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Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease, especially in pediatrics, but important to consider, as it may avoid unnecessary and/or invasive investigations and delayed diagnosis. This case report highlights an adolescent girl with rapid onset dyspnea but an unremarkable physical exam and initial testing. However, due to a high index of suspicion, a chest computed tomography (CT) scan was done, revealing a "crazy paving" pattern, which then prompted expedited assessment. This finding, however, is not as specific as often discussed and has a broad differential diagnosis, which will be reviewed in detail as part of this case. Furthermore, this report demonstrates a diagnostic approach for PAP that avoids lung biopsy, previously considered to be required for diagnosis of PAP, but is increasingly becoming unnecessary with more advanced blood tests and understanding of their sensitivity and specificity. Additionally, management strategies for PAP will be briefly discussed.Copyright © 2022 Canadian Thoracic Society.
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Background and Aims: The covid-19 pandemic has reversed years of progress in the fight to end tuberculosis. So, the discovery of new drugs as antituberculosis is very much needed. Our previous studies have shown that the extract of Centella asiatica is able to inhibit the growth of Mycobacterium tuberculosis in vitro and requires further research. The aims of this study is to prove the effect of Centella asiatica inhibit Mycobacterium tuberculosis in rat model tuberculosis. Method(s): The protocol in this study was approved by the veterinary ethics committee of Airlangga University. The rat tuberculosis model was induced by intrathecal injection of a suspension of Mycobacterium tuberculosis strain H37 Rv. Twenty-eight tuberculosis rat were randomly divided into four groups. Groups 1,2, and 3 were treated with ethanol extract of Centella asiatica at 375 mg/kgBW, 750 mg/kgBW and 1500 mg/kgBW, and the fourth group was the control group. Centella asiatica extract is administered orally via an intragastric feeding tube for two weeks, once daily At the end of the experimental period, rats were sacrificed by cervical decapitation. The left lung tissue was taken aseptically and cultured on Middlebrook 7H10. Result(s): The results showed that there was no bacterial growth on the culture media in the group that received Centella asiatica extract at a dose of 750 and 1500 mg/kg BW. Conclusion(s): The conclusion in this study, that Centella asiatica extract inhibit the growth of Mycobacterium tuberculosis at doses of 750 and 1500 mg/kg BW. We thank the Directorate of Research and Community Services, the Directorate General of Higher Education, and Ministry of Education and Culture in Indonesia for the financial supportCopyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.
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The reason for the publication of this article was the increase in the number of children with long-standing organic foreign bodies in the respiratory tract, the late diagnosis of which causes severe complications. The article presents the three most significant cases from the general series, when the diagnosis and treatment tactics at the stages of treatment were associated with errors both at the prehospital stage and in the hospital. In the first clinical case, as it turned out, the child had aspired multiple foreign bodies. The first bronchoscopy revealed one solid foreign body. Due to severe fibrinous-purulent endobronchitis and contact bleeding, the bronchoscopy procedure was aborted. However, after 10 days, the child independently coughed up the second seed, which was a surprise to us. Control bronchoscopy after 3 weeks revealed no foreign bodies. In the second clinical observation, a child developed bronchiectasis due to a long stay of a foreign body in the respiratory tract. The third case demonstrates the diagnosis and treatment tactics in a child with a foreign body against the background of a coronavirus infection. In the first and third cases, the results of treatment were satisfactory. In the second case, a long stay of peanuts in the respiratory tract led to bronchiectasis in the lower lobe of the left lung, which required its removal. In the follow-up, there are no complaints, the child grows and develops according to age. The study analyzes the mistakes made at the stages of diagnosis and treatment of children with foreign bodies in the respiratory tract. Conclusion. Young children with long-term and atypically current respiratory diseases, dubious and even normal radiological picture with the absence of comprehensive information on the anamnesis of diseases should alert the doctor to the possibility of aspiration of a foreign body in the respiratory tract and serve as the basis for performing bronchoscopy.Copyright © 2023 National Academy of Pediatric Science and Innovation. All rights reserved.
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Introduction: We report a case of a 67 year old lady with an acute drop in conscious level whilst on a transatlantic flight. She had a background history of TII DM and recent mild COVID. Past surgical history of a gastric bypass, at which time a CXR had incidentally shown a bulla, with no underlying respiratory symptoms, or history of COPD. Method(s): On arrival in the emergency department, her GCS was 7/15, and she required immediate intubation. Non-contrast CT head showed multiple tiny gas locules in keeping with air emboli. CT Chest, Abdo, Pelvis showed an 88mm bulla within the left lung lingula with a bronchus and many large pulmonary vessels running on its edge. Result(s): It was thought the change in air pressure during the flight caused a communication to open between the bulla and the pulmonary circulation resulting in the release of air emboli. Conclusion(s): She required ITU admission for 8 days. After initial stabilisation she was stepped down to HASU. Neurologically she was dysphagic, dysarthric, quadriplegic and GCS 14 due to confusion. MRI whole spine ruled out spinal cord pathology. Repeat CT head showed air initially present had completely resorbed leaving multifocal, small areas of cortical and subcortical ischaemia in both cerebral hemispheres. MRI head confirmed innumerable small early subacute embolic ischaemic infarcts across multiple vascular distributions.
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Introduction: The interest of respiratory physiotherapy maneuvers during a difficult fibroscopy in the intubated patient, sedated in a context of Covid-19 has not been reported so far. Case presentation: A 50-years-old patient with a severe form of Covid-19, requiring an endotracheal intubation, complicated by a ventilator-associated pneumonia and a complete atelectasis of the left lung. Because of adherent and purulent mucus, chest physiotherapy techniques and fiberoptic bronchoscopy conducted separately showed low effectiveness to remove the atelectasis. Chest physiotherapy manual techniques used during fiberoptic bronchoscopy allowed extracting easier the mucus;they helped to remove the atelectasis and to improve the hematosis as well as the prognosis for survival of the patient. Conclusion(s): Manual maneuvers of respiratory physiotherapy during the fibroscopy procedure could improve the efficiency of aspiration of very adherent secretions. Level of Evidence: 5.Copyright © 2022 Elsevier Masson SAS
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Case Report: Tsukamurella species are aerobic, partially acid fast saprophytes commonly isolated from soil and water. They are opportunistic pathogens known to infect multiple organs and can contribute to significant pathologies such as bacteremia, peritonitis, and respiratory tract infections. Moreover, Tsukamurella shares certain characteristic properties to Mycobacterium tuberculosis and Actinomyces species, including the acid fast stain, which can contribute to misdiagnosis of patients. A 68 year old female patient presented to the ED for shortness of breath, fatigue, and weight loss for 6 months. The patient's past medical history includes pulmonary fibrosis, type 2 diabetes, coronary artery disease with stent, hyperlipidemia, hypertension, and M. tuberculosis infection when she was 3 years old in Finland. On admission, labs revealed thrombocytosis (reactive 555 000/microL), leukocytosis (14 450/microL), and microcytic anemia (9.4 microg/dl). Moreover, C reactive protein was elevated and procalcitonin was normal (0.06 microg/l);a COVID-19 PCR was negative. An X-ray revealed severe patchy and interstitial infiltrates throughout both lungs with parenchymal scarring and pleural thickening in the periphery of the left mid-lung zone with multifocal pneumonia. Blood and sputum cultures were performed under the impression of pneumonia, and treatment with azithromycin and ceftriaxone was started. A M. tuberculosis infection was suspected due to a positive AFS. Further chest CT suggested multifocal pneumonia within the left lung in addition to apparent cavitary lesions versus bulla, a chronic interstitial lung disease with traction bronchiectasis, calcified right lower lung nodule, and calcified hilar lymph nodes suggesting a history of granulomatosis diseases. A bronchoscopy with Bronchoalveolar lavage was performed. The initial sputum specimen direct smear showed acid-fast stain positive with Actinomyces growth, and Penicillin G was added to the treatment. Samples were sent to the state department lab, and biopsy revealed granulomatous inflammation negative for malignant cells. One month later, the patient's sputum culture showed Tsukamurella for High-performance liquid chromatography (HPLC). Moreover, a rifampicin sensible M. tuberculosis complex by NAA was also positive six weeks later. The patient was started on a complete TB regimen and continued in the outpatient pulmonology clinic with the addition of levofloxacin for three months and rifampicin substituted for rifabutin. As demonstrated in the case above, a Tsukamurella infection can present similarly to a Mycobacterium infection. Patients may be misdiagnosed or potentially be co-infected. Our patient was further tested and appropriately treated for Tsukamurella after further extensive diagnostic screenings. Due to a high rate of missed cases, it is important to keep Tsukamurella infection on the differential diagnosis as the patient presentation may initially appear to be a Mycobacterium or other pulmonary infection. Copyright © 2023 Southern Society for Clinical Investigation.
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SESSION TITLE: Late Breaking Investigations From Pulmonary and Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Although spirometry is the standard lung functional test, it requires the patient to perform a series of maneuvers correctly, which is difficult for elderly, children, and patients with severe lung impairments. Furthermore, spirometry lacks regional assessment for detecting and monitoring subtle changes in lung diseases, e.g., chronic obstructive pulmonary disease (COPD) and potentially COVID-19. We aim to establish a home-based imaging system, portable electrical impedance tomography (EIT), that can detect lung function deterioration and monitor its recovery through a close-to-effortless breathing paradigm. METHODS: We developed a palm-sized EIT system and a novel guided breathing paradigm that consists of a periodic inhalation and exhalation at 12 breaths per minute. We validated them on healthy subjects (n=23) performing different breathing efforts (deep vs shallow), then on patients with ILD (n=2), COPD (n=8), asthma (n=4) and bronchiectasis (n=4) against healthy (n=8) cross-sectionally, and last monitored a COVID-19 discharged subject with two age- and gender-matched healthy controls longitudinally. We further applied machine learning to distinguish between healthy and patients, and calculated its sensitivity and specificity. RESULTS: We detected higher amplitude during deep breathing compared to shallow (p < 0.001) in healthy subjects, with right lung having more activated voxels and higher total amplitude than the left lung (p < 0.001), likely due to the position of the heart. Cross-sectionally, we observed lower amplitude in patients compared to healthy (p < 0.01), while coefficient of variation (CV) of the amplitude in the lungs is higher in patients (p < 0.05). Note that CV is a parameter reflecting inhomogeneity which is indicative of lung function deterioration. Longitudinally, the COVID-19 discharged subject had higher CV in the left lung (p < 0.001) which decreased across time (p < 0.01), suggesting a functional deterioration at the beginning followed by a recovery. Regional analysis further pin-pointed the potential deterioration and recovery was in the anterior left lung. Separately, despite the small sample size, the sensitivity and specificity for detecting patients using a machine learning classifier were 76% and 62%, respectively, and will likely increase with a larger sample. CONCLUSIONS: Home-based portable EIT with close-to-effortless guided breathing paradigm can map global and regional lung function deterioration and recovery cross-sectionally and longitudinally. More importantly, it can potentially be deployed as a screening tool for various lung diseases through the application of machine learning. CLINICAL IMPLICATIONS: Portable EIT with guided breathing paradigm enables lung function diagnostic screening and treatment monitoring at home, advancing telemedicine and lowering hospital burden. DISCLOSURES: no disclosure on file for Peng Cao;Owner/Founder relationship with Gense Technologies Ltd Please note: Since 2017 Added 06/06/2022 by Russell Chan, value=Ownership interest No relevant relationships by Wang Chun Kwok No relevant relationships by Wei-Ning Lee No relevant relationships by Terence Tam Employee relationship with Gense Technologies Please note: Setpember 2021 - Now Added 06/07/2022 by Adrien Touboul, value=Salary contractor relationship with Gense Technologies Ltd Please note: since Apr 2021 Added 06/06/2022 by Eddie Wong, value=Consulting fee Employee relationship with Gense Technologies Please note: since 2020 Added 06/06/2022 by Fedi Zouari, value=Royalty
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SESSION TITLE: Pulmonary Issues in Transplantation Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Fibrotic interstitial lung disease (fILD) can be idiopathic or associated with several underlying conditions and in response to various types of injury. Post COVID-19 fILD is an increasingly recognized clinical entity with the potential for a large burden of morbidity and mortality.[1] We present a series of 6 patients with progressive pulmonary fibrosis as sequela of COVID-19 requiring lung transplantation. CASE PRESENTATION: Four of the 6 patients had known underlying chronic ILD prior to COVID-19 infection (2 with idiopathic pulmonary fibrosis [IPF] and 1 each with scleroderma and rheumatoid arthritis associated ILD). The other 2 patients had no prior history of lung disease and asymptomatic before infection. One of these had a strong family history of IPF. The presentations involved signs of progressive respiratory failure after the initial lung injury from COVID-19. 4 patients were hospitalized during their acute COVID-19 illness and had varying treatments including steroids, antibiotics, anti-virals, convalescent plasma, Tocilizumab, and non-invasive positive pressure ventilation. At the time of transplant evaluation, CT imaging showed prominent interstitial thickening, honeycombing consistent with fibrotic processes for all our patients;PFT revealed severe restrictive ventilatory defect with reduced diffusion capacity ranging 24%-53%;3 patients required venous-venous extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation for 14 and 93 days. The remainder required 6-10 L of supplemental oxygenation at rest. Two patients underwent initial transplant evaluation while in respiratory failure.5 patients received bilateral lung transplantation and one single left lung transplantation.Duration of time between initial COVID-19 induced lung injury and transplantation ranged from 3-13 months, with a median 6-7 months.Lung explant pathology showed advanced usual interstitial pneumonia in all. Superimposed diffuse alveolar damage was noted in 3 cases. Post-transplant to discharge ranged 10-31 days and at 2 months follow-up, all patients were liberated of oxygen needs. All subjects remain alive at a median 11-12 months, with no evidence of allograft dysfunction. DISCUSSION: Since the emergence of SARS-COV2 in 2019, histopathological fibrotic anomalies have been found to be present in up to one-third of those who recover from ARDS due to COVID-19 [2] and their incidence increases as duration of ARDS increases [3]. Further work is required to understand the pathogenesis of the fibrotic process following acute COVID-19. CONCLUSIONS: We highlight this syndrome with our case series of 6 patients who showed progressive fibrotic disease after COVID-19. Patients with pre-exiting ILD appear to be particularly at risk but this entity may occur in those without pre-existing ILD. Lung transplantation offers a viable treatment option for selected patients with an otherwise poor prognosis. Reference #1: 1.Bharat, A., Querrey, M., Markov, N. S., Kim, S., Kurihara, C., Garza-Castillon, R., Manerikar, A., Shilatifard, A., Tomic, R., Politanska, Y., Abdala-Valencia, H., Yeldandi, A. V., Lomasney, J. W., Misharin, A. V., & Budinger, G. (2020). Lung transplantation for pulmonary fibrosis secondary to severe COVID-19. medRxiv : the preprint server for health sciences, 2020.10.26.20218636. https://doi.org/10.1101/2020.10.26.20218636 Reference #2: 2. Rai DK, Sharma P, Kumar R. Post covid 19 pulmonary fibrosis. Is it real threat?. Indian J Tuberc. 2021;68(3):330-333. doi:10.1016/j.ijtb.2020.11.003 Reference #3: 3. Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with C VID-19-related death using OpenSAFELY. Nature. 2020 Aug;584(7821):430-436. doi: 10.1038/s41586-020-2521-4. Epub 2020 Jul 8. PMID: 32640463;PMCID: PMC7611074. DISCLOSURES: no disclosure on file for Philip Camp;research relationship with United Therapeutics Please note: 2016- ongoing by Reda Girgis, value=Grant/Research research relationship with Pfizer Please note: 2014-2020 by Reda Girgis, value=Grant/Research Speaker/Speaker's Bureau relationship with Boehringher Ingelheim Please note: 2016-ongoing by Reda Girgis, value=Honoraria Speaker/Speaker's Bureau relationship with Genentech Please note: 2016-ongoing by Reda Girgis, value=Honoraria No relevant relationships by Ryan Hadley No relevant relationships by Sheila Krishnan No relevant relationships by Sheetal Maragiri No relevant relationships by Edward Murphy No relevant relationships by Jay Patel No relevant relationships by Keval Ray No relevant relationships by Gayathri Sathiyamoorthy No relevant relationships by Neel Shah No relevant relationships by Subhan Toor
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SESSION TITLE: Lung Cancer Imaging Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a lung condition that is caused by a build-up of proteins, fats, and other substances (collectively called surfactants) in the alveoli of the lungs. Here we describe a case of a 47-year-old female diagnosed with PAP, with radiologic features conflicting with Coronavirus Disease 19 (COVID-19) pneumonia. CASE PRESENTATION: The patient is a 47-year-old female with no significant medical history who presents to the outpatient pulmonology clinic for shortness of breath evaluation. She reported that for the past 3-4 months she has been having progressively worsening shortness of breath (SOB) associated with dry cough, and nasal congestion. She reports no recent illness, no history of COVID or COVID exposure, no second-hand smoke exposure, no toxin/chemical exposure, no pets/birds at home. Her SOB has been impacting her lifestyle. Pulmonary function tests showed no obstruction, moderate restriction, mildly decreased diffusion capacity. Computed tomography (CT) of the chest showed multiple ground-glass opacities with septal wall thickening (appears crazy paving pattern) - suggestive of infection or inflammatory process. Infectious/inflammatory work up with HIV, COVID-19, hypersensitivity pneumonitis (HP) panel, autoimmune panel, immunoglobulins, QuantiFERON gold, IgM mycoplasma antibodies was negative. Repeat CT chest in 6 weeks as per patient request, was unchanged from prior. A bronchoscopy was done, bronchoalveolar lavage (BAL) negative for infection - fungal, acid-fast bacilli, Mycobacterium tuberculosis;GMS (Grocott's methenamine silver) stain negative for fungus;negative PCP (Pneumocystis pneumonia);left upper lobe and left lung biopsy showed lung parenchyma with scant amorphous eosinophilic material in alveolar sacs, Periodic Acid-Schiff stain (PAS) stain was positive confirming PAP diagnosis. DISCUSSION: PAP is a rare disease, affecting about 1 person in 100,000 people worldwide, with fewer than 10,000 of them in the United States. The "crazy paving pattern" is characteristic of PAP but recently it has appeared in the list of radiologic findings for COVID 19 pneumonia1,2,3. In these COVID times, these kinds of interactions might make the decision tougher, often leading to misdiagnosis. The decision of diagnosis/treatment should be based on symptoms and their duration, medical history, previous tests, response to treatment. Given our patient never had a COVID infection in the past or current infection, CT chest was typical for PAP with a crazy-paving pattern, no significant subjective/radiological improvement lead us to the diagnosis of PAP with eventual work up with bronchoscopy. CONCLUSIONS: A high index of suspicion is needed for the diagnosis of such rare diseases as PAP, which can be misdiagnosed as COVID-19 pneumonia, given radiological similarities. Early diagnosis and treatment can improve morbidity and mortality of PAP. Reference #1: PAP with COVID-19 Radiology - Differential Diagnosis Discussion, PMID: 33646114 Reference #2: Proteinaceous Lung With COVID-19: The Mimicker, PMID: 34703683 Reference #3: COVID-19 pneumonia: the great radiological mimicker - https://insightsimaging.springeropen.com/articles/10.1186/s13244-020-00933-z DISCLOSURES: No relevant relationships by Ahmad Al-Alwan No relevant relationships by Arundhati Chandini Arjun No relevant relationships by Farhan Khalid no disclosure submitted for Boning Li;No relevant relationships by Rana Prathap Padappayil No relevant relationships by Raghu Tiperneni
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SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Lung toxicity due to antineoplastic therapy is reported with both cytotoxic and molecularly targeted agents [1]. We present one such case of lung injury induced by capecitabine. CASE PRESENTATION: A 79-year-old female with history of triple negative infiltrating duct carcinoma of the right breast (status post mastectomy and adjuvant chemotherapy with docetaxel and cyclophosphamide 3 years prior) presented to the hospital with dyspnea on exertion following her fourth cycle of capecitabine therapy for breast cancer recurrence. Patient developed nausea, vomiting, and malaise with cycles 1, 2, and 3 of capecitabine therapy with onset of severe dyspnea on exertion, cough, and hypoxia following cycle 4. Computed tomography (CT) scan of the chest on admission showed consolidative opacities in the right upper, right middle, and anterior right lower lobe along with smaller opacities in the left lung apex and small subcentimeter nodules;no pulmonary embolism. Antibiotics were given for a short duration for suspected pneumonia without improvement. Capecitabine was held on discharge. She presented again to the emergency room with worsening shortness of breath, diarrhea, fatigue, and dizziness. COVID test was negative. Chest x-ray redemonstrated patchy airspace disease involving the right apical, lateral, mid lower lung field. Oral steroids were recommended for suspected organizing pneumonia, but the patient refused due to concerns about side effects. Her hospital course was complicated by Clostridium difficile infection (treated with oral vancomycin) and left lower extremity deep venous thrombosis (treated with anticoagulation). Subsequently she followed up with pulmonology outpatient. Repeat imaging showed evolving infiltrates in the same areas with elevated aspergillus IgG level (18.0 mcg/ml) and IgE (178 kU/L) but negative galactomannan and sputum bacterial/fungal/acid fast cultures. Oral steroids were initiated with clinical and symptomatic improvement. DISCUSSION: Capecitabine is a prodrug of fluorouracil (antimetabolite). It is used as a chemotherapy agent in multiple types of cancer including breast cancer. Respiratory side effects include cough (<7%) and bronchitis (<5%). Lung injury/pneumonitis is a rare complication with only a few cases reported to date [2,3]. The timing of symptoms with chemotherapy administration and the negative infectious work-up supports capecitabine as the inciting etiology of lung injury. Withholding chemotherapy and starting systemic steroids were effective treatments in this case of chemotherapy induced lung toxicity. CONCLUSIONS: Capecitabine induced lung injury is a rare but important entity and should always be kept in mind while evaluating dyspnea in cancer patients. Reference #1: Capri G, Chang J, et al. An open-label expanded access study of lapatinib and capecitabine in patients with HER2-overexpressing locally advanced or metastatic breast cancer. Ann Oncol. 2010;21(3):474. Epub 2009 Oct 8. DOI: 10.1093/annonc/mdp373 Reference #2: C. J. Benthin, G. Allada. Capecitabine-Induced Lung Injury. American Journal of Respiratory and Critical Care Medicine 2016;193:A1653. Reference #3: Andrew K Chan, Bok A Choo, John Glaholm. Pulmonary toxicity with oxaliplatin and capecitabine/5-Fluorouracil chemotherapy: a case report and review of the literature. Onkologie. 2011;34(8-9):443-6. doi: 10.1159/000331133. Epub 2011 Aug 19. DISCLOSURES: No relevant relationships by William Karkowsky No relevant relationships by Chahat Puri No relevant relationships by Sahib Singh
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SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION: A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam: faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs: CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 1:40, dsDNA 1:640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR: opacification of the left lung up to midfield. CT chest: moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon: negative. Thoracentesis: 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura: necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity: pan-sensitive M. tuberculosis. Sputum: negative for TB. She was discharged on RIPE treatment for reactivation of TB. DISCUSSION: The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high. CONCLUSIONS: Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1: Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus: case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2):563-568. Reference #2: Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3: Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8):1211-7. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic
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SESSION TITLE: Lung Cancer Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The outbreak of the SARS-CoV-2 virus identified a need for healthcare systems to transform in order to accommodate the large volume of patients. As a result, innovative new methods to monitor patients have emerged. One type of innovation are remote patient monitoring (RPM) devices, which allow for home vital sign (VS) measurements and telemonitoring. We present a case utilizing this technology to monitor a middle-aged male with metastatic colon cancer to the lung, who required regular debulking therapy as a means of palliation. CASE PRESENTATION: A 59 year-old male with a history of stage IV colon adenocarcinoma with metastasis to the lungs status post lung wedge resection and radiation therapy 7 years previously was found to have an enlarging left lower lobe (LLL) mass. Fiberoptic bronchoscopy revealed resurgence of his metastasis. While undergoing palliative chemotherapy, the patient became increasingly dyspneic. Serial PET CTs showed evolution of his left lung mass with left upper and lower lobe collapse due to endobronchial disease prompting bronchoscopy with argon plasma coagulation (APC) for tumor debulking within the left mainstem bronchus and dilation of the LLL airways. While the patient's symptoms improved, he became dyspneic over several months, and interval CT scans demonstrated invasion of the left mainstem bronchus with complete collapse of the left lung. Repeat dilation and APC were performed with improvement in symptoms. Due to rapid tumor growth, he was enrolled in the continuous RPM (CRPM) program for 24/7 nursing-led telemonitoring. He completed daily questionnaires on a vendor-provided digital tablet, and his VS, composed of heart rate (HR), respiratory rate (RR), SpO2, and temperature, were automatically uploaded to a network using an FDA-approved wearable device. Intermittent readings using peripheral devices to measure blood pressure and spirometry were gathered. His VS mirrored his tumor progression, indicated by elevation in his mean RR and HR while his SpO2 declined necessitating 2L of oxygen. Further evaluation showed tumor invasion into the left mainstem bronchus and began to invade his right mainstem. Successive APC and cryotherapy were performed every 2-3 months with a total of 8 debulking bronchoscopies. Once his disease progressed to obstruct his entire left mainstem, the patient unenrolled from the CRPM program and enrolled in hospice care. DISCUSSION: Several RPM devices have previously been used, but require self-reported VS rather than automated, continuous oximetry. Our CRPM program was piloted as a means to monitor COVID-19 patients following hospital discharge. However, our patient displayed benefit from his 180 day CRPM enrollment while receiving palliative tumor debulking procedures in order to fulfill his wish to maximize time at home. CONCLUSIONS: RPM devices offer a novel method of monitoring patients outside of healthcare facilities. Reference #1: Gordon WJ, Henderson D, DeSharone A, et al. Remote Patient Monitoring Program for Hospital Discharged COVID-19 Patients. Appl Clin Inform. 2020;11(05). doi:10.1055/s-0040-1721039 Reference #2: O'Carroll O, MacCann R, O'Reilly A, et al. Remote monitoring of oxygen saturation in individuals with COVID-19 pneumonia. Eur Respir J. 2020;56(2). doi:10.1183/13993003.01492-2020 Reference #3: Grutters LA, Majoor KI, Mattern ESK, Hardeman JA, van Swol CFP, Vorselaars ADM. Home telemonitoring makes early hospital discharge of COVID-19 patients possible. J Am Med Informatics Assoc. 2020;27(11). doi:10.1093/jamia/ocaa168 DISCLOSURES: No relevant relationships by Kevin Loudermilk Speaker/Speaker's Bureau relationship with Janssen Please note: $1001 - $5000 by Michael Morris, value=Honoraria Speaker/Speaker's Bureau relationship with GSK Please note: $1001 - $5000 by Michael Morris, value=Honoraria Removed 03/29/2022 by Michael Morris No relevant relationships by Michal Sobieszczyk No relevant relations ips by Robert Walter No relevant relationships by Whittney Warren
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Introduction: Massive pulmonary embolism is a rare complication following Veno-Venous Extra Corporeal Membrane Oxygenation (VV-ECMO) decannulation. Management can be challenging. The authors present a case that required VV-ECMO re-cannulation and catheterdirected thrombolysis. Main body: 58-year-old gentleman, background of hypertension and asthma, admitted with severe respiratory failure secondary to COVID-19 pneumonitis. Due to lack of improvement with conventional ARDS treatment, he was referred and retrieved on VV-ECMO. After being off sweep gas for more than 24 hours he was decannulated on day 7. Five hours after decannulation the patient acutely deteriorated. He became tachycardic, hypotensive and hypoxic. A bedside TTE showed severely dilated and impaired right ventricle. The patient was started on milrinone and nitric oxide. Nevertheless, he deteriorated further and became profoundly hypoxic and hypercapnic, and a decision was made to start him on VV-ECMO. A TOE was done to guide cannulation and showed a thrombus in the RV and in the left pulmonary artery. Next day, a CT-pulmonary angiogram (CTPA) was done which showed saddle-shaped pulmonary embolism, with a large occlusive clot in the left main pulmonary artery causing complete non-perfusion of the left lung. After a multi-disciplinary team discussion, the patient had catheterdirected thrombolysis, with some haemodynamic improvement. Within 48 hours, TTE was repeated showing no significant improvement on RV function. CTPA showed very mild decrease of the clot burden. Decision was made to repeat catheter-directed thrombolysis and partial thrombectomy. Repeated imaging revealed decrease in the size of the left main pulmonary artery thrombus. It is thought that the massive pulmonary embolism could have been caused by showering of ECMO cannulas-related thrombi, which were dislodged during decannulation. Patient remained on VV-ECMO for 32 days and was decannulated successfully afterwards and was discharged home on apixaban and long-term pulmonary hypertension follow-up. Conclusion: ECMO cannulas related thrombi are not uncommon complications because of prolonged stay and coagulopathy related to ECMO circuit. However, massive embolism is rarely seen. The use of echocardiography was paramount on the differential diagnosis. In this TTE study, the right ventricle looks significantly dilated with severely impaired both longitudinal and radial functions. Additionally noted septal flattening in systole indicating RV pressure overload, diastolic notching of RVOT doppler trace consistent with significantly raised pulmonary artery pressure and mild to moderate tricuspid regurgitation. Otherwise, the left ventricle is small and has preserved function. (Figure Presented).
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Introduction: Mucormycosis is a life threatening fungal infection commonly seen in diabetics and immunocompromised individuals. It is caused by one of the members of mucoraceae family which includes mucor, rhizopus, rhizomucor, absidia and others. Its prevalence has become more common in covid pandemic. Methods: We report a rare case of large cavitatory Rhizopus infection in a renal transplant recipient. Patient was initiated on antitubercular therapy for tubercular lymphadenitis two months prior to transplant. He was given rabbit ATG as induction agent and was on triple maintenance immunosuppression with tacrolimus/ mycophenolate mofetil/ steroids. Patient developed post transplant Diabetes mellitus. Four months post transplant he presented with cough, fever and left sided chest and shoulder pain for 10 days. Covid RT PCR was done twice and it came out to be negative. High Resolution Computed tomography Chest revealed thick walled cavity abutting the chest wall (10.3 x 7.1cm) in left upper lobe. Blood culture was sterile after five days of incubation. Serum Beta galactomannan was negative. He was empirically started on broad spectrum antibiotics and antifungals (oral voriconazole). He underwent bronchoscopy on day 4 of admission. As tuberculosis was a differential, gene expert, tubercular culture and AFB stain was obtained on Bronchoalveolar(BAL) fluid which all came out to be negative. Microbiological sample from BAL Fluid revealed growth of Rhizopus species. He was started on Liposomal amphotericin B. Since the cavitatory lesion occupied almost the entire left lung, surgical resection was offered to the patient to which patient refused. Results: He improved symptomatically after 10 days of Liposomal amphotericin B. Total of 10 weeks of Liposomal amphotericin B was given. Follow up CT after 40 days showed significant reduction in size of cavity to 7.5cm. A surprising complete resolution of the lung cavity was seen after 4 months. Conclusions: This case is one of the very few reported cases of invasive pulmonary rhizopus infections. It emphasizes how medical treatment alone can lead to complete resolution of such large cavitatory lesions without surgical intervention. No conflict of interest
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CASE: A 64 year old female with a history of rheumatoid arthritis (RA) and hypertension presented to the hospital with shortness of breath. Her RA had been well controlled with prednisone 5mg daily and rituximab infusions every 6 months, last given three months prior. SARS-CoV-2 PCR was positive and she was treated with dexamethasone. Two months later, she presented to the emergency department with recurrent shortness of breath. At this time, her cycle threshold was 29.82 and CT chest demonstrated bilateral air bronchograms. No improvement was noted with antibiotics, BAL showed 500 WBCs, 70% lymphocytes and biopsy of the left lung showed chronic interstitial inflammation, consistent with patchy organizing pneumonia. She improved with a course of prednisone 30mg for five weeks. Four months later, she was admitted for worsening shortness of breath. At this time, she was noted to be SARS-CoV-2 PCR negative and bronchoscopy showed no growth on cultures. One month later (7 months from initial hospitalization) she was readmitted with hypoxia. Cycle time was 19 indicating high viral load, SARS-CoV-2 PCR positive, nucleocapsid antibody positive and spike IgG antibody negative thus suggesting reinfection with lack of immune response to vaccination. She was treated with remdesivir with minimal improvement. Due to concern for reinfection, she was treated with baricitinib and casirivimab-imdevimab monoclonal antibody treatment with improvement. CD19 count was <10 with <0.5%, consistent with B cell depletion. IMPACT/DISCUSSION: Rituximab, an anti-CD20 monoclonal antibody that results in B-cell depletion, is commonly used to treat rheumatoid arthritis. While it is essential for disease control, it also risks compromising antiviral immunity, re-infection to SARS-CoV-2, and impaired vaccine efficacy (1). Our case describes a patient with rheumatoid arthritis treated with rituximab infusion, and her subsequent prolonged COVID-19 re-infection with multiple hospitalizations. B-Cell depletion from rituximab infusion leading to a prolonged COVID-19 course is a rare and relatively new phenomenon that is being reported over the course of the pandemic. Given her intermittent negative testing, high viral load, and lack of response to prior vaccination, it is likely that her presentation represented true re-infection in the setting of insufficient antibody production due to rituximab, further supported by improvement with monoclonal antibody treatment. As demonstrated by this patient, monoclonal antibodies were particularly effective in clinical improvement given her own lack of antibody response. CONCLUSION: While rituximab may be safe for many patients, it may result in significant, prolonged B-cell depletion. This depletion may increase the risk of reinfection, affect vaccine response and antibody formation. Administration of monoclonal antibody treatment should be considered in immunosuppressed and B-cell depleted patients with COVID-19 infection.
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We present a case of a male patient who underwent right-sided pneumonectomy due to central low-grade squamous cell carcinoma of the right lung, chemo-, radio-, and immunotherapy. However, the disease progressed. In addition the patient got SARSCoV-2 pneumonia in the left lung, followed by postpneumonectomy empyema. Right-sided uniportal video-assisted thoracoscopy, debridement, and definitive drainage of the pleural cavity were performed.
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BACKGROUND: Coronavirus disease 2019 (COVID-19) has distracted the global health system due to significant morbidity and mortality. There are increasing mortality rates related to the existence of comorbidities. Due to immunologic conditions, other infectious diseases, such as multidrug-resistant tuberculosis (MDR-TB), might coinfect with COVID-19. We describe a case of MDR-TB with diabetes mellitus and critical COVID-19 patient with fatal outcome. CASE REPORT: A 60-year-old man was admitted to our hospital with shortness of breath for 2 days. A history of recurrent shortness of breath has had developed for about 7 months. Room air oxygen saturation was at 66%. RT-PCR SARS-CoV-2 nasopharynx swab result was positive. The chest X-ray series result showed destroyed left lung with increasing infiltrate in the lower right lung. The patient was diagnosed with pulmonary MDR-TB based on GeneXpert and LPA (Line Probe Assay) test 6 months prior and also has had history of diabetes mellitus for 7 years. Then, the patient was diagnosed with COVID-19, pulmonary MDR-TB, and diabetes mellitus. MDR-TB regimen, anti-diabetic medication, and management of COVID-19 were carried out. On the 6th day, the patient’s condition worsened to the point, where he needed intubation. The patient eventually passed away. CONCLUSION: The treatment outcome was highly related to the severity of COVID-19 symptoms and complications of comorbidities when patients are admitted to the hospital. The early screening and treatment of COVID-19 are important to prevent deteriorating clinical conditions caused by comorbidities.
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Objective: The patient was a 59-year-old man who was referred to the hospital due to shortness of breath due to increased activity, accompanied by cough, weakness, and lethargy. The patient also had a history of diabetes, hypertension, hyperlipidemia, and asthma. The patient also underwent cardiac stenting last year. LCX and LAD stenting Design and method: He had a continuous pan-systolic murmur on cardiac examination diagnosed with valvular dysfunction. Severe aortic regurgitation was reported on echo. The patient underwent a CT scan of the lungs and a PCR test to rule out Covid-19, which was negative. Finally, the patient was diagnosed with severe aortic regurgitation and underwent aortic valve replacement surgery. Echocardiography was performed before the operation, and the diagnosis was confirmed. Results: Echocardiography was performed postoperatively, which showed good valve function and no valve leakage. From the 5th day after the operation, the patient developed fever and increased leukocytosis. Suspected of having Covid19 and accordingly underwent PCR test, the test result was positive;the patient underwent a CT scan of the lungs. After that, he was transferred to the corona ICU. The patient was treated with Remdesivir, and after two weeks, his PCR was negative, and he was almost ready to be discharged. The patient had completed the entire course of treatment and developed pulmonary fibrosis due to Covid disease, but suddenly, after two weeks from the onset of the illness, she developed severe shortness of breath, which led to intubation. We find severe pulmonary fibrosis in the re-CT scan, especially in the left lung, where the entire left lung had fibrosis. Prednisolone was started at a dose of 50 mg three times a day. The patient was intubated for ten days, then gradually removed from the device. Now the patient is extubated and ready for discharge. Conclusions: Risk factors such as Past cardiac surgery and present cardiac intervention with diabetes mellitus increase the risk of developing lung failure in these Covid19 patients. Elective intubation is better than emergency intubation in patients with comorbidities. Corticosteroids can be effective in treating pulmonary insufficiency.
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Introduction: Pneumonic-type lung adenocarcinoma (P-ADC) exhibits a pattern of lung cancer that is radiologically like pneumonia1. It may be misdiagnosed and represents a diagnostic challenge in the setting of progressive respiratory failure. We report a case of P-ADC which presented with rarely described extensive diffuse air-space consolidation. Case Presentation: This is a 74-year-old female with a history of Crohn's disease on Mesalamine, Diabetes Mellitus, Hypertension, Hyperlipidemia and former smoker of 40 pack years admitted to the ICU for hypoxic respiratory failure requiring 100% O2 via HFNC. Twenty-two months prior to admission the patient underwent an EBUS following abnormal low dose lung cancer screening CT (Figure 1A-B). The CT demonstrated left infrahilar consolidation and multiple ground-glass nodules. The EBUS with biopsy/brushings of the mass in addition to bronchoalveolar lavage (BAL) were negative. She was lost to follow-up due to the COVID-19 pandemic. Two weeks prior to admission she was admitted for cough and dyspnea, treated for a community acquired pneumonia following CT showing excessive nodular opacities with left dense consolidations. On day of admission the patient presented from outpatient PFT with hypoxemia requiring 8LPM O2 and saturation of 90%, admitted to ICU on HFNC. Associated symptoms were recent unintentional 20 lbs weight loss and fatigue. CT imaging was remarkable for progressive, fulminant left lung consolidation and contralateral lung nodules (Figure 1C-D). The patient underwent a bedside bronchoscopy which showed normal anatomy and copious thin clear secretions. BAL samples showed malignant cells favouring nonsmall cell carcinoma. Further CT guided FNA showed the tumor cells were consistent with adenocarcinoma and positive for TTF1/Napsin A, negative for p40, and KRAS mutation detected. The patient was started on methylprednisolone, Carboplatin and Pemetrexad and discharged home on 6 LPM oxygen. The patient was shortly after re-admitted for a post obstructive pneumonia and progressive hypoxemic respiratory failure, she transitioned to hospice care and passed away during the hospitalization. Conclusion: P-ADC is uncommon and often misdiagnosed due to unusual presentation mimicking infectious and inflammatory diseases2. It is unclear whether P-ADC represents an extreme form, later stage, or entirely different entity of lung cancer and large airspace consolidations are rarely reported3. Lesions of pneumonia type that extend beyond one lobe on CT are associated with microscopy involvement of both lungs and pathologic correlation shows that CT is unable to reveal multifocality in a high percentage of cases which makes the extend of multifocal consolidations in this case rarely described4-6. (Figure Presented).
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Objective To explore the application value of CT pulmonary function imaging in patients with Coronavirus Disease 2019 (COVID‑19) in the convalescent phase. Methods The COVID‑19 patients who were clinically cured and discharged from Union Hospital, Tongji Medical College, Huazhong University of Science and Technology were prospectively collected from January to April 2020. Clinical pulmonary function tests (PFTs) and CT pulmonary function imaging were performed 3 months after discharge. The Philips IntelliSpace Portal image post‑processing workstation was used to obtain the paired inspiratory‑expiratory CT quantitative indexes of the whole lung, left lung, right lung and five lobes. The patients were divided into two groups according to whether residual lesions remain in inspiratory CT images: non‑residual lesion group and residual lesion group. The chi‑square test was used to compare the differences in the PFT results between groups;the Mann‑Whitney U test was used to compare the differences in PFT indexes [forced expiratory volume in the first second as percentage of predicted value (FEV1%), FEV1/forced vital capacity (FEV1/FVC), total lung capacity as percentage of predicted value (TLC%), FVC% ] and the differences in quantitative CT indexes [lung volume (LV), mean lung density (MLD), volume change in inspiratory phase and expiratory phase (∆ LV)] between groups. Multiple linear regression was used to analyze the relationship between CT pulmonary function imaging and PFT indexes of convalescent COVID‑19 patients. Results Of the 90 patients with COVID‑19, 35 were males and 55 were females;45 were included in the non‑residual lesion group and 45 were included in the residual lesion group. Fifty‑three patients had clinical pulmonary dysfunction 3 months after discharge, including 22 patients in the non‑residual lesion group and 31 patients in the residual lesion group. In patients with residual disease, left lower lobe and right lower lobe LV, left lower lobe and right lower lobe ∆ LV in the inspiratory and expiratory phase were smaller than those without residual disease;whole lung, left lung, right lung, left upper lobe, left lower lobe and right lower lobe MLD in the inspiratory phase and left lower lobe and right lower lobe MLD in the expiratory phase were greater than those without residual disease (P<0.05). Since there was no significant difference in FEV1/FVC and FVC% between residual and non‑residual lesion groups (P>0.05), FEV1/FVC and FVC% of two groups were combined. Multiple linear regression analysis showed FEV1/FVC= 91.765-0.016×LVin‑right middle lobe+0.014×MLDex‑left lower lobe (R2 =0.200, P<0.001), FVC% =-184.122-0.358× MLDin‑right lung-0.024× ∆ LVleft upper lobe (R2 =0.261, P<0.001). There was significant difference in TLC% between residual and non‑residual lesion groups (P<0.05), so multiple linear regression analysis was performed both in the two groups. In the non‑residual lesion group, TLC% =80.645+0.031× (R2 =0.132, P<0.001);In the residual lesion group, TLC% =-110.237-0.163× LVex‑right lower lobe MLDin‑right upper lobe-0.098×MLDex‑left upper lobe -0.025×LVex‑right lower lobe (R2 =0.473, P<0.001). Conclusion CT pulmonary function imaging can quantitatively analyze the whole lung, unilateral lung and lobulated lung, thus reflecting the regional pulmonary function, providing more valuable diagnostic information for the assessment of ulmonar function in convalescent atients with COVID‑19