On the pathogenesis of destructive pneumonia during COVID-19: a clinical case.

Community-acquired pneumonia is a potentially serious infection in children with high morbidity rate, risk of severe course and unfavorable outcomes. Specialists have noted the increased incidence of the destructive forms in the recent years. Aim. To present a clinical case of destructive pneumonia in a 1 year 2 month old child, hospitalized in the State Budgetary Healthcare Institution "Children's City Clinical Hospital of St. Vladimir Moscow Healthcare Department", and analyze it in terms of current understanding on the disease pathogenesis. Conclusion. During COVID-19 (COronaVIrus Disease 2019) pandemic, pulmonologists and pediatric surgeons encountered an unconventional course of destructive pneumonia. A large number of studies of pathophysiological processes in acute viral interstitial pneumonias have recently allowed to expand our understanding of the role of coagulation system. At the same time, new questions arose concerning the clinical course and development of the pathological infectious process.Copyright © Zaytseva O.V. et al., 2023.

On the pathogenesis of destructive pneumonia during COVID-19: a clinical case

Community-acquired pneumonia is a potentially serious infection in children with high morbidity rate, risk of severe course and unfavorable outcomes. Specialists have noted the increased incidence of the destructive forms in the recent years. Aim. To present a clinical case of destructive pneumonia in a 1 year 2 month old child, hospitalized in the State Budgetary Healthcare Institution "Children's City Clinical Hospital of St. Vladimir Moscow Healthcare Department”, and analyze it in terms of current understanding on the disease pathogenesis. Conclusion. During COVID-19 (COronaVIrus Disease 2019) pandemic, pulmonologists and pediatric surgeons encountered an unconventional course of destructive pneumonia. A large number of studies of pathophysiological processes in acute viral interstitial pneumonias have recently allowed to expand our understanding of the role of coagulation system. At the same time, new questions arose concerning the clinical course and development of the pathological infectious process. © Zaytseva O.V. et al., 2023.

On the pathogenesis of destructive pneumonia during COVID-19: a clinical case.

Community-acquired pneumonia is a potentially serious infection in children with high morbidity rate, risk of severe course and unfavorable outcomes. Specialists have noted the increased incidence of the destructive forms in the recent years. Aim. To present a clinical case of destructive pneumonia in a 1 year 2 month old child, hospitalized in the State Budgetary Healthcare Institution "Children's City Clinical Hospital of St. Vladimir Moscow Healthcare Department", and analyze it in terms of current understanding on the disease pathogenesis. Conclusion. During COVID-19 (COronaVIrus Disease 2019) pandemic, pulmonologists and pediatric surgeons encountered an unconventional course of destructive pneumonia. A large number of studies of pathophysiological processes in acute viral interstitial pneumonias have recently allowed to expand our understanding of the role of coagulation system. At the same time, new questions arose concerning the clinical course and development of the pathological infectious process.Copyright © Zaytseva O.V. et al., 2023.

Role of 'Radiological Phenotypes' in Diagnosis, Treatment and Assessment of Covid-19 Pneumonia: Multicentric study of 6000 cases in tertiary care setting in India

Methods: multicentric observational study, included 6000 COVID-19 RT PCR Positive cases with lung involvement on HRCT thorax at entry point & categorised as Radiological presentation phenotypes as severity assessmentmild, moderate, severe as per lung segment involvement (mild<7, moderate 8-15 and severe 16-25), Evolving and Evolved phenotype- with or without GGOs, consolidations, and crazy paving with or without spreading edges, Anatomical phenotype-Unilateral or bilateral as per lung lobe segment or lobe involvement, Clinicalradiological-pathological phenotypes-five types as classical GGOs, consolidations, Bronchopneumonia, Necrotizing pneumonia and cavitating. Response to treatment phenotypes-easy to treat and difficult to treat as per interventions required & response to treatment. Radiological outcome phenotypes as Resolving, Persistent and Progressive as per lung reticular and fibrosing lesions as with or without honeycombing and or tractional bronchiectasis. Statistical analysis by Chi test and students t test and ANOVA. Observations and analysis:In 6000 radiological assessment of covid-19 pneumonia, significant association was documented in Evolving and Evolved pneumonia phenotypes (p<0.000026), Unilateral and Bilateral pneumonia anatomical phenotypes (p<0.00001), Clinical-radiological-pathological phenotypes (p<0.00001), Easy to treat and Difficult to treat pneumonia phenotypes (p<0.00001), Radiological final outcome phenotypes-Persistent, Progressive & Resolving phenotype (p<0.00001) conclusion: Radiological phenotypes will guide in assessing severity, predicting response to therapy and final outcome in covid-19 pneumonia.

Spectrum of atypical pulmonary manifestations of COVID-19 on computed tomography

BackgroundThe typical CT manifestations of COVID-19 pneumonia include ground-glass opacity (GGO) with or without consolidation and superimposed interlobular septal thickening. These are often rounded in morphology and frequently bilateral, multilobar, posterior, peripheral, and basilar in distribution. The various atypical CT features of COVID-19 are seldom described in the literature. The study aims to enumerate the atypical pulmonary CT features in patients with COVID-19 pneumonia in correlation with the disease severity.ResultsA total of 298 confirmed cases of COVID-19 pneumonia with positive reverse transcription polymerase chain reaction (RT-PCR) who underwent chest CT scans were retrospectively evaluated. The cohort included 234 (78.5%) men and 64 (21.5%) women and the mean age was 53.48 ± 15.74 years. The most common presenting symptoms were fever [n = 197 (66.1%)] and cough [n = 139 (46.6%)]. Out of 298 cases of COVID-19 pneumonia, 218 cases (73.1%) showed typical CT features while 63 cases (21.1%) showed atypical CT features with concurrent classical findings and the remaining 17 cases (5.8%) were normal. Among the atypical CT features, the most common was pulmonary cysts [n = 27 (9%)]. The other features in the order of frequency included pleural effusion [n = 17 (5.7%)], nodules [n = 13 (4.3%)], bull's eye/target sign[n = 4 (1.3%)], cavitation [n = 3 (1.0%)], spontaneous pneumothorax [n = 2 (0.6%)], hilar lymphadenopathy [n = 2 (0.6%)], spontaneous pneumo-mediastinum with subcutaneous emphysema [n = 1 (0.3%)], Halo sign [n = 1 (0.3%)], empyema [n = 1 (0.3%)] and necrotizing pneumonia with abscess [n = 1 (0.3%)].ConclusionCT imaging features of COVID-19 pneumonia while in a vast majority of cases is classical, atypical diverse patterns are also encountered. A comprehensive knowledge of various atypical presentations on imaging plays an important role in the early diagnosis and management of COVID-19.

A contemporary view of the problem of destructive pneumonia in children

The problem of community-acquired pneumonia in children remains relevant at the present time. Complicated forms, which include pleural empyema, abscess, necrotizing pneumonia, bronchopleural fistulas and acute respiratory distress syndrome do not decrease, despite modern antibacterial therapy and the availability of vaccination against pneumococcus. The main pathogens associated with lung destruction in children are S. pneumoniae and S. aureus, often MRSA. The role of other pathogens in necrotizing pneumonia is much less frequently reported: Streptococcus pyogenes, Haemophilus influenzae, Pseudomonas aeruginosa, Fusobacterium nucleatum, Legionella pneumophila, Klebsiella pneumoniae, anaerobes. However not only pathogenic factors of the pathogen are important for necrotizing pneumonia development. Often, a viral prodrome, often associated with the influenza A (H1N1) virus, precedes complicated pneumonia. During the epidemic of COVID-19, endothelial damage with a high degree of probability was a predisposing factor for the development of a secondary bacterial infection with lung tissue necrosis. Significant destruction and liquefaction of the lung tissue may develop despite adequate antibiotic therapy. Great importance in the development of necrosis is attached to the activation of hemostasis and thrombus formation in the vessels of the lungs. Timely diagnosis often is difficult due to the predominance of general symptoms over local ones, especially in young children. Chest x-ray is the standard for diagnosing. However, the diagnostic capabilities of this method in necro-tizing pneumonia are limited. To assess a number of parameters of the state of the pleural cavity and lung tissue, ultrasound is preferred. It is necessary to analyze the current features of the course of necrotizing pneumonia in children and develop clinical guidelines for the management of patients in the acute period and rehabilitation. © 2023, Remedium Group Ltd. All rights reserved.

Necrotizing pneumonia due to Pseudomonas aeruginosa secondary to severe COVID-19 pneumonia.

Necrotizing pneumonia (NP) can occur as a secondary infection even if the clinical course of COVID-19 pneumonia is favorable, particularly in patients on mechanical ventilation and under immunosuppression.

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

BENIGN PLEURAL SCHWANNOMA WITH PLEURAL EFFUSIONS AND NECROTIZING PNEUMONIA

SESSION TITLE: Invasion of the Pleura SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Schwannoma is a well circumscribed encapsulated solitary neoplasm arising from myelin producing cells of peripheral nerve sheaths. Pleural schwannomas represent only 1-2% of thoracic tumors and rarely present with pleural effusion. To our knowledge only six cases of benign pleural schwannoma have presented with a pleural effusion to date. We present a rare case of a pleural schwannoma with bilateral serosanguinous pleural effusions complicated by necrotizing pneumonia. CASE PRESENTATION: 54 year old smoking male with no past medical history was transferred from an outside hospital after two weeks of worsening acute hypoxemic respiratory failure while being treated for necrotizing pneumonia, right sided loculated pleural effusion, and a right paramediastinal mass. His only presenting symptom was worsening dyspnea for three days. Upon arrival to our hospital, the patient was on maximal ventilator settings with two right sided chest tubes draining blood tinged pleural fluid. CTA of the chest showed a large cavitary consolidation in the right upper lobe with destruction of the lung parenchyma. Additionally, there was an intrapleural heterogenous mass in the posterior aspect of the right lung apex which abut the mediastinum measuring 9.7 x 7.5 x 10.3 cm. He was treated with zosyn for positive sputum cultures growing beta hemolytic strep group F. Patient underwent a flexible bronchoscopy with EBUS-TBNA of mediastinal lymphnodes and lung mass which was non-diagnostic. A CT guided biopsy revealed a spindle cell neoplasm with a Ki-67 of 10-20%. Immunohistochemical analysis demonstrated positive staining of the tumor cells for S-100 protein. The final pathological diagnosis was benign schwannoma. He underwent a tracheostomy and PEG and was sent to a rehab center with outpatient follow-up with cardiothoracic surgery for tumor removal. DISCUSSION: Pleural schwannomas are slow growing, rarely progress to malignancy, and are often located in the posterior mediastinum. Patients are usually asymptomatic but can present with symptoms associated with obstructive pneumonia. It is very rare for a benign pleural schwannoma to present with a pleural effusion. Literature review has revealed only six cases of benign schwannoma presenting with a pleural effusion, all of which were blood stained. Spontaneous tumor hemorrhage or cyst rupture has been a theory of etiology for the effusions. Prognostically, once the pleural schwannomas are surgically resected there is minimal chance of recurrence. CONCLUSIONS: Our case represents a benign pleural schwannoma that caused extrinsic compression on the right upper lobe bronchus leading to a necrotizing pneumonia along with bilateral serosanguinous pleural effusions. A pleural schwannoma should be considered in the differential diagnosis of intrathoracic tumors even when presenting with pleural effusions. Reference #1: Shoaib D, Zahir M, Khan S, et al. Difficulty Breathing or Just a Case of the Nerves? Incidental Finding of Primary Pleural Schwannoma in a Covid-19 Survivor. Cureus. 2021. 13(8): e17511. Reference #2: Bibby A, Daly R, Internullo E, et al. Benign Pleural Schwannoma Presenting with a Large, Blood Stained Pleural Effusion. Thorax. 2018. 73:497-498. Reference #3: Nosrati R, Annissian D, Ramezani F, et al. Benign schwannoma of posterior mediastinum accompanied by blood pleural effusion misdiagnosed as solitary fibrous tumor: A Case report. Casplan J Intern Med. 2019. 10:468-471. DISCLOSURES: No relevant relationships by Brittany Bass No relevant relationships by Oleg Epelbaum No relevant relationships by Theresa Henson No relevant relationships by Yasmin Leigh No relevant relationships by Ester Sherman No relevant relationships by Sally Ziatabar

SERRATIA MARCESCENS CAVITARY PNEUMONIA FOLLOWING COVID-19 INFECTION IN A YOUNG IMMUNOCOMPETENT HOST

SESSION TITLE: Complications of Thoracic Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Serratia marcescens is a gram negative bacteria known to colonize the human GI tract. While infections of urinary tract, respiratory tract, and CNS can occur, it is usually associated with immunocompromised hosts or patients who undergo invasive procedures or surgeries. Here, we present a 21-year-old immunocompetent male with Serratia marcescens cavitary pneumonia following COVID-19 infection. CASE PRESENTATION: A 21-year-old obese male with no past medical history presented with shortness of breath, cough and fevers for one week. In the emergency department (ED), he was febrile to 38.8°C, tachycardic, saturating 90% on room air. He was recently admitted to an outside hospital two weeks prior with COVID-19 pneumonia. He was treated with Remdesivir and decadron and discharged after five days. No invasive procedures were performed during his hospital stay and he never required advanced oxygen support other than simple nasal cannula. CTA of his chest in the ED showed thick walled bilateral lower lobe cavitary lesions and multifocal ground glass alveolar opacities. No pulmonary embolism was seen. Sputum cultures were collected but inadequate. Bronchoscopy with bronchoalveolar lavage (BAL) was performed and fluid studies showed white blood cell count of 70,029 cell/uL, with 94% neutrophils. BAL fluid cultures grew Serratia marcescens. He was originally placed on vancomycin and cefepime and discharged on oral Levaquin for four weeks based on sensitivities. HIV testing was negative. DISCUSSION: Serratia is a rod shaped gram negative bacteria found in soil, water, and human gut flora. It is known to be an opportunistic pathogen that can cause urinary, respiratory, CNS and blood stream infections in immunocompromised patients. Infections in immunocompetent are usually associated with invasive devices such as mechanical ventilation or central venous catheters. While superimposed bacterial infections in COVID-19 illness are well known, they are usually seen in patients with severe disease requiring mechanical ventilation and prolonged hospitalization. Those with underlying systemic illness, advanced age and impaired immune systems are particularly susceptible. Our patient was young, immunocompetent and only required minimal oxygen support while hospitalized for COVID-19. CONCLUSIONS: Serratia marcescens pneumonia is rarely seen in immunocompetent hosts, but should remain on the differential in patients with recent hospitalization and COVID-19 infection, regardless of severity of disease. Reference #1: Hidron, A., Quiceno, W., Cardeño, J. J., Roncancio, G., & García, C. (2021). Post-COVID-19 Necrotizing Pneumonia in Patients on Invasive Mechanical Ventilation. Infectious Disease Reports, 13(3), 835–842. https://doi.org/10.3390/idr13030075 Reference #2: Fazio, G., Galioto, F., Ferlito, A., Coronella, M., Palmucci, S., & Basile, A. (2021). Cavitated pulmonary nodules in a female patient with breast cancer: Keep in mind Serratia marcescens’ infections. Respiratory Medicine Case Reports, 33, 101441. https://doi.org/10.1016/j.rmcr.2021.101441 Reference #3: Jose, M., & Desai, K. (2020). Fatal Superimposed Bacterial Sepsis in a Healthy Coronavirus (COVID-19) Patient. Cureus. https://doi.org/10.7759/cureus.8350 DISCLOSURES: No relevant relationships by Lucy Checchio No relevant relationships by Syeda Hassan No relevant relationships by Jaclyn Rosenzweig No relevant relationships by Stephanie Tzarnas No relevant relationships by Laura Walters

Pulmonary Artery Aneurysm in a Teenager with Diabetes and COVID-19 Infection

Introduction: Pulmonary artery aneurysms (PAAs) are exceedingly rare. Etiology includes congenital, idiopathic, and acquired. Bacterial and fungal infections are the most common acquired causes. Herein described is a patient with new-onset diabetes mellitus I (DM1) with COVID-19 infection complicated by PAA and mucormycosis. Case Description: A 17-year-old female with new-onset DM1 was admitted to the PICU with diabetic ketoacidosis, and COVID-19 infection complicated by multifocal necrotizing pneumonia. She was treated with remdesivir, antibiotics, systemic glucocorticoids, and discharged on inhaled glucocorticoids. Two weeks later she presented with hemoptysis. Chest computed tomography angiography (CTA) showed a resolving necrotizing pneumonia with a 16 mm aneurysmal dilatation of the proximal portion of the right inferior pulmonary artery (RIPA). Hemoptysis resolved, with no intervention required. One month later she presented again with hemoptysis. Repeat chest CTA demonstrated increasing aneurysmal dilatation, measuring 20 mm in diameter. Echocardiography showed no evidence of endocarditis, congenital heart defects, or elevated right ventricular pressures. A comprehensive infectious workup was negative (Table 1). Due to recurrent symptoms, progressive aneurysmal enlargement, and concerns for rupture, patient underwent RIPA occlusion by cardiac catheterization. Two months later hemoptysis recurred. Chest CTA revealed erosion of the occlusion device into the right inferior segmental bronchus. She underwent emergent right middle and lower lobectomy, and arterial bronchial fistula repair. Lung histology revealed non-septate hyphae with peribronchial and perivascular necrotizing granulomas concerning for mucormycosis (Figure 1). She was treated with amphotericin B and discharged on oral posaconazole. Discussion: The incidence of PAA in adults is estimated to be 1 in 14,000 patients. In adults, the upper limit of normal of an interlobar PA by CTA is 17mm. Our patient's RIPA was dilated up to 20 mm, for which she underwent occlusion of the RIPA. The proinflammatory state generated by COVID-19 can result in vascular inflammation and ultimately aneurysmal dilatation. Desnos et al. reported four cases of hemothorax secondary to PAA rupture in COVID-19 patients on ECMO for severe ARDS. The etiology for PAA formation in our patient had a complex interplay of factors including new-onset diabetes, COVID-19 vasculitis, exposure to systemic glucocorticoids, and an opportunistic infection with Mucor spp. Mucormycosis in diabetic patients with COVID-19 has a mortality of 31% in adults. We believe that the lobectomy performed for the management of PAA in our patient led to better outcomes since surgical debridement is a mainstay of mucormycosis treatment, along with antifungal therapy. Conclusion: PAA in children is uncommon. We describe a diabetic patient with COVID-19 pneumonia, complicated by PAA and mucormycosis. In patients with COVID-19 presenting with hemoptysis, it is important to have a high index of suspicion for PAA. Furthermore, diabetic patients with COVID-19 treated with systemic steroids can be at increased risk for mucormycosis. (Table Presented).

SPONTANEOUS PNEUMOTHORAX IN AN HIV/AIDS PATIENT WITH CONCURRENT COVID-19 AND PNEUMOCYSTIS PNEUMONITIS

CASE: A 25-year-old homeless male with nonadherent HIV presented with dyspnea on exertion for 4 days, productive cough for 1 week, fevers, chills and night sweats. He arrived hypoxic to 74% requiring 2L O2 and was cachectic on exam. WBC, lactate and procalcitonin were normal. C-reactive protein was 26.7 mg/L, LDH was 686 units/L and COVID-19 was positive. An arterial blood gas showed a primary respiratory alkalosis with a secondary metabolic alkalosis. Computed tomography of the chest, abdomen and pelvis with contrast showed multifocal large thin-walled cavitary lesions throughout the bilateral lungs with subpleural large cystic disease. Dexamethasone, remdesivir and empiric antibiotics were initiated. Absolute CD4 count was 7 cells/uL with HIV-1 RNA load of 139,000 copies/mL. Sputum was positive for Pneumocystis jirovecii (PCP) by DFA and PCR, but no evidence of mycobacterium. Trimethoprim-sulfamethoxazole (TMP-SMX) was added. On hospital day 13, he developed severe right-sided chest pain, dyspnea and required up to 15L O2. A chest x-ray revealed a large right-sided pneumothorax (PTX) and a chest tube was placed. Cardiothoracic Surgery was consulted for consideration of bullectomy with pleurodesis;this was not recommended as the cystic lesions were extensive with some intraparenchymal. His oxygen requirements improved and his chest tube was removed in 6 days. He was discharged on hospital day 21 to begin prophylactic dosing of TMP-SMX until his CD4 count was over 200 cells/uL and to attend his first appointment at an outpatient HIV clinic the following day. IMPACT/DISCUSSION: Secondary spontaneous pneumothorax (SSP) can be a complication of necrotizing pneumonia due to PCP. In one study, in a cohort of 599 patients with HIV infection, only 1.2% developed a PTX. Bilateral PTX is more common with PCP, unlike in our patient. In HIV, the degree of immunosuppression can influence the cause of PTX. Our patient had a PTX with a CD4 count under 200, which is more common with PCP. In addition, SSP as a complication of SARS-CoV-2 is more rare. There are case series that describe COVID-19 patients who develop PTX in the absence of barotrauma secondary to mechanical ventilation. However, this is uncommon as one retrospective study reports PTX occurring in 1% of patients with COVID-19 requiring hospital admission. In this case, it is unclear to what extent the patient's concomitant COVID-19 contributed to the development of a PTX. Our patient was ineligible for definitive intervention to prevent recurrence, thus underwent tube thoracostomy placement which is consistent with the majority of treated patients. While the prognosis of PTX secondary to COVID-19 is generally good, prognosis of cominant co-infection with PCP is an area of further research as the overall mortality of PCP-induced PTX alone can be 23%. CONCLUSION: This case represents a rare occurrence of spontaneous pneumothorax secondary to both PCP and COVID-19. We suggest the incidence to increase as the pandemic continues.

NECROTIZING PNEUMONIA WITH HYDROPNEUMOTHORAX CAUSED BY MYCOBACTERIUM TUBERCULOSIS WITH IN A HEALTHY YOUNG WOMAN

CASE: Patient is a 21-year-old Guatemalan female with no significant past medical history was hospitalized with worsening productive cough for the last 4 weeks, with greenish sputum associated with pleuritic chest pain, shortness of breath and low appetite. Patient denies any fever, night sweating, weight loss. She states that she came from Guatemala around 3 years ago. Denies any nausea, vomiting, diarrhea, abdominal pain, falls or injuries. She works in the poultry industry. No sick contact. No recent travel. She denies any family members with similar symptoms. No reported history of TB in the family. On admission, she was alert, vitals were stable except for mild tachycardia, and was saturating well on room air. Physical examination revealed dullness on percussion, diffuse crackles, and decreasing breath sound bilaterally. Cell blood count with white blood cells 8.6G/L (72.4% neutrophil and 15% lymphocyte) and hemoglobin ad hematocrit 10.5/34.7 and mildly elevated liver transaminase level were recorded. Chest X-ray showed, Severe bilateral basilar pneumonitis worse on left. Moderate-sized left pleural effusion and the first contrast-enhanced chest computed tomography (CT)revealed severe multifocal necrotizing pneumonia with bilateral pleural effusions. The left pleural effusion raised the question of a loculated infected pleural effusion, and she also developed small apical hydropneumothorax. Patient was started on broadspectrum antibiotic coverage as well as pigtail placement on the left for drainage of pleural effusion. Fungal serologies, QuantiFERON gold assay, pleural fluid studies and sputum series for AFB stain were sent. COVID PCR negative. Cryptococcal negative. HIV negative. Sputum culture showing gram- negative rods Serratia marcescens and positive acid-fast bacilli for mycobacterium tuberculosis, pleural fluid is strongly exudative and sputum AFB smear showed positive PCR for Mycobacterium tuberculosis complex. She started on Rifampin, INH, Pyrazinamide and Ethambutol. IMPACT/DISCUSSION: Necrotizing pneumonia is a serious complication of community acquired Pneumonia, it's a rare but severe condition of lung parenchyma destruction commonly caused by bacterial pathogens. Necrotizing Pneumonia with M.tuberculosis have been reported in children and several cases of pulmonary gangrene in adults but very few cases of necrotizing pneumonia have been reported.The destruction of pulmonary parenchyma induced by M. tuberculosis usually develops from months to years but there are a few cases (necrotizing pneumonia and pulmonary gangrene) in which this destruction may progress rapidly causing severe respiratory failure. The pathogenic mechanism can be explained by the intensive tuberculous inflammation causing the widespread vascular thrombosis and arteritis. CONCLUSION: Our case report highlights the rarity of Mycobacterium tuberculosis causing necrotizing pneumonia and physicians should be aware of this rare presentation which develops rapidly causing severe respiratory failure.

THE ROLE OF THE HEMOSTASIS SYSTEM IN THE DEVELOPMENT OF DESTRUCTIVE PNEUMONIA IN CHILDREN: A BIBLIOGRAPHICAL REVIEW AND CLINICAL OBSERVATIONS

Complicated pneumonia in children remains an urgent problem in pediatrics because of increasing frequency of its current occurrence. The pathogenetic mechanisms of lung destruction have not been sufficiently studied as yet. The article presents an overview of current bibliographical data on the importance of the hemostasis system in the development of the infectious and inflammatory process in pneumonias. The clinical observations of various forms of destructive pneumonia in children are given as well.

Safe and effective administration of multiple recombinant factors on VA-ECMO via post-oxygenator pigtail during acute massive pulmonary hemorrhage

Introduction: Massive bleeding on extracorporeal membrane oxygenation (ECMO) is associated with multiple coagulation defects, including depletion of coagulation factors and development of acquired von Willebrand syndrome (AVWS). The use of recombinant factors, in particular recombinant activated factor VII (rFVIIa, Novoseven), to treat severe refractory hemorrhage in ECMO has been described. However, the use of multiple recombinant factors has been avoided in large part due to concern for circuit complications and thrombosis. Here, we describe the safe and effective administration of rFVIIa and recombinant von Willebrand factor complex (vWF/ FVIII, Humate-P) via post-oxygenator pigtail catheter on VA-ECMO for the treatment of massive pulmonary hemorrhage. Case Description: A 21-month-old (13.4 kg) girl with a recent history of COVID-19 infection presented to an outside hospital with parainfluenza bronchiolitis resulting in acute refractory hypoxemic respiratory failure (oxygenation index 58), refractory septic shock, and myocardial dysfunction. She was cannulated to VA-ECMO and subsequently diagnosed with necrotizing pneumonia from Pseudomonas and herpes simplex infections. Her course was complicated by a large left-sided pneumatocele and bronchopleural fistula requiring multiple chest tubes. She also had right mainstem bronchus obstruction from necrotic airway debris and complete right lung atelectasis. She was noted to have prolonged episodes of mucosal and cutaneous bleeding (oropharynx, chest tube insertion sites, peripheral IV insertion sites) associated with absent high molecular weight von Willebrand multimers consistent with AVWS. Tranexamic acid infusion was initiated and bivalirudin anticoagulation was discontinued. VA-ECMO flows were escalated to 140-160 ml/kg/min to maintain circuit integrity and meet high patient metabolic demand in the absence of anticoagulation. On ECMO day 26, she underwent bronchoscopy to clear necrotic debris from her airway to assist with lung recruitment. The procedure was notable for mucosal bleeding requiring topical epinephrine and rFVIIa. Post-procedure, she developed acute hemorrhage from her right mainstem bronchus, resulting in significant hemothorax (estimated 950 ml) with mediastinal shift, increased venous pressures, desaturation and decreased ECMO blood flow rate, necessitating massive transfusion of 2,050 ml (150 ml/kg) of packed red blood cells, platelets, plasma and cryoprecipitate. An airway blocker was placed in the mid-trachea to control bleeding. In addition to transfusion of appropriate blood products and continuation of tranexamic acid infusion, she was given both rFVIIa (100mcg/kg) and vWF-FVIII (70 units vWF/kg loading dose on the day of hemorrhage, followed by 40 units vWF/kg every 12 hours for 3 additional doses). Both products were administered over 10 minutes through a post-oxygenator pigtail to allow the product to circulate throughout the patient prior to entering the ECMO circuit. The circuit was closely monitored during administration and no changes to circuit integrity were noted in the subsequent hours while hemostasis was achieved. The ECMO circuit remained without thrombosis for 9 days after the bleeding event. Discussion: Balancing anticoagulation and hemostasis is a central challenge in maintaining ECMO support, especially given the prevalence of acquired coagulopathies such as AVWS. For our patient, AVWS contributed to mucosal bleeding necessitating cessation of anticoagulation and utilization of a high ECMO blood flow strategy to minimize circuit clot burden. This was further complicated by absent native lung function and minimal myocardial function, resulting in complete dependence on ECMO. An acute massive pulmonary hemorrhage was treated with multiple recombinant factors (rFVIIa and vWF/FVIII), that are often avoided on ECMO. To minimize clotting risk to the circuit and to maximize transit of these factors to our patient, we added a post-oxygenator pigtail for administration. While this approach was the result of extreme circumstances, th use of a post-oxygenator pigtail for administration of recombinant factors may represent a viable strategy for refractory hemorrhage while on ECMO.

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.

Pulmonary mucormycosis causing pulmonary artery pseudoaneurysm - A rare entity

Background: A pseudoaneurysm is an abnormal dilatation or outpouching of the artery which is lined only by the tunica adventitia. Pulmonary artery Pseudoaneurysm is very uncommon and associated with high mortality. Usually congenital but the acquired causes include trauma and infrequently infections mainly bacterial and fungal. Pulmonary mucormycosis is a rare opportunistic fungal infection seen in immunocompromised patients with diabetes, chronic renal failure, malignancies and is one of the most uncommon causes of pseudoaneurysm. Less than 30 cases have been reported worldwide for mucormycosis causing pulmonary artery pseudoaneurysm. Case 1: A 52 year old female who was COVID 19 positive 2 months back, admitted in RICU with recurrent hemoptysis and breathlessness. She is known Diabetic and Hypertensive. As her hemoptysis was persisting she underwent bronchoscopy and a soft mass was noticed in the right lower lobe bronchus which bleeds on touch. Bronchoalveolar lavage sent for microbiology confirmed Mucormycosis. CTPA done post bronchoscopy revealed pseudoaneurysm involving right descending pulmonary artery. Injection Amphotericin B started and surgical resection of right lower lobe done. Case 2: A 65 year old male, diabetic presented with cough and hemoptysis for 20 days with fever. CT thorax was suggestive of necrotising pneumonia in left lower lobe. As his hemoptysis was persisting Bronchoalveolar lavage was taken and the bronchoscopy showed a small swelling in the left lowerlobe bronchus. CECT Thorax was later done which confirmed descending pulmonary artery pseudoaneurysm. Treatment was same as for case 1. Discussion: Fungal pneumonia is a rare acquired cause of pulmonary artery pseudoaneurysm. The pseudoaneurysms are thin walled and easily ruptures producing massive hemoptysis. Infection accounts for 33% of the causes for pseudoaneurysms. Infective causes include pyogenic bacteria like S. pyogenes, S. aureus, Klebsiella and fungus like Mucor, and Aspergillus. Infection leads to chronic inflammation of vessel and leads to weakening of vessel wall which causes the internal layers to rupture. Mucor has the potential to cause direct invasion of the vessel wall leading to pseudoaneurysm. Conclusion: Pulmonary Artery Pseudoaneurysm and Pulmonary mucormycosis are individually uncommon clinical entities, but Pulmonary Artery Pseudoaneurysm due to underlying mucormycosis is a rare condition with a limited description in the literature. A high index of suspicion for both the clinician and radiologist is required and should be suspected in patients with underlying immunosuppression who develop hemoptysis. Pulmonary Artery Pseudoaneurysm can be successfully treated with embolization, but if mucormycosis is confirmed surgical resection is the only option.

Venovenous extracorporeal membrane oxygenation for treating very severe pneumonia in Aotearoa New Zealand: a 16-year experience

AIM: We sought to describe the aetiology, demographics and outcomes of patients with pneumonia undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO) in Aotearoa New Zealand. METHODS: Retrospective observational study. RESULTS: Between January 2004 and August 2020, 133 patients underwent VV-ECMO for pneumonia. This VV-ECMO cohort is representative of the geographic and ethnic distribution of the population of Aotearoa New Zealand. Six-month survival was 85/133 (64%). A primary viral aetiology was identified in 63/133 cases (47%) with bacterial co-infection present in 34/63 viral pneumonias (54%). Primary bacterial pneumonia was identified in 48/133 cases (36%). Twenty-three (17%) of 133 patients developed necrotising pneumonia. The most commonly identified microorganisms were influenza A, Staphylococcus aureus and Streptococcus pneumoniae. Infection with Staphylococcus aureus or Streptococcus species was strongly associated with necrotising pneumonia (OR 10.18, 95% CI 3.52–37.13, P<0.0001). Necrotising pneumonia was more common in Māori and Pacific Peoples than in other ethnic groups (OR 3.08, 95% CI 1.16–7.96, P=0.02). DISCUSSION: Outcomes from VV-ECMO for pneumonia in Aotearoa New Zealand are comparable to large international series. Although the use of VV-ECMO was matched to the ethnic distribution of the population of Aotearoa New Zealand, Māori may have reduced access because they have higher rates of pneumonia than non-Māori.

Post-COVID-19 Necrotizing Pneumonia in Patients on Invasive Mechanical Ventilation.

(1) Background: Few reports of necrotizing pneumonia in patients with COVID-19 have been published. We have observed an elevated incidence at two hospitals in our city, suggesting this complication is not uncommon, and may have been overlooked. (2) Methods: This article presents a retrospective, descriptive cohort study that was undertaken from 22 March 2020 to 15 June 2021 in two tertiary care hospitals in Medellín, Colombia. All adult patients admitted to the intensive care unit (ICU) for respiratory failure related to confirmed COVID-19, on invasive mechanical ventilation (IMV), with imaging or surgical findings documenting necrotizing pneumonia (NP) were included. (3) Results: Of 936 patients with COVID-19 that required IMV, 42 (4.5%) developed NP. Overall mortality was 57% and in-hospital mortality was 71%, occurring 15-79 days after COVID-19 diagnosis. NP was diagnosed at a median of 27 days after COVID-19 symptom onset and 15.5 days after initiation of IMV. Infections were polymicrobial in 52.4% of patients. Klebsiella pneumoniae (57%) and Pseudomonas aeruginosa (33%) were the most common etiologic agents. Pulmonary embolism (PE) was documented in 13 patients overall (31%), and in 50% of patients who underwent an angioCT. Drainage and/or surgical procedures were performed on 19 patients (45.2%) with a 75% mortality rate. (4) Conclusions: In our experience, NP is a relatively common, albeit neglected, complication in mechanically ventilated COVID-19 patients, possibly originating in poorly vascularized areas of lung parenchyma. Associated mortality is high. Although drainage procedures did not seem to favorably impact patient outcomes, diagnosis and treatment were late events in the overall disease course, suggesting that early recognition and timely treatment could have a positive impact on prognosis.