Bilateral Spontaneous Pneumothorax in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19

Introduction: Spontaneous pneumothorax is a rare complication of coronavirus disease 2019 (COVID-19), primarily reported in adults. Pediatric cases with bilateral pneumothorax are much less reported. Case Presentation: We presented the case of a five-year-old previously healthy boy who developed persistent fever, abdominal pain, generalized maculopapular rash, and dyspnea before admission. His chest computed tomography (CT) showed a viral involvement pattern of pneumonia suggestive of COVID-19. Subsequently, he was confirmed with multisystem inflammatory syndrome in children (MIS-C). While he responded well to the therapies, on the fifth day of admission, he developed respiratory distress again. A chest roentgenogram showed bilateral spontaneous pneumothorax. Bilateral chest tubes were inserted, and his condition improved sig-nificantly after five days of admission to the intensive care unit. Two weeks later, he was discharged in good condition. Conclusion(s): Children with MIS-C associated with COVID-19 may develop primary spontaneous pneumothorax. Owing to the clinical picture overlapping with MIS-C associated with COVID-19, the timely diagnosis of pneumothorax may be challenging in such patients.Copyright © 2022, Author(s).

Bilateral spontaneous pneumothorax as a late complication of COVID-19, a clinical case report.

Key Clinical Message: Bilateral spontaneous pneumothorax and sudden dyspnea can occur as late complication in patients with COVID-19 even without any history of mechanical ventilation usage. Abstract: Bilateral spontaneous pneumothorax can occur as a late complication in patients with COVID-19, even without any history of mechanical ventilation. Here, we present a patient with mild COVID-19 pneumonia with a left massive pneumothorax in the third week of hospitalization and the addition of a right pneumothorax.

Hemoptisis luego de COVID-19 y la importancia de los diagnósticos diferenciales: Síndrome de Birt-Hogg-Dubé

Birt-Hogg-Dubé syndrome is a genodermatosis of autosomal dominant inheritance characterized by mutations in the folliculin (FLCN) gene. There is an inappropriate inhibition/activation of a protein, the foliculin, which may cause tumor lesions in skin, renal and lung lesions;they could have more risk of developing pneumothorax compared to the normal population. A 38-year-old male patient with bronchial asthma who consulted for hemoptysis three weeks after recovery from COVID-19 infection. A chest tomography was requested, showing an air cyst in the left lower lobe. Physical examination shows evidence of thoracic skin lesions which a skin biopsy was performed on. The results were compatible with fibrofolliculoma. Differential diagnoses were proposed. A genetic disorder associated with skin lesions was suspected. A multi-genetic panel that includes BRCA1, BRCA2, TP53 and FLCN genes was requested, which reported the mutation of the FLCN gene in heterozygosis classified as pathognomonic of Birt-Hogg-Dubé syndrome. Patient is currently under clinical follow-up while genetic counseling was requested for relatives. El síndrome de Birt-Hogg-Dubé es una genodermatosis de herencia autosómica dominante caracterizada por mutaciones en el gen foliculina (FLCN), donde existe inhibición/activación inapropiada de una proteína, la foliculina, que puede causar lesiones tumorales sistémicas, principalmente a nivel de la piel, renal y lesiones pulmonares, presentando mayor riesgo de desarrollar neumotórax en comparación con la población normal. Comunicamos el caso de un varón de 38 años con asma bronquial que consultó por hemoptisis 3 semanas después de la recuperación de la infección por COVID-19. Se solicitó una tomografía de tórax, que mostró un quiste aéreo en el lóbulo inferior izquierdo. Además, presentaba en el examen físico una lesión cutánea que fue biopsiada, presentando diagnóstico de foliculoma. Se plantearon diagnósticos diferenciales y ante la sospecha de probable desorden genético, un panel genético fue solicitado. Se confirmó síndrome de Birt-Hogg-Dubé ante el hallazgo de la deleción heterocigota que comprende el exón 1 del gen FLCN clasificada como patogénica. Actualmente el paciente se encuentra en seguimiento clínico mientras se solicitó estudio genético para familiares.

Hemoptysis after COVID-19 and the importance of differential diagnosis: Birt-Hogg-Dubé syndrome.

Birt-Hogg-Dubé syndrome is a genodermatosis of autosomal dominant inheritance characterized by mutations in the folliculin (FLCN) gene. There is an inappropriate inhibition/activation of a protein, the foliculin, which may cause tumor lesions in skin, renal and lung lesions; they could have more risk of developing pneumothorax compared to the normal population. A 38-year-old male patient with bronchial asthma who consulted for hemoptysis three weeks after recovery from COVID-19 infection. A chest tomography was requested, showing an air cyst in the left lower lobe. Physical examination shows evidence of thoracic skin lesions which a skin biopsy was performed on. The results were compatible with fibrofolliculoma. Differential diagnoses were proposed. A genetic disorder associated with skin lesions was suspected. A multi-genetic panel that includes BRCA1, BRCA2, TP53 and FLCN genes was requested, which reported the mutation of the FLCN gene in heterozygosis classified as pathognomonic of Birt-Hogg-Dubé syndrome. Patient is currently under clinical follow-up while genetic counseling was requested for relatives.

El síndrome de Birt-Hogg-Dubé es una genodermatosis de herencia autosómica dominante caracterizada por mutaciones en el gen foliculina (FLCN), donde existe inhibición/activación inapropiada de una proteína, la foliculina, que puede causar lesiones tumorales sistémicas, principalmente a nivel de la piel, renal y lesiones pulmonares, presentando mayor riesgo de desarrollar neumotórax en comparación con la población normal. Comunicamos el caso de un varón de 38 años con asma bronquial que consultó por hemoptisis 3 semanas después de la recuperación de la infección por COVID-19. Se solicitó una tomografía de tórax, que mostró un quiste aéreo en el lóbulo inferior izquierdo. Además, presentaba en el examen físico una lesión cutánea que fue biopsiada, presentando diagnóstico de foliculoma. Se plantearon diagnósticos diferenciales y ante la sospecha de probable desorden genético, un panel genético fue solicitado. Se confirmó síndrome de Birt-Hogg-Dubé ante el hallazgo de la deleción heterocigota que comprende el exón 1 del gen FLCN clasificada como patogénica. Actualmente el paciente se encuentra en seguimiento clínico mientras se solicitó estudio genético para familiares.

Pulmonary infarct in post COVID-19 period, complicated with spontaneous pneumothorax - case report

Introduction: Lung cavitation is a rare finding in COVID-19 patients (1, 2). The aim of this presentation is to report a rare case of cavitary aseptic pulmonary infarct in post-COVID-19 period that is complicated with spontaneous pneumothorax. Case presentation: A 63-year old woman was presented with acute onset of chest pain and on 35th day of COVID19 infection. Chest X-Ray established right-sided total pneumothorax and tube thoracostomy was performed. Due to the persistent air leak computed tomography was performed on the 4th day of thoracostomy. Areas of lung consolidation with a cavitary mass with maximum diameter of 34 mm in the upper lobe were established (fig.1). The woman was scheduled for thoracoscopy and multiple petechiae on the lung surface with necrotic area (bronchopleural fistula) of the upper lobe were established. The procedure was converted to conventional operation with atypical resection of the upper lobe of the lung with removing the necrotic cavitary lesion. Histological examination of the resected lung specimen showed bland cavitary pulmonary infarct. Conclusion(s): This case presents one rare pathological condition in post COVID-19 period - blunt pulmonary cavitary infarct complicated with spontaneous pneumothorax.

Spontaneous pneumothorax and factors associated with its development in a cohort of COVID-19 patients in Latin America

Introduction: In patients infected by SARS-CoV-2, acute respiratory failure is secondary to acute respiratory distress syndrome. However, in these patients other acute complications have been detected in the differential diagnosis, such as spontaneous pneumothorax. Description: From a sample of 306 patients with COVID-19, 11 were found complicated with spontaneous pneumothorax and one of them, in addition, with spontaneous pneumomediastinum, two conditions very rarely associated with this infection. Methodology: Observational cohort study to determine the frequency and factors associated with spontaneous pneumothorax or pneumomediastinum in patients with a diagnosis of COVID-19 admitted between june 2020 and june 2021. Result(s): Of the total sample of 306 patients, the main affected gender was the male. Measures of central tendency such as mean (60.8 years), mode (40.9-80.7) were used and the Chi-square test was applied to appreciate statistical value between the various variables to be correlated. When correlating the variables, mortality occurred mainly in the age group over 60 years p <0.0007. COPD as antecedent p <0.0004, ROX index less than 4.88 p <0.0001, PAFI less than 100 mm Hg p <0.003. The mortality found was 8 of the 11 patients. Conclusion(s): The occurrence of pneumothorax is a serious complication in this patient population and is associated with greater severity, although it has not yet been established due to the limited evidence available, case reports so far indicate that mortality appears to be higher compared to those in they do not develop pneumothorax.

Spontaneous Pneumothorax as Clinical Presentation in a Patient with COVID-19

Spontaneous pneumothorax as an initial presentation is very rare in COVID-19 patient. We present a case where the initial presentation was that of a mild disease and on investigation was found to have pneumothorax without any predisposing risk factors. © 2022, Kathmandu University. All rights reserved.

Spontaneous pneumothorax and COVID-19: Precipitants to a complex HIV-AIDS diagnosis.

A 48-year-old male presented with spontaneous pneumothorax requiring chest tube placement in the setting of COVID-19 infection. CT chest revealed bilateral ground-glass opacities and multiple, large, gas-filled, cavitary lesions in the lungs bilaterally. These imaging findings led to an initial HIV diagnosis with the patient presenting at a CD4+ count of <32 cells/µL. He was found to additionally have infections with Mycobacterium kansasii, cytomegalovirus, Pneumocystis jirovecii, and Candida albicans. After developing worsening hypoxic respiratory failure, he developed additional pneumothoraces bilaterally, requiring repeated chest tube placement. He was treated with antimicrobial therapy for his underlying infections and subsequently started on combined antiretroviral therapy.

Surgical Management of Pneumothorax and Pleural Space Disease.

Pleural space diseases constitute a wide range of benign and malignant conditions, including pneumothorax, pleural effusion and empyema, chylothorax, pleural-based tumors, and mesothelioma. The focus of this article is the surgical management of the 2 most common pleural disorders seen in modern thoracic surgery practice: spontaneous pneumothorax and empyema.

Development of pneumatocele and spontaneous pneumothorax as a late complication of COVID-19 pneumonia

SARS-COV2 pandemic has spread like wildfire and has affected all the countries worldwide. The virus mainly affects the lungs and has numerous manifestations. The development of spontaneous pneumatocele and pneumothorax has rarely been reported in the literature, especially in spontaneously breathing patients. We report two cases of COVID-19 patients who developed these complications after discharge from our hospital. These complications are uncommon but can be potentially fatal and the treating physician should keep these complications as differential while managing such cases.

HOME-BASED PULMONARY REHABILITATION: NOVEL APPROACH OF AN ESTABLISHED MODEL IN A SINGLE VETERANS AFFAIRS MEDICAL CENTER EXPERIENCE

SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: To address rural healthcare disparities by providing access to home based pulmonary rehabilitation (HBPR) program for eligible veterans at the Salem Veterans Affairs Medical Center (VAMC) who reside in remote areas or those with barriers of long travel time and transportation hardship. METHODS: The Pulmonary Section at the Salem VAMC received a grant from the Office of Rural Health to establish HBPR program for eligible veterans. Its goal was to improve quality of life and potentially reduce COPD hospitalizations and exacerbations (AECOPD). Under the direction of pulmonologists, the program was run by an exercise physiologist (EP). Referrals were received from inpatient and outpatient providers. After an initial in-person evaluation, weekly telehealth meetings (telephone, video) occurred over 12 weeks. Veterans were provided with the equipment, and an individualized targeted exercise program along with education and counseling on tobacco cessation, nutrition, oxygen compliance, stress management, medication adherence. Follow up appointments were scheduled at 3, 6 and 12 months post completion. RESULTS: Between September 2020 and January 2022, 312 consults were received, 206 consults were scheduled and 175 veterans enrolled. To date, 100 have completed the program with 24 ongoing. 30% declined service, citing: comorbidities, physical debility, difficulty remembering scheduled appointments, lack of motivation, social reasons, worsening health status. Mean age was 71, male predominance (95%). Referral diagnoses included: COPD (86%), chronic hypoxic respiratory failure (55%), COVID-19 (11%), Interstital Lung Diseases (10%). Mean FEV1 was 57% predicted, mean MMRC Dyspnea Scale 2.5, mean BODE score 5. 20% of enrolled veterans were active smokers, 72% were former smokers. 6 minute walk test increased from 156 meters on enrollment to 216 meters on completion. 45 veterans required hospitalization for pulmonary issues during their participation in the program. EP identified on weekly appointments 20 AECOPD that were treated as outpatient, 1 spontaneous pneumothorax that led to hospitalization, and facilitated the refill of inhalers or adjustment of medical regimen. Patient satisfaction score, including perception of benefit post completion was 29.4/30. CONCLUSIONS: HBPR at the Salem VAMC provided access to eligible veterans, overcoming barriers of rurality, transportation hardship and lack of nearby conventional programs. It also offered off business hours PR to veterans who continue to work. It allowed decrease in community care referrals thus establishing useful and cost effective service. CLINICAL IMPLICATIONS: Pulmonary Rehabilitation has been shown to reduce morbidity, improve functional status and have mortality benefit. Healthcare discrepancies and disparities have been a major obstacle for enrollment. HBPR would address these issues and contribute to decreased health service utilization and costs. DISCLOSURES: No relevant relationships by Nathalie Abi Hatem No relevant relationships by Brittany Frost No relevant relationships by Mitchell Horowitz No relevant relationships by Deepa Lala

ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and Glue SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Secondary spontaneous pneumothoraxes commonly occur in patients with cystic fibrosis (CF) and can be complicated by persistent air leak (PAL) due to bronchopleural or alveolopleural fistula. More recently, bronchoscopic placement of one-way endobronchial valves (EBV) for PAL have been explored. We present the first case series of patients with CF who developed secondary spontaneous pneumothoraxes and were successfully treated with EBV. CASE PRESENTATION: A 30-year-old female with CF (F508del/dupex6B-10) and history of pneumothorax, presented with acute hypoxic respiratory failure. She was found to have a right-sided pneumothorax. A chest tube was placed, with a continuous air leak for 4 days. She was a suboptimal surgical candidate given extensive apical lung disease, making localization of the air leak difficult. In addition, the increased tissue density would have made wedge resection challenging. After multidisciplinary discussion, the patient underwent placement of 5 Zephyr EBV (Pulmonx Inc., Redwood City, CA) for PAL. The lung had re-expanded, but there was still an intermittent air leak. She underwent pleurodesis with betadine. Her chest tube was removed 2 days later, and she was discharged. She was seen in the pulmonary clinic 5 days after being discharged and was noted to have recurrent right pneumothorax. She underwent chest tube placement with flutter valve. The chest tube was removed after 10 days. The patient was scheduled for removal of EBV 6 weeks after placement, but the procedure was delayed to symptomatic COVID-19 infection. EBV were eventually removed 12 weeks after placement. Pneumothorax has not recurred 6 weeks post EBV removal. A 53-year-old female with CF (394delTT/3272-26A-G) and a small right apical secondary spontaneous pneumothorax 3 months prior to hospitalization presented with progressive dyspnea. Imaging showed that the pneumothorax had enlarged. A chest tube was placed with continuous air leak. After a multidisciplinary discussion, 5 Zephyr EBV were placed 2 days later. There was immediate improvement of the pneumothorax, with almost no air leak. Her chest tube was removed 48 hours after placement of EBV, and patient was discharged on day 4. The EBV were removed 8 weeks later with no recurrence of pneumothorax 1 month after valve removal. DISCUSSION: To our knowledge this is the first case series describing the use of Zephyr EBV in CF patients with secondary spontaneous pneumothorax complicated by PAL. Although previous guidelines still recommend surgery and/or pleurodesis for PAL, this may not be the best option for patients with CF who may require lung transplantation. EBV are currently FDA approved for lung volume reduction to treat emphysema, but it is likely a viable non-surgical alternative for PAL. CONCLUSIONS: EBV is a well-tolerated treatment option for PAL due to secondary spontaneous pneumothoraxes. Reference #1: Bongers KS, De Cardenas J. Endobronchial valve treatment of persistent alveolopleural fistulae in a patient with cystic fibrosis and empyema. J Cyst Fibros. 2020 Sep;19(5):e36-e38. doi: 10.1016/j.jcf.2020.03.014. Epub 2020 Apr 18. PMID: 32312675. Reference #2: Travaline JM, McKenna RJ Jr, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M, Criner GJ;Endobronchial Valve for Persistent Air Leak Group. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009 Aug;136(2):355-360. doi: 10.1378/chest.08-2389. Epub 2009 Apr 6. Erratum in: Chest. 2009 Sep;136(3):950. PMID: 19349382. Reference #3: Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest. 2017 Aug;152(2):417-423. doi: 10.1016/j.chest.2017.02.020. Epub 2017 Mar 4. PMID: 28267436;PMCID: PMC6026238. DISCLOSURES: No relevant relationships by Bryan Benn no disclosure on file for Julie Biller;No relevant relationships by Rose Franco Speaker/Speaker's Bureau relationship with Biodesix Please note: 2018 - present by Jonathan Kurman, value=Honoraria Consultant relationship with Level Ex Please note: 2018 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Medtronic Please note: 2020 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Pinnacle Biologics Please note: 2020 - present Added 04/01/2022 by Jonathan Kurman, value=Consulting fee Consultant relationship with Boston Scientific Please note: 2021 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Cook Medical Please note: 2021 - present by Jonathan Kurman, value=Consulting fee Speaker/Speaker's Bureau relationship with Erbe Please note: 2021 - present by Jonathan Kurman, value=Honoraria research panel relationship with Intuitive Please note: 2020 - present by Jonathan Kurman, value=Honoraria Removed 04/01/2022 by Jonathan Kurman Consultant relationship with Pulmonx Please note: 2020 - present by Jonathan Kurman, value=Consulting fee Travel relationship with Ambu Please note: 2021-present Added 04/01/2022 by Jonathan Kurman, value=Travel Removed 04/01/2022 by Jonathan Kurman Consultant relationship with Ambu Please note: 2022-present Added 04/01/2022 by Jonathan Kurman, value=Consulting fee Speaker/Speaker's Bureau relationship with Veracyte Please note: 2021-present Added 04/01/2022 by Jonathan Kurman, value=Honoraria No relevant relationships by Shreya Podder

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

SESSION TITLE: Obstructive Lung Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Individual cases of pneumothorax, pneumomediastinum and subcutaneous emphysema have been reported in asthma attacks, but rarely coincide. Pathophysiology is secondary to obstruction in the minor airways leading to air-trapping and barotrauma of distal airways with subsequent alveolar rupture. This case illustrates a case of asthma exacerbation with a synchronous triad of rare complications. CASE PRESENTATION: 65-year-old female with a history of breast cancer, asthma and hypertension presented with shortness of breath, wheezing, and productive cough since four days ago. Vital signs were remarkable for tachypnea and saturation of 91%. Physical examination revealed respiratory distress, and auscultation disclosed diffuse inspiratory and expiratory wheezing. Limited bedside ultrasound showed B-lines compatible for pulmonary edema. Arterial blood gases were compatible with respiratory acidosis and hypoxemia. Laboratories showed leukocytosis, hypotonic hyponatremia, normal brain natriuretic peptide, and negative COVID-19 PCR test. Chest Xray (CXR) demonstrated changes concerning for pneumonia with superimposed pleural effusion. The patient was admitted with the impression of asthma exacerbation versus community acquired pneumonia. Initially, the patient was placed in bi-level positive airway pressure to aid in respiratory discomfort, broad spectrum antibiotic regimen, and diuresis therapy. On follow up, she was found hypoxic with periorbital edema, dyspnea, and subcutaneous emphysema in neck, upper extremities, and thorax for which emergent intubation was performed. CXR and Thoracic CT confirmed pneumomediastinum, large right sided pneumothorax and a moderate left sided pneumothorax requiring tube thoracostomy. At the Intensive Care Unit, treatment included combination therapies with levalbuterol, ipratropium, terbutaline, theophylline, budesonide, IV steroids and magnesium without appropriate response. Mechanical ventilator was set to protective lung parameters to avoid worsening barotrauma. Subsequently, she was paralyzed for 48 hours to aid in synchrony and allow adequate pulmonary gas exchange. Nonetheless, severe bronchoconstriction was persistent along with depressed neurological status. Two months later, the patient passed away. DISCUSSION: We believe our patient developed barotrauma secondary to a cough attack combined with positive airway pressure. Similarities in presentation such as dyspnea, tachycardia, and hypoxia may prove difficult in differentiation. Although each of these pathologies separately can generally be self-limiting depending on size and hemodynamic compromise, the combination can be mortal and clinical suspicion is important in fast diagnosis and treatment. CONCLUSIONS: Our case demonstrates the importance of suspicion of barotrauma in patients with asthma attacks not responding adequately to therapy or developing worsening hypoxia which can be detrimental. Reference #1: Franco, A. I., Arponen, S., Hermoso, F., & García, M. J. (2019). Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack. The Indian journal of radiology & imaging, 29(1), 77–80. https://doi.org/10.4103/ijri.IJRI_340_18 Reference #2: Zeynep Karakaya, Şerafettin Demir, Sönmez Serkan Sagay, Olcay Karakaya, Serife Özdinç, "Bilateral Spontaneous Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema: Rare and Fatal Complications of Asthma", Case Reports in Emergency Medicine, vol. 2012, Article ID 242579, 3 pages, 2012.https://doi.org/10.1155/2012/242579 Reference #3: Subcutaneous Emphysema in Acute Asthma: A Cause for Concern? Patrick D Mitchell, Thomas J King, Donal B O'Shea Respiratory Care Aug 2015, 60 (8) e141-e143;DOI: 10.4187/respcare.03750 DISCLOSURES: No relevant relationships by Juan Adams-Chahin No relevant relationships by Gretchen Marrero No relevant relationships by natalia Mestres No relevant relationships by Are is Morales Malavé No relevant relationships by Carlos Sifre No relevant relationships by Paloma Velasco No relevant relationships by Mark Vergara-Gomez

WHEN NOTHING HELPS: A RARE CASE OF COVID-19 EMPYEMA IN A YOUNG HEALTHY MALE

SESSION TITLE: Problems in the Pleura Case Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Severe COVID 19 has now been known to cause devastating damage to the lungs. The manifestations include severe pneumonia, acute respiratory distress syndrome, spontaneous pneumothorax, etc. As we were learning about the pathogenesis of the infection, we were also learning rapidly about the therapeutics targeted against it. A report a case of severe COVID 19 ARDS in a non-vaccinated young male, who later developed empyema during his hospital course. CASE PRESENTATION: A 29-year-old male with no past medical history presented to the emergency department complaining of chest pain and shortness of breath. He was not vaccinated against COVID-19. He was discharged from the hospital on 2 liters of supplemental oxygen two days ago after undergoing treatment for COVID-19 pneumonia with dexamethasone and remdesivir. Physical examination revealed bilateral diminished lung sounds on auscultation. His blood pressure was 112/75 mm Hg, heart rate (HR) 120 per minute, respiratory rate 25 per minute, the temperature of 38.5 Celsius and he was saturating 91% on 15 L of oxygen via a non-rebreather mask. Initial CT scan revealed bilateral ground-glass opacities (figure 1.). Due to high oxygen requirements and CRP of 10.5 MG/DL, the patient was started on Sarilumab. Given his escalating oxygen requirements and worsening respiratory distress, he was intubated and transferred to the intensive care unit. Despite intermittent prone positioning, he became progressively hypoxemic and eventually required Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO). One week later he developed intermittent fever spikes up to 39.5 C with HR of 120 per minute and leukocytosis of 40.8 K/µL. Bedside point of care ultrasound revealed new bilateral complex pleural effusions. Chest CT-scan showed moderate bilateral pleural effusions with new cystic changes and worsening consolidations (figure 2). Pleural fluid analysis showed lactate dehydrogenase of 2798, pH of 7.11, and cell count of 100 with 98% neutrophils. Despite aggressive therapy with chest tube placements and broad-spectrum antibiotics his condition continued to worsen over the next month with the development of hydropneumothoraxes and traction bronchiectasis (figure 3). Given the clinical deterioration despite aggressive care, his family decided to pursue a comfort-oriented treatment approach and he eventually passed away. DISCUSSION: COVID-19 related pleural effusion is a reported complication of COVID-19 pneumonia in up to 2-11% of the cases [1]. Most cases are associated with comorbid conditions, such as heart failure, superimposed bacterial infections, and pulmonary embolism [2]. CONCLUSIONS: Our case indicates that bacterial empyema may complicate COVID-19 pneumonia later in the disease course even in young immune-competent patients, it is unclear if empyema is directly related to the disease process itself r the therapeutic used to treat the COVID 19 infection. Reference #1: Chong WH, Saha BK, Conuel E, Chopra A. The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review. Heart Lung. 2021;50(4):481-490. doi:10.1016/j.hrtlng.2021.02.015 Reference #2: Zhang L, Kong X, Li X, et al. CT imaging features of 34 patients infected with COVID-19. Clin Imaging. 2020;68:226-231. doi:10.1016/j.clinimag.2020.05.016 DISCLOSURES: No relevant relationships by Rimsha Ali No relevant relationships by Konstantin Golubykh No relevant relationships by Iuliia Kovalenko No relevant relationships by Maidah Malik No relevant relationships by Taaha Mirza No relevant relationships by Navitha Ramesh

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION: A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1: 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89:891. Reference #2: 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82:197. Reference #3: 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;92:1062. DISCLOSURES: No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel

OUT OF THIN AIR: A CASE OF SEVERE SUBCUTANEOUS EMPHYSEMA, PNEUMOMEDIASTINUM, AND PNEUMOTHORAX ASSOCIATED WITH COVID-19

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: One of the greatest challenges of the coronavirus (COVID-19) pandemic has been deciphering its unique properties, such as the propensity to infect and damage lung epithelium, thereby increasing susceptibility to pulmonary complications.(1, 2) A 2020 cohort study comparing patients with acute respiratory distress syndrome (ARDS) from COVID-19 and ARDS from other causes showed a significantly higher rate of subcutaneous emphysema and pneumomediastinum in the COVID-19 group, suggesting these diagnoses may be due to direct viral damage rather than exposure to positive pressure alone.(3) Presented here is a patient with no underlying lung pathology who was diagnosed with COVID-19 and developed severe subcutaneous emphysema, pneumomediastinum, and pneumothorax. CASE PRESENTATION: A 74 year old male with a history of hypertension presented to the emergency room with a 5-day history of difficulty breathing, cough, fever, chills, and weakness. He tested positive for COVID-19, required non-invasive positive pressure ventilation (NIPPV), and was started on ceftriaxone, doxycycline, and daily dexamethasone. He received a five-day course of remdesivir and one dose of convalescent plasma. By day 9, a chest x-ray revealed a left apical pneumothorax, bilateral subcutaneous emphysema, and pneumomediastinum. On day 12, his respiratory status deteriorated, necessitating invasive mechanical ventilation. A chest CT showed extensive subcutaneous emphysema involving the chest, supraclavicular and axillary regions, and abdominal wall, as well as extensive pneumomediastinum and a moderate left pneumothorax. A left-sided thoracostomy tube was placed and he was proned per ICU protocol. He required placement of a second left-sided chest tube due to persistent worsening pneumothorax. On day 28, despite all aggressive measures, he expired from acute hypoxemia. DISCUSSION: Although this patient was exposed to NIPPV, the severe degree of lung pathology was inconsistent with the amount of positive pressure administered. Furthermore, he lacked underlying pulmonary disease that would compromise his lung compliance to this magnitude. Combining evidence that COVID-19 can cause epithelial lung damage, the patient's absence of pulmonary risk factors, and his severe degree of lung damage incongruent with his exposure to positive pressure, is reasonable to extrapolate that a significant portion of his lung pathology was a result of direct damage from COVID-19. CONCLUSIONS: Patients with COVID-19 may be at higher risk for the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax, likely due to direct viral effect. Lung damage seen may be disproportionate to exposure of positive pressure and may also be seen in the absence of any underlying pulmonary comorbidities. Awareness of this observed pathophysiology may help guide clinicians to optimize ventilator management as well as anticipate potential complications. Reference #1: Hu B, Guo H, Zhou P, Shi ZL. Characteristics of SARS-CoV-2 and COVID-19 [published correction appears in Nat Rev Microbiol. 2022 Feb 23;:]. Nat Rev Microbiol. 2021;19(3):141-154. doi:10.1038/s41579-020-00459-7 Reference #2: Miró Ò, Llorens P, Jiménez S, et al. Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study. Chest. 2021;159(3):1241-1255. doi:10.1016/j.chest.2020.11.013 Reference #3: Lemmers DHL, Abu Hilal M, Bnà C, et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?. ERJ Open Res. 2020;6(4):00385-2020. Published 2020 Nov 16. doi:10.1183/23120541.00385-2020 DISCLOSURES: No relevant relationships by Shanaz Azad No relevant relationships by Sarah Monaghan No relevant relationships by Brandon Nance No relevant relationships by Samantha Peterson

A CASE OF STERNUTATION-INDUCED SECONDARY SPONTANEOUS PNEUMOTHORAX IN A PATIENT WITH PNEUMATOCELE FOLLOWING COVID-19 PNEUMONIA

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: The development of secondary spontaneous pneumothorax is one of the emerging post-coronavirus-19 disease (COVID-19) complications, more so in mechanically ventilated patients, during the acute phase of infection. High airway pressure delivered during respiratory support is commonly recognized as a potential culprit. CASE PRESENTATION: A 57-year-old male was hospitalized for a week for COVID-19 pneumonia with acute hypoxic respiratory failure and treated with oxygen supplementation (required high flow oxygen), remdesivir, and dexamethasone. No mechanical ventilatory support was needed. He had a history of significant smoking cigarettes and marijuana in the past. A week after the discharge, he re-presented to the hospital with complaints of worsening cough, chest pain, and difficulty breathing following three episodes of vigorous sneezing. Computed Tomography (CT) chest revealed large left pneumothorax and right lower lobe pneumatocele. Immediate chest tube insertion relieved his symptoms. The final diagnosis of spontaneous pneumothorax secondary to pneumatocele rupture was made in a patient with a history of COVID-19 pneumonia. DISCUSSION: Cystic lesions resulting from alveolar damage (swelling, inflammation, and fibrosis) with parenchymal damage from the virus, along with barotrauma, are thought to cause pneumothorax. Few cases have been reported in patients without mechanical ventilation. High airway pressures delivered by high flow oxygen, fragile airways due to acute COVID-19 infection, and smoking might have predisposed this patient to pneumatocele, with sneezing leading to rupture and pneumothorax. CONCLUSIONS: This case demonstrates pneumatocele as a sequela of COVID-19, with a risk of pneumothorax. Medical professionals should consider pneumothorax in patients who recovered from COVID-19 and present with new respiratory symptoms. Further studies are required to evaluate the need for routine follow-up imaging (CT chest) in post-COVID-19 infection for pneumatocele or pneumothorax. Reference #1: Marzocchi G, Vassallo A, Monteduro FSpontaneous pneumothorax as a delayed complication after recovery from COVID-19BMJ Case Reports CP 2021;14:e243578. Reference #2: Schiller M, Wunsch A, Fisahn J, Gschwendtner A, Huebner U, Kick W. Pneumothorax with Bullous Lesions as a Late Complication of Covid-19 Pneumonia: A Report on Two Clinical Cases. J Emerg Med. 2021 Nov;61(5):581-586. doi: 10.1016/j.jemermed.2021.04.030. Epub 2021 May 9. PMID: 34916057;PMCID: PMC8106878. Reference #3: Nunna K, Braun ABDevelopment of a large spontaneous pneumothorax after recovery from mild COVID-19 infectionBMJ Case Reports CP 2021;14:e238863. DISCLOSURES: No relevant relationships by Ziad Alkhoury no disclosure on file for Mostafa Mostafa;No relevant relationships by Roshan Subedi No relevant relationships by Mohammed Syed No relevant relationships by Qi Wang

CRYPTIC CRYPTO: PULMONARY CRYPTOCOCCOSIS IN AN IMMUNOCOMPETENT HOST

SESSION TITLE: Uncommon Presentations and Complications of Chest Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Cryptococcus is a ubiquitous fungus in the environment. Infections can occur in humans when Cryptococcus is aerosolized and inhaled. Severity of clinical presentation varies from asymptomatic pulmonary colonization to disseminated life-threatening infection such as meningitis. These infections usually occur with deficiencies in T-cell-mediated immunity, including those with HIV/AIDS and immunosuppression due to transplantation. Herein we present a case of isolated pulmonary cryptococcosis in an immunocompetent host. CASE PRESENTATION: The patient is a 36-year-old never-smoker male with history of recurrent left spontaneous pneumothorax status post VATS blebectomy, negative for alpha-1 antitrypsin deficiency and cystic fibrosis. A year later, he presented with fatigue, shortness of breath, and dry cough after a recent trip to Ohio. Viral panel including COVID-19 was negative. A chest x-ray showed a new 4 cm rounded opacity in the right middle lobe (RML). A CT scan of the chest showed 2 mass-like and nodular areas of consolidation with surrounding GGOs within the RML (Figure 1). He underwent navigational bronchoscopy with transbronchial biopsy (TBBx) of RML, BAL, and EBUS with transbronchial needle aspiration (TBNA). Cytology was negative for malignant cells. BAL showed rare yeast. Pathology of the TBBx showed the airway wall with chronic inflammation including granulomatous inflammation, positive for yeast, most consistent with Cryptococcus with positive Grocott methenamine silver (GMS) stain (Figure 2). Culture of the TBNA grew C. neoformans var. grubii. Other cultures were negative. Serum Cryptococcal antigen was positive. HIV test was negative. He started treatment with oral fluconazole with improvement of symptoms. DISCUSSION: Clinical presentation of pulmonary cryptococcosis can include a variety of symptoms in which immune status is critical for determining the course of infection. Infection can vary from asymptomatic infection to severe pneumonia and respiratory failure, and meningitis. Similarly, imaging findings can also vary and be characterized as pulmonary nodules, consolidations, cavitary lesions, and/or a diffuse interstitial pattern. The diagnosis of Cryptococcus is made using histology, fungal cultures, serum cryptococcal antigen, and radiography in the appropriate clinical and radiological context. Treatment recommendations are determinant on immune status of the patient as well as symptoms. Asymptomatic and localized disease in immunocompetent patients can be monitored and mild/moderate disease can be treated with fluconazole. Those with severe or disseminated infection warrant induction therapy with an amphotericin B and flucytosine CONCLUSIONS: Clinical and radiological presentation of cyptococcosis varies depending on immune status. Disease can occur in both immunocompromised and competent hosts. Immune status determines disease course and treatment. Reference #1: Huffnagle GB, Traynor TR, McDonald RA, Olszewski MA, Lindell DM, Herring AC, et al. Leukocyte recruitment during pulmonary Cryptococcus neoformans infection. Immunopharmacology. 2000 Jul 25;48(3):231–6. Reference #2: Kd B, Jw B, Pg P. Pulmonary cryptococcosis. Semin Respir Crit Care Med [Internet]. 2011 Dec [cited 2022 Apr 2];32(6). Available from: https://pubmed.ncbi.nlm.nih.gov/22167400/ Reference #3: Ms S, Rj G, Ra L, Pg P, Jr P, Wg P, et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am [Internet]. 2000 Apr [cited 2022 Apr 1];30(4). Available from: https://pubmed.ncbi.nlm.nih.gov/10770733/ DISCLOSURES: No relevant relationships by Mina Elmiry No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih no disclosure on file for Priyanka Makkar;No relevant relationships by Jonathan Moore