Sarcoidosis-Associated Immune Thrombocytopenic Purpura and Focal Segmental Glomerulosclerosis

Purpose of study A 32-years old male with known multi-system sarcoidosis in remission for 5 years off treatment presented to the emergency room with complaints of generalized weakness, hematemesis, epistaxis, and bruises. Physical examination was notable for petechiae, ecchymosis along with papules and plaques suggestive of active sarcoid skin lesions on his extremities. Laboratory workup was significant for thrombocytopenia 3000/uL, acute kidney injury with sub-nephrotic proteinuria. Peripheral blood smear did not show evidence of hemolysis and direct Coombs test was negative. Infectious workup including COVID-19, HIV, and hepatitis serologies were negative. Computed Tomography (CT) of chest, abdomen, and pelvis showed mild splenomegaly and an increased number of sub-centimeter hilar and mediastinal lymph nodes. The patient was treated with dexamethasone 40 mg daily for 4 days and intravenousimmunoglobulins (IVIG-2 gm/kg) for possible Immune Thrombocytopenic Purpura (ITP) with improvement in platelet count to 42000/uL by day 3. His workup for AKI and sub-nephrotic proteinuria was negative apart from a positive ANA (1: 160) with low complements. The anti-phospholipid antibody panel was negative. The ACE level was markedly elevated (>80U/L). The patient could not get a renal biopsy due to severe thrombocytopenia. He was discharged but was re-admitted in 15 days for severe thrombocytopenia of 1000/uL, epistaxis, and bruising. We continued high dose steroids along with IVIG 1 gm/kg for refractory ITP with minimal response and started anti-CD20 agent (Rituximab) 375 mg/m2 weekly with thrombopoietin-receptor agonist (Eltrombopag). His platelets count improved in response to treatment and subsequent renal biopsy showed focal and segmental glomerulosclerosis along with mild interstitial fibrosis, tubular atrophy thought to be from long standing sarcoidosis. There was also evidence of focal arteriosclerosis with no evidence of granulomas, immune complex, complement, or IgG4 deposition. Given skin lesions, thrombocytopenia, extensive lymphadenopathy, and renal involvement with markedly elevated ACE levels the overall picture was consistent with active multi-system sarcoidosis. His platelet count increased to 177,000/uL at the time of discharge. Currently, the patient is on slow steroid taper along with Eltrombopag 25 mg every other day without any recurrence of his symptoms so far. Methods used We described one case of sarcoidosis with hematologic and renal involvement. Summary of results Our patient developed hematologic and renal complications approximately 6 years after being diagnosed with sarcoidosis. Initially, he did not demonstrate sufficient clinical response to IVIG and high dose steroids. However, after a course of anti-CD20 agent (Rituximab) and with the addition of thrombopoietin-receptor agonist (Eltrombopag) he showed improvement of platelet count and stabilization of the renal function. Currently, the patient is receiving maintenance therapy with Prednisone 7.5 mg daily along with Eltrombopag 25 mg twice weekly with no recurrence of ITP and stable renal function. A further decision on whether the patient needs another cycle of Rituximab will be determined by the patient's clinical course. Conclusions Highly variable manifestations of Sarcoidosis can pose a significant diagnostic and therapeutic challenge as can be seen from our case. ITP is a rare hematological manifestation of sarcoidosis and addition of anti-CD20 agents should be considered in refractory cases.

Clinical features and chest CT findings in moderate and severe COVID-19 patients: an analysis of 506 cases from Wuhan Huoshenshan Hospital.

Objective: To investigate the clinical features and chest CT findings in moderate and severe COVID-19 patients. Method(s): A total of 506 patients with COVID-19 treated in Wuhan Huoshenshan Hospital during February 9 to March 9, 2020 were enrolled in the study, including 365 moderate cases and 141 severe cases. The clinical features and chest CT findings were retrospectively analyzed. Chi-square test and Fisher's exact probability were used for data analysis. Result(s): The proportions of patients with diabetes and hypertension in severe group were significantly higher than those in moderate group (chi2=9.377 and 15.085, P<0.01). Compared with the severe patients, the white blood cell counts and lymphocyte counts of moderate patients were statistically significant (chi2=14.816 and 30.097, P<0.01). The protortion of increased CRP in severe patients was higher than that in moderate patients (chi2=21.639, P<0.01). The cure rate and discharge rate of severe patients were significantly lower than those of moderate patients (P<0.01). Compared with the moderate cases of COVID-19, the CT images in severe patients mainly showed lesions of diffuse distribution, mixed density, with maximum diameter>10 cm and involved all five lung lobes (P<0.01). The severe patients had more imaging signs of air bronchogram, bronchovascular thickening, pleural thickening, mediastinal or hilar lymphnodes enlargement, pleural effusion and pericardial effusion than moderate patients (chi2=33.357, 11.114, 14.580, 5.978, 45.731 and 6.623, P<0.05 or <0.01). Conclusion(s): There are differences in clinical features and chest CT findings between moderate and severe patients, and chest CT findings can be used as important criteria for clinical classification.Copyright © 2020 by the Chinese Medical Association.

Clinical features and chest CT findings in moderate and severe COVID-19 patients: an analysis of 506 cases from Wuhan Huoshenshan Hospital.

Objective: To investigate the clinical features and chest CT findings in moderate and severe COVID-19 patients. Method(s): A total of 506 patients with COVID-19 treated in Wuhan Huoshenshan Hospital during February 9 to March 9, 2020 were enrolled in the study, including 365 moderate cases and 141 severe cases. The clinical features and chest CT findings were retrospectively analyzed. Chi-square test and Fisher's exact probability were used for data analysis. Result(s): The proportions of patients with diabetes and hypertension in severe group were significantly higher than those in moderate group (chi2=9.377 and 15.085, P<0.01). Compared with the severe patients, the white blood cell counts and lymphocyte counts of moderate patients were statistically significant (chi2=14.816 and 30.097, P<0.01). The protortion of increased CRP in severe patients was higher than that in moderate patients (chi2=21.639, P<0.01). The cure rate and discharge rate of severe patients were significantly lower than those of moderate patients (P<0.01). Compared with the moderate cases of COVID-19, the CT images in severe patients mainly showed lesions of diffuse distribution, mixed density, with maximum diameter>10 cm and involved all five lung lobes (P<0.01). The severe patients had more imaging signs of air bronchogram, bronchovascular thickening, pleural thickening, mediastinal or hilar lymphnodes enlargement, pleural effusion and pericardial effusion than moderate patients (chi2=33.357, 11.114, 14.580, 5.978, 45.731 and 6.623, P<0.05 or <0.01). Conclusion(s): There are differences in clinical features and chest CT findings between moderate and severe patients, and chest CT findings can be used as important criteria for clinical classification.Copyright © 2020 by the Chinese Medical Association.

Clinical features and chest CT findings in moderate and severe COVID-19 patients: an analysis of 506 cases from Wuhan Huoshenshan Hospital.

Objective: To investigate the clinical features and chest CT findings in moderate and severe COVID-19 patients. Method(s): A total of 506 patients with COVID-19 treated in Wuhan Huoshenshan Hospital during February 9 to March 9, 2020 were enrolled in the study, including 365 moderate cases and 141 severe cases. The clinical features and chest CT findings were retrospectively analyzed. Chi-square test and Fisher's exact probability were used for data analysis. Result(s): The proportions of patients with diabetes and hypertension in severe group were significantly higher than those in moderate group (chi2=9.377 and 15.085, P<0.01). Compared with the severe patients, the white blood cell counts and lymphocyte counts of moderate patients were statistically significant (chi2=14.816 and 30.097, P<0.01). The protortion of increased CRP in severe patients was higher than that in moderate patients (chi2=21.639, P<0.01). The cure rate and discharge rate of severe patients were significantly lower than those of moderate patients (P<0.01). Compared with the moderate cases of COVID-19, the CT images in severe patients mainly showed lesions of diffuse distribution, mixed density, with maximum diameter>10 cm and involved all five lung lobes (P<0.01). The severe patients had more imaging signs of air bronchogram, bronchovascular thickening, pleural thickening, mediastinal or hilar lymphnodes enlargement, pleural effusion and pericardial effusion than moderate patients (chi2=33.357, 11.114, 14.580, 5.978, 45.731 and 6.623, P<0.05 or <0.01). Conclusion(s): There are differences in clinical features and chest CT findings between moderate and severe patients, and chest CT findings can be used as important criteria for clinical classification.Copyright © 2020 by the Chinese Medical Association.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

Preoperative mediastinal staging in resectable non-small cell lung cancer in a single surgical centre

in non-small cell lung cancer (NSCLC) aids selection of patients suitable for lung resection. Guidelines released by the European Society of Thoracic Surgeons (ESTS) in 2014 outline that 100% patients with suspected cN1 or greater NSCLC require invasive mediastinal lymph node staging. Aim(s): The aim of this audit was to collect and analyse data on the adherence to the ESTS guidelines for patients with TNM stage N1 or greater clinical lung cancer in a single surgical centre in Belfast. Method(s): Data of all lung cancer resections between February 2019 and May 2021 were retrospectively reviewed using the Electronic Care record and the Dendrite operative database. 72 patients met the inclusion criteria. Data collection included whether patient received EBUS and/or mediastinoscopy, along with pre-operative N stage (from PET) and post-operative N stage Results: On analysis of the data: * 34% of cN1 patients received staging * 68% of cN2 patients received staging * 4 patients were under staged (cN1 pre resection and pN2 post resection) Conclusion(s): Our results fell short of the 100% standard set by ESTS. It should be highlighted that our audit was during the height of the Covid-19 pandemic. During this time, system pressures in healthcare, particularly in Northern Ireland, were unprecedented. This is highly likely to have impacted these results, particularly in patients where confirmatory staging may not change the eventual treatment. Re-audit is recommended.

IDIOPATHIC MULTICENTRIC CASTLEMAN DISEASE (IMCD) AS A MANIFESTATION OF POST-COVID-19 INFLAMMATORY SYNDROME

SESSION TITLE: Pulmonary Manifestations of Infections SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: Post-acute COVID-19 inflammatory syndrome is defined as persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms of original infection (1). These can manifest in various ways, but pulmonary, cardiac, and renal complications are the most common (1), with IL-6 thought to be an important mediator (2). We report what we believe to be the first case of Idiopathic Multicentric Castleman's Disease (iMCD) as a manifestation of post-acute COVID-19 inflammatory syndrome. CASE PRESENTATION: A 36-year old male with history of hypertension and childhood asthma (not on current therapy), and recently resolved COVID-19 from 4 weeks prior, is admitted to the hospital with progressive shortness of breath, cough, fevers and significant fatigue. Prior COVID-19 symptoms included fevers, cough, and shortness of breath, which improved after 2 weeks without treatment. Symptoms returned 2 weeks later and worsened. On admission, he was tachycardic to 108 with temp of 37.8C, and otherwise stable vitals. Pertinent labs included WBC 17 (neutrophil predominant), Hgb 11.6, Cr 2.52, Na 126 and albumin 2.7 (normal baselines). SARS-CoV2 PCR was negative. CT chest with PE protocol showed no PE but moderate bilateral pleural effusions and extensive mediastinal lymphadenopathy. 1.2L clear fluid (transudative with lymphocyte predominance) was removed via thoracentesis. Microbiology, flow cytometry and cytology were unremarkable. Renal and mediastinal lymph node biopsies were taken. Lymph node sampling was non-diagnostic x2, but renal biopsy showed acute microangiopathy without thrombi, concerning for acute glomerulonephritis. Serologic vasculitis and CTD workup were entirely negative. He was treated with a course of prednisone and improved, however as outpatient, had recurrence of all these issues. Repeat thoracentesis x3 was unrevealing. He was again admitted and had an excisional inguinal node biopsy, showing findings consistent with hyaline vascular Castleman Disease. Further heme/onc evaluation and discussion showed diagnosis meeting criteria for iMCD. DISCUSSION: Multicentric Castleman's Disease is most often associated with HHV-8 infection in the setting of HIV. If HHV-8 is negative, the disease is termed idiopathic (iMCD). In these cases, disease is mediated predominantly by IL-6, but the direct cause is unknown, though existing theories include non-specific viral infections, malignancy and autoimmune diseases (3). Our patient had no evidence of malignancy or autoimmune phenomena. Thus COVID-19 illness was the most plausible explanation, especially given known IL-6 activity in COVID-19 inflammatory syndromes. CONCLUSIONS: Post-acute COVID-19 inflammatory syndromes are extensive and can affect any organ system. iMCD is another possible manifestation, and must be diagnosed with excisional lymph node biopsy. High index of suspicion should be maintained to make this diagnosis. Reference #1: Nalbandian, Ani et al. "Post-acute COVID-19 syndrome." Nature medicine vol. 27,4 (2021): 601-615. Reference #2: Phetsouphanh, Chansavath et al. "Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-CoV-2 infection.” Nature immunology vol. 23,2 (2022): 210-216. Reference #3: Dispenzieri, Angela, and David C Fajgenbaum. "Overview of Castleman disease." Blood vol. 135,16 (2020): 1353-1364. DISCLOSURES: No relevant relationships by Kyle Halligan No relevant relationships by Chris Yan

A CASE OF GRANULOMATOSIS WITH POLYANGIITIS

SESSION TITLE: Critical Systemic Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatosis with polyangiitis(GPA) is an autoimmune small vessel vasculitis that is included in the group of anti-neutrophilic cytoplasmic antibody(ANCA)- associated small vessel vasculitides (AAVs). GPA is a systemic disease, however acronym ELK is used to describe the most common involvement of Ear, nose, throat, Lungs, and Kidneys. We report a case of GPA, highlighting its presentation. CASE PRESENTATION: 59-year old female presented with vaginal bleeding, malaise, blurry vision, non productive cough and shortness of breath few days after receiving COVID-19 vaccine. Physical exam was remarkable for bilateral conjunctival injection with right sided ptosis and inguinal lymphadenopathy. Laboratory findings were significant for acute kidney injury and anemia. Computed tomography (CT) of chest revealed bilateral bronchovascular nodules and masses with interlobular septal thickening and enlarged mediastinal lymph nodes. Fine needle aspiration of left inguinal lymph node was negative for malignancy. Bronchoscopy with bronchial brush revealed alveolar hemorrhage with capillaritis;bronchoalveolar lavage(BAL) showed hemosiderin laden macrophages. Tissue biopsy was negative for malignancy. Testing for pulmonary renal syndrome was positive for C-ANCA and proteinase-3 (PR-3) antibodies. Anti-GBM antibody and anti-MPO antibody was negative. Plasmapheresis (PLEX) and pulse dose steroids were initiated however the patient was unable to tolerate the treatment. Her clinical condition continued to decline requiring multiple pressors, broad spectrum antibiotics and continuous renal replacement therapy. She was transitioned to comfort care per family's wishes and passed away. DISCUSSION: GPA is a rare necrotizing granulomatous vasculitis of small to medium sized vessels that can affect any organ but mainly involves the upper and lower respiratory tract. Necrotizing glomerulonephritis is common. Pulmonary involvement can include consolidation, tracheal or subglottic stenosis, diffuse alveolar hemorrhage, pleural effusion and interstitial lung disease. Lymphadenopathy, as seen in our patient is a rare presentation. Tissue biopsy is crucial for the diagnosis. Association with PR-3 ANCA is seen in more than 80% of GPA patients. Cases of AAVs after administration of COVID vaccine have been reported in the literature, although it is difficult to demonstrate causal relationship. Treatment of GPA with immunosuppression, usually corticosteroids, rituximab or cyclophosphamide, is recommended. The role of PLEX continues to evolve with emerging data, but use of this therapy is reasonable for patients with severe kidney injury and DAH secondary to active vasculitis refractory to immunosuppressive therapy. CONCLUSIONS: Early diagnosis of GPA is challenging as it can mimic metastatic lung malignancy. It should be considered in a broad range of differentials when evaluating patients presenting with pulmonary nodules. Reference #1: Greco A, Marinelli C, Fusconi M, Macri GF, Gallo A, De Virgilio A, Zambetti G, de Vincentiis M. Clinic manifestations in granulomatosis with polyangiitis. Int J Immunopathol Pharmacol. 2016 Jun;29(2):151-9. doi: 10.1177/0394632015617063. Epub 2015 Dec 18. PMID: 26684637;PMCID: PMC5806708. Reference #2: Kitching, A. R., Anders, H. J., Basu, N., Brouwer, E., Gordon, J., Jayne, D. R., Kullman, J., Lyons, P. A., Merkel, P. A., Savage, C., Specks, U., & Kain, R. (2020). ANCA-associated vasculitis. Nature reviews. Disease primers, 6(1), 71. https://doi.org/10.1038/s41572-020-0204-y Reference #3: Szymanowska-Narloch, A., Gawryluk, D., Błasińska-Przerwa, K., & Siemińska, A. (2019). Atypical manifestations of granulomatosis with polyangiitis: the diagnostic challenge for pulmonologists. Advances in respiratory medicine, 87(6), 244–253. https://doi.org/10.5603/ARM.2019.0062 DISCLOSURES: No relevant relationships by Sean Davidson No relevant relationships by Eric Flenaugh No relevant relationships by Marilyn Foreman No relevant relationships by KOMAL KAUR No relevant relationships by Gabriela Oprea-Ilies

PRIMARY PULMONARY CAVITATING ADENOCARCINOMA IN A PATIENT PRESENTING WITH COVID-19 PNEUMONIA: A CASE REPORT

SESSION TITLE: Lung Cancer Imaging Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: SARS-CoV-2 pneumonia typically presents with ground-glass and consolidative pulmonary opacities, atypically small cavities may be seen in severe cases. In patients with cavities persisting beyond 12 weeks, an underlying malignancy is a worrisome concern. We present a case of a 39-year old female without significant risk factors for pulmonary malignancy who was found, surprisingly, to have a cavitating adenocarcinoma in the setting of COVID-19 Pneumonia. CASE PRESENTATION: A 39 year old obese African American female, never smoker, with co-existing metabolic syndrome presented to our institution with a four day history of productive cough (without hemoptysis), body aches, fever and fatigue. She denied weight loss or loss of appetite. No known family history of malignancy. She tested positive for SARS-CoV-2. She was clinically stable, hence discharged home with recommendations for quarantine and supportive care. She returned the following day with worsening dyspnea. Her chest radiograph noted a supra-hilar opacity with central lucency, Chest CT revealed wedge-shaped ground-glass and consolidative density in the right lower lobe and a 3.8 x 4.1 cm cavitary right upper lobe mass with mediastinal lymphadenopathy. She received parenteral antibiotic therapy and underwent infectious and autoimmune workup, which was negative. Repeat CT imaging, approximately three months post discharge, revealed persisting cavitary lesion and enlarging mediastinal lymphadenopathy. She underwent Electromagnetic Navigational Bronchoscopy with biopsy and fine needle aspiration of mediastinal lymph nodes (stations 7 and 4R) via endobronchial ultrasound. Biopsy results and fine needle aspiration of lymph nodes revealed adenocarcinoma with tumor cells being positive for TTF-1 and negative for CK20, CDX2, GATA3, PAX8 and Synaptophysin. Next generation sequencing reported several variants including EGFR and Tp53, there was also noted amplification of CDK4 and MDM2. PDL-1 was negative. DISCUSSION: A cavity is a gas-filled space, seen as a lucency or low-attenuation area, within a nodule, mass, or area of parenchymal consolidation. Underlying etiologies are typically classified as infectious, autoimmune and malignant. Cavities are atypical findings on CT imaging in patients with viral pneumonias, including SARS-CoV-2. Those cavities persisting beyond 12 weeks are typically classified as being chronic, with malignancy a key concern in these patients. The most common type of primary cavitary lung cancer is squamous cell carcinoma, in fact Primary Pulmonary Adenocarcinomas are unlikely to cavitate. Treatment options, depending on the presence of targetable mutations, include concurrent chemoradiation, chemoimmunotherapy or oral targeted agent. CONCLUSIONS: Though an atypical presentation, Pulmonary Adenocarcinoma may present as a cavitary lesion, particularly in the presence of persisting or enlarging lymphadenopathy. Reference #1: Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, Brown KK, Mehta A, Husta B, Ryu JH, Sarosi GA, Franquet T, Verschakelen J, Johkoh T, Travis W, Raoof S. Cavitary Lung Diseases: A Clinical-Radiologic Algorithmic Approach. Chest. 2018 Jun;153(6):1443-1465. doi: 10.1016/j.chest.2018.02.026. Epub 2018 Mar 6. PMID: 29518379. Reference #2: Radiological Society of North America Expert Consensus Document on Reporting Chest CT Findings Related to COVID-19: Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA Scott Simpson, Fernando U. Kay, Suhny Abbara, Sanjeev Bhalla, Jonathan H. Chung, Michael Chung, Travis S. Henry, Jeffrey P. Kanne, Seth Kligerman, Jane P. Ko, and Harold Litt Radiology: Cardiothoracic Imaging 2020 2:2 DISCLOSURES: No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No releva t relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Sulaiman Tijani

PUTTING THE "SARS” IN "SARS-COVID-19": A CASE OF SARCOID-LIKE INFLAMMATORY REACTION AFTER COVID-19 VACCINATION

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Sarcoidosis and sarcoid-like reactions tend to be diagnoses of exclusion when evaluating patients with malignancy, and have a number of inciting causes. This is a unique case of a patient diagnosed with non-necrotizing granulomatous inflammation on biopsy of mediastinal lymph nodes and skin lesions after receiving SARS-CoV-2 vaccine, while also being on Temozolamide (TMZ). Biopsy-proven sarcoid has rarely been reported in the literature following SARS-CoV-2 vaccine or TMZ. CASE PRESENTATION: 66-year-old female with a history of prolactinoma complicated by recurrence and progression of disease despite surgery, radiation, and medical therapy, who started her first cycle of TMZ and received her first SARS-CoV-2 vaccine 9 days later. About 2 weeks later, she noted numerous painless "bumps” on her bilateral upper and lower extremities with erythema, without fevers, joint pains, or other symptoms. She underwent a positron emission tomography (PET) scan which demonstrated multiple hypermetabolic subcutaneous lesions, along with intensely hypermetabolic bilateral hilar lymphadenopathy. She underwent punch biopsy notable for sparse inflammation. She underwent her second SARS-CoV-2 vaccine and second cycle of TMZ. After 1 week, she noticed increased induration and erythema over her lesions, and held her TMZ. She underwent incisional biopsy of her thigh which demonstrated granulomatous panniculitis. She also underwent bronchoscopy with endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) of her paratracheal and subcarinal lymph nodes, which demonstrated non-necrotizing granulomatous inflammation. Labs were only significant for ACE level of 60u/L (normal<40u/L). With a relative paucity of symptoms and no other obvious vital organ involvement, she was not treated, continued her TMZ without flares, and her symptoms self-resolved after opting out of the third SARS-CoV-2 vaccine. DISCUSSION: Sarcoid-like inflammatory reactions have rarely been reported in the literature following SARS-CoV-2 vaccine or TMZ. One case of panniculitis secondary to TMZ administration was reported that improved after discontinuation of TMZ [1]. Our patient continued TMZ therapy without further symptoms, which makes TMZ less likely as her inciting cause. Three cases of sarcoid-like reactions secondary to SARS-CoV-2 vaccine have been reported [2, 3] but two of these cases were diagnosed clinically as Löfgren syndrome without biopsy [3], making this case the second reported case of biopsy-proven de novo sarcoid reaction in the setting of SARS-CoV-2 vaccine. CONCLUSIONS: Sarcoid-like inflammatory reactions following SARS-CoV-2 vaccine have not been well-reported in the literature. This case, among the other limited cases reported, underscores the need to consider sarcoid on the differential of vaccine-related side effects, especially in those with bilateral hilar lymphadenopathy and cutaneous lesions. Reference #1: Virmani P., Chung E., Marchetti M. A. (2015). Cutaneous adverse drug reaction associated with oral temozolomide presenting as dermal and subcutaneous plaques and nodules. Jaad. Case. Rep. 1, 286–288. 10.1016/j.jdcr.2015.06.012 Reference #2: Bauckneht, M., Aloè, T., Tagliabue, E. et al. Beyond Covid-19 vaccination-associated pitfalls on [18F]Fluorodeoxyglucose (FDG) PET: a case of a concomitant sarcoidosis. Eur J Nucl Med Mol Imaging 48, 2661–2662 (2021). https://doi.org/10.1007/s00259-021-05360-w Reference #3: Rademacher JG, Tampe B, Korsten P. First Report of Two Cases of Löfgren's Syndrome after SARS-CoV-2 Vaccination-Coincidence or Causality? Vaccines (Basel). 2021 Nov 11;9(11):1313. doi: 10.3390/vaccines9111313. PMID: 34835244;PMCID: PMC8619392 DISCLOSURES: no disclosure on file for Alexander Geyer;No relevant relationships by Mustafa Jafri

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

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

Diagnostic conundrum in a patient with small cell lung cancer (SCLC)

Introduction: It is rare for pulmonary SCLC to present as a cavitating lesion unlike non-small-cell-cancer (NSCLC). Hence, if a cavitating lesion is found with histo-pathology showing SCLC, it is important to rule out alternate diagnosis e.g., infection [1]. Case: We present the case of a 41-year-old-male of Bangladeshorigin. He was referred on 2ww-pathway to UHL Glenfield hospital lung cancer team for haemoptysis. Clinical assessment (05/12/2019) revealed that he had 4kg weight loss/haemoptysis/anorexia/fatigue. He was a current smoker (10 pack-years) with no significant past/ family history. He worked in a restaurant. Clinical examination was unremarkable. Chest x-ray showed left-hilar-mass. CT scan revealed 3.2cm mass with peripheral cavitation and mild focal enhancement without calcification/mediastinal-lymphadenopathy. Differentials included cancer/rheumatoid arthritis/infection. Bloods including ANCA/ANA/rheumatoid factor and bronchial-washings microbiology/cytology were unremarkable. He was given antibiotics. He did not attend subsequent 2 out-patient-appointments. Repeat CT scan (March 2020) showed growing lesion with focally dilated vessel. CT-guided biopsy was advised but he declined it due to COVID19 pandemic. In May 2020, he agreed to undergo CT-guided biopsy. However, pre-procedure CT scan showed possible pseudoaneurysm. CT-guided biopsy was deemed high-risk and not attempted. Lung cancer MDT advised lobectomy given diagnostic dilemma. Patient declined surgery. CT in November 2020 showed progressive lesion. Patient still was not keen for surgery. He was admitted in June 2021 with haemoptysis. CT scan showed progressive cavitating disease with necrotic left hilar/mediastinal lymph nodes. He underwent EBUS-TBNA that confirmed SCLC. Given cavitating lesion and long history, left lower lobe lesion was deemed unlikely to be due to SCLC. He was referred to infectious disease (ID) clinic. Blood parasitology screen revealed positive Hydatid ELISA. He did not attend subsequent outpatient appointments in Oncology/ID clinics and has been discharged. Learning points: There were two pathologies: hydatid cyst (Fig. 1a);SCLC developed between November 2020 and June 2021 (Fig. 1b). 1) To look for cause of a cavitating lesion even if SCLC is diagnosed. 2) To consider hydatidcyst in lung-cavity differentials.(Figure Presented) Fig. 1

18F-FDG PET/CT in a patient with lung Hodgkin lymphoma and incidental COVID-19 interstitial pneumonia

Background-Aim: 18F-FDG PET/CT currently represents the nuclear medicine imaging procedure of choice for staging and posttreatment response assessment in patients with Hodgkin lymphoma (HL). It is well known that 18F-FDG also accumulates in sites of inflammation and infection. Here we report a case of a patient affected by lung HL and concomitant incidental COVID-19 interstitial pneumonia. Methods: The case refers to a 67 years old female patient affected by nodular sclerosing classical HL involving left axillary lymph nodes and both lungs. The patient came to our attention to perform wholebody 18F-FDG PET/CT at initial staging (scan 1), after two cycles of ABVD (scan 2) and at the end of treatment (scan 3). All 18F-FDG PET/CT examinations were performed according to standard acquisition protocols, starting approximately 60 min after i.v. injection of 3.7 MBq/kg of 18F-FDG. Results: At scan 1, 18F-FDG-PET/CT showed hypermetabolic left axillary lymph nodes and multiple disseminated avid lesions in both lungs. Scan 2 demonstrated complete metabolic response associated to almost complete resolution of axillary lymphadenopathy and lung lesions at CT scan. At the end of treatment, scan 3 showed hypermetabolic mediastinal lymph nodes and multiple areas of increased 18F-FDG uptake in both lungs, mostly in pulmonary regions other than those of the basal scan, and in correspondence of multiple ground-glass opacities and consolidations at CT. These findings were more suggestive for interstitial pneumonia than for HL residual disease;in addition, contrast-enhancement CT performed 1 week before scan 3, resulted completely negative. Given the ongoing SARS-CoV- 2 pandemic, the patient, although asymptomatic, was scheduled to perform nasopharyngeal molecular swab test for COVID-19;the test resulted positive, corroborating the hypothesis of early interstitial pneumonia. The patient was clinically monitored and 3 months later underwent a further 18F-FDG PET/CT scan which was negative, definitively confirming the absence of lymphomatous disease. Conclusions: In this patient affected by lung HL, an incidental early COVID-19 pneumonia was detected by 18F-FDG PET/CT. The comparison of basal and post-treatment PET/CT scans in combination with lung CT patterns have led to a correct assessment of chemotherapy response.

CASE REPORT OF LOCALLY ADVANCED NON-SMALL-CELL LUNGCANCER

Lung cancer is among the most commonly diagnosed cancers in Croatia in both genders, as well as the most common cause of cancer-related deaths. There are two major histological subtypes of lung cancer, non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). In the last decade great achievements have been made in the treatment of NSCLC in metastatic setting, with the discovery and identification of druggable oncogenes and compatible targeted therapies, as well as with the utilization of immunotherapy. Until recently, the standard treatment for patients with unresectable locally advanced NSCLC was definitive concurrent chemotherapy and radiation with curative intent, but it was often followed by a rapid progression of the disease. That being said, there was a need for new treatment options that could improve outcomes. The Pacific trial, which evaluated durvalumab consolidation therapy after concurrent chemotherapy and radiotherapy in unresectable NSCLC, demonstrated a statistically significant and clinically meaningful improvement in the terms of progression-free survival and overall survival. We report a case of locally advanced NSCLC diagnosed in 67-year old male. Computed tomography of the thorax and upper abdomen described the tumor of the upper left lobe with pathologically enlarged mediastinal lymph nodes. To obtain the diagnose he underwent bronchoscopy and transthoracic needle biopsies. Histopathological examination confirmed the diagnose of adenocarcinoma with no targetable mutations found on further testing, but PD-L1 expression was 50%. As there was no evidence of metastatic disease on fluorodeoxyglucose positron emission tomography/computed tomography scan, he was staged as having T2bN2M0 (Stage IIIA) disease. We recommended radical intent radiation therapy with concurrent chemotherapy and consolidation therapy with durvalumab up to twelve months. Concurrent radiotherapy and chemotherapy was interrupted by the sars-cov-2 virus infection. Follow-up CT scans of the thorax and upper abdomen were made approximately every 3 months. In the end of the treatment, a complete radiological response was achieved.

Beware of TB amid COVID 19 pandemic

Background: Tubercolosis has a worrisome connection with novel corona virus.Lingering respiratory symptoms in people who have recovered from Covid could well be mistaken as residual issues of Covid or secondary bacterial infections, missing TB diagnosis totally. Methods: A 28 year old female doctor by profession, initially asymptomatic tested Covid -19 positive as a part of contact tracing. On the 15th day, she developed fever, dry cough and fatigue which persisted even after taking symptomatic treatment. Repeat Covid testing was negative.HRCT chest was normal.Sputum CBNAAT was negative and other relevant blood investigations were normal. On examination she was febrile and matted subcentimetric right cervical lyphnodes(LN) were palpable.Excision Biopsy of cervical LN was done and report suggested Kikuchi's disease.As a part of work up of Pyrexia of Unknown Origin, she undertwent 18-FDG PET whole body CT scan and showed mediastinal lymph node uptake(2R,4R LN station). Mediastinoscopic biopsy report showed tuberculosis and Gene Expert showed mycobacterium complex with Rifampicin resistance. Results: Based on clinical, radiological and laboratory findings, MDR LN tuberculosis was diagnosed.Patient wad started on MDR TB regimen and symptoms got improved. Conclusion: There is an increased likelihood of tuberculosis in post COVID patients due to many factors like lung inflammation, altered immunity and stress due to COVID, use of steroids and uncontrolled diabetes.Therefore active tuberculosis should be vigorously ruled out in any post covid patients with continuous fever.

Pancarditis as the Clinical Presentation of Eosinophilic Granulomatosis with Polyangiitis: A Multimodality Approach to Diagnosis

Eosinophilic pancarditis (EP) is a rare, often unrecognized condition caused by endomyocardial infiltration of eosinophil granulocytes (referred as eosinophilic myocarditis, EM) associated with pericardial involvement. EM has a variable clinical presentation, ranging from asymptomatic cases to acute cardiogenic shock requiring mechanical circulatory support (MCS) or chronic restrictive cardiomyopathy at high risk of progression to dilated cardiomyopathy (DCM). EP is associated with high in‐hospital mortality, particularly when associated to endomyocardial thrombosis, coronary arteries vasculitis or severe left ventricular systolic dysfunction. To date, there is a lack of consensus about the optimal diagnostic algorithm and clinical management of patients with biopsy‐proven EP. The differential diagnosis includes hypersensitivity myocarditis, eosinophil granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome, parasitic infections, pregnancy‐related hypereosinophilia, malignancies, drug overdose (particularly clozapine) and Omenn syndrome (OMIM 603554). To our knowledge, we report the first case of pancarditis associated to eosinophilic granulomatosis with polyangiitis (EGPA) with negative anti‐neutrophil cytoplasmic antibodies (ANCA). Treatment with steroids and azathioprine was promptly started. Six months later, the patient developed a relapse: treatment with subcutaneous mepolizumab was added on the top of standard therapy, with prompt disease activity remission. This case highlights the role of a multimodality approach for the diagnosis of cardiac involvement associated to systemic immune disorders.

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

Clinical characteristics of patients with confirmed and suspected COVID-19

Objective: To compare the differences between two groups of patients with confirmed and suspected CO-VID-19. Methods: We retrospectively collected and analyzed the data of confirmed and suspected patients, including demographic, epidemic, laboratory, clinical, radiologic, and treatment data, at the fever clinic and isolation ward of our hospital from December 1, 2019 to December 30, 2019. Results: The study included 73 patients with confirmed or suspected COVID-19. The median age was 43.6 years old, and 41 patients (56.2%) were male. Patients in the suspected group (SG) (n=47) were significantly older than those in the confirmed group (CG) (n=26). Among 73 patients, 18 (24.6%) had comorbidities. Most laboratory test results in this study were normal, except for total lymphocyte counts and C-reactive protein levels. Patients in the CG had fewer lymphocyte count abnormalities than those of the SG. More patients in the CG (13 cases, 50%) displayed involvement of three or more lobes than those in the SG (8 cases, 17%). More patients in the SG (36 cases, 76.6%) displayed involvement of 1-2 lobes than those in the CG (12 cases, 46.2%). In the CG, computed tomography (CT) lung lesions were mainly distributed in the left lower lung lobe (65.4%) and left upper lung lobe (80.8%). Conclusion: The reference standard for detecting COVID-19 is still RT-PCR. However, characteristic chest CT results and a history of close contact strongly suggest COVID-19 infection.

Lung and mediastinal lymph nodes involvement in patients recovered from CoViD-19

Background and Aim: Several studies have shown high prevalence of mediastinal lymphadenopathy (ML) during CoViD-19. Many evidences in literature suggest correlations between pulmonary inflammation and immunological dysregulation. Aim of our study was to establish the incidence of ML in patients recovered from CoViD-19 and evaluate an eventual association between ML and the radiological features of CoViD-19 pneumonia. Materials and Methods: 40 patients with previous SARS-CoV-2 infection were recruited from March 2021 to May 2021 and retrospectively evaluated 3 months after viral nucleic acid test turned negative. They underwent chest CT with Lung Score (LS) and Lung Ultrasound (US) with severity Score (LUS). Results: The prevalence of ML was 36.1%, 44.4% had fibrous stripes (FS) and in 77.8% of the cases ground glass opacities persisted. Mean LS was 4±3.99 (range 0-14) and mean LUS 2.94±4.64 (range 0-20). ML was directly related to FS (r= 0.491;p= 0.002). Patients affected by ML had worse LUS (5±7.43 vs 2.58±2.89;p= <0.0001), higher LS in LID (1.73±0.9 vs 0.83±0.9;p= 0.018) and in LIS (1.45±0.83 vs 0.78±0.73;p= 0.037), although there were no significant differences in total LS (6.55±3.67 vs 3.72±3.89;p= 0.062). Conclusions: In patients recovered from CoViD-19, ML associated with FS persists. In patients with ML, CT and US pictures appears to be worse than in patients without ML.