroperitoneum during gynecologycal examination. These are usually benign, although a very low risk of malignant transformation has been reported. The purpose of this study was to describe the clinical and sonographic characteristics of benign, retroperitoneal, pelvic PNSTs. Methodology A retrospective, single, gynecologic oncology center study conducted between 1 January 2018 and 31 August 2022. All ultrasound images, clips, and final specimens of benign PNSTs were reviewed to describe: (1) the ultrasound appearance of the tumors using standardized terminology on a predefined ultrasound assessment form, (2) the origin of the tumors in relation to nerves and pelvic anatomy, and (3) the correlation between ultrasound features and histotopograms. Results Five women (mean age 53 years) with benign, retroperitoneal, pelvic PNSTs were identified: four with schwannomas and one with a neurofibroma, all of which were sporadic and solitary. All patients had good quality ultrasound images and clips and final biopsies of surgically excised tumors, except for one patient managed conservatively with a tru-cut biopsy. In four of these cases, the findings were incidental. All five PNSTs measured 31–50mm, were solid, moderately vascular tumors, with non-uniform echogenicity, well-circumscribed by hyperechogenic epineurium, and had no acoustic shadowing. They contained small, irregular, anechoic, cystic spaces (n = 3), and hyperechoic areas (n = 4). Conclusion Accurate preoperative diagnosis of these tumors may avoid the potential risks of surgery, especially collateral nerve and vascular damage. However, no ultrasound features reliably differentiated schwannomas from neurofibromas. In fact, they overlap with those of malignant tumors. Ultrasound-guided biopsy can be used to diagnose these tumors, which may be subsequently monitored with ultrasound surveillance. Disclosures On ultrasound, benign PNSTs were solid, non-uniform, moderately vascular tumors without acoustic shadowing. Most were round and contained small, irregular, anechoic, cystic spaces, and hyperechoic areas, consistent with degenerative changes on pathology. All tumors were well-circumscribed by a hyperechogenic rim composed of epineurium. This may support the development of a novel field using ultrasound to evaluate the pelvic nerves.

Introduction/Background To assess the interobserver-reality agreement on ovarian cancer staging, when the true-status of examined locations is known after surgery, biopsy or subsequent response to neoadjuvant treatment. Methodology Twenty-five participants divided in two groups with variable experience in ultrasound ovarian cancer staging were included. Each observer evaluated 380 videoclips from 4 compartments (upper and middle abdomen, pelvis and lymph nodes) which included 19 anatomical sites and 5 locations markers for resectability according to ESMO-ESGO guidelines. For each clip, raters were questioned on 1) presence/absence of the disease, 2) image quality of the clip from 0 to 10, 3) level of confidence of the answer to the first question (0 to 10).Data were evaluated using the generalized linear mixed model with random effects to assess the observer reality-agreement between the two groups, since the true-status of the disease was known. Results The general performance of the groups was very high for all the anatomical locations (probability of match from 0.956 to 0.975) and, when compared, it was not affected by expertise (P=0.413), number of scans for ovarian cancer per-year (P=0.533) nor by number of years performing ovarian cancer staging (P=0.679). They performed similarly also in the assessment of 5 sites markers of non-resectability (P=0.779). Overall performance of both groups was significantly affected by the quality of the clips (P<0.001) and level of confidence toward the clip (P<0.001). All participants achieved higher performance in the pelvis, then middle abdomen, lymph nodes and upper abdomen respectively (joint P<0.001). • Download figure • Open in new tab • Download powerpoint Abstract #743 Figure 1 Conclusion This is the first study to demonstrate the generalizability of ultrasound for ovarian cancer staging between sonographers with variable experience. Our study results are essential for the implementing of ultrasound as alternative to other imaging techniques in ovarian cancer staging and to be a potential single imaging modality in the concept of ‘one stop’ ovarian cancer clinic. Disclosures This work was supported by the Ministry of Health of the Czech Republic (Czech Health Research Council NV 19–03-00552).

Studies of flash glucose monitoring systems (FGMSs) in pregnancy are insufficient, especially in gestational diabetes (GD). Our aim was to evaluate Freestyle Libre’s usability and accuracy (compared to self-monitoring of blood glucose [SMBG]) for GD patients in real-life conditions. This is a prospective study with pregnant women diagnosed with GD (n = 24 for the usability analysis; n = 19 for the accuracy analysis). The study duration was up to 28 days (lifetime of two sensors). Participants executed a minimum of four daily FGMS readings obtained immediately after capillary SMBG. Analytical accuracy was assessed with mean absolute relative difference (MARD) and mean absolute difference (MAD); clinical accuracy was assessed with Surveillance Error Grid (SEG). Usability was evaluated with a user acceptability questionnaire. The mean pregestational BMI was 25.21 ± 5.15 kg/m2 (mean ± SD), the mean gestational age was 30.31 ± 2.02 weeks, and the mean glucose values were 76.63 ± 7.49 mg/dL. A total of 1339 SMBG–FGMS pairs of values were obtained. Analytical accuracy was good with an overall MARD of 14.07% and an in-target MARD of 13.79%. The number of SMBG–FMGS pairs for above-target values was low (122 of 1339) with an associated MARD of 17.95%. Clinical accuracy of the FGMS was demonstrated, with 94.4% of values in the no-risk or slight, lower risk zones of the SEG. FGMS accuracy was unaffected by pregestational BMI or gestational age. The user acceptability questionnaire showed high levels of satisfaction, with 95.8–100% preferring FGMS to SMBG. No unexpected or severe adverse effects occurred. FGMS showed good performance in GD regarding accuracy and usability. Larger studies are needed to corroborate our results, verify the analytical accuracy of above-target values as this glucose range might lead to initiation or adjustment of pharmacological therapy, and ultimately establish definitive recommendations regarding prescription of FGMS for GD patients.

Introduction Balloon eustachian tuboplasty (BET) allows the treatment of the main etiology of eustachian tube disfunction (ETD). Objective To evaluate the efficacy of isolated BET, through objective and subjective results, in the short and medium term, in patients with chronic obstructive ETD. Methods Adult patients diagnosed with chronic obstructive ETD who underwent BET between January 2018 and December 2020 were enrolled in the study. We performed a prospective observational study of BET efficacy, by comparing subjective data, based on the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7), and objective data, obtained by tympanometry, objective Valsalva maneuver and tubomanometry, prior to BET with these outcome tools on postprocedure follow-up. Results In total, 30 BETs were performed and analyzed. There were no complications with the procedure. Analysis of BET efficacy was performed in the short-term (average of 7.5 weeks) and in the medium-term (average of 8 months). There was a significant reduction ( p < 0.0001) in the total ETDQ-7 score from baseline to both follow-up periods. A normalization of the ETDQ-7 score was observed in 60 and 83.3% of the performed procedures, in the short- and medium-term, respectively. In tubomanometry, we verified a significant improvement ( p < 0.0001) at all pressures, with a normalization of tubomanometry values in 53.3% and 43.3% of cases in the short- and medium-term, respectively. Tympanogram normalization occurred in 71.4% of patients with abnormal preoperative assessments. Conclusion As an isolated procedure, BET results in significant improvements in symptomatology and objective metric results. This, associated with its safety profile, currently makes BET the most indicated therapeutic option in refractory obstructive ETD.

Objective To evaluate the risk factors for lymph node metastasis (LNM) after a non-curative (NC) gastric endoscopic submucosal dissection (ESD) and to validate and eventually refine the eCura scoring system in the Western setting. Also, to assess the rate and risk factors for parietal residual disease. Design Retrospective multicentre multinational study of prospectively collected registries from 19 Western centres. Patients who had been submitted to surgery or had at least one follow-up endoscopy were included. The eCura system was applied to assess its accuracy in the Western setting, and a modified version was created according to the results (W-eCura score). The discriminative capacities of the eCura and W-eCura scores to predict LNM were assessed and compared. Results A total of 314 NC gastric ESDs were analysed (72% high-risk resection (HRR); 28% local-risk resection). Among HRR patients submitted to surgery, 25% had parietal disease and 15% had LNM in the surgical specimen. The risk of LNM was significantly different across the eCura groups (areas under the receiver operating characteristic curve (AUC-ROC) of 0.900 (95% CI 0.852 to 0.949)). The AUC-ROC of the W-eCura for LNM (0.916, 95% CI 0.870 to 0.961; p=0.012) was significantly higher compared with the original eCura. Positive vertical margin, lymphatic invasion and younger age were associated with a higher risk of parietal residual lesion in the surgical specimen. Conclusion The eCura scoring system may be applied in Western countries to stratify the risk of LNM after a gastric HRR. A new score is proposed that may further decrease the number of unnecessary surgeries.

Major depressive disorder (MDD) is the most common mood disorder and a leading cause of disability worldwide. Trazodone, a triazolopyridine serotonin receptor antagonist and reuptake inhibitor (SARI) antidepressant approved for major depressive disorder (MDD) in adults, has established efficacy that is comparable to other available antidepressants, and is effective for a range of depression symptoms, including insomnia, which is one of the most common and bothersome symptoms of depression. Also, trazodone’s pharmacodynamic properties allow it to avoid the side effects of insomnia, anxiety and sexual dysfunction often associated with selective serotonin reuptake inhibitor antidepressants. In this narrative review, we have summarized recent clinical trials and real-world data on trazodone, including the recently introduced once-daily formulation, which has single dose pharmacokinetic properties that maintain effective blood trazodone levels for 24 h, while avoiding concentration peaks associated with side effects. This, combined with a low incidence of weight gain, and sexual dysfunction, may improve adherence to treatment. The most common adverse effects of trazodone are somnolence, headache, dizziness and xerostomia. It has minimal anticholinergic activity but may be associated infrequently with orthostatic hypotension (especially in patients with cardiovascular disease or older adults), QT interval prolongation, cardiac arrhythmias, and rare episodes of priapism. The low liability for activating side effects, the efficacy on symptoms such as insomnia and psychomotor agitation and the rapid onset of action make it useful for many depressed patients, both in monotherapy at nominal dosages of 150–300 mg/day, and in combination with other antidepressants at lower dosages.

Objectives: Insulin resistance (IR) affects children and adolescents with obesity and early diagnosis is crucial to prevent long-term consequences. Our aim was to identify predictors of IR and develop a multivariate model to accurately predict IR. Methods: We conducted a cross-sectional analysis of demographical, clinical and biochemical data from a cohort of patients attending a specialized Paediatric Nutrition Unit in Portugal over a twenty-year period. We developed multivariate regression models to predict IR. The participants were randomly divided into two groups: a model group for developing the predictive models and a validation group for cross-validation of the study. Results: Our study included 1423 participants, aged 3 to 17 years old, randomly divided in the model (n=879) and validation groups (n=544). The predictive models, including uniquely demographic and clinical variables, demonstrated good discriminative ability [AUC: 0.834-0.868; sensitivity: 77.0-83.7%; specificity: 77.0-78.7%] and high negative predictive values (88.9-91.6%). While the diagnostic ability of adding fasting glucose or triglycerides (TGs)/high density lipoprotein cholesterol index to the models based on clinical parameters did not show significant improvement, fasting insulin appeared to enhance the discriminative power of the model (AUC: 0.996). During the validation, the model considering demographic and clinical variables along with insulin showed excellent IR discrimination (AUC: 0.978) and maintained high negative predictive values (90-96.3%) for all models. Conclusion: Models based on demographic and clinical variables can be advantageously used to identify children and adolescents at moderate/high risk of IR, who would benefit from fasting insulin evaluation.

A 77-year-old woman with arterial hypertension and a history of stroke presented to the emergency department with a 3-month history of slowly progressive gait impairment due to muscle weakness and hypoesthesia of the lower limbs. She denied back pain, upper limbs muscle weakness or incontinence. On physical examination, she had lower limbs muscle weakness with proximal muscle atrophy, hyperkinetic osteotendinous reflexes, proprioceptive dysfunction and T4-level sting hypoesthesia. Dorsal spine MRI showed a T2–T3 right epidural intracanal lesion conditioning spinal cord compression (Fig. 1A and B). The lesion was surgically removed and the anatomopathological study revealed a macrophagic reaction with giant cells consistent with a gouty tophus (Fig. 1C and D). Infections and other causes of macrophage reaction were excluded. Outpatient rheumatology evaluation highlighted recurrent arthritic gout flares for several years, multiple subcutaneous tophi and a serum uric acid of 11.1 mg/dl. A diagnosis of tophaceous gout was made and the patient was started on urate-lowering therapy. After 6 months of follow-up, she did not recover autonomous gait but had no more flares. This case emphasizes the need to recognize the clinical signs of gout and acknowledge the potential formation of MSU crystals in the spine as a cause of neurological symptoms.

Aims In this study, we aimed to apply laboratory blood analysis to identify the hematological (based on hemoglobin concentration, erythrocytes, hematocrit, and RDW count) profiles associated with the most prevalent forms of digestive tract malignancies. Furthermore, we aimed to evaluate how these profiles contributed to distinguishing these tumors at diagnosis. Methods We collected data from the date of ICD-10 diagnostic coding for C15 esophagus, C16 stomach, C18 colon, and C19 rectum tumors of 184 individuals. The statistical analysis and data visualization approaches, notably the heat map and principal component analysis (PCA), allowed for creating a summary hematological profile and identifying the most associated parameters for each pathologic state. Univariate and multivariate data modeling and ROC analysis were performed in both SPSS and Python. Results Our data reveal unique patterns based on tumor development anatomical location, clustering the C18 colon and C19 rectum from the C15 esophagus and C16 stomach. We found a significant difference between C16 stomach carcinoma and the other tumors, which substantially correlated with raised RDW in conjunction with low hemoglobin concentration, erythrocytes, and hematocrit counts. In contrast, C18 colon carcinoma had the higher red blood cell count, allowing for the best classification metrics in the test set of the binary logistic regression (LR) model, accounting for an AUC of 0.77 with 94% sensitivity and 52% specificity. Conclusion This study emphasizes the significance of adding hematological patterns in diagnosing these malignancies, which could path further investigations regarding profiling and monitoring at the point of care.

Cellular angiofibromas (CAFs) are infrequent and benign soft-tissue tumors that primarily affect the genitourinary region in both genders. The authors report the case of a 71-year-old male patient who exhibited progressively increasing swelling in both testicles, with greater prominence noted on the left side. Initial findings from physical examination and scrotal ultrasound indicated the possibility of bilateral hydrocele, so the patient was recommended surgical intervention of the left more prominent side. Intraoperatively, a left paratesticular mass was identified and subsequently excised. Histopathological analysis confirmed the diagnosis of cellular angiofibroma. Surgeons should be cognizant of this tumor type to optimize treatment strategies, as local excision demonstrates a potential to preserve the testicle and yield favorable outcomes. Although occurrences of local recurrence are extremely rare, long-term follow-up is imperative.

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac surgery. The most consistent risk factor associated with the condition is a history of a prior stroke. Cerebral oximetry is a simple, non-invasive, and continuous monitoring device that uses near-infrared spectroscopy (NIRS) to monitor cerebral oxygenation. However, like other monitoring devices, cerebral oximetry has certain limitations, and it must be interpreted cautiously and by taking into account all available clinical information related to the patient. We present a case of a 62-year-old Caucasian woman with a past medical history of a transient ischemic attack (TIA), who had been advised to undergo a right pneumectomy by video-assisted thoracoscopic surgery for treating chronic infection of bronchiectasis. Before administering any drug and while the patient was still alert, we monitored NIRS, and the values recorded were 15 on the left side and 26 on the right side. Despite being Caucasian, she had a darker brownish skin color due to chronic clofazimine use, which is known to cause skin pigmentation. Skin pigmentation is known to attenuate the transmission of near-infrared (NIR) light, potentially affecting the estimation of cerebral oxygen saturation. Thus, our patient suffered from clofazimine-induced skin pigmentation, which may have interfered with the NIR light transmission, which explains the extremely low values observed. Regional intracerebral oxygen saturation should be interpreted in the context of all available clinical information since NIRS transmission can be influenced by several factors and skin pigment has been found to independently influence regional intracerebral oxygen saturation. Apart from race or high serum bilirubin concentration, we should also consider other causes of skin pigmentation alterations, such as pharmacological therapy.

Since the initial spread of severe acute respiratory syndrome coronavirus 2 infection, several viral variants have emerged and represent a major challenge for immune control, particularly in the context of vaccination. We evaluated the quantity, quality, and persistence of immunoglobulin G (IgG) and IgA in individuals who received two or three doses of messenger RNA (mRNA) vaccines, compared with previously infected vaccinated individuals. We show that three doses of mRNA vaccine were required to match the humoral responses of preinfected vaccinees. Given the importance of antibody-dependent cell-mediated immunity against viral infections, we also measured the capacity of IgG to recognize spike variants expressed on the cell surface and found that cross-reactivity was also strongly improved by repeated vaccination. Last, we report low levels of CXCL13, a surrogate marker of germinal center activation and formation, in vaccinees both after two and three doses compared with preinfected individuals, providing a potential explanation for the short duration and low quality of Ig induced.

The total number of spine surgeries is increasing, with a variable percentage of patients remaining symptomatic and functionally impaired after surgery. Rehabilitation has been widely recommended, although its effects remain unclear due to lack of research on this matter. The aim of this comprehensive review is to resume the most recent evidence regarding postoperative rehabilitation after spine surgery and make recommendations. The effectiveness of cervical spine surgery on the outcomes is moderate to good, so most physiatrists and surgeons agree that patients benefit from a structured postoperative rehabilitation protocol and despite best timing to start rehabilitation is still unknown, most programs start 4–6 weeks after surgery. Lumbar disc surgery has shown success rates between 78% and 95% after 2 years of follow-up. Postoperative rehabilitation is widely recommended, although its absolute indication has not yet been proven. Patients should be educated to start their own postoperative rehabilitation immediately after surgery until they enroll on a rehabilitation program usually 4–6 weeks post-intervention. The rate of lumbar interbody fusion surgery is increasing, particularly in patients over 60 years, although studies report that 25–45% of patients remain symptomatic. Despite no standardized rehabilitation program has been defined, patients benefit from a cognitive-behavioral physical therapy starting immediately after surgery with psychological intervention, patient education and gradual mobilization. Formal spine rehabilitation should begin at 2–3 months postoperatively. Rehabilitation has benefits on the recovery of patients after spine surgery, but further investigation is needed to achieve a standardized rehabilitation approach.

Background: Penile cancer is rising in most European countries. Several risk factors have been identified, namely human papillomavirus (HPV) infection. However, the exact role of HPV in penile cancer carcinogenesis is still unknown. Clarifying the contribution of HPV in penile cancer is crucial as it may improve prevention and treatment strategies. Objective: To describe the characteristics of patients with penile cancer and penile intraepithelial neoplasia (PeIN), evaluate the prevalence of HPV-DNA in tumor tissue, and identify differences between patients with and without HPV-DNA. Methods: A retrospective observational study including patients with histological diagnosis of penile squamous cell carcinoma (SCC) or PeIN between 2012 and 2021 in a university hospital was carried out. HPV analysis was performed using Anyplex TM II HPV28 Detection that detects and identifies 28 HPV types. (sensitivity of 95.9%). Results: A total of 25 patients were included. Most of the tumors identified were invasive SCC (n=11) and SCC in situ (PeIN 3) (n= 8). PeIN1/2 was found in the remaining six patients. HPV-DNA was tested in all tissue specimens and was detected in 18 of them. High risk HPV DNA was identified in all positive HPV samples, except one. HPV types included in the nonavalent HPV vaccine were identified in 16 of the 18 samples positive for HPV-DNA. Stratifying patients according to HPV-DNA detection, we found that patients with HPV-DNA were younger (57.5 years vs. 70 years, p=0.047), less likely to have phimosis (5.8% vs. 42.9%, p=0.022) and more likely to have PeIN lesions than invasive SCC (85.7% vs. 27.8%, p=0.025). Conclusion: This study shows a prevalence of HPV-DNA in penile SCC and premalignant lesions of 45.5% and 92.9%, respectively. Identifying HPV involvement in SCC and PeIN pathology has the potential to guide treatment and enhance follow-up strategies.

Introduction Obsessive‐compulsive disorder (OCD) is a severe condition with a profound impact on the health, social and professional functioning of the patients. More than one third of the patients do not achieve remission of the symptoms after first‐line treatment with cognitive‐behavioral therapy and selective serotonin reuptake inhibitor medication. Neurofeedback is a promising technique that allows the non‐invasive self‐regulation of neural activity associated with symptomatic manifestation. Previous literature reported preliminary evidence of positive effects of functional magnetic resonance imaging (fMRI) neurofeedback on OCD symptoms. However, these studies have small samples and/or were not controlled. Additionally, these studies did not involve treatment‐resistant patients. Objectives We aim at developing a fMRI neurofeedback task to treatment-resistant OCD patients and to explore the underlying brain changes. Methods We implemented a sham‐controlled double‐blinded fMRI neurofeedback protocol to target hyperactivity in orbitofrontal regions in treatment‐resistant OCD patients with contamination/cleaning symptoms. The protocol had two sessions of neurofeedback (72 min of total training). The patients included were under treatment‐as‐usual. Results Our preliminary results with the experimental group ( n = 10 patients) demonstrated decreased OCD and stress symptoms three months after the neurofeedback sessions. Moreover, immediately after the neurofeedback sessions, we observed reduced functional connectivity between orbitofrontal and temporoparietal regions, and increased brain activity in dorsolateral prefrontal and premotor areas during symptomatic provocation. The brain functional changes might be associated with a better control over obsessions. Conclusions fMRI neurofeedback led to long-term symptomatic reduction in treatment-resistant patients with OCD. Our results need further validation with the sham‐control group but highlight the efficacy of fMRI neurofeedback for refractory OCD and the necessity of prolonged neurofeedback protocols. Disclosure of Interest None Declared

Introduction Clozapine is the only available treatment for refractory schizophrenia and is rarely associated with the development of myocarditis. Usually, the onset of symptoms occurs within the first month of treatment. The symptoms of myocarditis include fever, flu-like symptoms, fatigue, and dyspnea, symptoms that overlap with the COVID-19 infection. Coronavirus has been associated with cardiovascular complications, including myocarditis. It is not known whether clozapine increases the risk of developing viral myocarditis in patients with COVID-19 infection. Objectives Report a case of myocarditis in a patient treated with clozapine, who also had a history of COVID-19 infection. Methods Collection of clinical information and review of the literature. Results A 24-year-old man was admitted following severe psychotic symptoms that have been developing for the past several months. He presented with disorganized speech and behavior, paranoid delusions, thought alienation, auditory hallucinations, and blunted affect. He had no known medical co-morbidity, but he had tested positive for COVID-19 the month before admission. The lab and imaging tests and the electrocardiogram (EKG) were normal. He was diagnosed with schizophrenia and after treatment failure with three antipsychotics, the patient was started on clozapine, with symptom improvement. Two weeks after clozapine initiation, he started flu-like symptoms, fever, chest pain, and tachycardia. Lab tests showed leukocytosis (12 400 cells/uL), elevated inflammatory markers (C-reactive protein 143,30 mg/L) and cardiac biomarkers (troponin I 12.139 ng/mL, NT-proBNP 9321 pg/ml). The evaluation for viruses, including SARS-CoV-2, was negative. The EKG revealed ST-segment elevations and a transthoracic echocardiogram showed systolic dysfunction (left ventricular ejection fraction was 37%). Cardiac magnetic resonance confirmed severe left ventricular dysfunction and diffuse myocardial edema. The patient’s symptoms resolved following the discontinuation of clozapine and supportive therapies. Troponin and EKG normalized over the following 7 days. By this time, the patient tested positive for COVID-19. Conclusions The temporal relationship with the initiation of clozapine supports the diagnosis of clozapine-associated myocarditis. However, the COVID-19 infection may have played a part in the emergence of cardiac alterations. We hypothesize that the co-occurrence of COVID-19 and clozapine treatment may act synergically as both factors increase the risk of developing myocarditis. However, further studies are needed to evaluate the relationship between these factors. While clinicians should stay alert for the risk of clozapine-associated myocarditis, the overall risk is low, and given the effectiveness of clozapine, as well as the absence of other evidence-based treatments, people with refractory schizophrenia should be given a monitored trial of clozapine, regardless of their COVID-19 status. Disclosure of Interest None Declared