Massive pulmonary embolism led to cardiac arrest two days after thoracoscopy in a young male with pleural tuberculosis.

TB itself is considered an independent risk factor for VTE; however, developing pulmonary embolism after medical thoracoscopy is extremely rare. Herein, we describe a 30-year-old previously healthy male with pleural tuberculosis developed a massive pulmonary embolism with subsequent cardiac arrest after a diagnostic medical thoracoscopy. Computed tomography pulmonary angiogram (CTPA) showed major right pulmonary embolism (PE). Unfortunately, the patient passed away despite resuscitation and extensive organ support in the intensive care unit (ICU). This case highlights the thrombotic risk in this population group in order to avoid such devastating complications.

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.

Follow up outcome in COVID-19 patients with persistent symptoms from central India

Introduction: Secondary infections are a known complication post viral respiratory infections. Secondary infections have always been significant cause of morbidity and mortality in previous well-studied influenza pandemics1. Aims and Objectives: We aimed to diagnose secondary infection early using indicated interventional procedures in post COVID-19 patients with persistent respiratory symptoms more than 4 weeks. Method(s): Post COVID-19 patients with persistent respiratory symptoms who presented to GHRI, Nagpur (India) during 2nd wave were selected for the study. Patients with persistent respiratory symptoms more than 4 weeks after recovering from COVID-19 infection and Radiological abnormality on either Chest X-ray or HRCT Chest were subjected to bronchoscopy or medical thoracoscopy as indicated. Result(s): A total of 72 patients with available culture reports were assessed. Persistent cough, fever and shortness of breath were present in 52.8%, 19.4% and 11.1% of patients respectively. We found evidence of respiratory infections in total 30.5% patients. 11.1% were found to be suffering from pulmonary (3 were drug resistant) and 2.8% from pleural tuberculosis. Also, 4.2% patients were found to be suffering from fungal and 12.5% patients from Bacterial and 6.9% of patients were found to be suffering from more than one infection. Conclusion(s): Meticulous follow up with indicated interventional procedures is useful and safe in diagnosing pulmonary infections early in post COVID-19 patients.

Day case thoracoscopy in a UK district general hospital

Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.

Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom.

BACKGROUND: Local anaesthetic thoracoscopy (LAT) can be a vital procedure for diagnosis of unexplained pleural effusions. Traditionally, poudrage for pleurodesis and insertion of a large bore drain necessitated admission. There has been a shift towards performing LAT as a day case procedure with indwelling pleural catheter (IPC) insertion. This was advocated during the COVID pandemic by the British Thoracic Society (BTS). To determine the feasibility of such pathways, continuous evaluations are required. METHODS: All day case LAT procedures with IPC insertion, performed in theatre, were identified at two large district general hospitals (Northumbria HealthCare in the North East of England and Victoria Hospital, NHS Fife, in Scotland). Rapid pleurodesis with talc was not performed due to local staffing problems. All patients had their LAT in theatre under conscious sedation with a rigid scope. Demographics, clinical, radiological and histopathological characteristics and outcomes were collected. RESULTS: 79 patients underwent day case LAT. The lung did not deflate, meaning biopsies were not enabled, in four of the patients. The mean age was 72 years (standard deviation 13). Fifty-five patients were male and twenty-four were female. The main diagnoses were lung cancers, mesotheliomas and fibrinous pleuritis with an overall diagnostic sensitivity of 93%. Other diagnoses were breast, tonsillar, unknown primary cancers and lymphomas. Seventy-three IPCs were simultaneously placed and, due to normal macroscopic appearances in two patients, two large bore drains were placed and removed within one hour of LAT termination. Sixty-six (88%) patients were discharged on the same day. Seven patients required admission: one for treatment of surgical emphysema, four because they lived alone, one for pain control and one for control of a cardiac arrythmia. Within 30 days, there were five IPC site infections with two resultant empyemas (9%), with no associated mortality. Two patients developed pneumonia requiring admission and one patient required admission for pain management. The median number of days for which the IPCs remained in situ was 78.5 days (IQR 95). The median length of stay (LoS) was 0 days (IQR 0). No patients required further interventions for pleural fluid management. CONCLUSIONS: Day case LAT with IPC insertion is feasible with this current set up, with a median stay of 0 days, and should be widely adopted. The health economics of preventing admission are considerable, as our previous analysis showed a median length of stay of 3.96 days, although we are not comparing matched cohorts.

VATS in complicated COVID-19 patients: case series.

Common complications of coronavirus disease 2019 (COVID-19) related ARDS and ventilation are barotrauma-induced pneumothorax, pneumatocele and/or empyema. We analysed indications and results of video-assisted thoracoscopic surgery (VATS) in complicated COVID-19 patients. This is a retrospective single-institution study analysing a case series of patients treated by VATS for secondary spontaneous pneumothorax (SSP), pneumatocele and empyema complicating COVID-19, not responding to drainage in Lodi Maggiore Hospital between February 2020 and May 2021. Out of 2076 patients hospitalized in Lodi Maggiore Hospital with COVID-19, nine Males (0,43%; mean age 58,1-33-81) were treated by VATS for complications of pneumonia (6 SSP and 3 empyema; 1 case complicated by haemothorax). 7 patients (77%) had CPAP before surgery for 21.3 days mean (4-38). Mean Operative time was 80.9 min (38-154). Conversion rate was 0%. 3 (33%) patients were admitted to ICU before VATS. Treatments were: bullectomy in six patients (66%), drainage of the pleural space in all patients, pleural decortication and fluid aspiration in five cases (55%). two patients (22%) needed surgery interruption and bilateral ventilation to restore adequate oxygenation. Mortality was 1/9 (11%) due to respiratory failure for persistent pneumonia. In one patient (11%) redo surgery was performed for bleeding. Mean postop Length of Stay (LOS) was 37.9 days (10-77). Our report shows that VATS can be considered an extreme, but effective treatment for COVID-19 patients with SSP, pneumatocele or empyema, for patients who can tolerate general anaesthesia. Attention must be paid to the aerosol-generation of infected droplets.

Polyserositis as a Post-Covid-19 Complication.

INTRODUCTION: Polyserositis is described as inflammation with effusion of more than one serous membrane. There is very little published literature linking it to COVID-19 as a late complication. OBJECTIVE: Present and describe a case of post-COVID-19 polyserositis. METHODS: Data were collected from the medical record of a female patient admitted for fainting spells and marked weakness. The patient underwent a clinical evaluation, additional hematology, imaging and histopathology tests, and a surgical procedure. The new index, called the abdominal adipose deposit index, was obtained by multiplying the subcutaneous fat thickness by visceral fat thickness, both measured by ultrasound. A cutoff point was established that facilitated discernment of an unhealthy phenotype: normal weight but metabolically obese, a cardiometabolic risk factor. RESULTS: We present the case of a 57-year-old female patient admitted to hospital for fainting spells and marked weakness, four months after COVID-19 infection. She also had a history of obesity, asthma, type 2 diabetes mellitus and a cholecystectomy in December 1992 for gallstones. Clinical assessment revealed pericardial effusion and bilateral pleural effusion, in addition to a tumor-like lesion outside the pericardium, proximal to the right ventricular wall. A surgical procedure and findings from additional tests led to diagnoses of thymic remnants and polyserositis. CONCLUSIONS: This is a case of polyserositis in a post-COVID-19 patient. After other causes of polyserositis were ruled out, and since there is a likely physiological and pathogenic mechanism operating between the two diseases, the polyserositis was determined to be a late complication of COVID-19. To date, it is the second case reported in the world and the first reported in Cuba.

DOES COVID-19 INCREASE THE RISK OF DEVELOPING CYSTIC LUNG DISEASE?

SESSION TITLE: Late Breaking Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: (1) Assess the characteristics of COVID-19 patients who developed pulmonary cysts, bullae, blebs, and pneumatoceles. (2) Investigate outcomes of patients who developed cystic lung disease from COVID-19. METHODS: A literature search using Pubmed, Cochrane, and Embase was performed for case reports from 2020 to 2022 describing COVID-19 patients who developed lung cysts, bullae, blebs and pneumatoceles. The following data were extracted: patient demographics, presence of underlying lung disease, history of smoking, maximum oxygen requirements during acute illness, imaging findings, complications, and patient mortality. RESULTS: 65 publications (11 case series and 54 case reports) with a total sample size of 76 patients were analyzed. The mean age of patients was 52.2 ± 15.8 years. A majority of the cases were males (n=67, 88.2%). Twelve (15.8%) cases had an underlying lung disease, such as COPD or asthma, and 16 (21.1%) cases had a history of smoking tobacco. We categorized severity of illness based on the levels of oxygen requirement defined as: (1) mild - 0 to 2 liters of oxygen, (2) moderate - greater than 2 liters of oxygen to face mask/venturi mask and (3) severe - high flow nasal cannula, non-invasive ventilation, or mechanical ventilation. The majority of patients (n=40, 52.6%) had severe illness while 7 (9.2%) and 17 (22.4%) presented with mild and moderate disease, respectively. Of the 25 (32.9%) patients who required invasive mechanical ventilation, duration of ventilator days was provided for 14 patients, with a median of 40 days (interquartile range=54). Twenty-one (27.6%) patients were found to have cysts on imaging, 26 (34.2%) were found to have bullae, 3 (3.9%) were found to have blebs, 15 (19.7%) were found to have pneumatoceles, and 11 (14.5%) were found to have more than one of the aforementioned findings. A total of 53 (69.7%) patients developed pneumothorax and 12 (15.8%) developed pneumomediastinum. Seventeen (22.4%) patients were on the mechanical ventilator while pulmonary complications occurred. Additionally, 41 (53.9%) required chest tube placement, 16 (21.1%) required surgical intervention including open thoracotomy or video assisted thoracoscopy. A total of 47 (61.8%) cases reported either resolution of symptoms and complications, or improved imaging findings following interventions. The rate of inpatient mortality was 11.8%. CONCLUSIONS: Patients with severe COVID-19 may have a higher risk for developing cystic lung disease, hence, increasing the risk for complications such as pneumothorax and pneumomediastinum. CLINICAL IMPLICATIONS: Patients who had severe COVID-19 may benefit from closer follow up and serial imaging for early detection of cystic lung disease. DISCLOSURES: No relevant relationships by Kavita Batra No relevant relationships by Rajany Dy No relevant relationships by Christina Fanous No relevant relationships by Wilbur Ji No relevant relationships by Max Nguyen No relevant relationships by Omar Sanyurah

SMARCA4-DEFICIENT UNDIFFERENTIATED TUMOR: A RARE THORACIC MALIGNANCY

SESSION TITLE: Rare Malignancies SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: SMARCA4 deficient undifferentiated tumors (SMARCA4-DUT) are rare and aggressive neoplasms that are most commonly encountered in young male smokers and portend a poor prognosis (1,2). They are characterized by loss of SMARCA4, a subunit of chromatin remodeling complexes, and loss of the tumor suppressor brahma-related gene 1 (BRG1). We present a case of an elderly female with an extensive smoking history who was diagnosed with SMARCA4-DUT. CASE PRESENTATION: An 84 year old female with approximately 70 pack year smoking history, emphysema, ischemic cardiomyopathy, and coronary artery disease, presented to the emergency room with upper abdominal pain which started one day prior to admission. She endorsed an unintentional 10 pound weight loss in the past two months. The patient was admitted for an incarcerated ventral hernia for which she underwent repair. Of note, one and a half years ago, she was found to have a right lower lobe 7mm nodule but was unable to follow up due to the COVID pandemic. On this admission, a CT chest revealed a 4.2 x 3.8 x 3.7cm mediastinal mass and subcarincal lymphadenopathy. She underwent an EBUS with biopsy of the mediastinal mass and subcarinal lymph node. Cytology showed highly atypical epitheloid cells, concerning for a neoplasm with neuroendocrine differentiation and granulomas. Given the high suspicion for malignancy, she had a PET CT (figure 1) which showed FDG activity (SUV 11) in the mass with areas of necrosis and was referred to thoracic surgery. She underwent thoracoscopy with mediastinal mass resection and lymph node dissection and pathology showed diffuse sheets of epithelioid cells with large foci of necrosis. Neoplastic cells showed preserved INI (SMARCB1) expression, non-reactivity for NUT, and complete loss of BRG1 (SMARCA4) expression, consistent with a SMARCA4-DUT with positive margins (figure 2). She was referred to Radiation Oncology with plans to pursue further therapy thereafter. DISCUSSION: SMARCA4-DUT is a new and distinctive clinicopathological entity of aggressive thoracic tumors (1). The novelty of this class of tumors poses challenges in terms of treatment. Immune checkpoint inhibitors have shown compelling outcomes in case reports (3), however larger studies are needed to delineate optimal treatment regimens. CONCLUSIONS: SMARCA4-DUT are are rare but highly aggressive thoracic neoplasms. They present as large tumors and are smoking related. Prompt recognition may aid in early diagnosis. No definitive therapy exists but immunotherapy has shown promising results. Reference #1: Chatzopoulos, K., Boland, J.M. Update on genetically defined lung neoplasms: NUT carcinoma and thoracic SMARCA4-deficient undifferentiated tumors. Virchows Arch 478, 21–30 (2021). Reference #2: Roden AC. Thoracic SMARCA4-deficient undifferentiated tumor-a case of an aggressive neoplasm-case report. Mediastinum. 2021;5:39. Published 2021 Dec 25. Reference #3: Henon C, Blay JY, Massard C, Mir O, Bahleda R, Dumont S, Postel-Vinay S, Adam J, Soria JC, Le Cesne A. Long lasting major response to pembrolizumab in a thoracic malignant rhabdoid-like SMARCA4-deficient tumor. Ann Oncol. 2019 Aug 1;30(8):1401-1403. DISCLOSURES: No relevant relationships by Sathya Alekhya Bukkuri No relevant relationships by Erin Meier No relevant relationships by Mangalore Amith Shenoy No relevant relationships by Alexandra Zavin

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION: A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam: faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs: CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 1:40, dsDNA 1:640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR: opacification of the left lung up to midfield. CT chest: moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon: negative. Thoracentesis: 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura: necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity: pan-sensitive M. tuberculosis. Sputum: negative for TB. She was discharged on RIPE treatment for reactivation of TB. DISCUSSION: The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high. CONCLUSIONS: Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1: Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus: case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2):563-568. Reference #2: Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3: Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8):1211-7. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic

IGG4-RELATED PLEURAL DISEASE: A CAUSE OF RECURRENT PLEURAL EFFUSION AFTER COVID-19 VACCINATION

SESSION TITLE: Challenging Disorders of the Pleura SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Great effort went into finding a vaccine to decrease the impact of COVID-19 virus. Pfizer vaccine which is a part of mRNA of the virus wrapped with lipid nanoparticles is one of them. Though its side effects are benign, rarely it can lead to IgG4 related lung disease (IgG4-RLD). Therefore, having a high degree of suspicion is important for early diagnosis and effective treatment. CASE PRESENTATION: The patient is a 71-year-old male with COPD, CAD, and prostate cancer developed dyspnea after receiving 2 doses of Pfizer vaccine. CT chest revealed a new left pleural effusion, 1.4L fluid was removed which was negative for malignant cells with lymphocytic predominance. After 10 days, his symptoms worsened and repeat CT scan revealed large left pleural effusion. Thoracoscopy was done with drainage of 2.5L pleural fluid followed by pleural biopsy and chemical pleurodesis with insertion of an indwelling tunneled catheter. Pleural biopsy revealed chronic organizing pleuritis with lymphoid and mesothelial hyperplasia. The tunneled catheter stopped draining after 3 months but oxygen requirement increased. A repeat CT scan revealed loculated pleural effusions and only 40 ml was drained due to bloody output. Thoracoscopy revealed multiloculated effusions with visceral pleural thickening and partial decortication was done. Pathology revealed pleural thickening and fibrosis with increased IgG4-positive plasma cells in pulmonary parenchyma. Blood IgG4 level was 268 mg/dl. He was diagnosed with IgG4-related disease (IgG4-RD) affecting lungs and pleura. DISCUSSION: Although IgG4 related nephritis after Pfizer vaccine has been reported(1), this is the 1st reported case of IgG4-RLD. Autoimmunity is a trigger for pathogenesis with involvement of Th-2 cell. The vaccine stimulates robust antigen-specific T-cell responses leading to antibody production that trigger autoimmune reactions due to molecular mimicry. Four patterns are observed including mediastinal, parenchymal, pleural, and airway involvement. Mediastinal and hilar lymphadenopathy is the commonest patterns(2). Our patient had loculated pleural effusion complicated by pleural thickening and fibrosis. For diagnosis of IgG4-RD, 3 criteria need to be fullfilled: consistent organ involvement;serum IgG4 level >135 mg/dL;histopathology showing marked lymphoplasmacytic infiltration(2). Our case fulfilled all 3 criteria and involved lungs;thus, diagnosed with IgG4-RLD. Most patients have a favorable response with corticosteroid therapy in 2 weeks. For steroid-refractory cases, immunosuppressants can be used(3). CONCLUSIONS: With increased COVID-19 vaccination, more autoimmune events including IgG4-RLD can happen. As multiple doses are offered, close observation is needed for prompt diagnosis and management of such diseases. Ultimately, theoretical risks must be balanced against known benefits, and discussion between providers and patients is important. Reference #1: Christophe M, Delphine K, Christine K A, Aurélie F, Gilles B, Mohamed H. Relapse of IgG4-related nephritis following mRNA COVID-19 vaccine. Kidney International. Vol 100, Issue 2, P465-466, August, 2021. DOI: https://doi.org/10.1016/j.kint.2021.06.002 Reference #2: Ryu JH, Sekiguchi H, Yi ES. Pulmonary manifestations of immunoglobulin G4-related sclerosing disease. Eur Respir J 2012;39:180–6 Reference #3: Campbell SN, Rubio E, Loschner AL. Clinical review of pulmonary manifestations of IgG4-related disease. Ann Am Thorac Soc 2014;11:1466–75. DISCLOSURES: no disclosure on file for Ola Al-Jobory;No relevant relationships by Ahmad Hallak No relevant relationships by Manish Patel No relevant relationships by Saria Tasnim

The uniportal VATS in the treatment of stage II pleural empyema: a safe and effective approach for adults and elderly patients-a single-center experience and literature review.

BACKGROUND: Pleural empyema (PE) is a frequent disease, associated with a high morbidity and mortality. Surgical approach is the standard of care for most patients with II-III stage PE. In the last years, the minimally invasive surgical revolution involved also thoracic surgery allowing the same outcomes in terms of safety and effectiveness combined to better pain management and early discharge. The aim of this study is to demonstrate through our experience on uniportal-video-assisted thoracoscopy (u-VATS) the effectiveness and safety of its approach in treatment of stage II PE. As secondary endpoint, we will evaluate the different pattern of indication of u-VATS in adult and elderly patients with literature review. METHODS: We retrospectively reviewed our prospectively collected database of u-VATS procedures from November 2018 to February 2022, in our regional referral center for Thoracic Surgery of Regione Molise General Surgery Unit of "A. Cardarelli" Hospital, in Campobasso, Molise, Italy. RESULTS: A total of 29 patients underwent u-VATS for II stage PE. Fifteen (51.72%) patients were younger than 70 years old, identified as "adults," 14 (48.28%) patients were older than 70 years old, identified as "elderly." No mortality was found. Mean operative time was 104.68 ± 39.01 min in the total population. The elderly group showed a longer operative time (115 ± 53.15 min) (p = 0.369). Chest tube was removed earlier in adults than in elderly group (5.56 ± 2.06 vs. 10.14 ± 5.58 p = 0.038). The Length of Stay (LOS) was shorter in the adults group (6.44 ± 2.35 vs. 12.29 ± 6.96 p = 0.033). Patients evaluated through Instrumental Activities of Daily Living (IADL) scale returned to normal activities of daily living after surgery. CONCLUSION: In addition, the u-VATS approach seems to be safe and effective ensuring a risk reduction of progression to stage III PE with a lower recurrence risk and septic complications also in elderly patients. Further comparative multicenter analysis are advocated to set the role of u-VATS approach in the treatment of PE in adults and elderly patients.

Contralateral diaphragmatic injury sustained from transhumeral amputation: an unusual case and brief literature review.

Right-sided diaphragmatic injury is an uncommon sequelae from blunt trauma and may be associated with other severe thoracoabdominal injuries. This injury can be easily missed on initial assessment and a high index of suspicion and clinical judgment is required. Recently, we treated a 25-year-old male inflicted with a right-sided diaphragmatic injury after a left-sided transhumeral amputation sustained from an overturned motor vehicle collision with thoracoscopic exploration and reapproximation.

A faster diagnosis for mesothelioma and lung cancer with a one-stop shop clinic for suspected pleural malignancy

Introduction: We audited the effect of implementing a One-stop Shop (OSS) clinic for combined assessment/diagnostic pro ce dure for suspected pleural malignancy, mainly lung cancer and mesothelioma, on achieving the NHS 28-day Faster Diagnosis Standard in the context of the COVID pandemic. Method: We retrospectively collected data on all cases of suspected pleural malignancy undergoing an outpatient procedure after implementing the OSS over 16 weeks (10th March to 30th June 2021). We analysed a cohort seen in the OSS clinic (“OSS”) and a cohort seen via the original clinic pathway (“Non-OSS”). We also analysed an earlier control group during an 18-week period prior to the COVID pandemic from November 2019 to March 2020 (“Pre- OSS”). Results: 21 patients were seen in the OSS clinic compared to 20 non- OSS and 31 pre-OSS. Final diagnoses were 15% (n=11) lung cancer, 18% (n=13) mesothelioma, 22% (n=16) other malignancy and 44% (n=32) benign. The proportions of initial diagnostic procedure were 22% (n=16) diagnostic aspirate, 36% (n=26) therapeutic aspirate, 8% (n=6) chest drain, 1% (n=1) indwelling pleural catheter, 21% (n=15) medical thoracoscopy and 17% (n=12) ultrasound only. The mean time from referral to follow-up with diagnosis for OSS patients was 19 days which was less than both non-OSS patients (mean 30 days) and pre-OSS patients (mean 38 days). Conclusion: Patients seen in the One-Stop Shop clinic received a final diagnosis considerably quicker than those in the standard pathway. Interestingly, after implementing the OSS, patients seen via the standard pathway also received a final diagnosis faster after than before (pre-COVID). This suggests that even if there is not capacity to see all patients in the OSS, all may benefit, perhaps due an increase in efficiency across the service. Our model can be successfully applied to services in the post-COVID era to streamline the diagnostic pathway

Video-assisted thoracic surgery in critically ill COVID-19 patients on venovenous extracorporeal membrane oxygenation.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) leads to thoracic complications requiring surgery. This is challenging, particularly in patients supported with venovenous extracorporeal membrane oxygenation (VV-ECMO) due to the need for continuous therapeutic anticoagulation. We aim to share our experience regarding the safety and perioperative management of video-assisted thoracic surgery for this specific population. METHODS: Retrospective, single-center study between November 2020 and January 2022 at the ICU department of a 1.061-bed tertiary care and VV-ECMO referral center during the COVID-19 pandemic. RESULTS: 48 COVID-19 patients were supported with VV-ECMO. A total of 14 video-assisted thoracic surgery (VATS) procedures were performed in seven patients. Indications were mostly hemothorax (85.7%). In eight procedures heparin was stopped at least 1 h before incision. A total of 10 circuit changes due to clot formation or oxygen transfer failure were required in six patients (85.7%). One circuit replacement seemed related to the preceding VATS procedure, although polytransfusion might be a contributing factor. None of the mechanical complications was fatal. Four VATS-patients (57.1%) died, of which two (50%) immediately perioperatively due to uncontrollable bleeding. All three survivors were treated with additional transarterial embolization. CONCLUSION: (1) Thoracic complications in COVID-19 patients on VV-ECMO are common. (2) Indication for VATS is mostly hemothorax (3) Perioperative mortality is high, mostly due to uncontrollable bleeding. (4) Preoperative withdrawal of anticoagulation is not directly related to a higher rate of ECMO circuit-related complications, but a prolonged duration of VV-ECMO support and polytransfusion might be. (5) Additional transarterial embolization to control postoperative bleeding may further improve outcomes.

Postpneumonectomy Empyema Following SARS-CoV-2 Infection in a Patient with Metastatic Lung Cancer

We present a case of a male patient who underwent right-sided pneumonectomy due to central low-grade squamous cell carcinoma of the right lung, chemo-, radio-, and immunotherapy. However, the disease progressed. In addition the patient got SARSCoV-2 pneumonia in the left lung, followed by postpneumonectomy empyema. Right-sided uniportal video-assisted thoracoscopy, debridement, and definitive drainage of the pleural cavity were performed.

Minimally invasive esophagectomy for cancer in COVID hospitals and oncological hubs: are the outcomes different?

Introduction: The outbreak of coronavirus disease 2019 (COVID-19) has caused significant delays in oncological care worldwide due to restriction of elective surgery and intensive care unit capacity. It has been hypothesized that COVID-free oncological hubs can provide safer elective cancer surgery compared to COVID hospitals. The primary aim of the present study was to analyze the outcomes of minimally invasive esophagectomy for cancer performed in both hospital settings by the same surgical staff. Methods: All esophagectomies for cancer performed during the pandemic by a single team were reviewed and data were compared with control patients operated during the preceding year. Screening for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) was performed prior to surgery, and special precautions were taken to mitigate hospital-related transmission of COVID-19 among patients and healthcare workers. Results: Compared to the prepandemic period, the esophagectomy volume decreased by 64%. Comorbidities, time from onset of symptoms to first visit, waiting time between diagnosis and surgery, operative approach and technique, and the pathological staging were similar. None of the patients tested positive for COVID-19 during in-hospital stay, and esophagectomy was associated with similar outcomes compared to control patients. Conclusion: Outcomes of minimally invasive esophagectomy for cancer performed in a COVID hospital after implementation of a COVID-free surgical pathway did not differ from those obtained in an oncological hub by the same surgical team.

Isolated pauci-immune pulmonary capillaritis associated with an extensive bilateral hemothorax and pleuro-pericarditis

Introduction: Isolated pauci-immune pulmonary capillaritis (IPIPC) is a rare disorder characterized by small vessel vasculitis limited to alveolar capillaries in the absence of systemic manifestations. There are very few case reports of this disorder in the medical literature. Case Report: A 37-yo male with no known history of autoimmune pathology who was admitted to the hospital for evaluation and treatment of dyspnea and thoracalgia. Peripheral blood cultures, serum studies to detect Legionella and Pneumococcus antigens, and a nasopharyngeal swab test for covid-19 were all negative. Chest imaging revealed bilateral pleural effusions from the base to the apices with concomitant atelectasis of the adjacent lung parenchyma. Although the results of an 18F-PET-CT scan revealed no pathological uptake, video-assisted thoracoscopy revealed diffusely edematous pleura with crater-like patches with new onset of venous vessel varicosities, intra-alveolar hemorrhages associated with disordered vascularization, suggesting small vessel vasculitis. Histologic findings included widespread intra-alveolar hemorrhage with organizing injury, hemosiderin-laden macrophages, scattered intra-arterial thrombi, and diffuse perivascular neutrophilic infiltrates consistent with a diagnosis of capillaritis. Conclusions: Given the negative immune studies (save for a weakly-positive lupus anticoagulant and no evidence for extra-pulmonary vasculitis, the diagnosis was Isolated pauci-immune pulmonary capillaritis. The patient recovered in response to immunosuppressive/anti-inflammatory therapy.

Oncological procedures and risk assessment of COVID-19 in thoracic cancer patients: A picture from an Italian cancer center

Background: Since Sars-Cov2 infection (COVID-19) has rapidly spread around the world, Italy has quickly become one of the most affected countries. Patients (pts) with thoracic malignancies had the highest frequency of severe complications. Healthcare systems introduced strict infection control measures to ensure optimal cancer care. This study aimed to investigate the efficacy of pre-procedure screening for COVID-19 and whether infection influenced the opportunity of patients to receive timely diagnosis and therapy. Material (patients) and methods: We retrospectively collected data of oncological procedures of pts with confirmed or suspected thoracic malignancies, treated at Oncology Dept or coming from Emergency Dept of San Luigi Gonzaga Hospital between Jun 2020 and Mar 2021 (from the end of the 1st wave until the middle of the 3rd one). Outpatients were evaluated by a nasopharyngeal swab (NPS) performed 24/48 hours before procedures. Inpatients were tested by NPS before and after hospitalization according to a predetermined schedule. 125 pts were included in this analysis. Median age was 72 years;males were 64%. ECOG Performance Status was 0-1 in 90% of pts. Histological types were: NSCLC (86.4%), SCLC (7.2%), mesothelioma (5.6%), amartochondroma (0.8%). Stages IV were 80%. 135 procedures were performed: 102 were diagnostic (75 lung biopsies, 21 bronchoscopies, 1 lumbar puncture, 2 thoracoscopies, 1 thoracentesis, 1 gastroscopy and 1 thoracic surgery), 25 palliative and 8 therapeutic. 89 and 46 procedures were performed in outpatients and inpatients, respectively. Of the 132 NPS performed, 8 were found to be positive. Positive pts were infected during the 2nd wave (from Nov 2020 to Jan 2021). One patient was infected during hospitalization, the other ones in community. Most of pts were asymptomatic, only 2 had mild symptoms. 6 procedures (4.4%) were postponed (5 diagnostic, 1 palliative), an explorative bronchoscopy was canceled and a diagnostic biopsy was performed even though the patient tested positive. The median time to resolution of the infection was 17 days (range 11-36). The median delay of the procedures was 36 days (range 14-55). 4 patients started systemic treatment in a median time of 40.5 days (range 21-57). Conclusions: Our analysis pointed out that Sars-Cov2 infection led to the postponement of a small but not negligible number of diagnostic and therapeutic procedures and that a structured screening for COVID19 is critical for the best management of scheduled procedures during pandemic.