ABSTRACT
SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Since the start of the COVID-19 pandemic, COVID-19 Associated Pulmonary Aspergillosis (CAPA) has been on the rise. This superinfection, if not properly identified and treated, has shown to increase mortality up to 67% in COVID-19 patients. We are presenting a late presentation of CAPA after 4-month of COVID-19 infection and treated successfully. CASE PRESENTATION: A 57-year-old female patient with past medical history type 2 diabetes mellitus, hypertension and cardiomyopathy in addition to COVID-19 pneumonia treated for months ago with azithromycin, Bamlanivimab/Etesevimab, and Dexamethasone who presents to the hospital with massive hemoptysis and shortness of breath requiring intubation and mechanical ventilation. There was no reported history of recent travel, smoking, alcohol, or illicit drug use. Physical exam showed diminished lung sounds at the right lower lobe. Her labs showed mild leukocytosis, lactic acidosis and negative COVID-19 PCR. CT scan showed dense consolidation on right lower lobe consistent with lobar pneumonia and centrilobular ground glass opacities in the right upper lobe. Bronchoscopy showed complete obstruction of right bronchus intermedius and minimal blood clots in LLL. BAL respiratory culture, fungal smear, acid fast bacilli were non-diagnostic and negative for malignancy. Patient continued to have hemoptysis and bronchoscopy was repeated with negative cytology and cultures. The patient continued to have hemoptysis and she was transferred to tertiary center were bronchoscopy was repeated and confirmed right bronchus intermedius stenosis, blood clots, and suspicious right mainstem nodules with mucosal lesion. Biopsy results from bronchoscopy came back positive for the morphologic features of Aspergillus species. The patient was started on voriconazole with significant improvement in her symptoms. DISCUSSION: The recent literature of COVID-19 suggest association between COVID infection and invasive pulmonary Aspergillosis. COVID-19 virus causes damage in the airway epithelium and enable aspergillus to invade the pulmonary tract leading to serious infections with Aspergillus. It has also been known that Aspergillus infections are associated with diabetes mellitus and immune suppression which can be precipitated by steroid use and other treatments for COVID-19 infection like IL-6 inhibitors. Here in our patient with help of tissue biopsy we diagnosed CAPA, started treatment early and treated successfully. CONCLUSIONS: CAPA can be difficult to diagnose and needs high index of suspicion in the appropriate clinical scenario when dealing with post COVID respiratory complaints like hemoptysis. Bronchoalveolar lavage alone without tissue biopsy might miss the diagnosis in the context of invasive aspergillosis like the scenario we observed in our case. Doing tissue biopsy through bronchoscopy might add more clinical benefit when Aspergillus infections are suspected. Reference #1: Chih-Cheng Lai, Weng-Liang Yu, COVID-19 associated with pulmonary aspergillosis: A literature review, https://doi.org/10.1016/j.jmii.2020.09.004 DISCLOSURES: No relevant relationships by Haytham Adada No relevant relationships by Mahmoud Amarna No relevant relationships by Rishika Bajaj No relevant relationships by Camelia Chirculescu No relevant relationships by Sonia Dogra No relevant relationships by Azad Patel
ABSTRACT
TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tofacitinib (Xeljanz) is common and popular Disease Modifying Anti-Rheumatic Drug used in the treatment of moderate to severe Rheumatoid Arthritis (RA) that was approved by US FDA in 2012. It now comes with a new black-box warning for venous thromboembolism (VTE). We present a patient taking Tofacitinib as well as an oral anticoagulant that developed pulmonary embolism (PE) after receiving his first COVID-19 vaccine. CASE PRESENTATION: An 80-year-old white male with severe RA on Tofacitinib (previously failed treatment with Methotrexate and Infliximab), mild interstitial lung disease likely related to occupational silica exposure, severe Chronic Obstructive Pulmonary Disease (COPD) with oxygen dependency, 50 pack-year smoking history (quit in 2016), coronary artery disease, atrial flutter on Rivaroxaban presents to ED for worsening shortness of breath. He had just received his first COVID-19 vaccine manufactured by Moderna two weeks prior. Vital signs include;heart rate 127 bpm, respirations 40 per minute, SpO2 84% on 6 LPM oxygen and fever of 101.2 F. Pertinent labs include WBC 12.4, Lactic Acid 3, BNP 175, Troponin 0.02. Chest X-ray revealed edema and/ or atypical pneumonia, but COVID-19 screen was negative. He received IV Solumedrol and Cefepime, before being admitted. Overnight he developed new onset chest pain with increased O2 requirements up to 15 LPM. CT Chest was immediately pursued revealing right upper lobe and bilateral lower lobe segmental pulmonary emboli without right ventricular strain. He was started on a heparin drip. Tofacitinib was stopped on the recommendation of his Rheumatologist and he was discharged on Apixaban. DISCUSSION: Tofacitinib is a JAK 1-3 inhibitor causing inhibition of the CD 16/56+ natural killer cells, serum IgG-IgM-IgA and CRP. Higher doses of Tofacitinib are associated with an increased incidence of DVT/PE in elderly population, with at least one cardiovascular risk factor [1]. In study A3921133, a higher frequency of PE and all-cause mortality was seen in higher dose of Tofacitinib (10 Mg BID) when compared to TNF inhibitors [2]. In another Long-term Extension (LTE) study involving 7061 patients taking Tofacitinib, VTE was reported in 59 (0.8%) patients with an IR (95% CI) of 0.3 (0.2 to 0.3), DVT was reported in 36 (0.5%) patients (IR 0.2 [95% CI 0.1 to 0.2]) and PE in 28 (0.4%), [2]. FDA has issued a 'Boxed warning’ regarding the risk of thrombosis with 10 mg BID dose of Tofacitinib [3]. CONCLUSIONS: Clinicians are strongly urged to evaluate the risk of DVT/PE before initiating higher dose of Tofacitinib in patients greater than 50 years old with at least one cardiovascular risk factor. In our case, another confounding aspect is the incidence of PE despite treatment with an oral anticoagulant. The thrombogenic potential of Tofacitinib should strongly be explored as an independent risk factor for PE by clinicians. REFERENCE #1: [1] Mease, Philip, et. Al;Incidence of Venous and Arterial Thromboembolic Events Reported in Tofacitinib rheumatoid arthritis, psoriasis and psoriatic arthritis Development Programs and from Real-World Data, 2020, Annals of Rheumatic Disease, 79(11): 1400-1413, DOI: 10.1136/annrheumdis-2019-216761 REFERENCE #2: [2] Cohen, Stanley;et Al;Long-term Safety of Tofacitinib up to 9.5 years: A Comprehensive Integrated Analysis of the Rheumatoid Arthritis Clinical Development Programme, 2020, Rheumatic and Musculoskeletal Disease, 6(3):e001395, DOI: 10.1136/rmdopen-2020-001395 REFERENCE #3: [3] U.S. Food and Drug Administration (FDA), Initial safety trial results find increased risk of serious heart-related problems and cancer with arthritis and ulcerative colitis medicine Xeljanz, Xeljanz XR (tofacitinib), 2021, Drug Safety Communication, Retrieved from;https://www.fda.gov/drugs/drug-safety-and-availability/initial-safety-trial-results-find-increased-risk-serious-heart-related-problems-and-cancer-arthritis DISCLOSURES: No relevant relationships by Mahmoud Amarn , source=Web Response No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Johnston Hospital, source=Web Response No relevant relationships by Rakesh Patel, source=Web Response No relevant relationships by Mallika Velichety, source=Web Response