A Rare Case of Isolated Renal Mucormycosis in an Immunocompetent Individual: Post Covid-19 Infection

Intro: Mucormycosis is known to effect patients with immunocompromised status from a variety of causes such as diabetes mellitus, hematologic malignancy, and HIV infection. Most common form of presentation is rhinocerebral infection. However, isolated presentation of renal mucormycosis is rare. With the ongoing COVID-19 pandemic and use of high-dose steroids and antibiotics, there have been increasing reports of bacterial and fungal coinfections in COVID-19 positive patients. We report a rare case of isolated renal mucormycosis, post COVID-19 infection, in a healthy individual presenting as unilateral right non-functioning pyonephrotic kidney. Method(s): A conscious, well oriented, afebrile 37 years old female patient presented with the complaints of right flank pain for one month. Patient was diagnosed as a case of post COVID-19 renal infarct with perinephric collection, right non-functioning pyonephrotic kidney. She had no previous comorbidities. Routine investigations, chest X-ray and CT scan were done. Finding(s): CT scan findings reveal a large right perinephric hyperdense collection inseparable from right kidney involving the internal oblique, psoas and quadratus lumborum muscles. Right simple nephrectomy was done and specimen was sent for histopathology and fungal culture. Histopathology report showed necrotizing granulomatous inflammation with broad, aseptate, irregularly branched fungal hyphae morphologically resembling Mucor species and fungal culture also confirmed Mucor species.Copyright © 2023

Granulomatous Hepatitis as Primary Manifestation of Disseminated Histoplasmosis in an Immunocompetent Host Diagnosed on EUS FNA and Liver Biopsy

Introduction: Disseminated histoplasmosis (DH) presents as primarily lung manifestations with extrapulmonary involvement in immunocompromised hosts. Granulomatous hepatitis as first presentation of DH in an immunocompetent host is uncommon. Case Description/Methods: 25-year-old female presented with one month of fever, fatigue, myalgias, 30-pound weight loss, cough, nausea, vomiting, and epigastric pain. She has lived in the Midwest and southwestern US. Presenting labs: TB 1.9 mg/dL, AP 161 U/L, AST 172 U/L, ALT 463 U/L. Workup was negative for COVID, viral/autoimmune hepatitis, sarcoidosis, tuberculosis, and HIV. CT scan showed suspected gallstones and 9 mm left lower lobe noncalcified nodule. EUS showed a normal common bile duct, gallbladder sludge and enlarged porta hepatis lymph nodes which underwent fine needle aspiration (FNA). She was diagnosed with biliary colic and underwent cholecystectomy, with white plaques noted on the liver surface (A). Liver biopsy/FNA showed necrotizing granulomas (B) and fungal yeast on GMS stain (C). Although histoplasmosis urine and blood antigens were negative, histoplasmosis complement fixation was >1:256. She could not tolerate itraconazole for DH, requiring amphotericin B. She then transitioned to voriconazole, discontinued after 5 weeks due to increasing AP. However, her symptoms resolved with normal transaminases. At one year follow up, she is asymptomatic with normal liver function tests. Discussion(s): DH is a systemic granulomatous disease caused by Histoplasma capsulatum endemic to Ohio, Mississippi River Valley, and southeastern US. DH more commonly affects immunocompromised hosts with AIDS, immunosuppressants, and organ transplant. Gastrointestinal involvement is common in DH (70-90%) with liver involvement in 90%. However, granulomatous hepatitis as primary manifestation of DH is rare (4% of liver biopsies). Hepatic granulomas are seen in < 20%. Patients may present with nonspecific systemic symptoms. Serum/urine antigens may be negative. Gold standard for diagnosis is identifying yeast on tissue stains. Recommended treatment is amphotericin B followed by 1 year of itraconazole. However, shorter treatment duration may be effective in immunocompetent hosts. This case is unique in that granulomatous hepatitis was the first presentation of DH in our immunocompetent patient diagnosed on EUS FNA and liver biopsy. Clinicians must have a high degree of suspicion for DH in patients with fever of unknown origin especially in endemic areas regardless of immunologic status. (Table Presented).

ADJUNCTIVE USE OF DISPOSABLE 1.1-MM CRYOPROBE WITH ROBOTIC-ASSISTED BRONCHOSCOPY

SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Peripheral pulmonary nodule biopsy can be challenging based on its location and size. Robotic bronchoscopy is augmenting peripheral navigation, allowing for approximation of peripheral nodules. The diagnostic yield is variable and is primarily dependent upon operator experience, selection of biopsy equipment and nodule texture. Hard pulmonary nodules are difficult to biopsy with a needle, brush and forceps. We report a case of utilizing combined disposable 1.1 mm cryoprobe and robotic bronchoscopy to diagnose a right lower lobe nodule. CASE PRESENTATION: A 83-year-old woman with a remote history of non-Hodgkin's lymphoma presented with dyspnea and fatigue. 18F-FDG PET/CT revealed a 2.7 cm hypermetabolic nodule with central photopenia in the right lower lobe (RLL) along with patchy bilateral ground-glass opacities related to COVID-19 infection. After a few weeks, robotic navigation was used for approximation of the RLL superior segment nodule. Under fluoroscopic and radial guidance with circumferential signal, 6 forcep biopsies and 5 fine needle aspirations with 21-gauge needle yielded a non-diagnostic sample. A decision was made to utilize a 1.1 mm disposable cryoprobe, which was inserted through the opening made by the forceps into the target lesion. Six cryo biopsies were obtained with 4-6 seconds freeze time. Minimal bleeding was encountered and no pneumothorax occurred. Histopathological examination revealed necrotizing granulomatous inflammation. DISCUSSION: To the best of our knowledge, this is the first reported case of combination 1.1 mm disposable cryoprobe biopsy with robotic bronchoscopy. Interventional pulmonologists are primarily using cryo probe for mechanical tumor debulking and peripheral lung biopsy for diagnosis of interstitial lung disease. The use of a 1.1 mm cryoprobe under robotic guidance allows for well-preserved tissue samples and possibly boosting diagnostic yield. The advantage of the 1.1 mm cryoprobe lies with its size and excellent flexibility. The robotic platform also corrects for any unwanted deflection. One limitation of using a flexible cryoprobe is its blunt tip, requiring an additional step in gaining access to nodules located outside the airway with either the biopsy needle or forceps. Future improvements in cryoprobe design with a sharp tip may address this limitation. CONCLUSIONS: Combining 1.1 mm disposable cryoprobe with robotic bronchoscopy is safe and can be considered as an adjunct to conventional biopsy, allowing for well-preserved tissue. Further prospective studies to evaluate its performance and safety is warranted. Reference #1: Kho SS, Chai CS, Nyanti LE, et al. Combination of 1.1 mm flexible cryoprobe with conventional guide sheath and therapeutic bronchoscope in biopsy of apical upper lobe solitary pulmonary nodule. BMC Pulm Med. 2020. 158(20). doi.org/10.1186/s12890-020-01199-3 Reference #2: Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047 Reference #3: Sahajal Dhooria, Inderpaul Singh Sehgal, Ashutosh NA Digambar Behera, Ritesh Agarwal. Diagnostic Yield and Safety of Cryoprobe Transbronchial Lung Biopsy in Diffuse Parenchymal Lung Diseases: Systematic Review and Meta-Analysis. Respiratory Care. 2016. 61(5):700-712. doi.org/10.4187/respcare.04488 DISCLOSURES: No relevant relationships by Sailendra Chundu No relevant relationships by Moiz Javed No relevant relationships by Abid Khokar No relevant relationships by Ali Saeed No relevant relationships by Andrew Talon No relevant relationships by Melinda Wang

A CHALLENGING CASE OF MYCOBACTERIUM TB-INDUCED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune activation in response to a variety of insults including malignant, autoimmune and infectious processes. The most common infectious trigger is a viral infection, but other pathogens have also been implicated including Mycobacterium tuberculosis (MTB) CASE PRESENTATION: 62-year-old male from Bangladesh presented due to lethargy, weakness, and anorexia for several weeks. He also reported fevers, diarrhea, and unintentional weight loss. On examination, he appeared acutely ill with diffuse bibasilar crackles on lung exam. Labs showed platelets of 132, ESR 45 mm/hr, CRP 9.6mg/dL, ferritin 1,765ng/mL and transaminitis. A viral panel was positive for Rhinovirus. Computed tomography (CT) of the chest showed diffuse bilateral ground-glass opacities and he was started on antibiotics for pneumonia. On day 3, his respiratory status worsened and he was emergently intubated. He underwent bronchoscopy and bronchoalveolar lavage (BAL) and started on high-dose steroids for possible hypersensitivity pneumonitis. On day 5, he was extubated to nasal cannula, however, his condition worsened despite treatment. Extensive infectious workup, including HIV, Covid and P jirovecii PCR, sputum, and blood cultures, and preliminary AFB smear were negative. Subsequent labs noted rising ferritin levels (4,164 ng/mL), high triglycerides, pancytopenia and transaminitis. Calculated H score was 211 which gave a 93-96% probability of HLH. Initiation of Etoposide was discussed but family deferred. He was later transferred to another facility. On follow-up, IL-2 receptor antibodies were elevated, bone marrow biopsy showed hemophagocytosis and necrotizing granulomas. He was intubated for worsening hypoxemia. Repeat bronchoscopy and BAL analysis showed many acid-fast bacilli. Anti TB treatment (ATT) was deferred due to his critical state. He further declined and eventually expired. DISCUSSION: The exact mechanism for which MTB triggers HLH is unclear, however, it is thought that MTB serves as an obligate intracellular pathogen after phagocytosis by phagocytic cells to induce TH1-mediated cytotoxicity, activating macrophages and NK cells, further releasing a large quantity of cytokines and chemokines. The lack of specific clinical signs, low sensitivity for acid-fast staining, and time-consuming culture make the diagnosis of TB-HLH difficult. However, the use of NAATs has improved the yield of sputum testing. Exceedingly high ferritin levels should serve as a red flag in cases of undetermined diagnosis. Moreso, Cytopenias, elevated LFTs, and coagulation dysfunction are other clues that a diagnosis of HLH should be on the differential. It is believed that early and effective ATT is the key to preventing HLH in TB patients. CONCLUSIONS: It is paramount to both recognize the features of TB as well as HLH as early diagnosis and treatment favor better outcomes. Reference #1: Padhi S, Ravichandran K, Sahoo J, Varghese RG, Basheer A. Hemophagocytic Lymphohistiocytosis: An Unusual Complication in Disseminated Mycobacterium Tuberculosis. Lung India (2015) 32(6):593–601. doi: 10.4103/0970-2113.168100 Reference #2: Dalugama, C., Gawarammana, I.B. Fever with pancytopenia: unusual presentation of extrapulmonary tuberculosis: a case report. J Med Case Reports 12, 58 (2018). https://doi.org/10.1186/s13256-018-1596-0 Reference #3: O M P Jolobe, Timely recognition of hematophagocytosis attributable to coexistence of lymphoma and tuberculosis, QJM: An International Journal of Medicine, Volume 112, Issue 4, April 2019, Page 315, https://doi.org/10.1093/qjmed/hcy198 DISCLOSURES: No relevant relationships by Katherine Acosta No relevant relationships by Chika Winifred Akabusi No relevant relationships by Uma Medapati No relevant relationships by Hector Ojeda-Martinez No relevant relationships by Busala Oke No relevant relationships by Mar o Torres

Reactivation of latent tuberculosis post SARS-CoV-2 infection

Introduction: Tuberculosis (TB) is an airborne infectious disease caused by the Mycobacterium tuberculosis (MTB) complex. It attacks the lungs and other extra-pulmonary sites. It remains a major public health concern in Malaysia with incidence of 79/100,000 in 2015. Case Description: We report a case of a 29-year-old lady, presented with a complain of generalised abdominal pain for 2 months. Patient had Covid-19 infection in pregnancy 8 months ago and underwent lower segment caesarean section at term for fetal distress. In 2018 she had TB screening for contact tracing which turned out to be negative. In this current presentation, a Computerized-Tomography (CT) Abdomen-Pelvis scan reported a left ovarian lesion with pseudomyxoma peritonei and omental caking. Diagnostic laparoscopy showed dense adhesions between peritoneal wall and surrounding organs with multiple pockets and fluid collections seen. Whitish friable lesion seen over the peritoneum. Samples sent for histopathology, culture and sensitivity and MTB PCR. Histopathology sample returned as caseating granuloma;suggestive of extrapulmonary tuberculosis. Microscopically, acid fast bacilli seen in Ziehl-Neelsen staining. Peritoneal fluid was transudative in nature. The diagnosis of peritoneal tuberculosis was established, and patient was referred to Infectious Disease team for treatment of active TB. Discussion: Reactivation of latent TB may be explained by immune-suppressive state associated with Covid-19 may be implicated in the progression of latent to active TB in a similar manner to HIV. Very few cases post Covid-19 activation of latent TB have been reported. This is one such a case.

Pulmonary Artery Aneurysm in a Teenager with Diabetes and COVID-19 Infection

Introduction: Pulmonary artery aneurysms (PAAs) are exceedingly rare. Etiology includes congenital, idiopathic, and acquired. Bacterial and fungal infections are the most common acquired causes. Herein described is a patient with new-onset diabetes mellitus I (DM1) with COVID-19 infection complicated by PAA and mucormycosis. Case Description: A 17-year-old female with new-onset DM1 was admitted to the PICU with diabetic ketoacidosis, and COVID-19 infection complicated by multifocal necrotizing pneumonia. She was treated with remdesivir, antibiotics, systemic glucocorticoids, and discharged on inhaled glucocorticoids. Two weeks later she presented with hemoptysis. Chest computed tomography angiography (CTA) showed a resolving necrotizing pneumonia with a 16 mm aneurysmal dilatation of the proximal portion of the right inferior pulmonary artery (RIPA). Hemoptysis resolved, with no intervention required. One month later she presented again with hemoptysis. Repeat chest CTA demonstrated increasing aneurysmal dilatation, measuring 20 mm in diameter. Echocardiography showed no evidence of endocarditis, congenital heart defects, or elevated right ventricular pressures. A comprehensive infectious workup was negative (Table 1). Due to recurrent symptoms, progressive aneurysmal enlargement, and concerns for rupture, patient underwent RIPA occlusion by cardiac catheterization. Two months later hemoptysis recurred. Chest CTA revealed erosion of the occlusion device into the right inferior segmental bronchus. She underwent emergent right middle and lower lobectomy, and arterial bronchial fistula repair. Lung histology revealed non-septate hyphae with peribronchial and perivascular necrotizing granulomas concerning for mucormycosis (Figure 1). She was treated with amphotericin B and discharged on oral posaconazole. Discussion: The incidence of PAA in adults is estimated to be 1 in 14,000 patients. In adults, the upper limit of normal of an interlobar PA by CTA is 17mm. Our patient's RIPA was dilated up to 20 mm, for which she underwent occlusion of the RIPA. The proinflammatory state generated by COVID-19 can result in vascular inflammation and ultimately aneurysmal dilatation. Desnos et al. reported four cases of hemothorax secondary to PAA rupture in COVID-19 patients on ECMO for severe ARDS. The etiology for PAA formation in our patient had a complex interplay of factors including new-onset diabetes, COVID-19 vasculitis, exposure to systemic glucocorticoids, and an opportunistic infection with Mucor spp. Mucormycosis in diabetic patients with COVID-19 has a mortality of 31% in adults. We believe that the lobectomy performed for the management of PAA in our patient led to better outcomes since surgical debridement is a mainstay of mucormycosis treatment, along with antifungal therapy. Conclusion: PAA in children is uncommon. We describe a diabetic patient with COVID-19 pneumonia, complicated by PAA and mucormycosis. In patients with COVID-19 presenting with hemoptysis, it is important to have a high index of suspicion for PAA. Furthermore, diabetic patients with COVID-19 treated with systemic steroids can be at increased risk for mucormycosis. (Table Presented).

IMMUNOSUPPRESSION SECONDARY TO SEPSIS AND POSTACUTE CARE SYNDROME LEADING TO LATENT TUBERCULOSIS REACTIVATION

CASE: A 59-year-old Mexican-American man with hypertension and type II diabetes (Hemoglobin A1c 11.5) was admitted for sepsis and Acute Respiratory Distress Syndrome secondary to COVID-19 pneumonia. He was ventilator- dependent for 66 days. His clinical course was complicated by acute renal failure requiring hemodialysis, pulmonary embolism, and recurrent ventilator-associated bacterial pneumonia. He was discharged to a long-term acute care center four months after his initial presentation, but was readmitted two weeks later for abdominal pain and fever. CT abdomen revealed diffuse mesenteric nodular stranding and pelvic ascites concerning for peritoneal carcinomatosis. Biopsy of an omental nodule, however, showed necrotizing granulomatous inflammation and no malignant cells. No cultures were sent from the initial biopsy, so repeat sampling was performed and culture was positive for Mycobacterium tuberculosis complex. Treatment for active tuberculosis was initiated with subsequent recovery. IMPACT/DISCUSSION: Initial infection by tuberculosis occurs in the lungs, where alveolar macrophages encounter and phagocytose the bacteria. The macrophages initiate a cytokine response and recruit lymphocytes to form a granuloma, which segregates the infection within the host. The granuloma is then perpetually maintained by an ongoing immune response that is driven by monocytes and CD-4 T cells. Reactivation of tuberculosis occurs when the ongoing immune response is disrupted. Sepsis has profound and complex effects on the immune system, including marked inhibition of lymphocyte proliferation that leads to reduced levels of B cells, CD-4 T cells, and follicular dendritic cells. Signaling pathways are disrupted without these lymphocytes, which then leads to the dysfunction of the remaining leukocytes. Further, critically ill patients often suffer from post-intensive care unit syndrome. This syndrome is marked by persistent inflammation, which prompts an immunosuppressive response that suppresses T-cell function and leads to T-cell apoptosis. Both sepsis and post-intensive care unit syndrome predispose patients to opportunistic infection by attenuation of the usual immune response. In this particular case, the specific loss of T-cell function in both syndromes allowed this patient's latent tuberculosis to reactivate several months after his initial presentation with sepsis from COVID-19 pneumonia. This case highlights the importance of maintaining a high index of suspicion for opportunistic infection after critical illness. CONCLUSION: Sepsis and post-intensive care unit syndrome disrupted this patient's ability to maintain the immune responses that prevent the progression of latent tuberculosis infection. The diagnosis was delayed due to a lack of awareness of the profound immunosuppression that accompanies and follows critical illness. Providers must recognize these syndromes and the impact they have on immunity in order to diagnose and treat opportunistic infections in a timely manner.

AN UNUSUAL CASE OF DISSEMINATED TUBERCULOSIS FOLLOWINGANTIPSYCHOTIC THERAPY: AN AUTOPSY-BASED CASE REPORT

Tuberculosis (TB) is a communicable bacterial infection caused by Mycobacterium tuberculosis. It is the second leading fatal infectious disease after COVID-19. Tuberculosis also stands at 13th position, with respect to the leading cause of death. In 2020, around 86% of new tuberculosis cases were reported in 30 countries, of which two-thirds of cases were recorded in eight countries alone, with India leading the chart. Tuberculosis in a mentally ill patient is a common entity because of its common comorbidities, but prolonged antipsychotic drug therapy is rare. Here we discuss a case of a 36 years old female who was brought dead to casualty. She was apparently alright 10 days back and then developed symptoms like fever, breathlessness, and cough. She had severe anorexia and cachexia for the past few months. She has been under antipsychotic medication for schizophrenia. On autopsy, there were multiple whitish nodules present all over the intestine and various abdominal organs. We identified disseminated tuberculosis, and we analyzed histopathology and microbiology of tissues. We reported Ziehl-Neelsen staining negative for TB. Culture reported positive for Mycobacterium tuberculosis. Histopathology study tissues showed caseous necrotizing granulomas. As seen in some literature, tuberculosis can be seen in mentally ill patients, whereas literature showing the association between tuberculosis and antipsychotic drugs is less. This article highlights the association between such occurrence of tuberculosis while undertaking antipsychotic drug therapy.

Post COVID 19 autoimmune complications: Two cases

Background: Autoimmune disease in adults, among spectrum of complications of COVID 19 is rare. Case Study: Both the cases were never smokers and had type 2 diabetes mellitus, hypertension and hypothyroidism with history of severe COVID 19 eleven months back in case I and seven months back in case II. Case I is 36 year old female, had off and on cough and fever (with spikes of 102o F) for one month along with loss of appetite and weight. CECT thorax showed multifocal GGOs and nodules and CT guided biopsy showed epitheliod granulomas. Fever had not responded to course of ATT. Monteux test showed no induration and BAL was negative for CBNAAT, fungal smear and culture and malignant cytology for both patients. PET CT showed metabolically active bilateral lung nodules. NCCT PNS was suggestive of pansinusitis. cANCA was positive. Case II is a 63 year male, had off and on dry cough and dyspnea off and on (grade 2 mMRC) for 2 months associated with loss of appetite and weight. Hb was 6 gm/ dl and indirect Coombs test was positive. USG whole abdomen showed coarse echotexture with multiple small nodular hypoechoic lesions in liver and spleen and splenomegaly. Serum ACE level was 95 mcg/ L. CECT thorax showed discrete areas of consolidation and ground glass opacity with perifissural and peribronchovascular nodules. TBLB showed non necrotizing granulomatous inflammation. Diagnosis of post COVID ANCA associated vasculitis was made in case I and post COVID sarcoidosis in case II. Both patients responded to immunosuppression. Discussion: Literature shows evidence for similar pathogenesis and clinical-radiological aspects between the hyper-inflammatory diseases and Covid-19 which might explain SARS-CoV-2 for the development of a rapid autoimmune and/or autoinflammatory dysregulation. Host-pathogen interactions at different points of the viral life cycle seem to be important for explaining in part the heterogeneity of clinical pictures that characterize COVID-19. Conclusion: In this progressively increasing global COVID-19 pandemic, it remains necessary to investigate early to find the effects and interactions of various immunological and autoimmune diseases in patients with recent history of COVID-19 and further intervene.

FIRST ADULT PULMONARY CASE OF PRIOR INFECTION OF POLYPORE MUSHROOM IRPEX LACTEUS

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Irpex lacteus is a basidiomycete found on decaying wood. Known uses include the saccharification of wheat for ethanol production;decolorization of textile effluent wastewater;and detoxification of effluents from the debittering process of olives. Rarely found to cause a human mycosis, and ours is the first adult pulmonary case that is reported. CASE PRESENTATION: 61 yr old male with Stage 4ae B cell lymphoma and bcl6 amplification s/p RCHOP, presented with recurrent right effusions. The patient yielded 500mL of transudative effusion. No prior COVID infections and he was fully vaccinated. He worked by cutting down wood in the forests. No complaints of hemoptysis, night sweats, or weight loss. PET scan revealed anterior mediastinal calcifications, a large right effusion, and a LLL nodule. The LLL nodule was biopsied, and pathology revealed necrotizing granulomas. Bronchoscopy with EBUS did not reveal granulomas within the mediastinal lymph nodes. BAL from the LLL revealed a fungal culture positive for I. lacteus. The patient did not undergo further treatment for the positive fungal culture. Follow up PET scan did not reveal progression of his lymphoma. DISCUSSION: The two documented cases of I. lacteus were within a 9 yr old with ALL and pulmonary abscess;and a 73 yr old with sarcoidosis and fungal meningitis. Due to his clinical stability, he did not require amphotericin B, as was needed in the two prior cases. CONCLUSIONS: I.lacteus is a rare cause of a human mycosis. Further investigation would be warranted in terms of treatment, as there are so few cases. DISCLOSURE: Nothing to declare. KEYWORD: fungal

Pulmonary mucormycosis and vascular complications in the setting of new-onset diabetes mellitus and COVID-19

Introduction: We present the case of a 17-year old female who had an unusual course of pulmonary vascular complications in the setting of new onset type 1 diabetes mellitus and Covid-19 infection. Objectives: Study the course of an unusual case of new onset type 1 diabetes mellitus (T1DM) presenting with diabetic ketoacidosis (DKA) in the setting of COVID-19. Understand that poorly controlled DM is a pro-inflammatory, procoagulant, and immunosuppressive condition and can synergistically act with SARS-Cov-2 in potentiating endothelial damage. Methods: A 17-year old previously healthy female was admitted to our institution for management of DKA in the setting of new onset T1DM. COVID test was positive on admission, however, she was afebrile and without respiratory distress at that time. After 2 days, DKA resolved, however, she presented fever. A chest X-ray showed necrotizing multifocal pneumonia with effusion, which was treated with remdesivir and antibiotics. No oxygen supplementation was needed, but course was complicated by right lower pulmonary artery aneurysm, requiring endovascular occlusion. The device eroded into pulmonary artery and a broncho-arterial fistula developed, needing emergent repair and lobectomy. Results: Histopathology of lung parenchyma showed necrotizing granulomas with hyphae, Mucor was isolated. It was treated with systemic antifungals. Immunologic and rheumatologic workup was negative. Conclusions: While poorly controlled DM is known to be a proinflammatory, pro-coagulant, and immunosuppressive condition, SARS-Cov-2 potentiates endothelial damage, suggesting a possible synergic effect in our patient's unique presentation. While sino-orbital mucormycosis is commonly seen in adults with DM, in children, the infection affects only about 15% with only scarce case reports of pulmonary involvement. Additional studies are needed to understand the synergy of a severe DM presentation with COVID-19 and its potential respiratory and systemic complications. (Figure Presented).