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SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration can affect ventilation-oxygenation dynamics causing significant morbidity and mortality in children and adults. Patient presentation can range from asymptomatic to life-threatening hypoxia. A thorough history and physical examination helps in narrowing differential diagnosis and provision of timely management. A myriad of complications can occur from aspirated Foreign body including recurrent pneumonia, lung abscess, obstructive emphysema, and death. Here we present a case of a patient with recurrent pneumonia from a chronically aspirated foreign body. CASE PRESENTATION: 37-year-old male with past medical history of a recent COVID-19 infection and bronchus intermedius endobronchial mass (squamous metaplasia on biopsy 2009) who presented with fever, chest pain, worsening dyspnea. Initial workup was consistent with severe sepsis. A CT chest showed complete collapse, cavitation in right lower lobe and presence of right bronchus stent. Patient was treated with IV fluids and antibiotics during the hospitalization. He underwent bronchoscopy for airway examination and bronchoalveolar lavage. Airway exam showed a large endobronchial mass in the bronchus intermedius. Endobronchial biopsies were taken, followed by tissue debulking using flexible forceps and cryoprobe. A yellow plastic foreign object was then visualized dislodged in the right lower lobe. This was successfully removed with grasping forceps. Patient had to be extubated and be reintubated to remove foreign object in one piece as it did not fit the endotracheal tube. Post debulking, bronchus intermedius and right lower lobe were patent and procedure was completed. Our patient responded well to treatment he was ultimately transitioned to oral antibiotics and discharged home with outpatient follow up. Repeat bronchoscopy 6 weeks later showed normal airways. DISCUSSION: Our case illustrated the importance of thorough investigation while treating patients with recurrent pneumonia, and this sometimes should include bronchoscopy with airway exam. In our case a bronchoscopy was done several years ago, however the foreign body was not identified as the cause of the endobronchial lesion. A lingering foreign body in the long run has significant morbidity as seen in our case despite appropriate treatment with antibiotics patient continued to have recurrent post obstructive pneumonias. Bronchoscopy remains the gold standard in definitive diagnosis and management of foreign body. Since the refinement of bronchoscopy and debulking, the rate of mortality from foreign body aspiration has been remarkably reduced. CONCLUSIONS: In summary patients with history suggestive of potential foreign body aspiration presenting with recurrent pneumonias at a particular anatomical location should prompt physicians to perform diagnostic bronchoscopy, which remains the gold standard for diagnosing of foreign body aspiration Reference #1: Foreign Body Aspiration Natan Cramer;Noel Jabbour;Melissa M. Tavarez;Roger S. Taylor. DISCLOSURES: No relevant relationships by Maria Abril No relevant relationships by Bilal Bangash No relevant relationships by Imran Tarrar
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Introduction Bilateral cavitary lung lesions with calcification in a patient with chronic COVID requiring transplantation are described. Case Report 46-year-old woman presented for lung transplant with respiratory failure due to COVID-19 pneumonia following remdesivir, decadron, tocilizumab and baricitinib therapy. Cavitary upper lobe lung lesions were noted on imaging with negative cultures. She was started on VV ECMO as a bridge to bilateral lung transplant. Explanted lungs were consolidated and fibrotic with bilateral upper lobe calcification surrounding cavitary lesions. Varied microscopic pathology included NSIP pattern of inflammation, and foci of airway centered inflammation with giant cells suggesting chronic hypersensitivity reaction. The calcification was reminiscent of dendriform/metastatic calcification, and involved areas of necrotic/mummified parenchyma. Summary Cavitation as a late stage complication of COVID19 has been described in rare cases and is considered atypical. The constellation of findings in our case, including cavitary lesions with associated dendriform like calcifications are unique and maybe attributable to COVID19 itself +/- exacerbation of underlying chronic lung disease +/- intercurrent infection, or COVID19 related cavitation with superimposed secondary changes due to ECMO treatment. Bilateral lung transplantation has a reasonable short-term prognosis for patients with end stage respiratory failure secondary to COVID19;examination of these native lungs may expand our concept of COVID19 related chronic lung injury patterns.
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TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: MIS-C is described as a clinical syndrome developing secondary to Coronavirus disease 2019 (COVID-19) in children and adolescents. The presentation is similar to Kawasaki syndrome, hemophagocytic lymphohistiocytosis (HLH) and toxic shock syndrome. We present a case of MIS-C in a young adult two weeks after receiving vaccination for COVID-19. CASE PRESENTATION: 21 year old female with a past medical history of asthma who presented to the emergency department (ED) with fevers, chills and photophobia since receiving the J&J COVID-19 vaccine 2 weeks prior. On evaluation, COVID test was negative. Labs were notable for leukopenia, elevated liver enzymes. She as admitted to the medical floor. Her course was complicated by worsening transaminases >2000 IU/L with progressive encephalopathy. She had witnessed seizure activity requiring intubation and transfer to the Intensive Care Unit (ICU). Computed Tomography (CT) abdomen was unremarkable. Head CT showed no acute abnormalities. Brain Magnetic Resonance Imaging (MRI) showed diffuse nonspecific white matter signal abnormalities. Additional labwork revealed ferritin of 937 mcg/L, and CRP of 47.3 mg/L and an elevated NT-proBNP. Film array and hepatitis panel was negative. COVID spike and nucleocapsid antibodies were both positive. She underwent a liver biopsy which was consistent with acute hepatitis and bone marrow biopsy which was negative for HLH. Lumbar puncture with elevated opening pressure of 27 cm H20. Extensive infectious workup for bacterial, fungal and viral etiologies were negative. She met criteria for MIS-C/A. She received high dose Intravenous Dexamethasone, Intravenous Immunoglobulin (IVIG) and anakinra infusion. Her labwork and encephalopathy improved and she was discharged home. DISCUSSION: MISC-C/A is seen in patients presenting 3 to 5 days after an asymptomatic or mild COVID infection. It is unclear whether the inflammatory response seen in our patient was secondary to a recent asymptomatic COVID infection, her vaccination or both. Cases have been mostly reported in children and patients under 21 years of age. Presentation is usually associated with gastrointestinal symptoms, evidence of mucocutaneous inflammation (rash, conjunctivitis, oromucosal changes), lymphopenia, and high levels of circulating inflammation. The goals of treatment for MIS-C are to decrease systemic inflammation and restore organ function, with use of high dose steroids, IVIG or anakinra. CONCLUSIONS: It is currently unknown if MIS-C/A might follow CVOID immunization, but a need exists to define this potential entity for monitoring as a potential adverse event. It is also important to maintain an index of suspicion for this disorder in the adult post-covid population. REFERENCE #1: Chao J.Y., Derespina K.R., Herold B.C., Goldman D.L., Aldrich M., Weingarten J. Clinical characteristics and outcomes of hospitalized and critically ill children and adolescents with coronavirus disease 2019 (COVID-19) at a tertiary care medical center in New York City. J Pediatr. 2020;223:14–19.e2 REFERENCE #2: CDC COVID-19 Response Team. Coronavirus disease 2019 in children—United States, February 12–April 2, 2020. Morb. Mortal. Wkly. Rep. 2020, 69, 422–426. DISCLOSURES: No relevant relationships by Bilal Bangash, source=Web Response No relevant relationships by Issa Makki, source=Web Response No relevant relationships by Joseph Pitcher, source=Web Response
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Introduction: Persistent radiographic and pulmonary function abnormalities are increasingly recognized following Corona Virus Disease (COVID-19) pneumonia. We present a case of rapidly progressive pulmonary fibrosis in a Usual Interstitial Pneumonia (UIP) pattern. Successful lung transplantation was performed two months following COVID-19 infection. Description: 68 years old with known history of mild Interstitial Lung Disease (ILD) , not on home oxygen, initially presented in July 2020 with worsening shortness of breath and cough. There was a strong family history for Interstitial pulmonary fibrosis (IPF). Her last pulmonary function tests showed a Forced Expiratory Volume in one second (FEV1) of 2.24 Liters (99%) and Forced Vital Capacity of 2.69 Liters (92%). Her last High Resolution Computed Tomography (HRCT) showed chronic stable mild interstitial fibrosis. On admission, she was positive for COVID 19 on her Polymerase Chain Reaction (PCR). Initial CT chest showed diffuse new ground glass changes. She was treated with remdesavir, dexamethasone and antibiotics. She did not require endotracheal intubation and showed improvement in her symptoms. Unfortunately, she could not be weaned off oxygen and was discharged on six liters flow oxygen through a nasal cannula. She presented again to the hospital, one month later with worsening shortness of breath. Her PCR was negative for COVID 19. Her CT angiogram of thorax however showed interval worsening of her interstitial changes. An urgent inpatient evaluation for lung transplantation was completed and she deemed to be a suitable candidate. After 4 days into her stay, acute deterioration in her respiratory status developed with tachypnea and increased work of breathing requiring endotracheal intubation and mechanical ventilation. Repeat CT chest showed fibrotic interstitial disease with associated traction bronchiectasis and a large amount of ground glass. She was subsequently placed on veno-venous Extra Corporeal Membrane Oxygenation (VV ECMO) which allowed extubation. A donor offer for bilateral lungs was accepted after one day on ECMO. She successfully underwent bilateral lung transplant in September 2020. Her post-operative course was uncomplicated. She is doing well 3 months post transplant without evidence of cellular rejection. Her explant pathology showed Diffuse Alveolar Damage plus UIP Discussion: Persistent and progressive pulmonary fibrosis may develop following COVID-19 pneumonia. Risk factors may include underlying ILD and family history of IPF. In suitable candidates, lung transplantation is a viable option.