A CASE OF STEROID RESPONSIVE SEVERE PNEUMONIA RELATED TO IMMUNE-LIKE RECONSTITUTION INFLAMMATORY RESPONSE 3 MONTHS AFTER RITUXIMAB THERAPY FOR PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISORDER ASSOCIATED WITH STREPTOCOCCAL INFECTIONS

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Immune reconstitution inflammatory syndrome (IRIS) has a wide variety of presentations including lung involvement with respiratory failure [1]. While traditionally invoked in AIDS, IRIS is also reported after rituximab therapy [2]. We present a case of inflammatory pneumonia 3 months after receiving Rituximab. CASE PRESENTATION: A 22-year-old woman with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS), hypothyroidism, and celiac disease presented with generalized weakness, myalgias, and worsening shortness of breath over a month. She was on Rituximab for 3 years with the last infusion 3 months ago. Interestingly, she reported COVID-19 a month earlier with minimal symptoms, requiring no therapy. She was febrile, tachycardic, and tachypneic requiring supplemental oxygen. Chest CT revealed right upper lobe (RUL) consolidation and patchy consolidative and ground-glass opacities in the left upper and lower lobes.Suspecting community acquired pneumonia, ceftriaxone and azithromycin were started. A COVID-19 and respiratory viral panel PCR were negative. Fever persisted and hypoxemia worsened. Therefore, bronchoscopy was performed. The next day, oxygen requirements increased, and she was moved to ICU on high-flow nasal cannula with 60L FiO2 1.0. Repeat CXR showed subtotal left chest opacification with no pleural effusion on ultrasound. Echocardiography showed preserved LV function. Bronchoscopy cultures were negative. With no response to antibiotics and rapidly worsening CXR changes, Solu-Medrol 125 mg IV q6h was added. Within 24 hours she was improving, being weaned off O2 in 6 days. RUL transbronchial biopsies showed benign alveolar lung parenchyma with some intra-alveolar fibrin deposition with a pool of histiocytic proliferation consistent with organization and with no definitive viral cytopathic effect, vasculitis, or diffuse alveolar damage. All cultures remained negative. CXR changes markedly resolved within 6 days. She was discharged with a slow taper of prednisone. DISCUSSION: This case illustrates a possible exaggerated immune response to tapering levels of immunosuppressive medications such as Rituximab. Her workup ruled out infection and while she also had no active COVID-19, it is conceivable that her recent COVID-19 infection may have activated an exaggerated inflammatory response as the immunosuppression related to Rituximab was subsiding. The rapidly progressing consolidating changes under these circumstances should prompt the clinician to consider IRIS like reactions and rapid institution of steroids seems key to treatment. Whether her PANDAS may have further impacted her immune system making her more prone to this IRIS like response is another consideration that deserves further study. CONCLUSIONS: IRIS is a rare differential diagnosis in rapidly progressing pneumonia that is not just ubiquitous to AIDS patients. REFERENCE #1: J. Mertens, Y. Laghrib, and C. Kenyon, "A Case of Steroid-Responsive, COVID-19 Immune Reconstitution Inflammatory Syndrome Following the Use of Granulocyte Colony-Stimulating Factor," Open Forum Infectious Diseases, vol. 7, no. ofaa326, Aug. 2020, doi: 10.1093/ofid/ofaa326. REFERENCE #2: A. Rao et al., "Safety, efficacy, and immune reconstitution after rituximab therapy in pediatric patients with chronic or refractory hematologic autoimmune cytopenias," Pediatric blood & cancer, vol. 50, no. 4, pp. 822–825, 2008. DISCLOSURES: No relevant relationships by Badri Giri, source=Web Response No relevant relationships by Ahmed Mahgoub, source=Web Response No relevant relationships by seyed pourshahid, source=Web Response No relevant relationships by Seyedmohammad Pourshahid, source=Web Response No relevant relationships by Edmundo Rubio, source=Web Response

GROUND GLASS OPACITIES: IT'S NOT ALL COVID

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: During the COVID-19 pandemic, superimposed infections with both bacterial and fungal organisms have been shown to complicate the viral process. Aspergillus and candida are the most common fungal organisms reported [2];but there have also been a few case reports with co-infection from Pneumocystis jirovecii pneumonia (PJP) [1,3]. We present a COVID patient with lymphopenia and diffuse ground glass opacities who was also diagnosed with PJP. CASE PRESENTATION: A 58-year-old male with past medical history of emphysema liver cirrhosis presented to the hospital with nausea, vomiting and abdominal distention. On examination he was afebrile, hypotensive with a blood pressure of 88/56, SpO2 was 96% on room air. His lungs were clear on auscultation and abdominal exam was notable for moderate ascites. There was 2+ pedal edema bilaterally. Laboratory work-up showed a WBC count of 12000/µL, only 7% of which were lymphocytes. Chest X-ray did not reveal any acute pathology and screening COVID-19 PCR was negative. He was admitted to the medical ward for management of alcohol withdrawal and decompensated liver cirrhosis. He developed hypoxic respiratory failure within 24 hours of presentation. CT chest (Figure 1) showed multifocal ground glass opacities along with bilateral pleural effusions and consolidative airspace disease at bases. A repeat COVID PCR resulted positive. His respiratory failure progressively worsened over the next two weeks despite being treated with remdesivir, dexamethasone and empiric broad spectrum antibiotics. He was intubated and placed on mechanical ventilation. Repeat imaging (Figure 2) showed worsening diffuse ground glass opacities now with more predominant cystic changes. Bronchoscopy with broncho-alveolar lavage (BAL) was performed, PCR testing of the BAL sample detected Pneumocystis jirovecii. He was then started on Bactrim in conjunction with steroids for the high A-a gradient. HIV antibody was negative, CD4 lymphocyte count was low at 304/µL and CD8 counts were normal at 311/µL. The patient slowly started to improve and was successfully extubated after three weeks. However, he later on developed septic shock from candidemia and was placed on hospice care by family due to his poor functional status. DISCUSSION: As with many viral infections, patient's with COVID-19 have demonstrated considerable risk for developing concomitant bacterial and fungal infections. We speculate that lymphopenia with low absolute CD4 count, combined with the use of corticosteroids may play a role in susceptibility to opportunistic infections in otherwise immunocompetent hosts. CONCLUSIONS: When critically ill COVID patient's fail to improve and have persistent lymphopenia, co-infections should be considered and appropriately worked up. REFERENCE #1: A case of COVID-19 and Pneumoncystis jirovecii Coinfection. A. Menon et al. Am J Respir Crit Care Med. 2020 Jul REFERENCE #2: Invasive Fungal Disease Complicating Coronavirus Disease 2019: When It Rains, It Spores. M.Hoenigl. Clinical infectious diseases. 2020 September REFERENCE #3: Pneumocystis and Severe Acute Respiratory Syndrome Coronavirus 2 Coinfection: A Case Report and Review of an Emerging Diagnostic Dilemma. C. Rubiano. Open Forum Infectious Diseases. January 2021. DISCLOSURES: No relevant relationships by Ahmed Mahgoub, source=Web Response No relevant relationships by Joseph Meharg, source=Web Response No relevant relationships by Leandro Ramirez, source=Web Response No relevant relationships by Ajit Thota, source=Web Response

Multifocal pneumonia during a pandemic

Intro: In patients with advanced melanoma, immune checkpoint inhibitors (ICPIs) have demonstrated a substantial advantage when compared to cytotoxic chemotherapies. By augmenting the immune response with these medications, immune-related adverse effects can occur, and often include dermatological toxicity, hepatotoxicity, endocrinopathies, and much more rarely, pneumonitis. Case Presentation: An 80-year-old with past medical history of bronchial asthma, hypertension, 30 pack year smoking history discontinued over 2 decades ago, and metastatic melanoma (MM) on neoadjuvant nivolumab presented to our hospital in September of 2020 with 5 days of worsening shortness of breath. He denied any fever, cough, chest discomfort, palpitation, nausea, vomiting, epigastric/abdominal pain, leg pain, or palpitations. He had been diagnosed with stage IIIc MM in March of 2020 and underwent surgical resection of his left hallux and had completed 5 cycles of immunotherapy with Nivolumab. On admission, the patient had sinus tachycardia to 115, respiratory rate of 18 bpm, normotensive, oxygen saturation 80% on room air, improved to 94% on 4L nasal cannula. Laboratory studies were remarkable for acute kidney injury with Creatinine 1.7mg/dl (1.1 baseline), procalcitonin less than 0.05 ng/dl, elevated D-Dimer to 2.6mg/L, complete blood count, and comprehensive metabolic panel unremarkable. Viral serologies and sputum cultures resulted negative. Chest x-ray demonstrated extensive multifocal bilateral airspace. CTPA revealed severe diffuse bilateral airspace disease concerning for infectious, versus noninfectious pneumonia or a neoplastic process. He subsequently underwent bronchoscopy with BAL of RLL/LLL and RLL brush biopsy, which was negative for malignancy and infectious etiologies, including COVID-19. The patient was diagnosed with grade 3 nivolumab induced pneumonitis, and treated with high dose steroids, and empiric antibiotics. His condition improved, steroids were tapered, and he was discharged on day 13. Discussion: Pneumonitis is a rare, life-threatening complication in patients being treated with nivolumab. When severe symptoms are present and hospitalization and oxygen supplementation are indicated, treatment includes discontinuation of the immunotherapy agent, high dose steroids, prophylactic antibiotics, and additional immunosuppressive therapy if no response to During the midst of a global pandemic, findings of multifocal pneumonia are presumed to be SARS-CoV-2 until proven otherwise. Despite the burden many physicians have faced amid the COVID-19 pandemic, maintaining a broad differential until the diagnosis is made for accurate treatment.

A case of roasted pancreas from COVID-19 infection

INTRODUCTION: Although respiratory tract manifestations are most commonly reported symptoms in COVID-19, gastrointestinal system (esophagus, liver, gallbladder, pancreas and colon) is also affected by SARS-CoV-2, on the basis that they express angiotensin-converting enzyme 2 (ACE 2) receptor, the major receptor of SARS-CoV-2. We present a case of a patient with acute pancreatitis with COVID-19 infection that developed on day 6 of admission requiring a prolonged stay despite a normal respiratory status. CASE DESCRIPTION/METHODS: 68 year old male with a past medical history of hypertension, diabetes, CKD stage 3 who was a nursing home resident that tested positive for COVID-19 and was sent to ED for abnormal laboratory values. His admission labs were significant for Creatinine 6.6, BUN 77, CRP 158, Ferritin 920 and D-dimer 1.61. His creatinine improved to baseline with hydration. On day 6 of admission, he started complaining of nausea and vomiting. CT abdomen and pelvis and MRCP showed peripancreatic inflammatory changes consistent with acute pancreatitis. No biliary ductal dilatation or choledocholithiasis was seen. Lipase was 2035 along with an increase in WBC to 15.3 from 6.6. Abdominal exam was benign. His respiratory status was normal. He was managed with bowel rest and iv hydration. Gradually symptoms of nausea and vomiting improved. Diet was advanced gradually and the patient was discharged on day 19. DISCUSSION: The most common digestive symptoms reported in COVID-19 are lack of appetite, diarrhea, vomiting and abdominal pain. This was an example of a patient that had a delayed onset of GI symptoms including pancreatitis, while having normal respiratory function. Fluid hydration must be done judiciously in these patients, keeping in mind their respiratory status as it is suspected that these patients can be easily harmed by excessive fluid administration. (Figure Presented).