Normative reference values of major thoracic arterial vasculature in Turkiye.

OBJECTIVE: The aim of this study was to determine normative reference values for major thoracic arterial vasculature in Turkiye and to evaluate differences according to age and gender. METHODS: Low-dose unenhanced chest computerized tomography images acquired with pre-diagnosis of COVID-19 between March and June 2020 were evaluated retrospectively. Patients with known chronic lung parenchymal disease, pleural effusion, pneumothorax, chronic diseases such as diabetes, hypertension, obesity, and chronic heart diseases (coronary artery disease, atherosclerosis, congestive heart failure, valve replacement, and arrhythmia) were excluded from the study. The ascending aorta diameter (AAD), descending aorta diameter (DAD), aortic arch diameter (ARCAD), main pulmonary artery diameter (MPAD), right pulmonary artery diameter (RPAD), and the left pulmonary artery diameter (LPAD) were measured in the same sections by standardized methods. The variability of parameters according to age (<40 years; ≥40 years) and gender (male to female) was evaluated by statistical methods. The Student's t test was used to compare the normal distribution according to the given quantitative age and gender, while the data that did not fit the normal distribution were compared with the Mann-Whitney U test. The conformity of the data to the normal distribution was tested with the Kolmogorov-Smirnov, Shapiro-Wilk test, and graphical examinations. RESULTS: Totally 777 cases between the ages of 18-96 (43.80±15.98) were included in the study. Among these, 52.8% (n=410) were male and 47.2% (n=367) were female. Mean diameters were 28.52±5.13 mm (12-48 mm in range) for AAD, 30.83±5.25 mm (12-52 mm in range) for ARCAD, DAD 21.27±3.57 mm (11-38 mm in range) for DAD; 23.27±4.03 mm (14-40 mm in range) for MPAD, 17.27±3.19 mm (10-30 mm in range) for RPAD, and 17.62±3.06 mm (10-37 mm in range) for LPAD. Statistically significantly higher values were obtained in all diameters for cases over 40 years of age. Similarly, higher values were obtained in all diameters for males compared to females. CONCLUSION: The diameters of all thoracic main vascular structures are larger in men than in women and increase with age.

Inferior vena cava and pulmonary artery diameters for prognosis of Coronavirus disease Pulmonary vascular diameters in Coronavirus disease

Aim: In this study, we aimed to analyze the relationship between pulmonary artery (PA) and inferior vena cava (IVC) diameters in non-contrast chest computerized tomography (CT) images of patients with coronavirus disease 2019 (COVID-19) and overall survival. Material(s) and Method(s): This retrospective study consisted of 404 consecutive patients who underwent chest CT after admission to the emergency department between May 1 and June 31, 2021. CT measurements were performed by two radiologists. The prognostic value of PA and IVC diameters, the computerized tomography severity score (CT-SS), quick sequential organ failure assessment (qSOFA), and confusion, urea, respiratory rate, blood pressure, and age >=65 years (CURB-65) score on overall survival were examined. Result(s): The median age of the participants was 62 years (49-72), and 196 (48.5%) were male. Of the 404 patients, 61 died after admission. While main-PA, left-PA, right-PA (p < 0.001) and IVC-transverse (IVC-Tr) (p = 0.045) diameters were larger and statistically significant in the patients who died (AUC;0.686, 0.722, 0.746, and 0.581, respectively), a statistically significant difference was not detected in terms of IVC anteroposterior diameter (IVC-AP) (p = 0.053) and the IVC-Tr/AP (p = 0.754) ratio. There was a statistical difference in mortality in qSOFA, CURB-65, and CT-SS values (AUC;0.727, 0.798, and 0.708 p < 0.001, respectively). Discussion(s): PA diameters measured from chest CT images at admission (main-PA >= 26.5 mm, right-PA >= 22.9 mm, and left-PA >= 21.6 mm) and the IVC-Tr diameter (>=34.5 mm) can be used as mortality predictors for COVID-19, along with other prognostic scores.Copyright © 2022, Derman Medical Publishing. All rights reserved.

BLUE FINGERS, EOSINOPHILIC LUNGS: ACUTE EOSINOPHILIC PNEUMONIA FOLLOWING COVID-19 INFECTION

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal

ACUTE PULMONARY EMBOLISM IN A PATIENT WITH A NORMAL D-DIMER

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Several studies on COVID-19 have helped us better understand the dynamics of this viral illness. Initially considered to be a respiratory disease, research later showed that it was the initiation of an aggressive systemic inflammatory response including a prothrombotic state. Clinicians have used inflammatory markers such as D-dimer as an indicator for underlying thrombotic state. We present the case of a pulmonary embolism (PE) despite normal D-dimer levels. CASE PRESENTATION: A 73-year-old female with a past medical history of hypertension and recent hospitalization for COVID-19 pneumonia. D-dimer on initial admission was 150, patient was treated for COVID-19 pneumonia and discharged home on 2L of O2 via nasal cannula. She returned to the hospital 1 month later with complaints of palpitations. EKG on admission showed sinus tachycardia, the patient was found saturating at 98% on 2L of oxygen, unchanged from time of discharge, otherwise vitally stable. Patients’ wells score was calculated at 1.5 which pointed towards patients being low risk for PE, D-dimer measured at 645, was within normal limits when adjusted for age, indicating a low probability of VTE. Due to recent hospitalization and infection with COVID-19, CT Angiography was obtained and showed PE of the right main pulmonary artery extending into segmental right upper and lower lobe pulmonary arteries with no right ventricular strain. Patient was started on anticoagulation, and she was discharged home in stable condition. DISCUSSION: It is now well established that COVID 19 infection causes a hypercoagulable state, Initial recommendations for management of patients with Covid-19 included measurement of serial D-dimers throughout the course of illness. This recommendation has since changed. In our case, despite the rise in inflammatory marker, the age-adjusted value was within normal limits. In addition, Wells Score, which is used to predict DVT and PE, did not serve to be a reliable scoring system. CONCLUSIONS: Trending laboratory markers like D-dimers from previous admissions should be used as a valuable tool when post COVID disease is suspected. Any increase in D-dimer even if below the cutoff for age-adjusted D-dimer should be an indicator for further evaluation with imaging to rule out underlying clots. Reference #1: Logothetis CN, Weppelmann TA, Jordan A, et al. D-Dimer Testing for the Exclusion of Pulmonary Embolism Among Hospitalized Patients With COVID-19. JAMA Netw Open. 2021;4(10):e2128802. doi:10.1001/jamanetworkopen.2021.28802 DISCLOSURES: No relevant relationships by Kevser Akyuz No relevant relationships by Hanan Hannoodee No relevant relationships by verisha khanam No relevant relationships by Zain Kulairi No relevant relationships by DANYAL TAHERI ABKOUH

Rare and interesting case of solitary peripheral pulmonary artery aneurysm

Background: We report a rare case of solitary peripheral pulmonary artery aneurysm in a patient who was evaluated for haemoptysis. Incidentally, his total antibodies were positive for Coronavirus 2019 infection. Patient underwent right lower lobectomy uneventfully. Peripheral pulmonary artery aneurysms arising from segmental or intrapulmonary branches are extremely rare. Untreated, the majority end fatally due to sudden rupture and exsanguination. The purpose of this article is to report our rare case and review the pertinent literature. Case Study: A 40-year-old man presented with an episode of haemoptysis. He had a history of intermittent mild grade fever, cough and dyspnea lasting for a month. He had no history of haemoptysis in the past. He had no pre-existing medical conditions or Coronavirus 2019 (COVID-19) infection. His clinical examination was unremarkable. Blood investigations were within normal limits. Reverse transcription polymerase chain reaction test was negative for COVID-19 infection, but his total antibodies test was elevated -117 (biologicalreference range <1.0). 2D Echocardiography was normal. Chest radiography showed a solitary pulmonary lesion in the right lower lung zone [Figure 1a].A computed tomography of the chest plain and contrast confirmed the presence of a 3.7 cm-3.6 cm, well-defined, circumscribed and densely enhancing lesion in apicoposterior segment of right lower lobe. It is seen along the course of descending branch of the right pulmonary artery. Areas of consolidation are also seen in apicoposterior segment. Postcontrast study shows heterogenous enhancement of this lesion suggestive of an aneurysm. The rest of lung parenchyma was normal [Figure 1b and c].The diagnosis of a solitary peripheral pulmonary artery aneurysm (PAA) was considered and right lower lobectomy was performed through posterolateral thoracotomy. Discussion: The estimated incidence of PAA is 1 in 14 000 autopsies, and these lesions can be central aneurysms and peripheral aneurysm. An aneurysm can be true or pseudo aneurysm. In this patient, an aneurysm is a true aneurysm and origin may be idiopathic or post-inflammatory with superadded fungal infection in thrombus, post-COVID-19 infection. Long-term follow up is required to observe the future course Conclusion: True solitary peripheral PAA is an extremely rare entity. A high degree of suspicion is needed for diagnosing PAAs on imaging. Intervention is mandatory as soon as the diagnosis is made, to prevent rupture and death. PAA has been managed most often by lobectomy but occasionally by pulmonary artery repair or endovascular approach.

Pulmonary artery pseudoaneurysm in a covid survivor

Introduction: Pseudoaneurysm of the pulmonary artery (PAP) is a rare cause of hemoptysis with a wide array of aetiologies. This case report discusses our clinical experience of PAP associated with pulmonary mucormycosis (PM) in a COVID survivor. Case Report: A 58-year-old gentleman presented with a 1-week history of high-grade fever and progressive dry cough. Four weeks before his presentation, he was treated for mildly symptomatic COVID-19 infection with unusually high doses of steroids. On admission, a chest x-ray and CT chest showed a cavitatory lesion in the right lower lobe. He underwent a FOB with BAL and endobronchial biopsy, which were inconclusive. On day 5 of his hospital admission, he had an episode of massive hemoptysis leading to hemodynamic instability. CT showed an increase in the size of the cavity and a pulmonary angiogram showed the descending segmental branch of the right pulmonary artery traversing through the consolidative cavitating lesion with focal dilatation of the same measuring up to 1.5 x 1.9 cm. Consistent hemostasis couldn't be achieved after gluing an interlock coiling of pseudoaneurysm, hence he underwent video-assisted thoracic surgery for right lower lobectomy and stump ligation of the right lobar pulmonary artery. Lobectomy specimen on histopathology revealed large areas of necrosis with aseptate fungal hyphae. He responded well to antifungal therapy during follow on 4th week post discharge. Conclusion: Mucormycosis is characterized by angioinvasion, vessel thrombosis, and subsequent tissue thrombosis. Pseudoaneurysm formation is rarely seen in PM and can be associated with fatal hemoptysis. Irrational use of systemic steroids in the management of COVID makes the patient more vulnerable to an otherwise rare disease.

Pathophysiology of thromboembolic risk in SARS-CoV-2 pneumonia

Background: SARS-CoV-2 disease may be associated with a state of hypercoagulability and an increased risk of both venous and arterial thromboembolism. Clinical and biological evidence has documented a high thromboembolic risk in the acute phase of the infection, but the incidence of the risk in the late phase of the disease requires further investigation. Description of the case: A hypertensive and diabetic patient comes to the emergency room for dyspnea and fever. It is hypotensive, tachycardic and hypoxemic. Elevated D-dimer and troponin. ECG: sinus tachycardia and right bundle branch block. Echocardiogram: hypertensive heart disease and right overload. Chest CT: bilateral interstitial pneumonia, with filling defects at the bifurcation of the right pulmonary artery. Nasopharyngeal swab for SARSCoV- 2: positive. Conclusions: SARS-CoV-2 is configured as a multidimensional disease whose characteristic physiopathological and clinical aspects are being defined: a) an increased immunological and inflammatory response with activation of a cytokine storm and consequent coagulopathy, which favours both venous thromboembolism events and thrombosis in situ in the pulmonary arterioles and alveolar capillaries;b) a high intrapulmonary shunt, which accounts for the severity of respiratory failure, attributed to a reduced hypoxic pulmonary vasoconstriction with pulmonary neoangiogenic phenomena. These patients may benefit from anticoagulant therapy initiated as early as the diagnosis of SARS-CoV-2 pneumonia.