ABSTRACT
Anaplastic large-cell lymphoma (ALCL) is an aggressive subtype of non-Hodgkin lymphoma. There are two forms of ALCL: primary and secondary. Primary can be systemic, affecting multiple organs, or cutaneous, affecting mainly the skin. A secondary form occurs when another lymphoma undergoes an anaplastic transformation. ALCL rarely presents as initial symptoms of respiratory failure. In most of these situations, the trachea or bronchial involved with an obstruction was present. We present an unusual case of ALCL where the patient rapidly progressed to acute hypoxic respiratory failure with a patent bronchus and trachea. Unfortunately, the patient rapidly deteriorated and died before diagnosis. Only upon at autopsy, it was found that his lung parenchyma was diffusely involved with ALCL. The autopsy report showed that the patient had CD-30 anaplastic lymphoma kinase (ALK)-negative ALCL diffusely involving all lung fields.
ABSTRACT
Introduction: Cardiac sarcoidosis (CS) classically manifests as a restrictive cardiomyopathy or conduction abnormalities, though the full scope of phenotypes may be underrecognized. We present an atypical case of mitral regurgitation (MR) and aortic regurgitation (AR) attributed to CS. Case Presentation: A 33-year-old woman with a history of hypertension, tobacco use, and COVID-19 infection two months prior presented with worsening dyspnea on exertion, orthopnea and lower extremity edema. Initial work up revealed elevated pro-BNP and troponin, and a CXR with pulmonary edema. A prior CTA showed mediastinal and hilar lymphadenopathy. Echocardiogram was notable for mildly dilated LV, severe hypokinesis of the basal inferior myocardium, LVEF 50-55%, moderate MR and moderate AR. cMR revealed multiple foci of predominantly mid-wall late gadolinium enhancement (LGE) in the LV, including a focus adjacent to the posteromedial papillary muscle (Fig. 1). Cardiac PET showed extensive patchy, focal hypermetabolic activity in the LV inferobasal, anterobasal and anterolateral walls. With high suspicion for CS, the patient opted for treatment with steroids and follow-up PET over extracardiac lymph node biopsy due to procedural risk. Discussion(s): Isolated CS is underdiagnosed and can present with a wide range of symptoms. Detection is limited by current diagnostic criteria, namely difficulty ascertaining affected tissue, which may limit recognition of the full range of presentations. Diagnosis and treatment vary widely among institutions but there is consensus on starting immunosuppression and pursuing follow-up cardiac PET for suppression of inflammatory activity in cases of high clinical suspicion. Our patient plans to undergo repeat PET and have ongoing discussion about lymph node biopsy. COVID-19 myocarditis remains on our differential, however given the patchy nature of LGE on cMR which correlated with the FDG uptake on PET, CS is considered the most probable diagnosis. Conclusion(s): CS should be considered in the differential diagnosis for young patients with structural valve abnormalities, even in the absence of arrhythmias or cardiomyopathy. High clinical suspicion may justify early immunosuppressive treatment to prevent irreversible myocardial injury and/or fatal arrhythmias. Whether this treatment will result in resolution of the structural defects remains to be seen and further investigated.Copyright © 2022
ABSTRACT
Introduction: Instillations with balcillus Calmette - Guerin (BCG) are established adjuvant therapy for superficial bladder cancer. Although generally safe and well tolerated, they may cause a range of different, local, and systemic complications. Case description: We present a patient treated with BCG instillations for three years, who was admitted to our hospital due to fever and progressive dyspnea. Blood test revealed elevated CRP and liver function tests. On CT scan massive bilateral ground glass opacities in the middle and lower parts of the lungs, parenchymal infiltrations, bronchial walls thickening, and hilar lymphadenopathy were visible. PCR test for SARS-CoV-2 as well as sputum, blood, and urine cultures were negative. Initial empiric antibiotic therapy was ineffective and respiratory failure progressed with the need of oxygen supplementation of 15l/min. Finally, positive cultures for M. tuberculosis ssp. bovis (BCG) were available from sputum and bronchoalveolar lavage fluid. Antituberculous treatment (rifampin, isoniazid, etambuthol) was implemented together with systemic corticosteroids resulting in the quick improvement of the patient's clinical condition. Due to hepatotoxicity and finally reported resistance of the BCG strain to isoniazid, it was replaced with levofloxacin with a good tolerance. Follow up CT scan showed partial resolution of the infiltrates. The patient was discharged home and continued treatment without further side effects. Conclusion(s): The diagnosis of BCG infection in the lungs must be taken into consideration in every patient treated with BCG instillations and symptoms of unexplained infection.
ABSTRACT
BackgroundThe typical CT manifestations of COVID-19 pneumonia include ground-glass opacity (GGO) with or without consolidation and superimposed interlobular septal thickening. These are often rounded in morphology and frequently bilateral, multilobar, posterior, peripheral, and basilar in distribution. The various atypical CT features of COVID-19 are seldom described in the literature. The study aims to enumerate the atypical pulmonary CT features in patients with COVID-19 pneumonia in correlation with the disease severity.ResultsA total of 298 confirmed cases of COVID-19 pneumonia with positive reverse transcription polymerase chain reaction (RT-PCR) who underwent chest CT scans were retrospectively evaluated. The cohort included 234 (78.5%) men and 64 (21.5%) women and the mean age was 53.48 ± 15.74 years. The most common presenting symptoms were fever [n = 197 (66.1%)] and cough [n = 139 (46.6%)]. Out of 298 cases of COVID-19 pneumonia, 218 cases (73.1%) showed typical CT features while 63 cases (21.1%) showed atypical CT features with concurrent classical findings and the remaining 17 cases (5.8%) were normal. Among the atypical CT features, the most common was pulmonary cysts [n = 27 (9%)]. The other features in the order of frequency included pleural effusion [n = 17 (5.7%)], nodules [n = 13 (4.3%)], bull's eye/target sign[n = 4 (1.3%)], cavitation [n = 3 (1.0%)], spontaneous pneumothorax [n = 2 (0.6%)], hilar lymphadenopathy [n = 2 (0.6%)], spontaneous pneumo-mediastinum with subcutaneous emphysema [n = 1 (0.3%)], Halo sign [n = 1 (0.3%)], empyema [n = 1 (0.3%)] and necrotizing pneumonia with abscess [n = 1 (0.3%)].ConclusionCT imaging features of COVID-19 pneumonia while in a vast majority of cases is classical, atypical diverse patterns are also encountered. A comprehensive knowledge of various atypical presentations on imaging plays an important role in the early diagnosis and management of COVID-19.
ABSTRACT
Objective: To investigate the clinical features and chest CT findings in moderate and severe COVID-19 patients. Method(s): A total of 506 patients with COVID-19 treated in Wuhan Huoshenshan Hospital during February 9 to March 9, 2020 were enrolled in the study, including 365 moderate cases and 141 severe cases. The clinical features and chest CT findings were retrospectively analyzed. Chi-square test and Fisher's exact probability were used for data analysis. Result(s): The proportions of patients with diabetes and hypertension in severe group were significantly higher than those in moderate group (chi2=9.377 and 15.085, P<0.01). Compared with the severe patients, the white blood cell counts and lymphocyte counts of moderate patients were statistically significant (chi2=14.816 and 30.097, P<0.01). The protortion of increased CRP in severe patients was higher than that in moderate patients (chi2=21.639, P<0.01). The cure rate and discharge rate of severe patients were significantly lower than those of moderate patients (P<0.01). Compared with the moderate cases of COVID-19, the CT images in severe patients mainly showed lesions of diffuse distribution, mixed density, with maximum diameter>10 cm and involved all five lung lobes (P<0.01). The severe patients had more imaging signs of air bronchogram, bronchovascular thickening, pleural thickening, mediastinal or hilar lymphnodes enlargement, pleural effusion and pericardial effusion than moderate patients (chi2=33.357, 11.114, 14.580, 5.978, 45.731 and 6.623, P<0.05 or <0.01). Conclusion(s): There are differences in clinical features and chest CT findings between moderate and severe patients, and chest CT findings can be used as important criteria for clinical classification.Copyright © 2020 by the Chinese Medical Association.
ABSTRACT
Objective: To investigate the clinical features and chest CT findings in moderate and severe COVID-19 patients. Method(s): A total of 506 patients with COVID-19 treated in Wuhan Huoshenshan Hospital during February 9 to March 9, 2020 were enrolled in the study, including 365 moderate cases and 141 severe cases. The clinical features and chest CT findings were retrospectively analyzed. Chi-square test and Fisher's exact probability were used for data analysis. Result(s): The proportions of patients with diabetes and hypertension in severe group were significantly higher than those in moderate group (chi2=9.377 and 15.085, P<0.01). Compared with the severe patients, the white blood cell counts and lymphocyte counts of moderate patients were statistically significant (chi2=14.816 and 30.097, P<0.01). The protortion of increased CRP in severe patients was higher than that in moderate patients (chi2=21.639, P<0.01). The cure rate and discharge rate of severe patients were significantly lower than those of moderate patients (P<0.01). Compared with the moderate cases of COVID-19, the CT images in severe patients mainly showed lesions of diffuse distribution, mixed density, with maximum diameter>10 cm and involved all five lung lobes (P<0.01). The severe patients had more imaging signs of air bronchogram, bronchovascular thickening, pleural thickening, mediastinal or hilar lymphnodes enlargement, pleural effusion and pericardial effusion than moderate patients (chi2=33.357, 11.114, 14.580, 5.978, 45.731 and 6.623, P<0.05 or <0.01). Conclusion(s): There are differences in clinical features and chest CT findings between moderate and severe patients, and chest CT findings can be used as important criteria for clinical classification.Copyright © 2020 by the Chinese Medical Association.
ABSTRACT
Background: Poor prognosis of lung cancer is linked to its late diagnosis, typically in the advanced stage 4 in 50-70% of incidental cases. Lung Cancer Screening Programs provide low-dose lung CT screening to current and former smokers who are at high risk for developing this disease. Greece is an EU country, returning strong from a long period of economic recession, ranked 2nd place in overall age-standardized tobacco smoking prevalence in the EU. In December 2020, at the Metropolitan Hospital of Athens, we started the 1st Screening Program in the country. We present our initial results and pitfalls met. Method(s): A weekly outpatient clinic offers consultation to possible candidates. LDCT (<=3.0mGy), Siemens VIA, Artificial Intelligence multi-computer-aided diagnosis (multi-CAD) system and LungRADS (v.1.1) are used for the validation of any abnormal findings with semi-auto measurement of volume and volume doubling time. Patients get connected when necessary with the smoking cessation and Pulmonology clinic. USPSTF guidelines are used, (plus updated version). Abnormal CT findings are discussed by an MDT board with radiologists, pulmonologists/interventional pulmonologists, oncologists and thoracic surgeons. A collaboration with Fairlife Lung Cancer Care the first non-profit organization in Greece is done, in order to offer the program to population with low income too. An advertisement campaign was organized to inform family doctors and the people about screening programs, together with an anti-tobacco campaign. Result(s): 106 people were screened, 74 males & 32 females (mean age 62yo), 27/106 had an abnormal finding (25%). 2 were diagnosed with a resectable lung cancer tumor (primary adenocarcinoma) of early-stage (1.8%). 2 with extended SCLC (lung lesion & mediastinal adenopathy). 1 with multiple nodules (pancreatic cancer not known until then). 3 patients with mediastinal and hilar lymphadenopathy (2 diagnosed with lymphoma, 1 with sarcoidosis). 19 patients were diagnosed with pulmonary nodules (RADS 2-3, 17%) - CT follow up algorithm. Conclusion(s): We are presenting our initial results, from the first lung cancer screening program in Greece. Greece represents a country many smokers, who also started smoking at a young age, with a both public and private health sector, returning from a long period of economic recession. COVID-19 pandemia has cause practical difficulties along the way. LDCT with AI software, with an MDT board and availability of modern diagnostic and therapeutic alternatives should be considered as essential. A collaboration spirit with other hospitals around the country is being built, in order to share current experience and expertise. Copyright © 2022
ABSTRACT
Lymphadenopathy (LAP) refers to abnormalities in the size or consistency of lymph nodes. A wide range of etiologies contributes to the difficulty in diagnosing LAP, from mild self-limited viral infections to grave autoimmune diseases and malignancies. Detailed history-taking and a thorough physical examination are essential. Some physicians in developing countries may consider therapeutic testing. Certain groups may require additional evaluations and special treatment. When treating LAP, the etiology is targeted, but corticosteroids should not be administered before a complete diagnosis has been established due to their ability to mask the histological diagnosis of lymphoma and malignancy. This review aims to provide more straightforward and affordable methods available in almost all healthcare settings, especially those with limited resources.
ABSTRACT
SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Sarcoidosis is a disorder with multisystem involvement of unclear, and likely multifactorial, etiology. A majority of cases (up to 90%) include lung involvement, and hilar/mediastinal lymphadenopathy is frequently seen. Since the beginning of the COVID-19 pandemic, multiple complications of COVID-19 have been reported. We present a case of a female patient who developed new-onset, biopsy-proven Pulmonary Sarcoidosis after having COVID-19 pneumonia. CASE PRESENTATION: A forty-eight-year-old female with a past medical history of hypertension presented to the emergency department with a complaint of fever, shortness of breath, and cough. She was subsequently diagnosed with COVID-19 infection/pneumonia. A computed tomography angiogram of the chest was completed to evaluate an abnormal chest radiograph and to rule out pulmonary embolism and revealed pulmonary nodules throughout both lungs with mediastinal and hilar lymphadenopathy. She was referred to the pulmonary clinic for further evaluation of her abnormal computed tomography scan of the chest and presented after quarantine for her COVID-19 infection. She denied any history of Sarcoidosis and denied any mold exposure. She underwent bronchoscopy, and pathology results were consistent with non-caseating granulomas concerning for Sarcoidosis. Over the course of a few days, her symptoms improved. Repeat computed tomography scan of the chest was completed, which showed complete resolution of the previously identified pulmonary nodules with interval improvement of mediastinal adenopathy. DISCUSSION: With the increased number of COVID-19 cases worldwide, an ever-growing list of pulmonary and extrapulmonary manifestations of COVID-19 have been reported. To our knowledge based on literature review, there have only been a few case reports of COVID-19 induced Sarcoidosis. Although the pathophysiology of Sarcoidosis largely remains unknown, inflammation is mediated through the dysregulation of several different cytokines (1). Behbahani, et al. proposed noncaseating granulomas formation as a sarcoid-like immune reaction to SARS-CoV-2. Ekinci et al. reported type-I IFN and IFN-γ role in triggering granuloma formation (2). In our patient, the biopsy-proven presence of non-caseating granuloma formation and subsequent rapid improvement of radiological lesions on computed tomography scan after recovery from COVID-19 pneumonia supports the diagnosis of COVID-19 induced Sarcoidosis. CONCLUSIONS: With the COVID-19 pandemic ongoing, physicians must be aware of the pulmonary and extrapulmonary manifestations of COVID-19 infection. Further studies are required in order to manage such cases and to evaluate COVID-19 infection as an infectious antigen capable of triggering granulomatous inflammation resulting in Pulmonary Sarcoidosis. Reference #1: Capaccione KM, McGroder C, Garcia CK, Fedyna S, Saqi A, Salvatore MM. COVID-19-induced pulmonary sarcoid: A case report and review of the literature. Clin Imaging. 2022;83:152-158. doi:10.1016/j.clinimag.2021.12.021 Reference #2: Polat Ekinci A, Büyükbabani N, Meşe S, Pehlivan G, Okumuş NG, Ağaçfidan A, Özkaya E. COVID-19-triggered sarcoidal granulomas mimicking scar sarcoidosis. J Eur Acad Dermatol Venereol. 2021 Aug;35(8):e477-e480. doi: 10.1111/jdv.17286. Epub 2021 May 1. PMID: 33871106;PMCID: PMC8250646. DISCLOSURES: No relevant relationships by Zachary Anderson No relevant relationships by Sakina Batool No relevant relationships by Adnan Khan No relevant relationships by Bireera Muzaffar No relevant relationships by Ramsha Zafar
ABSTRACT
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: Sarcoidosis and sarcoid-like reactions tend to be diagnoses of exclusion when evaluating patients with malignancy, and have a number of inciting causes. This is a unique case of a patient diagnosed with non-necrotizing granulomatous inflammation on biopsy of mediastinal lymph nodes and skin lesions after receiving SARS-CoV-2 vaccine, while also being on Temozolamide (TMZ). Biopsy-proven sarcoid has rarely been reported in the literature following SARS-CoV-2 vaccine or TMZ. CASE PRESENTATION: 66-year-old female with a history of prolactinoma complicated by recurrence and progression of disease despite surgery, radiation, and medical therapy, who started her first cycle of TMZ and received her first SARS-CoV-2 vaccine 9 days later. About 2 weeks later, she noted numerous painless "bumps” on her bilateral upper and lower extremities with erythema, without fevers, joint pains, or other symptoms. She underwent a positron emission tomography (PET) scan which demonstrated multiple hypermetabolic subcutaneous lesions, along with intensely hypermetabolic bilateral hilar lymphadenopathy. She underwent punch biopsy notable for sparse inflammation. She underwent her second SARS-CoV-2 vaccine and second cycle of TMZ. After 1 week, she noticed increased induration and erythema over her lesions, and held her TMZ. She underwent incisional biopsy of her thigh which demonstrated granulomatous panniculitis. She also underwent bronchoscopy with endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) of her paratracheal and subcarinal lymph nodes, which demonstrated non-necrotizing granulomatous inflammation. Labs were only significant for ACE level of 60u/L (normal<40u/L). With a relative paucity of symptoms and no other obvious vital organ involvement, she was not treated, continued her TMZ without flares, and her symptoms self-resolved after opting out of the third SARS-CoV-2 vaccine. DISCUSSION: Sarcoid-like inflammatory reactions have rarely been reported in the literature following SARS-CoV-2 vaccine or TMZ. One case of panniculitis secondary to TMZ administration was reported that improved after discontinuation of TMZ [1]. Our patient continued TMZ therapy without further symptoms, which makes TMZ less likely as her inciting cause. Three cases of sarcoid-like reactions secondary to SARS-CoV-2 vaccine have been reported [2, 3] but two of these cases were diagnosed clinically as Löfgren syndrome without biopsy [3], making this case the second reported case of biopsy-proven de novo sarcoid reaction in the setting of SARS-CoV-2 vaccine. CONCLUSIONS: Sarcoid-like inflammatory reactions following SARS-CoV-2 vaccine have not been well-reported in the literature. This case, among the other limited cases reported, underscores the need to consider sarcoid on the differential of vaccine-related side effects, especially in those with bilateral hilar lymphadenopathy and cutaneous lesions. Reference #1: Virmani P., Chung E., Marchetti M. A. (2015). Cutaneous adverse drug reaction associated with oral temozolomide presenting as dermal and subcutaneous plaques and nodules. Jaad. Case. Rep. 1, 286–288. 10.1016/j.jdcr.2015.06.012 Reference #2: Bauckneht, M., Aloè, T., Tagliabue, E. et al. Beyond Covid-19 vaccination-associated pitfalls on [18F]Fluorodeoxyglucose (FDG) PET: a case of a concomitant sarcoidosis. Eur J Nucl Med Mol Imaging 48, 2661–2662 (2021). https://doi.org/10.1007/s00259-021-05360-w Reference #3: Rademacher JG, Tampe B, Korsten P. First Report of Two Cases of Löfgren's Syndrome after SARS-CoV-2 Vaccination-Coincidence or Causality? Vaccines (Basel). 2021 Nov 11;9(11):1313. doi: 10.3390/vaccines9111313. PMID: 34835244;PMCID: PMC8619392 DISCLOSURES: no disclosure on file for Alexander Geyer;No relevant relationships by Mustafa Jafri
ABSTRACT
SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multisystem inflammatory syndrome in adults (MIS-A) is a rare but clinically significant complication of COVID-19 infection characterized by severe illness with extrapulmonary organ dysfunction, markedly elevated inflammatory markers in the absence of severe respiratory illness or other obvious source of infection (1). We present a case of a 37-year-old male, with negative infectious evaluation and marked clinical improvement after administration of IVIG. CASE PRESENTATION: We present a 37-year-old black male with a past medical history of type 2 diabetes who was admitted to the hospital with shock and organ failure;prior to his presentation, he was diagnosed with COVID-19 pneumonia requiring outpatient therapy. On presentation, he was tachycardic, febrile, hypotensive with significant renal failure and lactic acidosis;inflammatory markers were elevated (CRP 640, ESR 108). Imaging was significant for mediastinal and hilar lymphadenopathy, with clear parenchyma (Figure 1). Broad coverage antibiotics, vasopressors, and stress dose steroids were initiated. Infectious evaluation was unrevealing with negative blood, urine, and sputum cultures;Echocardiogram revealed LVEF of 40% with mild RV dysfunction. His renal failure worsened, requiring CRRT. Vasculitis evaluation with ANA, ANCA, MPO, PR3, GBM, HIV, C3-C4 and cryoglobulins returned normal. Eventually, the patient was weaned from vasopressor support on hospital day four. Trials of weaning steroids resulted in recurrence of fevers and increasing vasopressor support. Given continued fevers without obvious infection there were concerns for MIS-A occurring shortly after COVID-19 infection. Antibiotics were discontinued and he received 2g/kg of IVIG with marked clinical improvement and was rapidly weaned from vasopressor support. We initiated methylprednisolone 1 mg/kg twice daily with steroid taper. He had improvement in inflammatory markers after IVIG and high dose steroids (CRP-6.7, ESR-49 prior to discharge). DISCUSSION: MIS-A is a rare disease that occurs after COVID-19 infection, with few reported cases in literature. Presentation is variable, but symptoms include high fever, dyspnea, lethargy, myalgias, and a diffuse maculopapular rash. Notably, hypoxia is not a prominent feature, a significant distinction from classic COVID-19 infection. Patel et al noted a predominance in young adults, males, and non-Hispanic black or Hispanic persons (2). The proposed mechanism stems from dysregulated immune response, with abnormal interferon production which drives macrophage activation and organ damage (3). There are no treatment guidelines available, and treatment of MIS-A is extrapolated from MIS-C and includes immunomodulatory therapies with IV IG, IL-1 receptor antagonist, and methylprednisolone. CONCLUSIONS: Prompt recognition of MIS-A critical given its potential for significant multi-organ dysfunction. Reference #1: Centers for Disease Control and Prevention. Multisystem Inflammatory Syndrome in Adults (MIS-A) Case Definition Information for Healthcare Providers. Available at Multisystem Inflammatory Syndrome in Adults (MIS-A) Case Definition Information for Healthcare Providers (cdc.gov). Accessed 3/19/2022 Reference #2: Patel, P., Decuir, J., Abrams, J., Campbell, A. P., Godfred-Cato, S., & Belay, E. D. (2021). Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults: A Systematic Review. In JAMA Network Open (Vol. 4, Issue 9). https://doi.org/10.1001/jamanetworkopen.2021.26456 Reference #3: Weatherhead, J. E., Clark, E., Vogel, T. P., Atmar, R. L., & Kulkarni, P. A. (2020). Inflammatory syndromes associated with SARS-cov-2 infection: Dysregulation of the immune response across the age spectrum. Journal of Clinical Investigation, 130(12). https://doi.org/10.1172/JCI145301 DISCLOSURES: No relevant relationships by Mohammed Al-Charakh No relevant relationships by John Pare t no disclosure on file for Maximiliano Tamae Kakazu;
ABSTRACT
SESSION TITLE: Critical Care Infections SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Francisella tularensis is a zoonotic disease by an aerobic, gram negative coccobacillus. It is transmitted by exposure to infected animal or vectors in individuals who landscape or camp. Common symptoms are fever, chills, anorexia, and headache. Abdominal tularemia can present with abdominal pain, emesis, diarrhea, and rarely intestinal ulceration and hemorrhage. It is treated with aminoglycosides, fluoroquinolones and tetracycline. CASE PRESENTATION: 38-year-old male presented with fever, cough, anorexia, and black stool for 5 days. Patient worked as a landscaper. He has no pets, travel history or sick contacts. He does not take any medications at home. Physical exam was significant for sinus tachycardia and rhonchi of right upper lobe. Significant labs include WBC of 9.8 with 41% bands, hemoglobin 15.5, sodium 125, procalcitonin 27.3, and lactic acid 1.8. COVID-19, MRSA, Legionella and Pneumococcal urine antigen were negative. CTA chest revealed mass-like opacity in right upper lobe with multiple bilateral pulmonary nodules. Lower respiratory culture showed Candida albicans. Patient was empirically started on ceftriaxone and azithromycin. He was transferred to intensive care for worsening respiratory status and was placed on non-invasive ventilation on hospital day 1. Antibiotics were broadened to ceftaroline and levofloxacin due to suspicion of tularemia. Amphotericin B was added. Labs for Histoplasma, Blastomyces, TB, Leptospira, and HIV were negative. Patient then suffered a cardiac arrest on hospital day 2 after having large brown secretions pouring from his mouth. Cardiopulmonary resuscitation was initiated and patient was intubated and started on vasopressors with return of spontaneous circulation. Massive blood transfusion protocol was initiated. Emergent bedside upper endoscopy showed large blood clot adherent to duodenal ulcer. Interventional radiology planned on performing gastric duodenal artery embolization. However, patient suffered two more cardiac arrest with resuscitation efforts terminated per family request. Karius Digital Culture later was positive for Francisella tularensis. Autopsy revealed diffuse alveolar hemorrhage, hilar lymphadenopathy, and perforated duodenal ulceration with large adherent clot. DISCUSSION: Gastrointestinal tularemia is rare and usually from drinking contaminated water or oral inoculation of bacteria. Intestinal tract involvement can present with mesenteric lymphadenopathy and ulcerative lesions resulting in gastrointestinal bleeding with case fatality rate of 50%. Even though this is noted in the literature, to our knowledge no case reports have been published. CONCLUSIONS: Careful history taking and early identification of risk factors are important when severe tularemia infection is suspected such as in individuals with extensive outdoor activities. Treatment should be empirically initiated in high risk patients. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585636/ Reference #2: https://casereports.bmj.com/content/2017/bcr-2017-22125. Reference #3: Altman GB, Wachs JE. Tularemia: A pathogen in nature and a biological weapon. Aaohn Journal. 2002 Aug;50(8):373-9. DISCLOSURES: No relevant relationships by Maria Haider Baig
ABSTRACT
SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multisystem inflammatory syndrome in children (MIS-C) is a systemic condition that causes multi-organ dysfunction accompanied by fever and extremely elevated inflammatory markers. This syndrome been primarily identified in children or adolescents similar to Kawasaki disease. The hallmark of this illness includes life-threatening complications such as shock and cardiac dysfunction. As the cases of COVID-19 continue to increase worldwide, a form of MIS-C can present in adults known as multisystem inflammatory syndrome in adults (MIS-A). We describe a case of MIS-A after exposure to COVID-19. CASE PRESENTATION: A 28-year-old Hispanic male with no medical history presented with 3 days of persistent fever, diarrhea, and fatigue. He was unvaccinated for COVID-19 but had mild disease three months prior, which did not require hospitalization. Vitals were remarkable for tachycardia and constant fever of up to 103.5 F. Labs were notable for leukocytosis of 26.0 k/uL, CRP of 43 mg/dL, and procalcitonin of 90 ng/mL. Computed tomography with intravenous contrast of his chest revealed multifocal nodular and consolidative airspace disease of the right upper and middle lobes with mediastinal and hilar lymphadenopathy. Echocardiogram revealed ejection fraction (EF) of 29% without wall-motion abnormalities. PCR test for COVID-19 was negative and his infectious work-up was unrevealing. His course was further complicated by shock requiring pressors, intubation, and renal replacement therapy. Despite antibiotics, he did not improve. He was started on pulse dose steroids and intravenous immunoglobulin (IVIG), which decreased his CRP to 34 mg/dL and procalcitonin to 51 ng/mL. He was weaned off the ventilator and pressor support with EF recovery to 51%. He was eventually discharged home without further needs. DISCUSSION: While limited data exists, adult patients of all ages with prior SARS-CoV-2 infection can develop MIS-A. Preliminary reports suggest increased incidence among African American, Hispanic, and Asian ethnic groups. Diagnosis includes one primary and two secondary clinical criteria with two supporting laboratory evidence. Primary criteria includes cardiac dysfunction or rash with conjunctivitis. Secondary criteria includes neurological signs, shock, gastrointestinal disease, or thrombocytopenia. Lab markers include elevated CRP, ferritin, IL-6, ESR, or procalcitonin with a positive SARS-Cov-2 PCR, serology, or antigen detection. Treatment consists of steroids, IVIG, and supportive care based on case reports. There are no current evidence-based guidelines. The best preventative measures include COVID-19 vaccination CONCLUSIONS: MIS-A is a rare complication of unvaccinated COVID-19 cases. Diagnostic criteria include one primary and two secondary clinical signs with supporting lab data. Treatment includes steroids, IVIG, and supportive care. Reference #1: Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. The Lancet. 2020;395(10237):1607-1608. doi:10.1016/s0140-6736(20)31094-1 Reference #2: Kunal S, Ish P, Sakthivel P, Malhotra N, Gupta K. The emerging threat of multisystem inflammatory syndrome in adults (mis-A) in COVID-19: A systematic review. Heart & Lung. 2022;54:7-18. doi:10.1016/j.hrtlng.2022.03.007 Reference #3: Morris SB, Schwartz NG, Patel P, et al. Case series of multisystem inflammatory syndrome in adults associated with SARS-COV-2 infection — United Kingdom and United States, March–August 2020. MMWR Morbidity and Mortality Weekly Report. 2020;69(40):1450-1456. doi:10.15585/mmwr.mm6940e1 DISCLOSURES: No relevant relationships by Sadaf Afraz No relevant relationships by Christine Girard No relevant relationships by Jose Rivera No relevant relationships by Ivan Romero-Legro No relevant relationships by Amy Van
ABSTRACT
SESSION TITLE: Challenging Disorders of the Pleura SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Great effort went into finding a vaccine to decrease the impact of COVID-19 virus. Pfizer vaccine which is a part of mRNA of the virus wrapped with lipid nanoparticles is one of them. Though its side effects are benign, rarely it can lead to IgG4 related lung disease (IgG4-RLD). Therefore, having a high degree of suspicion is important for early diagnosis and effective treatment. CASE PRESENTATION: The patient is a 71-year-old male with COPD, CAD, and prostate cancer developed dyspnea after receiving 2 doses of Pfizer vaccine. CT chest revealed a new left pleural effusion, 1.4L fluid was removed which was negative for malignant cells with lymphocytic predominance. After 10 days, his symptoms worsened and repeat CT scan revealed large left pleural effusion. Thoracoscopy was done with drainage of 2.5L pleural fluid followed by pleural biopsy and chemical pleurodesis with insertion of an indwelling tunneled catheter. Pleural biopsy revealed chronic organizing pleuritis with lymphoid and mesothelial hyperplasia. The tunneled catheter stopped draining after 3 months but oxygen requirement increased. A repeat CT scan revealed loculated pleural effusions and only 40 ml was drained due to bloody output. Thoracoscopy revealed multiloculated effusions with visceral pleural thickening and partial decortication was done. Pathology revealed pleural thickening and fibrosis with increased IgG4-positive plasma cells in pulmonary parenchyma. Blood IgG4 level was 268 mg/dl. He was diagnosed with IgG4-related disease (IgG4-RD) affecting lungs and pleura. DISCUSSION: Although IgG4 related nephritis after Pfizer vaccine has been reported(1), this is the 1st reported case of IgG4-RLD. Autoimmunity is a trigger for pathogenesis with involvement of Th-2 cell. The vaccine stimulates robust antigen-specific T-cell responses leading to antibody production that trigger autoimmune reactions due to molecular mimicry. Four patterns are observed including mediastinal, parenchymal, pleural, and airway involvement. Mediastinal and hilar lymphadenopathy is the commonest patterns(2). Our patient had loculated pleural effusion complicated by pleural thickening and fibrosis. For diagnosis of IgG4-RD, 3 criteria need to be fullfilled: consistent organ involvement;serum IgG4 level >135 mg/dL;histopathology showing marked lymphoplasmacytic infiltration(2). Our case fulfilled all 3 criteria and involved lungs;thus, diagnosed with IgG4-RLD. Most patients have a favorable response with corticosteroid therapy in 2 weeks. For steroid-refractory cases, immunosuppressants can be used(3). CONCLUSIONS: With increased COVID-19 vaccination, more autoimmune events including IgG4-RLD can happen. As multiple doses are offered, close observation is needed for prompt diagnosis and management of such diseases. Ultimately, theoretical risks must be balanced against known benefits, and discussion between providers and patients is important. Reference #1: Christophe M, Delphine K, Christine K A, Aurélie F, Gilles B, Mohamed H. Relapse of IgG4-related nephritis following mRNA COVID-19 vaccine. Kidney International. Vol 100, Issue 2, P465-466, August, 2021. DOI: https://doi.org/10.1016/j.kint.2021.06.002 Reference #2: Ryu JH, Sekiguchi H, Yi ES. Pulmonary manifestations of immunoglobulin G4-related sclerosing disease. Eur Respir J 2012;39:180–6 Reference #3: Campbell SN, Rubio E, Loschner AL. Clinical review of pulmonary manifestations of IgG4-related disease. Ann Am Thorac Soc 2014;11:1466–75. DISCLOSURES: no disclosure on file for Ola Al-Jobory;No relevant relationships by Ahmad Hallak No relevant relationships by Manish Patel No relevant relationships by Saria Tasnim
ABSTRACT
Introduction Sarcoidosis is a granulomatous disease with protean manifestations. The aetiology is not fully understood. Infectious agents are considered to potentially contribute to its pathogenesis. This case report highlights the emergence of neurosarcoidosis after COVID-19 infection. Case: A 48 year old female developed cough, myalgia and fatigue and was diagnosed with COVID-19 based on serological testing in April 2020. Post-infection, she developed a reactive arthritis, then presented in June with left facial lower motor neuron weakness, initially treated as a Bell's palsy with a significant neuralgic component. This pain resolved with steroid treatment. One month later she developed multiple cranial neuropathies and bilateral leg weakness. MRI brain showed bilateral enhancement of the trigeminal and facial nerves. CSF was abnormal (CSF protein 0.95g/L, WCC 9/uL). Leg power rapidly improved with intravenous immunoglobulins, and FDG-PET identified mediastinal and axillary hilar lymphadenopathy. A neck node showed non-necrotising granulomatous inflammation. CSF angiotensin converting enzyme was elevated (2.07umol/min/L). She has since commenced high dose steroids for probable neurosarcoidosis. Discussion This case suggests a possible association between COVID-19 and the emergence of sarcoidosis. At present the strength of any association is uncertain and putative mechanisms remain to be determined.
ABSTRACT
Introduction: Sarcoidosis is a multisystem disorder which can involve lungs and extrapulmonary organ systems. Bone marrow involvement is extremely rare. Here we present a case of sarcoidosis with pulmonary and bone marrow involvement mimicking hematological malignancy. Case Report: 46 year old female presented with dry cough, generalized weakness and joint pain lasting 2 months. One month back she was treated in an outside hospital as covid-19 pneumonia due to fever with bilateral lung infiltrates. One month after she was presented to our department with same symptoms and thrombocytopenia with anemia. CT chest shown peribronchovascular infiltrates with hilar lymphadenopathy. PET CT shown hilar adenopathy along with metabolically active foci in liver, lungs, spleen and multiple bones. So,lymphoma was suspected. Later, TBLB was done from hilar lesion;which shown chronic granulomatous lesion. Serum ACE and Calcium level also elevated. Bone marrow biopsy also shown chronic granuloma. So final diagnosis of sarcoidosis is made and she had good response to steroids. Discussion: In the present case of sarcoidosis, patient has both pulmonary and bone marrow involvement which mimicked hematological neoplasm. TBLB from hilar lymph node helped to make diagnosis.Patient had good response to steroids. Conclusion: Sarcoidosis with lung and lymphatic involvement is common;but bone marrow involvement is extremely rare. Steroids are the mainstay of treatment.
ABSTRACT
Introduction and importance: Vaccine-associated hypermetabolic lymphadenopathy (VAHL) after a COVID 19 vaccination is a common adverse event and also a diagnostic challenge especially in patients with a history of a malignancy. Case presentations: A 47-year-old woman presented with enlarged lymph nodes in the right hilar, subcarinal, and right supraclavicular regions detected by computed tomography as a postoperative follow-up study of thyroid cancer. Fluorine-18 fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) performed 3 weeks later revealed an FDG uptake in those swollen lymph nodes and in the novel lymphadenopathy in the left axilla and left subclavicular regions. Both biopsy specimens from the right supraclavicular and hilar lymph nodes revealed only multiple small granulomas with multinucleated giant cells without malignancy, consistent with sarcoidosis. The left axilla and subclavicular lymphadenopathy detected by the FDG-PET subsequently spontaneously regressed. Clinical discussion: The coincidental occurrence of VAHL and lymphadenopathy in sarcoidosis patients could cause diagnostic confusion especially in those with breast cancer. Conclusion: Sufficient attention should be paid both to the injection site and the time interval between the vaccination and imaging test in the era of nationwide mass vaccinations against COVID 19.
ABSTRACT
Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has created a global pandemic. As we try to understand the virus, we are learning that it can affect many organ systems. Most commonly coronavirus disease 2019 (COVID-19) virus affects the respiratory tract and the lungs impairing oxygen transport to the systemic circulation. Its effect on the cardiovascular system can be equally as devastating. Patients can develop pericarditis, myocarditis, and pericardial effusion that can at times lead to tamponade. Here we present an unusual case of a patient with COVID-19 pneumonia who presented with pericardial effusion along with enlarged mediastinal lymph nodes.
ABSTRACT
Background:During the ongoing COVID19 pandemic period, any new cases of acute-onset respiratory illness are likely to be treated as suspected COVID-19 by default. Methods:A 42year-old lady was admitted with a 4-week history of fever and cough, followed by a 4-days history of increasing short- ness of breath. Fever was intermittent, high grade and was associated with chills and rigor. The patient had a history of uncontrolled type II diabetes mellitus and on admission HbA1C was 15.5%. On examination she had a temperature of 102° F, blood pressure (BP) of 101/67mm Hg, heart rate of 130 beats per minute, respiratory rate (RR) of 24 breaths per minute and O2 saturations of 92% in room air. On respiratory examination, there were crackles in the left infrascapular and infraaxillary area. The patient was admitted in the COVID suspect ward with an impression of moderate COVID-19 infection and nasopharyngeal swab was sent for SARS-CoV-2 on RT-PCR. The patient underwent a CECT scan of thorax, abdomen and pelvis that revealed consolidation in bilateral lung fields with a cavity in lingular lobe with presence of air-fluid level. Mediastinal and hilar lymphadenopathy were present. [Formula presented] Results: SARS-CoV-2 RT-PCR was negative. The patient’s sputum sample revealed pure growth of purple, flat, dry, wrinkled colonies on Ashdown agar after 48 hours which was identified as Burkholderia pseudomallei. The Isolate was susceptible to ceftazidime, mero- penem, co-trimoxazole, amox-clav and chloramphenicol. The patient was started on I.V Meropenem 500mg every 8hourly for 21 days and was discharged on co-trimoxazole tablet. Conclusions: The case definitions of COVID-19 such as fever, cough and shortness of breath can be associated with other infectious etiologies. The role of the microbiology laboratory is thus very crucial in COVID-19 from overshadowing other infec- tious diseases, particularly in endemic areas, hence preventing misdiagnosis and consequent adverse outcomes for patients.
ABSTRACT
Objective: To compare the differences between two groups of patients with confirmed and suspected CO-VID-19. Methods: We retrospectively collected and analyzed the data of confirmed and suspected patients, including demographic, epidemic, laboratory, clinical, radiologic, and treatment data, at the fever clinic and isolation ward of our hospital from December 1, 2019 to December 30, 2019. Results: The study included 73 patients with confirmed or suspected COVID-19. The median age was 43.6 years old, and 41 patients (56.2%) were male. Patients in the suspected group (SG) (n=47) were significantly older than those in the confirmed group (CG) (n=26). Among 73 patients, 18 (24.6%) had comorbidities. Most laboratory test results in this study were normal, except for total lymphocyte counts and C-reactive protein levels. Patients in the CG had fewer lymphocyte count abnormalities than those of the SG. More patients in the CG (13 cases, 50%) displayed involvement of three or more lobes than those in the SG (8 cases, 17%). More patients in the SG (36 cases, 76.6%) displayed involvement of 1-2 lobes than those in the CG (12 cases, 46.2%). In the CG, computed tomography (CT) lung lesions were mainly distributed in the left lower lung lobe (65.4%) and left upper lung lobe (80.8%). Conclusion: The reference standard for detecting COVID-19 is still RT-PCR. However, characteristic chest CT results and a history of close contact strongly suggest COVID-19 infection.