ORGANIZING PNEUMONIA WITH FOREIGN BODY REACTION AS A RESULT OF SODIUM HYDROXIDE AND AMMONIUM SALT VAPOR EXPOSURE

SESSION TITLE: Occupational and Environmental Lung Disease Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Sodium hydroxide and ammonium salt vapor exposure are known to cause epithelial necrosis of the tracheobronchial tree, but no pathologic descriptions exist of subsequent inflammatory pneumonitis. CASE PRESENTATION: A 56-year-old man presented to the outpatient clinic with 2 months of progressive scant hemoptysis and dyspnea on exertion. He had a mild smoking history, a history of longstanding stable UC, and had a history significant only for recently performing multiple weeks of cleaning work on a large, enclosed HVAC system with chemicals containing sodium hydroxide and ammonium. He wore no respiratory protection at work. CXR was significant for streaky bilateral lower lobe opacities and CT Chest revealed bilateral basilar ground-glass opacities with a small left pneumothorax. His PFT demonstrated mild restriction with a diffusion defect. Infiltrates persisted after treatment with levofloxacin. A broad autoimmune panel was normal. Bronchoscopy with cryobiopsy showed organizing pneumonia with foreign body reaction. BAL showed primarily mast cells and no organisms were found. Prednisone at 60mg daily with Bactrim prophylaxis and a subsequent prolonged wean was initiated with marked improvement. DISCUSSION: Industrial HVAC cleaning agents are widely used with the proliferation of HVAC systems in the post-COVID world. Other examples exist of prolonged cleaning product use and lung function decline (Svanes et al). Our case report hypothesizes a link between inhalational exposure to sodium hydroxide and ammonium salts with organizing pneumonia with foreign body features, a previously unknown effect. Prednisone led to improvement. CONCLUSIONS: High suspicion for occult pneumonitis should exist when patients present with prolonged exposure to cleaning/noxious chemical vapors exist. Respiratory protection should be emphasized as a public health policy to prevent lung damage among any type of cleaner use including high-skilled (HVAC) cleaners. Reference #1: Advenier, A., & Grandmaison, G. (2022). PULMONARY ACUTE LESIONS AFTER CAUSTIC EXPOSURE. Retrieved 31 March 2022, from https://www.lungdiseasesjournal.com/articles/pulmonary-acute-lesions-after-caustic-exposure.html Reference #2: Svanes, Ø., Bertelsen, R. J., Lygre, S., Carsin, A. E., Antó, J. M., Forsberg, B., García-García, J. M., Gullón, J. A., Heinrich, J., Holm, M., Kogevinas, M., Urrutia, I., Leynaert, B., Moratalla, J. M., Le Moual, N., Lytras, T., Norbäck, D., Nowak, D., Olivieri, M., Pin, I., … Svanes, C. (2018). Cleaning at Home and at Work in Relation to Lung Function Decline and Airway Obstruction. American journal of respiratory and critical care medicine, 197(9), 1157–1163. https://doi.org/10.1164/rccm.201706-1311OC Reference #3: Gorguner, M., & Akgun, M. (2010). Acute inhalation injury. The Eurasian journal of medicine, 42(1), 28–35. https://doi.org/10.5152/eajm.2010.09 DISCLOSURES: no disclosure on file for Ai-Yui Maria Tan;No relevant relationships by Sudha Misra No relevant relationships by Amrik Ray

Esophageal Strictures in Children, a Six Year Case Series Experience in a Tertiary Center in Mexico City

Introduction: Esophageal strictures in children are in most cases associated with a benign etiology. There are multiple conditions that are associated with esophageal strictures including congenital stenosis, secondary to surgical repair of esophageal atresia, caustic burns following ingestion of acids or alcalis, radiation therapy and secondary to some pathologies as gastroesophageal reflux disease, eosinophilic esophagitis, scleroderma, epidermolysis bulllosa and idiopathic. Esophageal dilation can be performed with different techniques that include endoscope dilators, dilations performed over the wire and using the endoscope itself. Some cases require other adjunctive techniques that improve the results after failed progressive dilation. This therapies includes medical treatment and surgical derivations, with some cases known as recalcitrant. Also, esophageal strictures and its management could produce motility disorders. There is no consensus in the literature regarding the management process, especially in frequency of interventions, use of adjunctive therapies and alternatives for conservative management. This problem is more evident in developing countries. Objective(s): The objective of this study was to describe the cases of esophageal strictures and its management in children between 2016 and 2022 in the Instituto Nacional de Pediatria in Mexico City. Method(s): This was a six year retrospective study involving pediatric patients with esophageal stricture. We retrospectively reviewed the medical records of 23 pediatric patients who underwent endoscopic treatments for esophageal strictures, between January 2016 and May 2022 in the Comprehensive Pediatric Gastroenterology Diagnostic Unit in the Instituto Nacional de Pediatria in Mexico City. Result(s): The mean age at diagnosis was 24 months (Q1 15, Q3 35), 12 patients were male (52%) and 11 patients were female (48%). The most prevalent etiology was caustic strictures in 10 patients (43%). Six patients (26%) had esophageal atresia (4 type III, 1 type I and 1 type V), all whose received surgical management in the first days of life. All required repeated pneumatic dilation (between 1 and 11) for the management of postsurgical stenosis. Other etiologies that were found include Schatzki Ring, congenital stenosis, esophageal fibrosis associated with congenital dyskeratosis, epidermolysis bullosa, graft-versus-host disease and gastroesophageal reflux disease (one patient for each cause). In one patient the etiology remains unknown. Seventeen patients had one stricture, 5 patients had two strictures and 1 had 3 strictures. Ten patients had esophageal pseudodiverticula and two had mucosal fold. Six patients underwent dilation with Savary-Guilliard dilators combined with pneumatic balloon dilation. Four patients received mitomycin- C as an adjuvant therapy during dilations. The average diameter of stenosis was increased from 7 mm (range 4-15 mm) to 13,5 mm (range 8-18mm). Two patients had severe complications, one had a esophageal perforation associated with dilation. The other one had a pneumothorax related with anesthetic management. In the outcome 6 patients are asymptomatic, 1 patient persist with dysphagia after completed treatment, 9 patients are under treatment, 1 patient died secondary to its underlying disease and 6 patients lost follow up. Conclusion(s): Post-corrosive esophagitis and post-esophageal atresia anastomotic strictures were the most frequent types of cicatricial esophageal strictures. The conservative treatment was the first management strategy in the majority of patients, being the endoscopic balloon dilation the first choice. The SARS-COV-2 sanitary emergency limited the progressive intervention rate and appropriate clinical follow up of patients, reason why there is an important loss of follow up in the described group. A number of patients are currently on management, reason why their outcomes will be assessed in the future.

Tiny batteries. big danger

Foreign body ingestion is common in the paediatric population, especially in children under five years of age. The most commonly ingested objects are coins, with batteries accounting for approximately 5% of ingestions. Most ingested batteries pass spontaneously through the gastrointestinal tract;however, those lodged in the oesophagus may lead to dangerous complications, such as oesophageal perforation and aorto-oesophageal fistula. There has been a dramatic increase in morbidity and mortality after battery ingestion worldwide in recent years. This is related to the wider use and easier availability of electronic devices and the growing popularity of more powerful 20 mm lithium button batteries, which are more likely to get impacted in the paediatric oesophagus, leading to serious injury if not promptly removed. Ingestion of these larger batteries resulted in death or serious complications in 12.6% of children. An increased incidence of battery ingestion has also been seen during the COVID-19 pandemic due to lockdown restrictions, with children spending more time at home. The main mechanism of injury is the generation of electric current between the poles of the battery. This is facilitated by the oesophagal mucosa being in contact with them and completing the circuit. The resultant caustic reaction leads to liquefactive necrosis of surrounding tissues, with clinically significant damage being reported as early as 2 hours after impaction. The time-sensitive nature of button-battery ingestion requires fast mobilisation of a multidisciplinary team and urgent removal. Clinicians must be able to recognise and manage button battery ingestion as per the latest guidelines. These patients often require anaesthesia for endoscopic battery removal;therefore, anaesthetists must familiarise themselves with the management of battery ingestion and be aware of its potential complications. This review focuses on the anaesthetic considerations and immediate management of ingested button batteries.

The impact of COVID-19 pandemic on caustic ingestion at a tertiary care center in South India

Background: The COVID-19 pandemic has had a significant impact on the mental health of individuals which has sometimes led to attempts at deliberate self-harm including the ingestion of caustic substances. This study was aimed to compare the rates of caustic substance ingestion during the pandemic to a similar period in the preceding year at our center. Methodology: We carried out a retrospective analysis, in which patients' details (demographic, clinical, endoscopic, and outcomes) were collected and compared between April 2019 and December 2019 (pre-COVID-19 pandemic) and from April 2020 to December 2020 (during the COVID-19 pandemic). Results: A total of 41 patients were included in this study, 26 (63.4%) in the pandemic period and 15 (36.5%) in the prepandemic period. The majority were female in both the prepandemic (60%) and pandemic periods (53.9%). More adolescents (<18 years of age) were seen in the pandemic period (15.3%) than in the prepandemic period (6.7%). The proportion of patients admitted with caustic substance ingestion in the pandemic period (3.53%) was significantly higher than in the prepandemic period (1.57%) (P = 0.0094). Conclusion: Caustic substance ingestion almost doubled in our center during the COVID-19 pandemic highlighting the burden of mental health issues during a pandemic.

INCREASED BURDEN OF SWALLOWING DISORDERS DURING THE COVID-19 PANDEMIC: A HOSPITAL SYSTEM-WIDE AUDIT

BACKGROUND: The indirect health impact of COVID-19 caused by delayed access to care or deferred medical procedures is yet to be fully appreciated. METHODS: We conducted a hospital system-wide audit of all inpatient gastrointestinal (GI) consults performed during the lockdown phase (3/23/2020 – 5/10/2020, n = 558) and the reopening phase (6/1/2020 –7/19/2020, n = 713) of the pandemic and compared against data from 2019 in order to discover any changes in disease burdens. GI diagnoses were derived from the patients' discharge summaries and verified by an independent review of the associated GI consult notes. RESULTS: The volume of inpatient consults was reduced by 27.7% during the lockdown phase compared to the same period in 2019. Yet, the proportion of consults for swallowing disorders (food impaction or chronic dysphagia from eosinophilic esophagitis or achalasia) was increased by 50.9% (p = 0.04). Coincidentally, all outpatient esophageal motility study or elective endoscopic dilation procedures at our hospital system were post-poned during this phase. While the volume of consults was restored during the reopening phase to 101% of that of the same period in 2019. The proportion of consults for swallowing disorders remained elevated by 47.7% (p = 0.02). In comparison, there was no significant change in the proportions of consults for foreign/caustic substance ingestion, inflammatory bowel diseases, or gastrointestinal bleeding during either the lockdown phase or the reopening phase. CONCLUSIONS: There was a significant surge in the demand for inpatient consults for swallowing disorders following the onset of the COVID-19 pandemic, coinciding with the postponement of elective endoscopic procedures. Resources should be allocated to manage patients with underlying esophageal motility disorders more effectively as the pan-demic continues.