MUCORMYCOSIS-RELATED CENTRAL AIRWAY OBSTRUCTION MANAGED BY CUSTOM 3-D PRINTED AIRWAY STENT

SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and Glue SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: While rarely reported, there has been an increasing incidence of tracheobronchial mucormycosis in patients infected with COVID-19, especially when associated with uncontrolled diabetes mellitus. We describe a complex case of central airway obstruction due to mucormycosis that was managed with a custom 3D printed silicone Y-stent. CASE PRESENTATION: A 54-year-old woman with diabetes, prior COVID-19 infection, presented with dyspnea and cough. She underwent a CT chest which showed left lower lobe atelectasis and left main stem bronchus (LMSB) obstruction. Bronchoscopy showed a large exophytic mass extruding from the LMSB. There was necrosis leading to a fistula between the left and right mainstem bronchi distal to the carina. Pathology of the mass showed necrotic bronchial mucosa and cartilage with invasive mucormycosis. She underwent placement of a 10X40mm covered stent in LMSB. However, due to granulation tissue and recurrent mucus plugging, she needed a bronchoscopy every 3-4 weeks and multiple stent revisions. Despite these interventions, her respiratory symptoms did not change significantly. Ultimately, her airway was also complicated by tracheobronchomalacia (TBM) of the right main stem bronchus (RMSB). Subsequently a custom printed 3D silicone Y-stent from VisionAir was placed that allowed successful recanalization of LMSB and management of the TBM of RMSB simultaneously. The patient reported significant improvement in respiratory symptoms. She was maintained on Isavuconazole for mucormycosis suppression therapy DISCUSSION: Mucormycosis infections commonly occur in the pulmonary or rhino-cerebral region with high morbidity and mortality. Mucor can involve the major airways as well as rarely invade the tracheal cartilage leading to TBM. There is often granulation tissue, gray-white mucoid material, with edematous and necrotic airway. This can be associated with complex central airway obstruction. While the covered tracheobronchial stent (Bonastent) allowed us to recanalize LMSB, it was complicated by obstructive granulation tissue formation and mucous plugging requiring frequent stent revision to maintain stent patency. At the same time, the TBM in the right airway was contributing significantly to dyspnea and cough. While a standard silicon Y stent was considered for the management of bilateral mainstem bronchi disease, due to the significant distortion in airway anatomy this was not an ideal option. By using the VisionAir stent, we placed a custom stent that would best fit her airway anatomy. The patient had sustained improvement in her symptoms for several months following the procedure. CONCLUSIONS: This is the first case report of a custom designed and 3D printed stent for the treatment of benign central airway obstruction caused by tracheobronchial mucormycosis. Custom stents are a promising tool to individualize and tailor intervention for patients with complex airway anatomy. Reference #1: Tracheal Mucormycosis Pneumonia: A Rare Clinical Presentation. Satyawati Mohindra, Bhumika Gupta, Karan Gupta and Amanjit Bal. Respiratory Care November 2014, 59 (11) e178-e181 Reference #2: Keshishyan S, DeLorenzo L, Hammoud K, Avagyan A, Assallum H, Harris K. Infections causing central airway obstruction: role of bronchoscopy in diagnosis and management. J Thorac Dis. 2017;9(6):1707-1724. doi:10.21037/jtd.2017.06.31 Reference #3: Leon CA, Inaty H, Urbas A, Grafmeyer K, Machuzak M, Sethi S, Gildea T. Early outcomes with 3D printing and airway stents. CHEST 2019 annual meeting s. DISCLOSURES: No relevant relationships by Sisir Akkineni No relevant relationships by Kelly Daymude No relevant relationships by Wissam Jaber No relevant relationships by Abesh Niroula

LIFE CYCLE OF A COVID-19-INDUCED LUNG CYST

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: COVID-19 has affected over 200 million people worldwide. Clinicians continue to observe unusual manifestations of this disease. In an attempt to improve our understanding of COVID-19 pneumonia, we present the details of one patient who developed large bilateral pulmonary cysts. CASE PRESENTATION: A 40-year-old woman with no known medical problems presented with the chief complaint of fever, nausea, vomiting, generalized weakness followed by difficulty breathing that developed over a few days. Her vital signs on admission included temperature 98.4° F, heart rate 104 beats/minute, respiratory rate 48 breaths/minute, O2 saturation 88 percent on 15 liters of oxygen through a non-rebreather mask, and Body Mass Index 42 kg/m2. The patient tested positive for COVID-19. Computed tomography (CT) of the chest to rule out a pulmonary embolism showed bilateral extensive ground-glass opacities and reticular and nodular opacities. She was intubated for acute hypoxic respiratory failure. Twenty days into the hospital admission, she was noted to have a bulla in the right lower lobe. A repeat CT chest on day 45 revealed an increase in the number and size of cysts bilaterally. Patient was discharged to rehab and later readmitted for worsening respiratory status. This time she tested positive for human metapneumovirus. A CT chest showed increase in the size of the right sided lung cysts;the left sided lung cysts had resolved. DISCUSSION: The first COVID-19 related pulmonary cystic lesions were reported in May 2020(1). Since then, several reports have now established a relationship between an infection and cyst formation. The most common distribution is peripheral in the lower lobes. The pathogenesis remains uncertain, but several mechanisms have been proposed. Microthrombi in the pulmonary circulation could lead to ischemia and subsequent remodeling of interstitial matrix and bronchial obstruction with distal hyperinflation due to check valve mechanism. (1,2). Hamad et al. propose that pneumatoceles are formed by air leaked in to the interstitium which causes stripping and separation of a thin layer of lung parenchyma with further injury to the small blood vessels and bronchioles. The rate of barotrauma in non-COVID-19 related ARDS is 0.5%;the rate in COVID-19 ARDS is 15% (3). This suggests a close relation between COVID-19 pneumonia and subsequent development of pulmonary cysts. Our patient had no preexisting pulmonary disease and was noted to have pulmonary cysts after being on mechanical ventilation for almost 2 weeks. The patient later contracted the human metapneumovirus infection and CT showed that the right-sided lung cysts had become bigger in size. However, the left-sided cysts which had a maximum diameter of 4.8 cm had resolved. CONCLUSIONS: We need to follow patients with COVID 19 induced lung cysts clinically and radiologically to understand the clinical course and best management strategies. Reference #1: Kefu Liu et al. COVID 19 with cystic features on Computed tomography;Medicine (Baltimore) 2020May;99(18): e20175. PMCID: PMC7486878 Reference #2: Galindo J, Jimenez L, Lutz J et al. Spontaneous pneumothorax with or without pulmonary cysts, in patients with COVID 19 Pneumonia. Journal of infections in developing countries 2021;15(10);1404-1407 Reference #3: McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, Thomas KM, Moore WH. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology. 2020;297(2): E252–E262. doi: 10.1148/radiol.2020202352 DISCLOSURES: No relevant relationships by Arunee Motes No relevant relationships by Kenneth Nugent No relevant relationships by Tushi Singh No relevant relationships by Myrian Vinan Vega

Safe and effective administration of multiple recombinant factors on VA-ECMO via post-oxygenator pigtail during acute massive pulmonary hemorrhage

Introduction: Massive bleeding on extracorporeal membrane oxygenation (ECMO) is associated with multiple coagulation defects, including depletion of coagulation factors and development of acquired von Willebrand syndrome (AVWS). The use of recombinant factors, in particular recombinant activated factor VII (rFVIIa, Novoseven), to treat severe refractory hemorrhage in ECMO has been described. However, the use of multiple recombinant factors has been avoided in large part due to concern for circuit complications and thrombosis. Here, we describe the safe and effective administration of rFVIIa and recombinant von Willebrand factor complex (vWF/ FVIII, Humate-P) via post-oxygenator pigtail catheter on VA-ECMO for the treatment of massive pulmonary hemorrhage. Case Description: A 21-month-old (13.4 kg) girl with a recent history of COVID-19 infection presented to an outside hospital with parainfluenza bronchiolitis resulting in acute refractory hypoxemic respiratory failure (oxygenation index 58), refractory septic shock, and myocardial dysfunction. She was cannulated to VA-ECMO and subsequently diagnosed with necrotizing pneumonia from Pseudomonas and herpes simplex infections. Her course was complicated by a large left-sided pneumatocele and bronchopleural fistula requiring multiple chest tubes. She also had right mainstem bronchus obstruction from necrotic airway debris and complete right lung atelectasis. She was noted to have prolonged episodes of mucosal and cutaneous bleeding (oropharynx, chest tube insertion sites, peripheral IV insertion sites) associated with absent high molecular weight von Willebrand multimers consistent with AVWS. Tranexamic acid infusion was initiated and bivalirudin anticoagulation was discontinued. VA-ECMO flows were escalated to 140-160 ml/kg/min to maintain circuit integrity and meet high patient metabolic demand in the absence of anticoagulation. On ECMO day 26, she underwent bronchoscopy to clear necrotic debris from her airway to assist with lung recruitment. The procedure was notable for mucosal bleeding requiring topical epinephrine and rFVIIa. Post-procedure, she developed acute hemorrhage from her right mainstem bronchus, resulting in significant hemothorax (estimated 950 ml) with mediastinal shift, increased venous pressures, desaturation and decreased ECMO blood flow rate, necessitating massive transfusion of 2,050 ml (150 ml/kg) of packed red blood cells, platelets, plasma and cryoprecipitate. An airway blocker was placed in the mid-trachea to control bleeding. In addition to transfusion of appropriate blood products and continuation of tranexamic acid infusion, she was given both rFVIIa (100mcg/kg) and vWF-FVIII (70 units vWF/kg loading dose on the day of hemorrhage, followed by 40 units vWF/kg every 12 hours for 3 additional doses). Both products were administered over 10 minutes through a post-oxygenator pigtail to allow the product to circulate throughout the patient prior to entering the ECMO circuit. The circuit was closely monitored during administration and no changes to circuit integrity were noted in the subsequent hours while hemostasis was achieved. The ECMO circuit remained without thrombosis for 9 days after the bleeding event. Discussion: Balancing anticoagulation and hemostasis is a central challenge in maintaining ECMO support, especially given the prevalence of acquired coagulopathies such as AVWS. For our patient, AVWS contributed to mucosal bleeding necessitating cessation of anticoagulation and utilization of a high ECMO blood flow strategy to minimize circuit clot burden. This was further complicated by absent native lung function and minimal myocardial function, resulting in complete dependence on ECMO. An acute massive pulmonary hemorrhage was treated with multiple recombinant factors (rFVIIa and vWF/FVIII), that are often avoided on ECMO. To minimize clotting risk to the circuit and to maximize transit of these factors to our patient, we added a post-oxygenator pigtail for administration. While this approach was the result of extreme circumstances, th use of a post-oxygenator pigtail for administration of recombinant factors may represent a viable strategy for refractory hemorrhage while on ECMO.

Magnet-related foreign body aspiration in two children requiring thoracotomy: A concerning report

With the increase in use of smaller magnets in gadgets and toys at home, magnets pose a growing aspiration risk in children. We present two simultaneous cases of magnet-related foreign body aspiration (FBA) in two children, in two different cities: Karachi, and Lahore. They presented with similar signs and symptoms: tachypnea, tachycardia and asymmetric breath sounds on auscultation. They were initially diagnosed with the help of a chest X ray. Both the cases were complicated by failed bronchoscopy attempts due to the slippery texture of the magnet. Due to the failed bronchoscopy, both patients had a prolonged and complicated course including a 24–48 hour stay in the PICU prior to magnet removal. They eventually had to undergo thoracotomy for successful removal of the magnet. Both had an unremarkable post-operative course and were discharged in good health.

Actinomyces bacteriemia secondary to pseudomembranous necrotizing oral-tracheobronchial and invasive pulmonary aspergillosis in a patient with CoViD-19

Description of the case: A 79-year-old smoking patient with COPD, diabetes, previous bladder cancer, and family members positive for SARS-CoV2 was admitted to the hospital for pneumonia and severe respiratory insufficiency. During hospitalization, the nasopharynx sample was persistent negative for SARS-CoV-2, but the serology positive. CT showed signs of interstitial pneumonia. Antibiotic therapy, high-dose dexamethasone, and oxygen therapy were introduced. After an initial worsening of clinical conditions, inflammation indices normalization and marked clinical improvement until the suspension of oxygen therapy were observed. In the discharge phase, fever and increase in CRP and IL6 returned without respiratory failure. Black lesions with a necrotic ulcerated base located on the palate and posterior tongue were observed. Blood cultures were positive for Actinomyces oris, and Aspergillus galactomannan- antigen was detected. CT showed consolidations, cavitations, ground-glass opacity. Fibrobronchoscopy found tracheobronchial full-layer involvement with pharyngeal/laryngeal and bronchial obstruction by necrotic pseudomembranes. BAL was positive for SARS-CoV-2 and Aspergillus niger, and Aspergillus fumigatus. Voriconazole and beta-lactam antibiotics were started. The patient improved with the need for repeated FB to eliminate the pseudomembranes, but he died in the ICU due to heart failure. Conclusions: Hematogenous spread of Actinomyces is rare as well as pseudomembranous necrotizing oral-tracheobronchial aspergillosis, but to be considered in CoViD-19 patients receiving high doses of steroids.