Case Series of Burkholderia Pseudomallei Causing Melioidosis (Pulmonary, Cerebral, and Splenic Abscess)

Burkholderia pseudomallei is soil saprophytic Gram-negative bacilli that cause a fatal disease called melioidosis. Melioidosis is capable of causing cutaneous infection and systemic infections in the respiratory tract, cardiovascular, gastrointestinal, urinary, skin and soft tissue, and musculoskeletal and central nervous systems. Here, we report rare forms of pulmonary, cerebral, and splenic abscess case series of melioidosis caused by B. pseudomallei. Imported cases have been reported among tourists, immigrants, and soldiers who returned from endemic areas. The acquisition of infection is through percutaneous, inhalation, and ingestion of contaminated water;person-to-person transmission is very rare. Melioidosis cases are primarily found in the rainfall season and are usually associated with risk factors such as diabetes, alcoholism, and chronic renal diseases. However, 20-26% of cases were not associated with predisposing conditions. The identification is based on colony morphology, Gram stain, antibiotic susceptibility testing, and other supportive automated and molecular assays when we suspect B. pseudomallei. There are two phases, the intensive and eradication phases, in managing melioidosis. In the intensive phase, ceftazidime for 2 weeks showed efficacy in almost 50% of cases, and the eradication phase treatment with co-trimoxazole and doxycycline or amoxicillin/clavulanic acid for 3-6 months showed an excellent response. The improper clinical diagnosis and management of B. pseudomallei can lead to complications. Hence, early diagnosis with microbiological approaches such as culture, biochemical reactions, or automated systems available and antimicrobial sensitivity testing will cure the patient quickly without mortality.Copyright © 2023 The Authors.

Exploring the mechanism of action of three agents white powder in the care for pulmonary diseases based on network pharmacology and technology for molecular docking

Based on the international concern about COVID-19 and pulmonary diseases, the number of cases of lung injury caused by COVID-19 pneumonia and its complications has increased dramatically in recent years, and the complexity of the situation makes the combination of single drugs a major problem in respiratory diseases. Therefore, it would be feasible to replace single drug combinations with compounded formulations for the treatment of a diverse array of pulmonary diseases. At the same time, the visualization of the chemical composition of herbal formulations and the study of molecular interactions to reveal the mechanism of action will be of practical significance. This paper introduced the therapeutic mechanisms of the traditional Chinese medicine formula Three Agents White Powder. Three major pulmonary diseases, COVID-19, pulmonary fibrosis, and lung abscess, were investigated using molecular docking and network pharmacology approaches. Mainly using TCMSP, DAVID, STRING, Genecard database screening, and autodock molecular docking methods, this paper verified that this drug applies its healing benefits to pulmonary diseases through multiple components, multiple targets, and multiple pathways, and illustrated the effectiveness of this formula in the adjuvant treatment of extensive pulmonary diseases. © 2023 SPIE.

Expect the Unexpected: Invasive Central Nervous System (Cns) Aspergillosis in Non-Neutropenic Patients - a Case Series of 15 Patients from India

Intro: Invasive aspergillosis of CNS is a severe form of aspergillosis & is associated with high mortality. Most of these cases are suspected & diagnosed in neutropenic patients. We hereby describe a series of 15 patients with CNS aspergillosis in non-neutropenic patients from a tertiary care hospital in India. Method(s): All patients with clinical & radiological features suggestive of CNS aspergillosis were screened for microbiological evidence of invasive aspergillosis, either by demonstration of hyphae by microscopy or histology, culture or galactomannan assay. Patients demographic details, clinical features, risk factors, diagnosis, management & outcome details were documented. Finding(s): A total of 15 patients were found to have CNS aspergillosis, 5 isolated CNS infections & 10 showing concomitant CNS & pulmonary aspergillosis in one between January 2021 to July 2022. The average age was 41.46+/-14.6y, with majority being male. Among the risk factors, most common ones were fungal sinusitis (46.6%), steroid use (40%), COVID-19 (33.3%). One patient had history of endoscopic sinus repair, another had h/o lung abscess. Most common symptoms of CNS aspergillosis were headache (73.3%), fever (60%), altered sensorium (53.3%) & seizures (47.6%). Radiologically, the common findings included ring enhancing lesion, s/o cerebral abscesses were observed in four patients. Direct microscopy s/o fungal hyphae were reported in 5 patients, with 4 culture positives. Average serum galactomannan was 1, while CSF galactomannan showed better sensitivity with mean CSF galactomannan being 2.53. Almost all patients were treated with Voriconazole based on weight, but showed high mortality of 60% even after initiation of therapy. Complete resolution were seen in only two patients, while 4 patients remaining static in improvement during 6 months follow up. Conclusion(s): Invasive CNS aspergillosis must be suspected even with nonneutropenic patients with newer emerging risk factors like steroid use, COVID-19 & h/o fungal sinusitis presenting with clinical & radiological manifestations.Copyright © 2023

Lung Abscess and Pyothorax in Critically Ill COVID-19 Patients: A Single-Center Retrospective Study.

The mortality rate of patients with COVID-19 pneumonia requiring mechanical ventilation remains high. This study determined the percentage and characteristics of patients who developed lung abscesses or pyothorax and their mortality rates among adult patients with COVID-19 admitted to the ICU who required mechanical ventilation. Of the 64 patients with COVID-19 assessed, 30 (47%) developed ventilator-associated pneumonia (VAP), of whom 6 (20%) developed pyothorax or lung abscess. There were no statistically significant differences in patient characteristics, treatment after ICU admission, or outcomes between those with and without these complications, except for age. VAP complicated by Lung abscess or pyothorax was caused by a single organism, with Staphylococcus aureus (n = 4) and Klebsiella species (n = 2) being the primary causative agents. Occur infrequently in patients with COVID-19 requiring mechanical ventilation. Large-scale studies are required to elucidate their effects on clinical outcomes.

[Surgical approach for destructive pneumonia associated with COVID-19]. / Taktika khirurgicheskogo lecheniya destruktivnoi pnevmonii, assotsiirovannoi s infektsiei COVID-19.

There were over 400 million people with COVID-19 pneumonia worldwide and over 12 million in the Russian Federation after 2020. Complicated course of pneumonia with abscesses and gangrene of lungs was observed in 4% of cases. Mortality ranges from 8 to 30%. We report 4 patients with destructive pneumonia following SARS-CoV-2 infection. In one patient, bilateral lung abscesses regressed under conservative treatment. Three patients with bronchopleural fistula underwent staged surgical treatment. Reconstructive surgery included thoracoplasty with muscle flaps. There were no postoperative complications that required redo surgical treatment. We observed no recurrences of purulent-septic process and mortality.

Lung abscess as a secondary infection of COVID-19: A case report and literature review.

A 16-year-old male was admitted with persistent fever, diarrhea, and anorexia 8 days after the diagnosis of coronavirus disease-2019 (COVID-19). Radiological examination of the lungs showed a cavitary lesion with an air-fluid level, but no apparent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. The lesion was diagnosed as a lung abscess after COVID-19. Treatment with antimicrobials was initiated, which attenuated symptoms and the lung lesion. Specific pathogens were not detected despite repeated sputum cultures, which suggested that lung abscess was caused by oral bacteria as a secondary infection of COVID-19. To date, several cases of lung abscess as a complication of COVID-19 have been reported. However, the majority of cases occurred after intubation to treat COVID-19, and there have been no cases involving young adults. This healthy young patient may have developed lung abscess due to COVID-19.

A complicated tale of an acquired tracheoesophageal fistula: A case report

Background: Esophageal atresia (EA) with distal trachea-esophageal fistula (TEF), the most common variety of EA, is managed by primary end-to-end anastomosis. Recurrent TEF constitutes the most difficult-to-manage complication of the primary repair and has an incidence of 2% to15%. Case Presentation: We present a case of rare recurrent TEF after primary repair of EA. The difficulties faced in view of the COVID pandemic and difficult diagnosis are discussed. We share our experience in the successful management of acquired TEF and lessons learned. Conclusion: Recurrent trachea-esophageal fistula is one of the rare and challenging complications to manage. The surgical option carries the best overall prognosis. © 2022 Manchanda et al.

Lung abscess due to Streptococcus intermedius associated with SARS CoV-2 infection in pregnancy: Unusual presentation and complication of a commensal bacteria during pregnancy.

Streptococcus intermedius is a commensal bacterium reported in a few cases as the causative agent of brain and lung abscesses, pneumonia, and endocarditis. Lung abscesses due to Streptococcus intermedius are rare, especially in pregnancy. We describe the first case of lung abscess due to Streptococcus intermedius in a pregnant woman.

Diagnosis and management challenges of a pulmonary hydatid cyst in the context of the COVID-19 pandemic-case presentation

Hydatid cyst is a parasitic disease which occurs in multiple locations. The pulmonary localisation is preferential and responsible for an important symptomatology, being the second localisation after the hepatic one, which in most cases evolves asymptomatically. We present the case of a 24-year-old patient, who is a non-smoker and has had exposure to respiratory allergens (cat hair and dog hair), and who was admitted to the Pneumology Hospital with the complaints of cough with mucopurulent sputum and minimal haemoptysis and mild fever (37.1°C). It was reported that 3-5 weeks before hospitalisation, the patient had presented with an episode of vomiting, in moderate amounts with a typical appearance, but in the current context of the Coronavirus Disease-2019 (COVID-19) pandemic, he had delayed his presentation to the hospital. On clinical evaluation, the patient presented with diminished right basal vesicular murmur with overlying crackling rales. Following the investigations, the postero-Anterior pulmonary radiography describes, at the level of the right lung, a hydro-Aerial image with an uncertain appearance of unspecified aetiology. In this context, a native chest tomography (CT) was performed, which revealed a cystic formation at the level of the middle lobe, with thin walls and a prolific membrane detached inside, which are suggestive aspects for a hydatid cyst. Subsequently, a surgical consultation was performed, which concluded the superinfection of the cyst by a secondary lung abscess and the need for lobectomy. The peculiarity of the case consists in the appearance of persistent symptomatology and complications in a young patient without comorbidities and risk factors, and the fact that an accurate diagnosis was delayed because of the patient's delayed presentation in the hospital in the context of the COVID-19 pandemic. © 2022 Claudia Elena Tonca et al., published by Sciendo.

COVID-19 infections and vaccinations among patients receiving ozanimod in the daybreak open-label extension trial

Introduction: COVID-19 emerged in late 2019. It is unclear whether selective sphingosine 1-phosphate (S1P) receptor modulators affect clinical outcomes of COVID-19 in patients with relapsing multiple sclerosis (RMS), including those who received SARS-CoV-2 vaccination. Objective(s): To characterise COVID-19 outcomes and vaccine breakthrough infections during ozanimod use, an S1P1 and S1P5 modulator, for treatment of RMS in an ongoing open-label extension (OLE) study. Method(s): DAYBREAK (NCT02576717), an OLE study of ozanimod 0.92 mg/d, began 16Oct2015. Patients who completed a phase 1-3 ozanimod RMS trial were eligible;>90% are from Eastern Europe. In this post hoc analysis, COVID-19 events from 1Nov2019 to 28Jan2022 in DAYBREAK were identified by MedDRA 24.1 COVID-19 SMQ (narrow scope). Each patient's most recent infection and all postvaccination infections were characterised. Result(s): Of 2181 patients in DAYBREAK during the analysis period, 319 (14.6%) developed COVID-19 (274 confirmed, 45 suspected). COVID-19 was nonserious in 291 (91.2%). During COVID-19, ozanimod was continued in 220 (69.0%) patients, interrupted in 94 (29.5%), and permanently discontinued in 3 (0.9%);action was unknown in 2 (0.6%) patients. At data cutoff, 285 (89.3%) had recovered (including 195 who had continued ozanimod), 6 (1.9%) recovered with sequelae, 5 (1.6%) were recovering, 16 (5.0%) had not recovered, and 5 (1.6%) died;a sixth COVID-19-related death due to lung abscess occurred after recovery with sequelae from COVID-19 infection. Of 1984 patients in DAYBREAK on 11Dec2020, when COVID-19 vaccines emerged, 596 (30.0%) received >=1 vaccine dose (415 [69.6%] mRNA;99 [16.6%] replication-defective viral vector;65 [10.9%] inactivated SARS-CoV-2;26 [4.4%] other);504 (25.4%) were fully vaccinated. COVID-19 occurred in 39/596 (6.5%) vaccinated patients and 213/1388 (15.3%) unvaccinated patients;3 postvaccination cases (including 1 case after 2 mRNA doses) were serious. Of 39 patients with postvaccination infections, 28 (71.8%) recovered (including 2/3 serious cases), 1 (2.6%) recovered with sequelae, 3 (7.7%) were recovering, and 7 (17.9%, including the third serious case) had not recovered at data cutoff. There were no COVID-19-related deaths among vaccinated patients. Conclusion(s): COVID-19 cases were largely nonserious, and the majority of infected patients recovered while continuing ozanimod. Few vaccinated patients developed COVID-19;most who did recovered without sequelae.

ROLE OF DEBULKING FOR BENIGN ENDOBRONCHIAL LESIONS: A CASE OF CHRONICALLY ASPIRATED FOREIGN BODY PRESENTING AS NECROTIZING PNEUMONIA

SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration can affect ventilation-oxygenation dynamics causing significant morbidity and mortality in children and adults. Patient presentation can range from asymptomatic to life-threatening hypoxia. A thorough history and physical examination helps in narrowing differential diagnosis and provision of timely management. A myriad of complications can occur from aspirated Foreign body including recurrent pneumonia, lung abscess, obstructive emphysema, and death. Here we present a case of a patient with recurrent pneumonia from a chronically aspirated foreign body. CASE PRESENTATION: 37-year-old male with past medical history of a recent COVID-19 infection and bronchus intermedius endobronchial mass (squamous metaplasia on biopsy 2009) who presented with fever, chest pain, worsening dyspnea. Initial workup was consistent with severe sepsis. A CT chest showed complete collapse, cavitation in right lower lobe and presence of right bronchus stent. Patient was treated with IV fluids and antibiotics during the hospitalization. He underwent bronchoscopy for airway examination and bronchoalveolar lavage. Airway exam showed a large endobronchial mass in the bronchus intermedius. Endobronchial biopsies were taken, followed by tissue debulking using flexible forceps and cryoprobe. A yellow plastic foreign object was then visualized dislodged in the right lower lobe. This was successfully removed with grasping forceps. Patient had to be extubated and be reintubated to remove foreign object in one piece as it did not fit the endotracheal tube. Post debulking, bronchus intermedius and right lower lobe were patent and procedure was completed. Our patient responded well to treatment he was ultimately transitioned to oral antibiotics and discharged home with outpatient follow up. Repeat bronchoscopy 6 weeks later showed normal airways. DISCUSSION: Our case illustrated the importance of thorough investigation while treating patients with recurrent pneumonia, and this sometimes should include bronchoscopy with airway exam. In our case a bronchoscopy was done several years ago, however the foreign body was not identified as the cause of the endobronchial lesion. A lingering foreign body in the long run has significant morbidity as seen in our case despite appropriate treatment with antibiotics patient continued to have recurrent post obstructive pneumonias. Bronchoscopy remains the gold standard in definitive diagnosis and management of foreign body. Since the refinement of bronchoscopy and debulking, the rate of mortality from foreign body aspiration has been remarkably reduced. CONCLUSIONS: In summary patients with history suggestive of potential foreign body aspiration presenting with recurrent pneumonias at a particular anatomical location should prompt physicians to perform diagnostic bronchoscopy, which remains the gold standard for diagnosing of foreign body aspiration Reference #1: Foreign Body Aspiration Natan Cramer;Noel Jabbour;Melissa M. Tavarez;Roger S. Taylor. DISCLOSURES: No relevant relationships by Maria Abril No relevant relationships by Bilal Bangash No relevant relationships by Imran Tarrar

LARGE BILATERAL PNEUMATOCELES COMPLICATING COVID-19 RECOVERY

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pulmonary clinicians are all too familiar with the ground-glass and consolidative pulmonary opacities that are the hallmark of COVID-19 pneumonia on imaging. As the pandemic continues, we encounter an ever-growing list of complications of SARS-CoV-2 infection. Pneumatoceles are thin-walled, gas-filled spaces within the lungs that occur in association with pneumonia or chest trauma and typically resolve spontaneously1 but may rupture and cause pneumothorax2. Reports of pneumatoceles due to COVID-19 are uncommon. In this case report, I describe a patient who developed large bilateral pneumatoceles as a complication of COVID-19. CASE PRESENTATION: A 25-year-old male non-smoker with no significant past medical history presented with dyspnea after a lab-confirmed diagnosis of COVID-19 nine days prior. Initial chest radiograph showed multifocal bilateral airspace infiltrates consistent with COVID-19 pneumonia. He was admitted for management of acute hypoxic respiratory failure and treated with dexamethasone, remdesivir, and tocilizumab. He required heated high-flow nasal cannula oxygen up to 60 LPM but did not require CPAP or mechanical ventilation. On hospital day 5 he developed increasing tachypnea and exertional desaturation. CT pulmonary angiogram (CTPA) ruled-out pulmonary embolus but revealed progression of bilateral infiltrates and extensive pneumomediastinum with subcutaneous air in the neck and chest wall, and no clear evidence for pneumothorax. The patient discharged on day 12 with oxygen but returned 2 days later with new onset hemoptysis. CTPA on admission showed new bilateral pneumothoraces and he was transferred to a quaternary hospital for intensive care where bilateral chest tubes were placed. Repeat CT Chest after lung expansion revealed bilateral cystic areas within the lungs initially concerning for necrotizing infection. Bacterial and fungal cultures were negative. Despite resolution of the pneumothoraces and removal of chest tubes, he continued to experience hemoptysis and chest pain. CT Chest demonstrated enlargement of now clearly very large pneumatoceles with air-fluid levels. After conservative management and discharge, a 6-week surveillance CT showed significant decrease in the pneumatoceles but a new moderate-to-large right pneumothorax. Ultimately after 2 more admissions and 90 days since COVID-19 diagnosis, he underwent wedge resection and mechanical pleurodesis for definitive management of secondary pneumothoraces. DISCUSSION: A pneumatocele, especially when large and containing an air-fluid level, may mimic hydropneumothorax, empyema, or pulmonary abscess among other diagnoses. Failure to recognize a pneumatocele and differentiate it from other conditions could lead to inappropriate treatment and cause patient harm3. CONCLUSIONS: It is important to recognize pneumatoceles as a potential complication in the post COVID-19 setting to guide appropriate management. Reference #1: Quigley, M. J., & Fraser, R. S. (1988). Pulmonary pneumatocele: pathology and pathogenesis. AJR. American journal of roentgenology, 150(6), 1275–1277. https://doi.org/10.2214/ajr.150.6.1275 Reference #2: Odackal, J., Milinic, T., Amass, T., Chan, E. D., Hua, J., & Krefft, S. (2021). A 28-Year-Old Man With Chest Pain, Shortness of Breath, and Hemoptysis After Recovery From Coronavirus Disease 2019 Pneumonia. Chest, 159(1), e35–e38. https://doi.org/10.1016/j.chest.2020.07.096 Reference #3: Jamil A, Kasi A. Pneumatocele. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556146/ DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: 2018 to present Added 04/01/2022 by Erin Peterson, value=Honoraria

A BLOODY MASQUERADE: A CURIOUS CASE OF HEMOPTYSIS

SESSION TITLE: Variety in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Actinomyces is a Gram-positive anaerobic and micro aerophilic filamentous bacillus that normally colonize the human mouth and digestive and urogenital tracts. They most commonly cause cervical and abdominopelvic infections and rarely pulmonary actinomycosis. CASE PRESENTATION: 67-year-old female with past medical history of recurrent DVT with IVC filter placement, non- ischemic cardiomyopathy, atrial fibrillation, 40 pack year history, recent COVID19 infection, lung nodules & COPD presented with complaint of coughing up blood associated with chest pain for the past 2 days. She had a low-grade fever with stable vitals with preliminary labs showing she was anemic and had reactive leukocytosis. She was recommended to hold oral anticoagulation and follow-up outpatient during when her symptoms worsened. On admission she was started on tranexamic acid nebulization for hemostasis and underwent CTA chest which showed no evidence for pulmonary embolism but commented on a right lower lobe perihilar 12.5 mm mass which has increased in size compared to previous scans. Patient underwent bronchoscopy which showed generalized edema of the tracheobronchial tree with bleeding from superior segment of the right lower lobe bronchus with no visualization of mass. PET scan showed hyper-metabolic lung mass with concerns for malignancy. CT guided biopsy of nodule was done and was not staining for malignant cells, acid fast bacilli with no fungal or bacterial growth. Blood cultures and Karius Digital cultures were also negative. She began expectorating blood clots despite being on treatment and cardiothoracic surgery was consulted. A partial lobectomy with lysis of adhesions of the right lower lobe was done. Specimen sent to pathology showed no evidence for malignancy but instead elicited a contained pulmonary abscess containing filamentous bacteria with parenchymal inflammation with areas of chronic hemorrhagic fibrosing pleuritis and hilar thrombi. She was diagnosed with pulmonary actinomycosis and started on IV 24,000,000 IU penicillin. She underwent a panoramic dental x-ray which was read as suboptimal dentition with multiple missing teeth and did not identify a source. Patient symptoms resolved post lobectomy and since discharged on long course of antibiotics. She continued to have no more episodes of hemoptysis. DISCUSSION: Hemoptysis as a symptom of pulmonary actinomycosis is a rather rare presentation. Actinomycosis causes cavities, nodules, and pleural effusions. It is commonly mistaken for chronic suppurative lung disease and sometimes malignancy. Isolation and identification occur only a minority of cases with a high culture failure rate due to previous antibiotic therapy, inadequate incubation time or culture conditions. CONCLUSIONS: Due to it's variable presentation pulmonary actinomyces has a large overlap with other diseases but must be considered in the differential of unexplained hemoptysis. Reference #1: Hemoptysis secondary to actinomycosis: A rare presentation. PMID: 24778485 PMCID: PMC3999682 DOI: 10.4103/0970-2113.129864 DISCLOSURES: No relevant relationships by Victoria Famuyide No relevant relationships by rukhsaar khanam

FINGERNAIL CLIPPING AS A FOREIGN BODY CAUSING SEVERE EMPYEMA

SESSION TITLE: Chest Infections with Pleural Involvement Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration (FBA) is an uncommon cause of dyspnea and respiratory infection. 80% of cases occur in children under 15-years-old, with the highest mortality in children under 1 and adults over 75. We present an unusual case of a fingernail clipping causing severe empyema in a middle-aged male. CASE PRESENTATION: A 44-year-old male with diabetes mellitus presented with a 3-day history of dyspnea, productive cough, and anorexia, and a 1-day history of fevers and substernal chest pain. Exam was notable for fever, tachypnea, tachycardia, and hypoxemia requiring a non-rebreather mask. Labs were significant for a negative COVID-19 polymerase chain reaction (PCR) test, white blood cell (WBC) count 17,000 μL, and lactate 3.4 mmol/L. He was given albuterol-ipratropium nebulizer treatments and methylprednisolone 125 mg. Chest x-ray revealed a large right-sided air-fluid level, dense consolidation of the lung base, and complicated pleural effusion. Computed Tomography (CT) of the chest revealed a large right mid-lung abscess, right middle lobe (RML) and right lower lobe (RLL) consolidations, and loculated pleural effusion with hydropneumothorax. A surgical chest tube was placed that drained purulent fluid. The effusion grew Klebsiella pneumoniae, which was treated with ampicillin-sulbactam. Repeat CT chest revealed improved loculated effusion, but persistent RML and RLL consolidations with concern for endobronchial obstruction. Flexible bronchoscopy was performed, which identified and removed a human fingernail clipping obstructing the RML. Post-procedure, his oxygen requirements, cough, and dyspnea improved remarkably. He was discharged with a 4-week course of amoxicillin-clavulanate. On outpatient follow-up 6 weeks later, he was asymptomatic. DISCUSSION: In our patient, a fingernail clipping was lodged in the opening of the RML, resulting in a post-obstructive pneumonia complicated by empyema. Post-bronchoscopy, the patient admitted to anxiety-induced nail-biting. FBA most commonly occurs in the right bronchial tree (71.5%) as compared to the left bronchial tree (22.8%) and trachea (5.7%). Objects were most commonly lodged in the bronchus intermedius (27%) and right lower lobe (33%). Foreign bodies can be removed via rigid or flexible bronchoscopy, with a 90% success rate in the latter. Instruments such as forceps and baskets can be used to remove the foreign body, and Trendelenberg positioning can be useful in moving the object proximally. In up to 76% of cases, granulation tissue caused by a localized reaction to the foreign body may occur and can be minimized with systemic steroids for 24 hours. CONCLUSIONS: FBA in a middle-aged patient is an unusual cause of respiratory infection, but should be on the differential diagnosis for post-obstructive pneumonia. Reference #1: Hsu Wc, Sheen Ts, Lin Cd, Tan Ct, Yeh Th, Lee Sy. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg. 2000 Mar;122(3):450-4. doi: 10.1067/mhn.2000.98321. PMID: 10699826. Reference #2: Blanco Ramos M, Botana-Rial M, García-Fontán E, Fernández-Villar A, Gallas Torreira M. Update in the extraction of airway foreign bodies in adults. J Thorac Dis. 2016;8(11):3452-3456. doi:10.21037/jtd.2016.11.32. Reference #3: Fang YF, Hsieh MH, Chung FT, Huang YK, Chen GY, Lin SM, Lin HC, Wang CH, Kuo HP. Flexible bronchoscopy with multiple modalities for foreign body removal in adults. PLoS One. 2015 Mar 13;10(3):e0118993. doi: 10.1371/journal.pone.0118993. PMID: 25768933;PMCID: PMC4358882. DISCLOSURES: No relevant relationships by Nuzhat Batool No relevant relationships by Lisa Glass No relevant relationships by Alice Mei No relevant relationships by Daisy Young

THE TRUTH THE TEETH TOLD: THE UNUSUAL CASE OF A SUBPHRENIC MASS

CASE: A 75-year-old man with a history of aortic stenosis status post transcatheter aortic valve replacement (TAVR), compensated cirrhosis in the setting of alcohol use disorder, and osteoarthritis presented with hyper-acute dyspnea and chest pain that awoke him from sleep. Three years prior to admission, an abdominal computed tomography (CT) for his TAVR evaluation revealed a 2 cm, irregular, peripherally-enhancing mass in the right subphrenic space, most concerning for malignancy but stable in size a year later. Further work-up was delayed due to the COVID-19 pandemic. One week prior to this presentation, he returned to care with 6 months of progressive right shoulder pain, pleuritic chest pain, and 5 kg of unintentional weight loss and was found to have growth of the right subphrenic mass to 4.9 cm, for which he underwent interventional radiology-guided aspiration and biopsy from a subxiphoid approach. Pathology on the core biopsy was inconclusive, revealing granulation tissue with chronic inflammatory changes and negative routine cultures. He was hemodynamically stable and discharged home. On admission, he was afebrile, tachypneic to 26, tachycardic to 120, hypotensive to 80/40, and saturating 94% on room air. He was found to have a large pericardial effusion with tamponade physiology, upon which 500 mL of serous fluid was drained via emergent pericardiocentesis. Laparoscopic biopsy of the subphrenic mass revealed a purulent fluid collection. 16S/18S sequencing and MALDI cultures were most consistent with Actinomyces spp. With further history-taking alongside an Italian language interpreter, he was found to have had prior dental abscesses, the likely origin of his Actinomyces infection, although the curious propensity for the subphrenic location remains unknown. Periodontal disease had been diagnosed but not fully treated given lack of insurance coverage and perceived importance. His pericarditis and ensuing tamponade was attributed to irritation and seeding from the subxiphoid approach for attempted fluid aspiration. IMPACT/DISCUSSION: Actinomyces spp. are a part of the normal human gut and oral cavity flora, but when pathogenic, they are often associated with dental, pulmonary, and urinary tract infections. In addition to periodontal disease, this patient's risk factors for Actinomyces abscess formation include cirrhosis (via transient gut translocation from elevated portal pressures) and alcohol use disorder (via increased aspiration risk). There have been several reports of Actinomyces spp. causing pericarditis and tamponade following seeding from liver, lung, and oral cavity abscesses- to our knowledge, however, none from subphrenic abscesses. CONCLUSION: This case highlights the importance of an oral health history in work-up of an indolent growing thoracic mass and the challenges in comprehensive history-taking in patients with limited English proficiency. Increasing coverage of dental services (e.g. a Medicare dental benefit) is key to health and health equity.

Study on Postcovid pulmonary complications in patients attending tertiary care centre

Background: SARS-COV-2 has caused morbidity and mortality at an unprecedented scale globally. During recovery, several patients are found to have functional impairment and radiological abnormalities. Case Study: An observational study done on 54 post-covid patients attending our center during July to November. A detailed history, radiology and clinical data during acute and post-covid visit were analyzed. Aims: To document various post-covid complications, assessing risk factors for complications Discussion: Mean age group of presentation 49.2years, mean time of follow-up presentation is 66.4 days. Incidence is higher in males (64.8%) than females (35%),83.3% are having one or more existing comorbidities during acute covid mainly diabetes 61%, hypertension 38%, Both in 25%, copdin 7.4%, tuberculosis in 3.7%, HIV in 1.85 %. About 79.6% had more than 3 weeks of hospital stay,46.2% are on NIV support during acute covid. Majority of post-covid patients came with dyspnea -75.9%, cough -74%, fatigue -31.4%, productive cough -14%, fever -9%, chest pain -7%. Resting hypoxia is seen in 29.6% of patients. Of post-covid patients,88% presented with pulmonary fibrosis,12.9% with pnemothorax,12.9%with lung cavity,3.6%with necrotizing pneumonia and 1.8%with lung abscess. Both pneumothorax and fibrosis are seen in 9.25%, both cavity and fibrosis in 5.5%. post-covid pulmonary cavities (7) were due to tuberculosis, klebsiella, pseudomonas, E. coli, fungal itology.Comparativelyradiological improvement is seen in 86% of the patients Conclusion: Diabetes,nonvaccinating, severe covid at admission, mechanical ventilation, older age contributes to severe post-covid complications.Regularfollow up,rehabilitation therapy, screening for tuberculosis is to be considered.

Treatment-emergent COVID-19 infections in ozanimod ulcerative colitis and multiple sclerosis clinical trials

Background: Ozanimod, a sphingosine 1-phosphate (S1P) receptor S1P1 and S1P5 modulator, is approved in the United States for moderately to severely active ulcerative colitis (UC) and in multiple countries for relapsing multiple sclerosis (MS). We describe COVID-19 outcomes in ozanimod-treated UC or MS patients (pts) in active phase 3 openlabel extension (OLE) studies. Methods: A database search identified COVID-19 infection reports in ozanimod-treated pts with UC in the True North OLE and MS in the DAYBREAK OLE. The analysis period was November 1, 2019 to either August 31, 2021 (UC) or May 10, 2021 (MS). The last COVID-19 event from all pts with ≥1 event was analyzed. Results: Among 2792 ozanimod-treated pts with UC or MS, 258 developed COVID-19 (confirmed: 215);thus, the incidence in these clinical trial settings was 9.2% during the analysis periods. Most pts with confirmed cases (193/215 [89.8%]) had nonserious infections not requiring hospitalization or meeting other International Conference on Harmonisation criteria for a serious event. Of 611 ozanimod-treated pts with UC, 68 (11.1%) developed COVID-19 (confirmed: 55;Fig 1). A majority of UC pts with confirmed cases (45/55 [81.8%]) had nonserious COVID-19;most (54/55 [98.2%]) recovered (2 with sequalae) and 1 was recovering at data cutoff. One UC pt with confirmed COVID-19 discontinued ozanimod (1.8%), 23 temporarily interrupted it (41.8%), and 31 had no change to treatment (56.4%). No COVID-19-related deaths were reported in UC pts. Of 2181 ozanimod-treated pts with MS, 190 (8.7%) developed COVID-19 (confirmed: 160;Fig 2). Most MS pts with confirmed COVID-19 (148/160 [92.5%]) had nonserious cases;most (158/160 [98.8%]) recovered (5 with sequelae) (Fig 1). No MS pts with confirmed cases discontinued ozanimod, 61 temporarily interrupted it (38.1%), and 99 had no change to treatment (61.9%). Outcomes in 13 additional UC pts (Fig 1) and 30 additional MS pts (Fig 2) with suspected COVID-19 were similar to those with confirmed cases. There were 3 COVID-19-related deaths in the MS program. One pt died from a presumed pulmonary embolism;this pt had received high-dose corticosteroids for MS relapse immediately before COVID-19 symptom onset. Another pt died from suspected COVID-19-related respiratory failure. One tetraplegic, cachectic pt died from a lung abscess following COVID-19 infection. Conclusion: In the UC and MS OLE studies, most pts with confirmed COVID-19 had nonserious infections, recovered, and did not require ozanimod discontinuation. There were 3 deaths in MS patients (casefatality rate 1.6% in MS, 1.2% overall).

Pulmonary Abscess as a Complication of COVID-19 Associated Pneumonia: a Clinical Case

The article describes a case of polysegmental destructive viral-bacterial pneumonia complicated with acute pulmonary abscess, pleural empyema, and pneumopleurofibrosis in a 50-year-old female patient infected with the SARS-CoV-2 virus. The first clinical, laboratory and radiological signs of purulent-necrotic inflammation appeared only 20 days after receiving a positive RT-PCR test result with a nasopharyngeal swab. A month later, an emerging abscess in the lower lobe of the right lung was diagnosed. Subsequently, it spontaneously drained into the pleural cavity. Coagulopathy with the formation of microthrombi in small pulmonary vessels is one of the causative factors of lung abscess in patients infected with the SARS-CoV-2 virus. © 2021 New Terra Publishing House. All rights reserved.

LUNG ABSCESSES WITH FORMATION OF SEVERAL CAVITIES AND PNEUMOMEDIASTINUM AS RARE COMPLICATIONS IN COVID-19

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 emerged in China at the end of 2019. SARS-CoV-2 is a highly pathogenic and transmissible coronavirus that primarily spreads through respiratory droplets and close contact. A growing body of clinical data suggests that a cytokine storm is associated with COVID-19 severity and is also a crucial cause of death from COVID-19. Because of the severe immunomodulation and lymphocyte depletion caused by this virus and the subsequent administration of drugs directed at the immune system, bacterial and fungal superinfection can occur. We are presenting a case of lung abscesses developed in CoVID-19 patient as complication. We hypothesized that corticosteroid therapy administration could have predisposed the patient with COVID-19 to develop superinfection of bacterial origin leading to formation of multiple lung abscesses due to a diminished innate immune response. A lung abscess is a cavity of the pulmonary parenchyma filled with fluid caused by infection or necrotic debris. High rates of morbidity and mortality are associated with lung abscess despite appropriate antibiotic therapy and better supportive care. Clinicians have to highly consider the probability of the pulmonary abscess development in CoVID-19 patients administered the high therapeutic dosage of steroids despite the evidence of the absence of procalcitonin elevation in dynamics, intoxication signs and febrile fever. A chest computerized tomography scan has to be done even in case of a small suspicion of such complications.

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

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