AN UNUSUAL PRESENTATION OF CHRONIC LYMPHOCYTIC LEUKEMIA AS ORGANIZING PNEUMONIA

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Organizing pneumonia (OP) is a form of interstitial lung disease with a distinct histopathological pattern where bronchioles and alveoli become inflamed. It is associated with many clinical conditions including infections and connective tissue disease. OP has also been seen in patients with hematologic malignancies, however, primary pulmonary presentation of chronic lymphocytic leukemia (CLL) is uncommon. We present a rare case of OP as an initial presentation of CLL. CASE PRESENTATION: A 62 year-old male with a sixty pack year smoking history and COVID-19 infection one month ago presents with complaints of worsening dyspnea, headaches, productive cough, and congestion of 10 days duration. Patient is unvaccinated and did not require hospitalization for his COVID-19 infection. His vital signs on admission were significant for tachypnea with respiratory rate of 35 and hypoxia with oxygen saturation of 84% on room air. He initially required oxygen supplementation via non-rebreather mask to maintain oxygen saturation >88%. A chest tomography (CT) scan was completed and revealed bilateral dense consolidations with ground-glass opacities and air bronchograms consistent with OP. The scan was also significant for bulky mediastinal lymphadenopathy. The patient denied any personal or family history of autoimmune disease, occupational exposures, and recent travel. Evaluation for infection and for underlying connective tissue disease was unremarkable. He was started on broad spectrum antibiotics and high dose steroids. Due to fluctuating lymphocytosis, bulky lymphadenopathy, and negative infectious workup despite clinical improvement, he underwent a bronchoscopy with endobronchial ultrasound guided transbronchial needle aspiration of lymph nodes. Immunohistochemical (IHC) stains of these samples were compatible with CLL. Additionally, peripheral blood flow cytometry was also diagnostic of CLL. Oncology was consulted for further evaluation and treatment of CLL. The patient's respiratory symptoms improved and oxygen requirements decreased with steroid treatment and he was discharged home. DISCUSSION: OP occurring in patients with hematologic malignancies has multiple etiologies. Most case reports describe patients with previous exposure to chemotherapy, radiotherapy, or bone marrow transplant. However, our patient had no such exposure history and no prior diagnosis of a hematologic malignancy. Infectious and autoimmune etiology were considered, but serologic evaluation was unremarkable. Flow cytometric analysis of lymph node tissue along with lymphocytic bronchoalveolar lavage was consistent with initial diagnosis of CLL. CONCLUSIONS: Despite the low incidence, hematologic malignancy should be considered as a differential diagnosis in all patients who present with organizing pneumonia. Prednisone therapy for 6-12 month duration has been shown to reduce respiratory symptoms and may improve survival. Reference #1: Craig E. Daniels, Jeffrey L. Myers, James P. Utz, Svetomir N. Markovic, Jay H. Ryu. Organizing pneumonia in patients with hematologic malignancies: A steroid-responsive lesion. Respiratory Medicine, 101 (1) (2007), pp. 162-168. Reference #2: M. Mokhtari, P.B. Bach, P.A. Tietjen, D.E. Stover. Bronchiolitis obliterans organizing pneumonia in cancer: a case series. Respiratory Medicine, 96 (4) (2002), pp. 280-286. DISCLOSURES: no disclosure on file for Guillermo Garrido;No relevant relationships by Anita Gopalakrishnan No relevant relationships by Rameez Rao No relevant relationships by Mohammad Salimian

Fungitell Tells It All: A Case of Pneumocystis Jirovecii Pneumonia

Introduction: The Fungitell assay is an in vitro diagnostic test for the qualitative detection of (1-3)-beta-D-Glucan (BDG) in serum. It can be particularly useful in early diagnosis of fungal infections that would otherwise take weeks to finalize in culture.Description:This is a case of a 73 year old Filipino female with a history of diffuse large B-cell lymphoma status post RCHOP therapy, currently maintained on Ritixumab, and rheumatoid arthritis treated with Methotrexate who was admitted to the hospital with increasing shortness of breath for several weeks. In the Emergency Department she was hypoxic and required 2 liters of oxygen via nasal cannula and with 92% oxygen saturation. Her vital signs were otherwise normal. She was afebrile and WBC was 9.4. She had a negative respiratory viral PCR which included COVID-19. Infectious work up including sputum culture and urine antigens were also sent. A CT chest was performed and showed bilateral ground glass opacities suspicious for atypical pneumonia.There was concern for drug toxicity from Methotrexate which was subsequently suspended. A bronchoscopy and bronchoalveolar lavage (BAL) was performed to rule out infection prior to starting steroids for suspected pneumonitis. Cell count from the BAL revealed low neutrophils. There was negative growth over the next 48 hours. Steroids were initiated at 1 mg/kg daily and patient was discharged home with close outpatient follow up scheduled. A fungitell (serum beta D glucan) that was collected from the BAL had resulted after the patient was discharged home. The level returned very elevated (>500). The patient was contacted and she reported that her symptoms did not improve with the steroids. She was still requiring up to four liters of oxygen at home. She was asked to return to the hospital to work up an undiagnosed fungal or PJP pneumonia. A repeat bronchoscopy was performed and a PJP PCR was tested on the BAL. This returned positive. She was started on Bactrim for 14 days to treat PJP pneumonia. She was weaned down to 2 liters of oxygen and was doing well from a pulmonary standpoint at her outpatient follow up visit 2 weeks later. Discussion: The Fungitell assay test in this case was crucial to help guide us to the correct diagnosis. In patients who are immunocompromised, physicians should utilize specialty testing such as Fungitell when it is available. Compared to microbial fungal culture, Fungitell results faster, has a higher sensitivity and a higher negative predictive value. (Figure Presented).

Modified VGG deep-learning architecture for COVID-19 classification using chest radiography images

Background: The world faced a deadly disease encounter by the starting of 2020, known as coronavirus disease 2019 (COVID-19). Due to the rapid increase in the counts of COVID cases, the WHO declared the COVID-19 as a pandemic on March 11, 2020. Among the different screening techniques available for COVID-19, radiography of the chest is one of the efficient way for disease detection. While other disease detection techniques take time, radiography takes less time to identify because of the abnormalities caused by the disease in the lungs. Methods: In the rapid development era of artificial intelligence and deep-learning techniques, various models are being developed for COVID disease detection. COVID-19 can be easily detected from Chest X-ray images and the pretrained models yield high accuracy with small dataset. Results: In this paper, one of the standard deep-learning architectures, VGGNet, is modified for classifying chest X-ray images under four categories. The proposed model uses open source dataset that contains 231, 2503, 1345, and 1341 images of four classes such as COVID, bacterial, normal, and viral chest radiography images, respectively. Conclusion: The performance matrices of the proposed work were compared with the five benchmark deep-learning architectures namely VGGNet, AlexNet, GoogLeNET, Inception-v4, and DenseNet-201. © This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License.