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Spontaneous pneumomediastinum (SPM) is a decisive complication reported to be associated with COVID-19. Here, we present a case of SPM in a COVID-19positive patient that was not caused by any iatrogenic or known reasons. At the time of admission, the patient was COVID-positive and distressed. He was immediately subjected to hematological and radiological investigations (chest X-ray, HRCT), which confirmed pneumomediastinum. The patient was hypoxic and hypotensive even after receiving ionotropic support. Considering the patient's critical condition, a mediastinal pigtail catheterization was performed instead of a thoracotomy, and the catheter was in situ for nine days. Arterial blood gas was monitored during the hospital stay, and supplementary oxygen therapy was provided accordingly. The patient subsequently recovered and was discharged. Hence, SPM in this COVID patient was treated by pigtail catheterization, and major surgical interventions were avoided.Copyright © 2023 LookUs Scientific. All rights reserved.
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Background: The present radiological COVID literature is mainly confined to the CT findings. Using High Resolution Computed tomography (HRCT) as a regular 1st line investigation put a large burden on radiology department and constitute a huge challenge for the infection control in CT suite. Materials and Methods: A prospective study of 700 consecutive COVID positive cases who underwent Chest Xray (CXR) and HRCT thorax were included in the study. Many of these CXR were repeated and followed up over a duration of time to see the progression of disease. Results: 392/700 (56%) were found to be negative for radiological thoracic involvement. 147/700 (21%) COVID positive patients showed lung consolidations, 115/700 (16.5%) presented with GGO, 40/700 (5.7%) with nodules and 42/700 (6%) with reticular–nodular opacities. 150/700 patients (21.4 %) had mild findings with total RALE severity score of 1-2. More extensive involvement was seen in 104/700 (14.8 %) and 43/700 (6.2%) patients, who had severity scores of 3-4 and 5-6 respectively. 11/700 patients had a severity score of >6 on their baseline CXR. Those with severity score of 5 or more than 5 (54/700, 7.7%) required aggressive treatment with mean duration of stay of 14 days, many of them died also (23/54, 42.5%). Conclusion: In cases of high clinical suspicion for COVID-19, a positive CXR may obviate the need for CT. Additionally, CXR utilization for early disease detection and followup may also play a vital role in areas around the world with limited access to CT and RT-PCR test.
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SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: This report describes the case of a patient presenting with pneumothorax and Severe Acute Respiratory Syndrome (SARS) Coronavirus-2 (SARS-cov-2) infection leading to Coronavirus Disease 2019 (COVID-19) pneumonia, with worsening presentation, later found to have underlying Pleuroparenchymal Fibroelastosis (PPFE). CASE PRESENTATION: A 68 year old male with a past medical history of hypertension and type 2 diabetes presented to his primary care clinic with shortness of breath. He underwent a Chest X-Ray as an outpatient which revealed a moderate right-sided pneumothorax (PTX), and he was sent to the Emergency Department by his primary care provider. He was found to be COVID positive on initial workup, also requiring supplemental oxygen. Other routine laboratory tests did not reveal any significant abnormalities. His shortness of breath worsened and on repeat X-rays his pneumothorax increased in size therefore a chest tube was placed by Cardiothoracic Surgery. Computerized Tomography of the chest revealed moderate right pneumothorax, bilateral diffuse ground glass opacities and pulmonary micronodules [Figure 1]. The patient had mild initial improvement and the chest tube was removed but he had recurrence of the PTX and he underwent urgent Video Assisted Thoracoscopic Surgery (VATS), with right upper lobe wedge resection and talc pleurodesis. A biopsy of the resected lung revealed a benign lung with fibroelastotic scarring, diffusely involving subpleural tissue and prominently extending into and entrapping areas of underlying alveolated tissue, with no inflammation, granulomas or pneumonia noted. Workup for tuberculosis, autoimmune disorders, HIV was negative. He eventually was discharged home with close pulmonology and cardiothoracic surgery follow ups, planned for disease surveillance and malignancy workup. DISCUSSION: PPFE is a rare entity, and classified amongst rare causes of idiopathic interstitial pneumonias (IIP) [1]. It is characterized by upper lobe fibrosis, supleural and parenchymal scarring. It can occur at any age, and the usual presentation is of pneumothorax in a thin male, with a shortened anteroposterior diameter of the chest. Radiographic findings typically include subpleural nodular or reticular opacities in the upper lobes, usually sparing the middle and lower lobes. Pathology reveals increased elastic tissue and dense collagen fibers, along with subpleural fibrosis [2]. Pulmonary function testing reveals a restrictive pattern with reduced diffusion capacity and it is usually resistant to steroids [3]. CONCLUSIONS: PPFE is an uncommon cause of insidious, slowly progressive fibrotic lung disease often limited to the upper lobes. It should be suspected in any person presenting with recurrent pneumothorax or blebs without other known inciting causes. Lung biopsy helps establish the diagnosis. Patients with this condition need close pulmonology follow up to assess progression. Reference #1: Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, Ryerson CJ, Ryu JH, Selman M, Wells AU, Behr J, Bouros D, Brown KK, Colby TV, Collard HR, Cordeiro CR, Cottin V, Crestani B, Drent M, Dudden RF, Egan J, Flaherty K, Hogaboam C, Inoue Y, Johkoh T, Kim DS, Kitaichi M, Loyd J, Martinez FJ, Myers J, Protzko S, Raghu G, Richeldi L, Sverzellati N, Swigris J, Valeyre D;ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013 Sep 15;188(6):733-48. doi: 10.1164/rccm.201308-1483ST. PMID: 24032382;PMCID: PMC5803655. Reference #2: Frankel SK, Cool CD, Lynch DA, Brown KK. Idiopathic pleuroparenchymal fibroelastosis: description of a novel clinicopathologic entity. Chest. 2004 Dec;126(6):2007-13. doi: 10.1378/chest.126.6.2007. PMID: 1559 706. Reference #3: Watanabe K. Pleuroparenchymal Fibroelastosis: Its Clinical Characteristics. Curr Respir Med Rev. 2013 Jun;9(4):299-237. doi: 10.2174/1573398X0904140129125307. PMID: 24578677;PMCID: PMC3933942. DISCLOSURES: No relevant relationships by FNU Amisha No relevant relationships by Perminder Gulani No relevant relationships by Hyomin Lim No relevant relationships by paras malik No relevant relationships by Divya Reddy
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SESSION TITLE: Critical Diffuse Lung Disease Cases 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 12:45 pm INTRODUCTION: Acute exacerbations (AE) of idiopathic pulmonary fibrosis (IPF) are well recognized in the progression of this uniformly fatal disease. Here we describe a case of AE of undiagnosed IPF after ankle surgery. Our aim is to discuss the role of non-pulmonary surgery as a precipitating factor and its outcome. CASE PRESENTATION: The patient is a 61-year-old male with a medical history of chronic smoking, recent open reduction internal fixation of left ankle 5 days before the presentation, comes to the emergency room with acute onset, gradually worsening shortness of breath along with non-productive cough and pleuritic chest pain. He denied any sick contacts, COVID exposure, travel history, inhalation of toxic fumes, or any chemical/pets/bird exposure. He was saturating around 85% on room air, was switched to a nasal cannula with improvement in saturation. Computed tomography (CT) of the chest showed no evidence of pulmonary embolism but diffuse ground-glass opacities (GGO) were noted bilaterally with no effusion or emphysematous changes, which were new compared to CT chest 10 days prior (that is 5 days before ankle surgery) which showed only mild reticular opacity along anterior convexity of the lungs bilaterally. He was started on intravenous steroids with gradual improvement in clinical status. Bronchoscopy biopsies revealed no malignant cells, bronchoalveolar lavage with no infections, and a negative serum autoimmune panel. He was discharged with outpatient follow-up for a repeat CT chest 6 weeks later which showed improvement in GGO (not back to baseline) and he was still requiring oxygen support. DISCUSSION: The most common triggers for IPF are smoking, environmental toxins, viral (COVID infection) or bacterial infections, medications like antidepressants, beta-blockers, NSAIDs. There is increasing evidence that surgery can cause acute respiratory worsening in IPF, presumably through increased mechanical stress to the lungs. Prolonged mechanical ventilation, high tidal volume, and high concentration of supplemental oxygen during surgery have been proposed as potential causes(1). As per the results from the retrospective study, the incidence of postoperative AE of IPF in patients undergoing non-pulmonary surgery is slightly lower than in patients undergoing pulmonary surgery (2,3). As in our case, non-pulmonary surgery procedures can pose risk for IPF exacerbation, but at this time we have limited research evidence to conclude if this exacerbation can alter the course of the disease. Some studies showed preoperative elevated C-reactive protein as a possible risk factor for AE of IPF after a non-pulmonary surgery but a multicenter study is needed to clarify the preoperative risk factors for AE of IPF after non-pulmonary surgery. CONCLUSIONS: We need further studies to check risk factors and disease course alteration, to have better guidance to classify preoperative risk in our IPF patients. Reference #1: Acute Exacerbation of Idiopathic Pulmonary Fibrosis: A Proposal, PMID: 2441663 Reference #2: Exacerbations in idiopathic pulmonary fibrosis triggered by pulmonary and non-pulmonary surgery: a case series and comprehensive review of the literature, PMID: 22543997 Reference #3: Postoperative acute exacerbation of interstitial pneumonia in pulmonary and non-pulmonary surgery: a retrospective study DISCLOSURES: No relevant relationships by Arundhati Chandini Arjun No relevant relationships by Harshil Fichadiya no disclosure submitted for Boning Li;No relevant relationships by Gaurav Mohan No relevant relationships by Rana Prathap Padappayil No relevant relationships by Raghu Tiperneni
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SESSION TITLE: Critical Diffuse Lung Disease Cases 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Polymyositis (PM) and dermatomyositis (DM) are inflammatory syndromes that have been shown to be associated with interstitial lung disease in up to 64% of cases. Current management strategies for PM/DM-ILD are mostly derived from treatment of PM/DM and rely on the immunomodulatory effects of steroids and steroid sparing medications. Literature supports the use of intravenous immunoglobulins for the management of PM/DM-ILD. However, this stems from isolated case reports. CASE PRESENTATION: Our patient is a 43-year-old female, previously healthy, who was referred to our ILD clinic for evaluation of possible diffuse interstitial lung disease. Her symptoms began May of 2019 with dyspnea, cough, and muscle aches. Her initial workup was significant for reticular opacities in the mid to lower lung fields on x-ray, moderate restriction, and severe diffusion impairment on pulmonary function tests. High resolution CT scan (HRCT) of the lungs showed a radiological pattern suggestive of nonspecific interstitial pneumonitis (NSIP) with mid to lower lung predominant ground glass opacities, mild subpleural reticulation, traction bronchiectasis with no evidence of honeycombing or air trapping. Further workup showed a positive antinuclear antibody (ANA) in a speckled pattern with a titer of 1:320. Her other rheumatological workup was initially largely unremarkable and she denied significant drug/toxin exposure. She was treated with steroids with initial improvement, however had significant clinical deterioration requiring hospitalization and oxygen supplementation and was eventually started on Mycophenolate Mofetil in Aug 2020. Her pulmonary disease remained stable until she was admitted again in Jan 2021 with new hypoxemic respiratory failure requiring 6 L supplemental oxygen. During that admission, she was diagnosed with polymyositis and referred for a lung transplant evaluation, she also started on IVIG for the treatment of active myositis to wean her off steroids prior to transplant listing. She was discharged home and underwent a full transplant workup. She required readmission for worsening hypoxemia now requiring 12 L supplemental oxygen in May 2021, HRCT showed worsening ground glass opacities. She was again treated with IVIG and a steroid course and had near complete resolution of her hypoxia with a 2 L oxygen requirement only on ambulation. She continues to follow up with our interstitial lung disease team and the pulmonary transplant team. Her course has been complicated by multiple admissions with bacterial pneumonia as well as COVID-19 infection. DISCUSSION: Treatment of PM/DM associated ILD relies heavily on the use of steroids as well as steroids sparing agents such as Mycophenolate or Rituximab. IVIG has been implicated in improving underlying lung disease with data derived from case reports. CONCLUSIONS: Our case highlights the importance of further advanced research in this field. Reference #1: Peshbahar, S., & Bendstrup, E. (2020). Remarkable benefits of intravenous immunoglobulin (IVIG) in a patient with polymyositis-associated acute interstitial lung disease. European Clinical Respiratory Journal, 7(1), 1840706. Reference #2: Fathi, M. (2006). Interstitial lung disease in polymyositis and dermatomyositis. Karolinska Institutet (Sweden). DISCLOSURES: No relevant relationships by Hafsa Abdulla No relevant relationships by ALAA ABU SAYF