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SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Eosinophilia is the most commonly reported adverse event following administration of the Pfizer/BioNTech vaccine, accounting for 237 of 372 events (63.7%). Eosinophilic pneumonia has been described noted in 3 of all reported cases. CASE PRESENTATION: We present the case of a 73 year-old male presented to his PCP with a 3 week history of nonproductive cough and wheezing. He completed a 2-shot series of BNT162b2 mRNA (Pfizer/BioNTech) COVID vaccine 1 week prior to symptom onset. He had no history of respiratory symptoms, smoking, sick contacts, recent travel, chemical or biological exposures. On presentation, he was afebrile, tachycardic and required 3LPM supplemental oxygen to maintain peripheral oxygen saturation (SpO2) above 94%. Laboratory findings noted leukocytosis (13,200/mL) and eosinophilia at 5% (Absolute Eosinophil Count (AEC): 580 cells/L). Respiratory viral panel, procalcitonin, ESR and D-dimer were negative. Chest CT scan was unremarkable. He was treated with azithromycin, prednisone and inhaled bronchodilators with improvement in hypoxia. 2 weeks later, he reported intermittent dyspnea during a pulmonary clinic visit. Pulmonary function testing was normal (FEV1/FVC: 76%;FVC: 3.67L (90% predicted);FEV1: 2.80L (88% predicted). IgE level was normal and eosinophilia had resolved. 6 months after initial symptom onset, the patient received his third BNT162b2 mRNA vaccine dose. 2 weeks after vaccination, he presented to the ED with severe dyspnea, wheezing and cough with yellow sputum. He also noted a new itchy, erythematous bilateral forearm rash and painless oral ulcers. On exam, he was afebrile, tachypneic with SpO2 of 93% on 4LPM supplemental oxygen and audibly wheezing with a prolonged expiratory phase. Laboratory studies noted elevated creatinine and leukocytosis (23,100/mL) with marked eosinophilia (29.5 %, AEC: 6814 cells/L). Chest CT scan revealed a 2 cm rounded ground-glass opacity in the right upper lobe. (Figure 1.) Further workup revealed a weakly positive antihistone antibody (1:4 titer). IgE, ANA, ANCA, SS-A/B, anti-CCP, and complement levels were normal. Intravenous methylprednisolone treatment was initiated with rapid improvement in dyspnea, eosinophilia and renal function. A transbronchial biopsy (Figure 2.) of the RUL lung lesion revealed organizing pneumonia with mixed inflammatory infiltrate. Bronchoalveolar lavage analysis revealed elevated WBC (432 cells/L) with neutrophilic predominance (85%). Patient was discharged home on a prednisone taper with resolution of symptoms. DISCUSSION: Subsequent allergy work up did not indicate any apparent etiology of hypereosinophilia. Testing for strongyloides, coccidiosis and aspergillosis were also negative. A final diagnosis of BNT162b2 mRNA vaccine related pulmonary eosinophilia was made. CONCLUSIONS: Additional study is warranted into eosinophilic disease associated with the BNT162b2 mRNA vaccine. Reference #1: 1. United States Department of Health and Human Services (DHHS), Public Health Service (PHS), Centers for Disease Control (CDC) / Food and Drug Administration (FDA), Vaccine Adverse Event Reporting System (VAERS) 1990 - 03/11/2022, CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/vaers.html on Mar 11, 2022 1:18:37 PM DISCLOSURES: No relevant relationships by Matthew Haltom No relevant relationships by Nikky Keer No relevant relationships by Thekrayat Khader No relevant relationships by Muthiah Muthiah
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SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is an atypical cause of acute hypoxic respiratory failure in adults, however if not identified can prove to be fatal. It can all be a COVID19 mimic during the pandemic. AEP has several causes, such as inhalational drugs, infections and various pharmaceuticals. Often, patients will have an acute respiratory syndrome for less than one-month, pulmonary infiltrates on chest computed tomography (CT) or radiography (CXR), in addition to bronchoalveolar lavage (BAL) with more than 25% of eosinophils. CASE PRESENTATION: A 79 y/o man underwent an elective total knee replacement complicated by acute lower limb ischemia from an occluded bypass graft. He developed methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE) joint and soft tissue infection of the lower extremity. He was prescribed a 6-week course of Daptomycin. He presented about 3 weeks into treatment with shortness of breath. He was initially diagnosed with acute on chronic congestive heart failure (CHF) exacerbation and COVID negative. He was initially treated with diuretics. He developed acute renal failure requiring dialysis and acute hypoxic respiratory failure requiring intubation. CXR revealed bilateral lung infiltrates with BAL having 80% eosinophils, eosinophilia and urinalysis positive for eosinophils. Daptomycin was discontinued and he was started on systemic steroids for a two-week course. He was successfully extubated 5 days after diagnosis of AEP and was subsequently discharged to a rehabilitation facility on lifelong Doxycycline for MRSA prosthetic joint infection prophylaxis. DISCUSSION: AEP related to Daptomycin was first reported in 2007, in a patient that developed the condition after receiving treatment for endocarditis. Daptomycin caused an inflammatory reaction within the lungs, due to an accumulation of the drug within the pulmonary surfactant. Our case report patient met all components for AEP diagnosis, in addition to symptom onset being approximately 3 weeks into treatment. The ultimate treatment for AEP is to stop the reversible cause, if identifiable, along with glucocorticoids and symptomatic support. Prognosis for patients with AEP is excellent when diagnosis is prompt, and usually infiltrates are resolved within 1 month without long term adverse pulmonary effects. Our patient was discharged to an acute rehab facility without supplemental oxygen therapy and continues to improve from functional standpoint. This case a definite cause of AEP from Daptomycin presented as COVID19 pneumonia mimic. It highlights the importance of rapid diagnosis to prevent morbidity and mortality. CONCLUSIONS: The differential in a patient with acute hypoxic respiratory failure is numerous, especially during the COVID19 pandemic. During these challenging times, it is important to think of atypical causes, such as AEP to improve the patient's clinical status. Reference #1: Allen JN, Pacht ER, Gadek JE, Davis WB. Acute Eosinophilic Pneumonia as a Reversible Cause of Noninfectious Respiratory Failure. N Engl J Med. 1989;321:569-574 Reference #2: Hayes Jr. D, Anstead MI, Kuhn RJ. Eosinophilic pneumonia induced by daptomycin. J Infect. 2007;54(4):e211-213. Reference #3: Rachid M, Ahmad K, Saunders-Kurban M, Fatima A, Shah A, Nahhas A. Daptomycin-Induced Acute Eosinophilic Pneumonia: Late Onset and Quick Recovery. Case Reports in Pulmonology. 2017. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zinobia Khan No relevant relationships by Kaitlyn Mehern
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SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Daptomycin is an antibiotic that exerts its bactericidal effect by disrupting multiple aspects of bacterial cell membrane function. It has notable adverse effects including myopathy, rhabdomyolysis, eosinophilic pneumonitis, and anaphylactic hypersensitivity reactions. CASE PRESENTATION: A 46-year-old male with a history of type 2 diabetes presented with a 1-week history of dyspnea and productive cough. 2 weeks prior, he was started on vancomycin for MRSA osteomyelitis of the right foot, but was switched to daptomycin due to vancomycin induced nephrotoxicity. On presentation he was afebrile, tachycardic 100, hypertensive 183/109, tachypneic to 26, hypoxemic 84% on room air, which improved to 94% on nasal cannula. Chest exam noted coarse breath sounds in all fields and pitting edema of lower extremities were present. Labs showed leukocytosis of 15.2/L, Na of 132 mmol/L, and creatinine 3.20mg/dL (normal 1 month prior). COVID-19 testing was negative. Chest X-ray noted new bilateral asymmetric opacifications. Daptomycin was discontinued on day 1 of admission, he was started on IV diuretics and ceftaroline. Further study noted peripheral eosinophilia. Computed tomography of the chest showed bilateral centrally predominant ground-glass infiltrates with air bronchograms and subcarinal and paratracheal lymphadenopathy. On day 4, he underwent bronchoscopy with bronchoalveolar lavage. Cytology noted 4% eosinophil with 43% lymphocytes. Eventually, oxygen requirements and kidney function returned to baseline. He was discharged on ceftaroline for osteomyelitis DISCUSSION: Daptomycin-induced acute eosinophilic pneumonitis (AEP) often results in respiratory failure in the setting of exposure to doses of daptomycin >6mg/kg/day. It is characterized by the infiltration of pulmonary parenchyma with eosinophils and is often associated with peripheral eosinophilia. AEP has been associated with certain chemicals, non-steroidal anti-inflammatory agents, and antibiotics including daptomycin. Renal dysfunction is associated with an increased risk for developing AEP. The mechanism for daptomycin-induced lung injury is unknown but is believed to be related to daptomycin binding to pulmonary surfactant culminating in epithelial injury. Diagnostic criteria include recent daptomycin exposure, fever, dyspnea with hypoxemic respiratory failure, new infiltrates on chest radiography, BAL with > 25% eosinophils, and clinical improvement following daptomycin discontinuation. Our patient met four out of six criteria;we believe that BAL results were due to discontinuing daptomycin days before the procedure was performed. Sometimes stopping daptomycin is enough for recovery, however, steroids may be beneficial and were used in some of the cases reported in the literature CONCLUSIONS: Clinicians should consider AEP in a patient on Daptomycin presenting with respiratory failure, as timely discontinuation favors a good prognosis Reference #1: Uppal P, LaPlante KL, Gaitanis MM, Jankowich MD, Ward KE. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control. 2016;5:55. Published 2016 Dec 12. doi:10.1186/s13756-016-0158-8 Reference #2: Kumar S, Acosta-Sanchez I, Rajagopalan N. Daptomycin-induced Acute Eosinophilic Pneumonia. Cureus. 2018;10(6):e2899. Published 2018 Jun 30. doi:10.7759/cureus.2899 Reference #3: Bartal C, Sagy I, Barski L. Drug-induced eosinophilic pneumonia: A review of 196 case reports. Medicine (Baltimore). 2018;97(4):e9688. doi:10.1097/MD.0000000000009688 DISCLOSURES: No relevant relationships by Chika Winifred Akabusi No relevant relationships by Shazia Choudry No relevant relationships by Hector Ojeda-Martinez No relevant relationships by Mario Torres
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SESSION TITLE: Challenges in Asthma SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Dupilumab is one of the recently developed biological anti-asthma medications which is a human IgG4 monoclonal antibody. Dupliumab inhibits the biological effects of both IL-4 and IL-13. In 2018, Dupilumab was approved for treating moderate to severe asthma with an eosinophilic phenotype or with oral corticosteroid-dependent asthma. Transient, laboratory eosinophilia is a common side effect of Dupilumab, but clinical consequences are hardly ever reported. CASE PRESENTATION: We present a 66-year-old female patient with history of severe persistent asthma with an eosinophil's baseline of 1403 cells/mm3. She was started on Dupilumab a month prior to presenting to our hospital with shortness of breath, facial rash, recurrent fever and fatigue. Upon further investigations, patient was found to have severe peripheral eosinophilia (35%, absolute eosinophil count of 6100 cells/mm3), imaging studies that included CT scan of the chest showed patchy pulmonary consolidations, ground glass opacification and mediastinal lymphadenopathy. Non-invasive infectious work up including COVID-19 was negative. Then, patient underwent fiberoptic bronchoscopy with bronchoalveolar lavage (BAL), transbronchial biopsy, ultrasound guided lymph node fine needle aspiration and endobronchial biopsy (for diffuse endobronchial nodular lesions). Infectious work up from the BAL was negative but the BAL cytology showed eosinophilic alveolitis (31%). Histopathologic examination of the above biopsies showed significant interstitial inflammation with predominant eosinophils. Subsequently, Dupilumab was discontinued, and patient was started on prednisone 60 mg daily with remarkable eosinophils count reduction from a peak of 11,232 to 84 cells/mm3 along with significant improvement in her symptoms. CT chest 8 weeks later showed near complete resolution of pulmonary opacities. DISCUSSION: Dupilumab is an effective treatment for moderate to severe persistent asthma, by lowering rates of asthma exacerbation, as well as better lung function and asthma control. However, it has been reported that dupilumab can rarely cause a state of significant hyper-eosinophilia, which can rarely lead to complications such as eosinophilic pneumonia. Our patient was treated with dupilumab for her severe persistent asthma and after an intensive work up, we reached a diagnosis of severe Dupilumab induced hyper–eosinophilia leading to eosinophilic pneumonia and skin rash. CONCLUSIONS: We believe that this unique report is an important add to the reports in literature as it describes this rare entity in the differential diagnosis. Monitoring serum eosinophils count closely for the first few weeks of treatment with dupilumab should be considered, particularly for patients with unusual high level of eosinophils at baseline, to prevent severe complications. We believe that more studies are needed to better describe dupilumab induced severe hyper–eosinophilia Reference #1: Pelaia, Corrado, et al. "Dupilumab for the treatment of asthma.” Expert opinion on biological therapy 17.12 (2017): 1565-1572 Reference #2: Castro, Mario, et al. "Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma.” New England Journal of Medicine 378.26 (2018): 2486-2496 Reference #3: Menzella, Francesco, et al. "A case of chronic eosinophilic pneumonia in a patient treated with dupilumab.” Therapeutics and clinical risk management 15 (2019): 869 DISCLOSURES: No relevant relationships by Hamza Alsaid No relevant relationships by Mark Cowan No relevant relationships by Kamel Gharaibeh no disclosure on file for Kathryn Robinett;Consultant relationship with Medtronic Please note: 1 year Added 04/04/2022 by Ashutosh Sachdeva, value=Consulting fee Consultant relationship with Intuitive Inc Please note: Intermittent Added 04/04/2022 by Ashutosh Sachdeva, value=Consulting fee Consultant relationship with MErit Please note: 2 years Added 04/04/2022 by Ashutosh Sa hdeva, value=Consulting fee Scientific Medical Advisor relationship with AMBU Please note: 6 months Added 04/04/2022 by Ashutosh Sachdeva, value=Consulting fee
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SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We present two cases of symptomatic post-COVID eosinophilic pneumonia responsive to steroids. CASE PRESENTATION: Case 1: A 73-year-old gentleman with underlying asymptomatic rheumatoid arthritis (RA), was admitted with COVID pneumonia for which he received tocilizumab, remdesivir, and 12 days of dexamethasone. His course was complicated by MRSA pneumonia and bacteremia, so was discharged on IV Vancomycin. Six days post discharge, he redeveloped respiratory distress. Labs showed a WBC 18,000 and proBNP 2828. A chest CT revealed bilateral ground-glass opacities, worsening right upper lung airspace disease and bilateral pleural effusions. Despite receiving Furosemide, Vancomycin, and Ceftazidime, he required high-flow nasal cannula oxygenation (HFNC). Bronchoscopy demonstrated thick right bronchial secretions. BAL fluid revealed 7% eosinophils and grew MRSA. Case 2: A 70-year-old gentleman with extensive smoking history, emphysema, psoriasis, Guillain-Barré syndrome and a recent hospitalization for COVID pneumonia was discharged on a steroid taper. He returned 23 days post discharge in respiratory distress requiring HFNC, 5 days after discontinuing steroids. The chest CT revealed worsening fibrosis and bronchiectasis. Intravenous Levofloxacin and Vancomycin resulted in no clinical improvement. Bronchoscopy showed inflamed bronchi with secretions and BAL analysis revealed 6% eosinophils. For both patients, BAL was negative for fungi and PJP and CTA ruled out PE. Both patients were started on Prednisone with a prolonged taper. They improved clinically with decreased oxygen requirements to 4L nasal cannula and dramatic decrease in subjective dyspnea within 48 hours of starting steroids. DISCUSSION: The differential diagnosis for the clinical deterioration and worsening radiographs in both patients includes bacterial/fungal superinfection, PE, post-COVID-ILD and eosinophilic pneumonia. For the first patient, his RA was inactive. His BAL was positive for MRSA but did not improve until steroids were initiated. Neither of the patients were stable for VATS biopsy. Eosinophilic pneumonia is defined as pulmonary infiltrates with peripheral blood eosinophilia =500/ml, BAL eosinophils > 5% or eosinophilic infiltration on lung biopsy [1]. Both of our patients had >5% BAL eosinophils. Potentially, prolonged COVID-ILD stimulates T-Helper-2 cells, causing the release of IL-4/5/13 with recruitment of eosinophils. Studies report post-COVID-ILD biopsies show organizing pneumonia and fibrosis but have not yet been associated with eosinophilia. In both patients, we observed eosinophilia on BAL. It can be hypothesized that a delayed inflammatory response mediated by eosinophils play a role. CONCLUSIONS: Pulmonary eosinophilic pneumonia is a complication of post-COVID-ILD and can be successfully managed with steroids. Reference #1: De Giacomi F, Vassallo R, Yi ES, Ryu JH. Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management. Am J Respir Crit Care Med. 2018 Mar 15;197(6):728-736. doi: 10.1164/rccm.201710-1967CI. PMID: 29206477. DISCLOSURES: No relevant relationships by farrukh ahmad No relevant relationships by Deborah Markowitz No relevant relationships by Dhiraj Shah No relevant relationships by Garima Singh No relevant relationships by Aakriti Soni
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SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is a rare cause of acute respiratory failure. AEP has been reported in association with smoking, drugs, and infections. Very few reports of AEP accompanied by Coronavirus disease 2019 (COVID-19) exist in current literature. Here we describe a case of AEP in association with COVID-19. CASE PRESENTATION: A 58-year-old female, non-smoker, with no medical history presented to the emergency room with fever, cough, and shortness of breath for 10 days. She received two doses of vaccine against COVID-19. Her vital signs were notable for oxygen saturation of 56% on room air and respiratory rate of 35 breaths per minute. Her physical exam was notable for distress, tachypnea, and diffuse rhonchi on lung auscultation. Her chest x-ray showed multifocal bilateral peripheral and basilar airspace opacities. A respiratory pathogen panel detected SARS-CoV-2. She was admitted to the medical intensive care unit and suffered worsening acute hypoxemic respiratory failure requiring intubation. She was treated with dexamethasone 6mg for a 10-day course with gradually decreasing oxygen requirements, and she underwent tracheostomy on hospital day 11. Despite this, she continued to deteriorate clinically. Review of laboratory results showed significant eosinophilia of 15.6% on her complete blood count upon withdrawal of steroids. A CTA scan of the chest showed no evidence of pulmonary embolic disease and demonstrated bilateral extensive dense consolidations. A diagnosis of acute eosinophilic pneumonia was suspected. Fungal cultures and stool ova and parasites were negative. She was started on methylprednisolone 1mg/kg and a bronchoscopy was performed with bronchioalveolar lavage (BAL) samples showing 4% eosinophils despite high dose steroid therapy. She was continued on high dose steroids with rapid improvement in her oxygen requirements. DISCUSSION: AEP is an acute febrile illness that can lead to acute respiratory failure. The presence of dense infiltrates in the early stages of COVID-19 and elevated inflammatory markers and reticence to perform bronchoscopy can delay making a diagnosis of AEP in a patient diagnosed with COVID19. The diagnostic hallmark of AEP is the detection of > 25% eosinophils in BAL samples. While this patient did not meet that criterion, she received high dose corticosteroids which may have suppressed pulmonary eosinophilia. A high index of suspicion for AEP should be maintained in patients with COVID-19 with evidence of eosinophilia and clinical deterioration, given that AEP improves rapidly with the appropriate treatment. CONCLUSIONS: AEP is an uncommon cause of respiratory failure that should be considered in patients with unexplained worsening respiratory status and evidence of eosinophilia. Bronchoscopy with bronchoalveolar lavage should be considered early, even in the setting of COVID-19 in patients without risk factors who develop severe disease. Reference #1: De Giacomi F, Vassallo R, Yi ES, Ryu JH. Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management. Am J Respir Crit Care Med. 2018;197(6):728-736. doi:10.1164/rccm.201710-1967CI Reference #2: Murao K, Saito A, Kuronuma K, Fujiya Y, Takahashi S, Chiba H. Acute eosinophilic pneumonia accompanied with COVID-19: a case report. Respirol Case Rep. 2020;8(9): e00683. Published 2020 Nov 16. doi:10.1002/rcr2.683 DISCLOSURES: No relevant relationships by Hadya Elshakh No relevant relationships by Christina Jee Ah Rhee no disclosure on file for Lourdes Sanso;
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CASE: A 35-year-old female with history of pulmonary coccidiomycosis s/p treatment 15 years ago, ex-smoker who quit 8 years ago, unvaccinated for COVID-19 presented with two weeks of progressively worsening shortness of breath, fever, chills, generalized body aches, sore throat with hoarseness of voice, nonproductive cough, wheezing and midsternal chest pain. Denied sick contacts, recent travel, allergies or bird contact. On presentation, vitals were significant for hypoxia with SpO2 84% requiring 2L of nasal canula, sinus tachycardia to 109, tachypneic in 30s. Physical exam showed stridor and bilateral diffuse expiratory wheezing. Stridor improved with racemic epinephrine and dexamethasone 10mg IV. CBC, CMP, Procalcitonin, BNP, COVID-19 and Respiratory PCR were negative, while coccidioidomycosis antibody was positive. UDS was positive for methamphetamine. Chest X-ray showed features of atypical pneumonitis. CT Chest showed similar findings and was negative for pulmonary embolism. She was managed symptomatically with albuterol inhaler. Respiratory symptoms improved during hospitalization without any further interventions. IMPACT/DISCUSSION: Methamphetamine can cause toxic lung parenchyma injury irrespective of frequency of use. With recent increase in use of methamphetamine, paucity of literature and unclear mechanism in lung injury, it is important for physicians to be aware of methamphetamine associated lung injury as a differential diagnosis of acute/subacute respiratory distress with the risk factors of illicit drug use in the era of COVID pandemic. According to National Survey on Drug Use and Health (NSDUH) in 2018, 1.6 million people (age > 26 years) used methamphetamine in one year which is 0.5% more than 2016-2017. Crystalline methamphetamine is a widely used inhaled stimulant with few reported cases of acute respiratory distress syndrome, eosinophilic pneumonia, pneumonitis, and diffuse alveolar hemorrhage. Even though the mechanism of injury is unclear in human beings, toxicity was studied in animals. Chronic methamphetamine use causes thickened alveolar walls and reduced alveolar sacs by oxidative stress and by increased free radical formation. Patients often present with non-specific symptoms including cough, shortness of breath, sore throat or chest pain. The temporal relation of symptomatology with methamphetamine use and exclusion of infectious and other pulmonary etiology based on labs and radiological findings are crucial in establishing the diagnosis. Early diagnosis, symptomatic treatment and cessation of substance use are core management. CONCLUSION: We discussed a case of methamphetamine-induced pneumonitis, who presented with upper and lower respiratory symptoms that resolved dramatically with the early diagnosis and supportive care. We recommend considering methamphetamine-induced lung injury as a differential diagnosis in patients with risk factors of illicit drug use, especially in the era of the COVID-19 pandemic for early diagnosis and appropriate management.
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Introduction: Daptomycin is an antibiotic approved by FDA in 2003 with an excellent coverage for Gram positive cocci including methicillin resistant Staph. Aureus and vancomycin resistant Enterococci.Acute Eosinophilic Pneumonia(AEP) is a rare but potentially fatal complication of daptomycin is characterized by febrile illness, Hypoxemia,Diffuse Bilateral pulmonary infiltrates and BAL with >25% eosinophils. Case Report: 79 Y/O M with the CKD stage 4 and hypertension presented to the hospital with fever, dry cough and worsening shortness of breath after a recent hospital admission for MRSA bacteremia.Patient was admitted 1 week before presentation for symptoms of pyelonephritis and was found to have MRSA bacteremia for which he was discharged on IV daptomycin for 6 weeks. On admission,patient was febrile with hypoxic to 81%. Labs did show leukocytosis with mild peripheral eosinophilia.PCR for respiratory viruses including covid was negative.Chest X ray was done, which was consistent with multifocal Pneumonia which was followed by Chest CT scan which demonstrated new bilateral dense ground-glass and consolidative opacities.Given concerns for aspiration pneumonia, fungal infections or eosinophilic pneumonitis,pulmonology was consulted for possible bronchoscopy.Bronchoscopy with BAL was done the next day.BAL revealed a WBC of 260/μL with 45% eosinophilic predominance. Given the bronchoscopy results,his symptoms were attributed to Daptomycin related eosinophilic pneumonia.Patient was started on 40mg oral prednisone for a total of 4 weeks with rapid taper.Over the hospital course, his symptoms completely resolved. Discussion: The prosed mechanism involves presentation of drug or drug-hapten combination by the macrophages to the T helper cell results in interleukin-5 release which along with macrophage released eotaxin, results in eosinophilic migration to lungs.The criteria for to diagnose AEP due to daptomycin consist of 4 components which includes febrile illness,hypoxemia,diffuse bilateral pulmonary infiltrates and BAL with >25% eosinophils.Peripheral eosinophilia may not be present in all cases. It is also possible that daptomycin, a renally excreted drug, persists in the lungs of patients with renal dysfunction as seen in our patient and as such may lead to higher incidence of daptomycin induced AEP.In most cases, a short course of steroids(2-3 weeks)is sufficient for complete resolution of symptoms. Conclusion: Daptomycin induced AEP is increasingly seen in patients with high doses of drug and underlying renal dysfunction,and not related to therapy duration as it can occur as early as day 3 of treatment and as late as week 6 of treatment course. Bronchoscopy with BAL should be considered in all cases suspected. (Figure Presented).
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Cocaine use has a significant public health impact, causing over 1.2 million ER visits annually. Cocaine can cause a wide range of pulmonary pathology, including diffuse alveolar hemorrhage (“Crack Lung”), barotrauma, bronchiectasis, granulomatous disease, and pulmonary vascular disease. Acute eosinophilic pneumonia (AEP) is a rare and potentially life-threatening complication of cocaine use that can be successfully treated if identified. We describe a case of persistent fevers, hypoxemia, and air space opacities due to AEP related to cocaine use.A 34-year-old male with a history of polysubstance abuse was found unresponsive, apneic, and surrounded by vomitus at a party, where he had smoked marijuana and cocaine and injected heroin. Upon hospital arrival, he was hypotensive and severely hypoxic and was intubated. He had severe rhabdomyolysis, lactic acidosis, acute kidney injury, and acute liver injury. His chest radiograph demonstrated diffuse bilateral alveolar infiltrates. COVID-19 was ruled out. Sputum cultures grew Klebsiella and E. Coli;Streptococcus Pneumoniae urine antigen was positive. He received IV fluids, vasopressors, and broad spectrum antibiotics for septic shock and aspiration pneumonia in the setting of drug overdose. His septic shock and hypoxemia improved, allowing tracheostomy and gastrostomy to be performed. Despite prolonged courses of antibiotics, he had persistent fevers, worsening infiltrates on chest radiograph, and persistent hypoxemia. CT imaging demonstrated diffuse, bilateral ground glass opacities and consolidations, with reticulation and interlobular septal thickening. Viral, bacterial, and fungal cultures collected via bronchoscopy were negative, however, cell count revealed 315 WBC / mm3, with 27% eosinophils. He was started on methylprednisolone 80mg IV every eight hours and had resolution of fevers and improvement in oxygenation and infiltrates. 1 month after discharge, he was decannulated and did not require supplemental oxygen. DiscussionThis case highlights an important aspect of assessing fever in the ICU despite broad spectrum antibiotics in patient with drug overdose. In the above , bronchoscopy unmasked an eosinophilic pneumonia allowing a rapid transition to trach collar and prevention of progression to pulmonary fibrosis. (Figure Presented).
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Introduction: The known etiologies of acute eosinophilic pneumonia (AEP) have grown recently, culminating in the creation of the term drug-induced AEP 3. One of the newer causes of druginduced AEP is Daptomycin, which has grown in popularity for its use in treating methicillin-resistant staph aureus (MRSA) infections. As a result, the Food Drug Administration created the following criteria to diagnosis Daptomycin-induced AEP: 1) concurrent exposure to Daptomycin, 2) fever, 3) dyspnea with increased oxygen requirement or requiring mechanical ventilation, 4) new infiltrates on imaging, 5) bronchoalveolar lavage (BAL) with >25% eosinophils and 6) clinical improvement following Daptomycin withdrawal. Given this statement, we present a case of Daptomycin-induced AEP. Case Presentation: A 45-year old female presented to the ER with a complaint of shortness of breath for four days. She had recently been diagnosed with Covid-19 with concomitant globicatella bacteremia and discharged 17 days ago with home oxygen (requiring 3L) and to complete 2 weeks of IV Daptomycin. In the ER, a CT Angio Chest was obtained showing bilateral airspace opacities with no evidence of thromboembolism. She was also noted to be saturating at 92% while on 15L Venturi-mask. The patient was started on broad-spectrum antibiotics and cultures were obtained. Her condition worsened and a bronchoscopy with bronchoalveolar lavage (BAL) was performed, however there was inadequate specimen to run cytology. Due to worsening status despite antibiotics, the patient was started on methylprednisolone 80 mg three times a day. After initiation of steroids, the patient's respiratory status returned to baseline and repeat imaging showed improvements of opacities. Complete infectious and autoimmune workups were complete ruling out other etiologies. The patient was discharged with a steroid taper and repeat CT imaging ordered, but never done. Discussion: Though we were unable to obtain a BAL specimen, we are confident of our diagnosis. Our patient not only had a known inciting factor, but also had resolution of symptoms with withdrawal of Daptomycin and initiation of steroids. Our case study highlights two important points about the disease. First, AEP should be on the differential for patients with a complaint of shortness of breath with a known inciting factor. Secondly, it should be noted that while our patient was unable to meet all criteria created by the FDA, this should not rule out the diagnosis. It is important to be proactive in treatment if clinical suspicion is high.
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Introduction: Eosinophilic lung diseases (ELD) are a group of conditions that are characterized by pulmonary eosinophilia. Acute eosinophilic pneumonia (AEP) may be idiopathic in many patients, however, changes in smoking habits and drug use can trigger the disease. Case: A 24-year-old female presented to the emergency room with dyspnea for 1 week. She also had productive cough, fever of 38.7C (101.7F) and chest tightness. Although she had been vaping for the past year she switched to heavy cigar smoking 3 weeks prior to admission. Vital signs on presentation were blood pressure 127/72 mmHg, heart rate 122 beats/min, respiratory rate 28/min, oral temperature 37.4°C (99.4°F) and oxygen saturation 88% on room air. Lung exam revealed mild rhonchi. Blood work showed leukocytosis 29.13 x 103/mcL (N:4-12 x 103/mcL) with neutrophilia 26.6 x 103/mcL (N: 1.60-7.71 x 103/mcL), mild lymphopenia 1.07 x 103/mcL and a normal metabolic panel. SARS-CoV-2 PCR was negative 3 times. CT chest revealed consolidative opacities involving the right lung more than left and small bilateral pleural effusions. The patient was provided supplemental oxygen via nasal cannula and started on ceftriaxone and azithromycin for community acquired pneumonia. She rapidly declined requiring endotracheal intubation for invasive mechanical ventilation. Antibiotic coverage was broadened to vancomycin, piperacillin-tazobactam, doxycycline and levofloxacin. Further negative work up included viral pathogen panel, respiratory cultures, HIV screening, fungal antibodies, urine pneumococcal and legionella antigens, ANA and ANCA, and serum next-generation sequencing. She developed peripheral eosinophilia on hospital day 2 which peaked at 3.29 x 103/mcL (N: 0.0-0.40 x 103/mcL) on day 6. Bronchoscopy revealed no organisms on gram stain and there was no alveolar hemorrhage. Cell count from bronchoalveolar lavage (BAL) was not available. She was started on methylprednisone 60 mg every 6 hours IV for presumed AEP with marked improvement over the next 48 hours. She was discharged home shortly thereafter on an 8 week steroid taper. Discussion: AEP has been associated with new onset or resumption of cigarette smoking. Our patient had an acute onset febrile illness rapidly progressing to hypoxic respiratory failure, initial peripheral neutrophilic leukocytosis with subsequent peripheral eosinophilia, patchy bilateral ground glass and consolidative opacities with small pleural effusions, and immediate response to steroids. Prognosis is excellent if the disease is recognized and treated promptly. Conclusion: AEP is a rare cause of acute respiratory failure that can be confidently diagnosed with careful history, a constellation of symptoms and signs, and BAL eosinophilia (>20-25%).
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Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a medium and small vessel vasculitis. Discussion: A 58-years man was admitted to the Emergency Department in January 2022 for myalgia and weakness of lower limbs in recent COVID-19 infection. He had a clinical history of allergic asthma and eosinophilic pneumonia (ANCA negative) diagnosed as secondary to sensitization work-related in 2001. Blood test showed a severe hypereosinophilia (absolute eosinophil count: 9875/microL) and elevated creatine kinase (CK: 7555 U/L). He was hospitalized in HUB COVID. During hospitalization reported paraesthesia of upper and lower limbs and fever;blood test showed elevation of inflammation markers. Autoimmune screening showed a antineutrophil cytoplasmic antibodies positivity (ANCA anti-MPO 178UI/mL). A sinus CT showed nasal polyposis. A neurological evaluation and electromyography were performed with the evidence of polyneuropathy. Muscle biopsy showed eosinophil-associated vascular occlusion and eosinophilassociated tissue damage. The investigation excluded renal, cardiac, pulmonary and gastro-intestinal involvement. A steroid therapy (Prednisone 1 mg/kg/die) was started with clinical improvement. Conclusions: EGPA is a multisystemic disorder, typically suspected based on a combination of clinical findings, such as asthma, nasal and sinus symptoms, peripheral neuropathy, and eosinophilia ≥1500/microL. ANCA antibodies are positive in around 40% of patients and diagnosis can often be challenging and delayed.
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Introduction: Evaluation of the effectiveness of diagnostic computed tomography of the chest in differentiating between coronavirus 2019 (COVID-19) ground glass opacities and other reasons of ground glass opacities (GGO) not related to COVID-19. Place and Duration: In the department of Radiology, Miangul Abdul Haq Jahenzeb Kidney Hospital Swat for six-months duration from March 2021 to August 2021. Methods: 90 total covid-19 confirmed patients by RT-PCR having GGO (53 males and 37 females, with 47.20 ± 15.10 years mean age) and 110 patients (63 males and 47 males) who were confirmed GGO on chest CT but not due to Covid-19 were selected for the study. The experienced radiologists studied all chest CT scans after removing all descriptive information from the images. They tested negative or positive for COVID-19 and noted other features of CT of the lungs, including laterality, distribution pattern and lobe involvement. The laboratory results and clinical data were documented. Results: This study consisted of 90 COVID19 patients and 100 non-COVID-19 with ground glass opacities on CT chest. In terms of age;no statistically significant alteration was noted amid the 2 groups (p-value = 0.129). Non-COVID-19 cases with GGO;6 patients have atypical bacterial pneumonia, 42 patients have GGO after viral pneumonia, 14 patients have interstitial pneumonia, 5 patients have PJP, eosinophilic pneumonia in 3 patients, 9 patients have hypersensitivity pneumonia, 6 patients have drug-induced lung injury, 5 patients have pulmonary alveolar hemorrhage and pulmonary edema in 11 patients (cardiogenic and noncardiogenic). Conclusion: Chest CT is rational for distinguishing ground glass opacities form COVID-19 and non-COVID-19 reasons, with less specificity for distinguishing COVID-19 from viral pneumonia and intermediate specificity for distinguishing COVID-19 from other reasons of ground glass opacities.
ABSTRACT
Case report-IntroductionCOVID-19 pandemic affected medical practise significantly and caused difficulties in accessing necessary investigations at the appropriate time. As of March 2020, NHS England issued measures to redirect staffs and resources in preparation for the rising cases of coronavirus. As a result of this, non-urgent tests/treatments were put on hold. We present a new case of EGPA admitted to our district general hospital during the COVID-19 pandemic to highlight the challenges faced. The diagnosis was reached based on clinical judgment in the absence of some confirmatory tests as well as the decision of starting immunosuppressant treatment during the pandemic.Case report-Case descriptionA 41-years-old lady with a background of well-controlled asthma, presented with five days history of paraesthesia and swelling in both legs. She also reported mild pleuritic chest pain, which radiated to her left arm. Physical examination revealed left foot drop. She had reduced sensation on the L5-S1 dermatomal distribution with absent ankle reflex and reduced knee reflex of her left leg. Her left calf was swollen and tender. The rest of her examination was unremarkable.Baseline blood revealed raised WCC of 19.3 with significant eosinophilia (10). CRP and ESR were 135 mg/L and 48mm/hr, respectively. Electrocardiogram showed new T-wave inversion in the anterolateral leads with significantly raised troponin levels. There was ground glass appearance in both lungs, keeping with suspected COVID-19 and no evidence of pulmonary embolus was found on CTPA. MRI spine confirmed no evidence of cauda equina compression. Deep vein thrombosis was also excluded with US doppler.She was treated as myocarditis and pneumonia secondary to probable COVID-19 infection. Echocardiogram revealed severe LVSD (EF < 35%) with no LV hypertrophy. Three days later, she became acutely breathless and required high flow oxygen. New bilateral basal crackles were found on auscultation. Her antibiotic regimes were escalated to intravenous infusion.A revised CT report suggested the findings may correlate with eosinophilic pneumonia or EGPA. MRI of lower legs proved muscular oedema in bilaterally, which was suggestive of myositis with fasciitis. There was no significant change on the thigh musculature. CK level was slightly elevated (403 IU/L). Urinalysis was positive for blood (3+). Given the strong clinical suspicion of EPGA, a decision to start high dose steroid therapy was made, despite the pending immunology results. After the third dose of the methylprednisolone, pulsed cyclophosphamide was started along with high dose oral prednisolone. The patient was discharged home following significant clinical improvement.Case report-DiscussionThis patient has fulfilled 4 out of 6 criteria of ACR 1990 classification for EGPA, which are eosinophilia, bronchial asthma, mononeuritis multiplex and pulmonary infiltrates on radiological images. However, in the context of current pandemic, these changes on chest CT findings could also be suggestive of COVID-19 pneumonitis.At present, there is no reliable test for COVID-19. Even though RT-PCR testing has been the gold standard for diagnosing suspected cases, the clinical sensitivity and specificity of these tests are variable. A negative test may not rule out infection. In our case, the patient was tested twice at separate times to rule out the possibility of COVID-19 infection.During the pandemic, there is extremely limited access to some confirmatory tests. We were not able to perform nerve conduction studies on our patient as the service was suspended, instead, we sought neurologist's review to confirm the mononeuritis multiplex. We also sought advice from haematologist to rule out the possibility of hyper-eosinophilic syndrome as bone marrow biopsy was unavailable. The screen for atypical pneumonia, aspergillosis, viruses, and tuberculosis were negative. By excluding the alternative diagnoses related to eosinophilia, we concluded that this was likely to be a case of first presentation EGPA.Our next obstacle was intr ducing remission-induction regimens during COVID-19 pandemic. BSR does not recommend starting new treatment due to the increased risk of infection. We had to weigh out the benefits and risks of initiating immunosuppression. Our patient was made aware of the potential risks involved which include severe infection with COVID-19. She was also shifted to a side room with strict infection control precautions and PCP prophylaxis prescribed before starting pulsed methylprednisolone and cyclophosphamide. Fortunately, her neurological symptoms resolved after three days of steroid therapy. Eosinophils count dropped within 1 day to zero, after the first dose of IV methylprednisolone.Case report-Key learning pointsDespite the rising cases of COVID-19 infection, it is essential to keep an open mind and consider alternative diagnosis if a patient did not respond to conventional treatment. As EGPA and COVID-19 pneumonia share similar clinical and radiological presentation, clinical judgement is essential when making the diagnosis as the treatments for both conditions are vastly different. When EGPA is suspected, a multidisciplinary team should be involved in the evaluation of different organ involvements as well as ruling out other causes of eosinophilia. The role of specialists' inputs is extremely important in reaching the diagnosis, especially with limited access to the usual confirmatory tests due to reduced services during the pandemic.In addition, when there is an increased risk of infection such as during the COVID-19 pandemic, it is essential to weigh up the benefits and risks of commencing immunosuppressant treatment carefully. Patients need to be involved in the decision-making process as well as take precautions to minimise the risk of infection. The decision to start remission induction regimes should not be delayed if there is a presence of life or organ threatening disease manifestations in EGPA patients. Our patient has had a life-threatening disease because of multi-organ involvements (cardiac, pulmonary, and neurological systems).