Extracorporeal membrane oxygenation for airway emergencies

Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).

A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.

Pneumomediastinum (PM) as a complication of COVID-19 disease

Case report Introduction: PM is a rare, but potentially life-threatening complication during COVID 19 pandemic, being reported in patients affected by COVID-19 pneumonia, even in the absence of mechanical ventilation-related barotrauma. Case details: We reported the clinical data of 4 cases affected by COVID-19 pneumonia complicated with PM. Chest CT scan showed multiple confluent areas of ground-glass opacities, crazy paving pattern, PM, cervical subcutaneous emphysema, and pneumothorax in one case. Management included pharmacological treatment, oxygen supplementation and no acute intervention recommended by cardiothoracic surgery. Case 1: 50-year- old male without past medical history, non-smoker, hypoxic on the day of admission. During the hospital stay, he continued to require increasing levels of oxygen and was subsequently flown to a tertiary care center for higher level of care. Case 2: 38-year- old male admitted with a 7-day history of fever, dyspnea and cought. He continues to be symptomatic with neurological manifestations (COVID19 Encephalopathy). Finally whose dyspnea regressed during hospitalization, he was discharged at his own request to come for control. Case 3: 73-year- old male with a history of hypertension, non-smoker, presented with complaints of shortness of breath for 1 week. He did not receive non invasive positive pressure ventilation. The pneumothorax and PM were managed conservatively. Case 4: 53-year- old lady with no significant past medical history, presented with fever and cough for 10 days and worsening shortness of breath for two days. Progressive deterioration of respiratory function transferred her to the intensive care unit. In view of worsening hypoxia and increased work of breathing, she was intubated on the same day and was started on volume control ventilator support. Despite the support measures she developed multiple organ failure and passed 35 days after the symptoms initiated. Conclusion(s): PM is usually self-limiting and is managed conservatively. Treatment of the underlying causes and least damaging ventilator settings possible to achieve adequate oxygenation are the mainstays in managing PM. COVID-19 patients with PM seem to have a more complicated clinical course and poor outcome.

Intermediate Respiratory Care Units: Questions and Answers

The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.Copyright © 2022

Preliminary Recommendations on the Timing of Lung Surgery after Novel Coronavirus Infection in Patients with Pulmonary Nodules and Lung Cancer.

In recent years, the corona virus disease 2019 (COVID-19) pandemic has had a huge impact on the global medical, political and economic fields. Since the beginning of the COVID-19 epidemic, our understanding of the impact of COVID-19 has grown exponentially. Recently, the COVID-19 epidemic has changed rapidly in China, and there has been controversy over how to carry out surgical operations for patients with lung neoplastic lesions. Some studies have shown that lung cancer patients undergoing surgery are more likely to experience respiratory failure and perioperative death after contract-ing COVID-19 than the general population, however, delays in cancer treatment are also associated with increased mortality among these patients. In particular, the novel coronavirus Omikron variant has a higher transmissibility and may escape the immunity obtained through the previous novel coronavirus infection and vaccination. In order to minimize the risk of novel coronavirus infection in surgical patients, it is necessary to develop new treatment guidelines, expert consensus and preventive measures. However, the current rapid change of the epidemic situation has led to insufficient time and evidence to develop guidelines and consensus. Therefore, thoracic surgeons need to evaluate specific patient populations at higher risk of severe complications before surgery and weigh the benefit of surgical treatment against the risk of novel coronavirus infection. We try to give some recommendations on lung surgery during the current domestic epidemic situation based on the guidelines and consensus of oncology and thoracic surgery organizations in different regions on lung surgery.Copyright © 2023, Chinese Journal of Lung Cancer. All rights reserved.

Periinterventional management of edoxaban in major procedures: Results from the DRESDEN NOAC REGISTRY

Introduction Edoxaban is a non-vitamin K dependent oral anticoagulant (NOAC) licensed for venous thromboembolism (VTE) treatment or stroke prevention in atrial fibrillation (SPAF). Major surgical procedures are not uncommon in anticoagulated patients but data on perioperative edoxaban management are scarce. Method Using data from the prospective DRESDEN NOAC REGISTRY we extracted data on major surgical procedures in patients who took edoxaban within the preceding 7 days. Periinterventional edoxaban management patterns and rates of outcome events were evaluated until day 30 after procedure. Results Between 2011 and 2021, 3448 procedures were identified in edoxaban patients, including 287 (8.3 %) major procedures. Overall, patient characteristics were comparable for major and non-major procedures, but significant differences existed with regard to gender, concomitant antiplatelet therapies and the proportion of patients with a CHA2DS2-VASc score >= 2 (Table 1). Major procedures consisted of orthopaedic/trauma surgery (44.3 %);open pelvic, abdominal or thoracic surgery (30.4 %), central nervous system surgery and procedures (13.9 %), vascular surgery (9.1 %) and extensive wound revision surgery (2.4 %). A scheduled interruption of edoxaban was observed in 284/287 major procedures (99 %) with a total median edoxaban interruption time of 11.0 days (25- 75th percentile 5.0-18.0 days). Heparin bridging was documented in 183 procedures (46 prophylactic dosages, 111 intermediate and 26 therapeutic dosages). Overall, 7 (2.4 %;95 %-CI 1.2 %-4.9 %) major cardiovascular events (5 VTE, 2 arterial thromboembolic events) occurred and 63 bleeding events were observed in 287 major procedures (22.0 %;95 %-CI 17.6 %-2.71 %), comprising of 38 ISTH major bleeding events (13.2 %;95 %-CI 9.8 %-17.7 %) and 25 ISTH CRNM bleedings (8.7 %;95 %-CI 6.0 %-12.5 %). Rates of major cardiovascular events with or without heparin bridging were comparable (6/183;3.3 %;95 %-CI 1.5 %-7.0 % vs. 1/36;2.8 %;95 %-CI 0.5 %-14.2 %;p = 0.7173). ISTH major bleeding occurred numerically more frequent in patients receiving heparin bridging (30/183;16.4 %;95 %-CI 11.7 %-22.4 %) versus procedures without heparin bridging (2/36;5.6 %;95 %-CI 1.5 %-18.1 %;p = 0.1542) (Fig. 1). Within 30 days of follow up, 6 patients died (2.1 %;95 %-CI 1.0 %-4.5 %) with causes of death being a ruptured truncus coeliacus following palliative angioplasty for an infiltrating pancreas cancer (ruled as fatal bleeding), septic organ failure, pneumocystis jirovecii pneumonia, COVID-19-pneumonia, septic complications following clipping of a ruptured cerebrovascular aneurism or terminal malignant disease. No fatal cardiovascular event occurred. Conclusion Within the limitations of our study design, periprocedural edoxaban management seems effective and safe in routine care. Use of heparin bridging seems to have limited effects on reducing vascular events but may increase bleeding risk. (Table Presented).

Universal COVID-19 pre-procedural swabs in children in a developing country: A comparison of findings over two transmission waves

Aim: The Coronavirus disease (COVID-19) pandemic has strained healthcare systems worldwide. Some institutions have implemented additional precautionary measures such as pre-procedural swabbing (PPS) to reduce transmission in patients and healthcare workers. We evaluate our experience with universal pre-procedural screening for COVID-19 in low-risk pediatric patients. Method(s): We performed a retrospective review of patients aged 18 years and below who underwent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real-time reverse transcription-polymerase chain reaction (rRT-PCR) assay swabs in our center over two waves (1st May 2020 to 31st July 2020 and 1st April 2021 to 30th June 2021). We included patients who underwent rRT-PCR for SARS-CoV-2 prior to any procedures requiring general anesthesia and were deemed low risk for COVID-19 according to our institutional screening criteria. All study patients were followed up for 14 days post-procedure. Result(s): Of 2065 swabs done for patients aged 18 years and below during the study period, 645 (31.2%) were pre-procedural swabs. Patients were aged 4.2 years (median, interquartile range: 1.6 years-9.8 years). Two patients (0.3%) tested positive for COVID-19 by PPS, detected during Period 2 - both had risk criteria which were overlooked by healthcare workers. Within 14 days post-procedure, 10 patients had unscheduled readmissions and 15 required repeat rRT-PCR, all of which were negative. Conclusion(s): In patients deemed low risk for COVID-19 infection according to our screening criteria, routine pre-procedural swabbing returns a low positive rate. Our findings can guide screening protocols at institutions that provide surgical services during the COVID-19 pandemic. Copyright © The Author(s) 2022.

Using Extracorporeal Membrane Oxygenation for COVID-Positive Urgent Tracheostomy

Introduction: Extracorporeal membrane oxygenation (ECMO) can be used during difficult airway surgery because it provides an unobstructed operative field while ensuring adequate oxygenation without need for ventilation. We present a case of utilizing ECMO to perform urgent tracheostomy on a COVIDpositive patient with a large oropharyngeal mass causing critical airway narrowing. Method(s): A 62-year-old man presented with 6 months of worsening dyspnea. Computed tomography imaging and flexible laryngoscopy showed a large oropharyngeal mass extending into the nasopharynx and larynx causing critical airway narrowing and severely distorted upper airway anatomy. Traditional methods to secure the airway including transnasal vs transoral intubation vs awake tracheostomy were considered inadequate due to tumor location/friability, trismus, inability to lie flat, and unclear tracheal landmarks on palpation. In addition, on the day of surgery, the patient tested positive for COVID. We decided ECMO was the safest method to safely perform tracheostomy while minimizing COVID aerosolization. Result(s): The thoracic surgery team proceeded with bifemoral cannulation, and ECMO was initiated in less than 30 minutes. Standard tracheostomy was performed, and biopsies of the oropharyngeal mass were obtained. The patient was weaned off ECMO after <1 hour and awakened without any issues. There were no complications from bi-femoral venous access. Conclusion(s): Multiple methods to secure this patient's difficult airway were considered. Fiber-optic nasal intubation would require navigating the bronchoscope around the large tumor partially obstructing the nasopharynx and larynx. Awake tracheostomy was considered risky due to his large neck circumference, significant coughing episodes, and inability to lay supine. Both of these options would also be associated with high levels of COVID aerosolization. The use of ECMO allowed for apneic tracheostomy while minimizing the risk of COVID infection to all operating room personnel. In the era of COVID, ECMO is an unconventional but powerful tool that should be added to the armamentarium of highrisk airway surgery.

ROLE OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN SALVAGE THERAPY FOR CENTRAL AIRWAY OBSTRUCTION: A CASE REPORT

SESSION TITLE: Pulmonary Procedures: Creativity and Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Recent advances in the management of airway disorders have provided additional therapeutic options for pathology, such as central airway obstruction (CAO). Symptomatic CAO has been managed by bronchoscopic interventions with a high risk of airway compromise and respiratory failure. Other alternatives such as mechanical and jet ventilation may not ensure adequate respiratory support during the procedure and cause delays in life-saving treatments. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used as an adjunct to preserve safety during these airway interventions [1,2]. We present a case of complete tracheal occlusion successfully intervened using VV ECMO support. CASE PRESENTATION: The patient is a 55-year-old male with a history of ventilator-dependent respiratory failure s/p tracheostomy, secondary to post COVID-19 fibrosis, who presented from a long-term acute care facility with worsening hypoxemia. The patient was transferred to the intensive care unit, where he underwent flexible bronchoscopy via the tracheostomy lumen, which did not reveal a patent airway. Orotracheal intubation was unsuccessful as there was complete occlusion of the airway below the vocal cords with abundant granulation tissue. Interventional pulmonology was consulted, and emergent recanalization of the airway with rigid bronchoscopy-mediated debulking was performed. Due to the severity of hypoxemia, cardiothoracic surgery was consulted, and the patient was placed on VV ECMO to support further intervention. The patient was intubated with EFER-DUMON 13 mm rigid bronchoscope. Complete recanalization was achieved using a rigid barrel and forceps with patency of both mainstems and all segmental bronchi. There were no postprocedural complications, and the patient returned to his baseline ventilator settings. DISCUSSION: VV ECMO has been used as an adjunct to preserve safety during high-risk bronchoscopic interventions, primarily in CAO. Acute respiratory decompensation remains a feared complication during these interventions in cases of CAO. Initiating ECMO before these interventions may reduce the incidence of respiratory failure and airway compromise. In a case series, ECMO has been described by Stokes et al. as a supportive measure facilitating such interventions [3]. Further guidelines are required to standardize ECMO initiation as procedural support during airway interventions. CONCLUSIONS: Planned preprocedural ECMO initiation can prevent respiratory emergencies and allow therapeutic high-risk airway interventions. The choices for this patient were stark- either airway recanalization without ECMO bridge with a risk of hypoxic brain injury vs. VV ECMO support and curative airway intervention. In the absence of large-scale data and based on local availability of excellent ECMO support and Interventional Pulmonology, the latter approach was used, leading to successful and safe airway recanalization. Reference #1: Zapol WM, Wilson R, Hales C, Fish D, Castorena G, Hilgenberg A et al.Venovenous bypass with a membrane lung to support bilateral lung lavage. JAMA 1984;251:3269–71. Reference #2: Fung R, Stellios J, Bannon PG, Ananda A, Forrest P. Elective use of venovenous extracorporeal membrane oxygenation and high-flow nasal oxygen for resection of subtotal malignant distal airway obstruction. Anaesth Intensive Care 2017;45:88–91. Reference #3: Stokes JW, Katsis JM, Gannon WD, Rice TW, Lentz RJ, Rickman OB, Avasarala SK, Benson C, Bacchetta M, Maldonado F. Venovenous extracorporeal membrane oxygenation during high-risk airway interventions. Interact Cardiovasc Thorac Surg. 2021 Nov 22;33(6):913-920. doi: 10.1093/icvts/ivab195. PMID: 34293146;PMCID: PMC8632782 DISCLOSURES: No relevant relationships by Vatsal Khanna No relevant relationships by Anurag Mehrotra No relevant relationships by Trishya Reddy No relevant relationships by Bernadette Schmidt

IT'S NEXT TO THE PLEURA

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: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan

PLEUROPARENCHYMAL FIBROELASTOSIS UNCOVERED IN A PATIENT WITH COVID-19 PRESENTING WITH PNEUMOTHORAX

SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: This report describes the case of a patient presenting with pneumothorax and Severe Acute Respiratory Syndrome (SARS) Coronavirus-2 (SARS-cov-2) infection leading to Coronavirus Disease 2019 (COVID-19) pneumonia, with worsening presentation, later found to have underlying Pleuroparenchymal Fibroelastosis (PPFE). CASE PRESENTATION: A 68 year old male with a past medical history of hypertension and type 2 diabetes presented to his primary care clinic with shortness of breath. He underwent a Chest X-Ray as an outpatient which revealed a moderate right-sided pneumothorax (PTX), and he was sent to the Emergency Department by his primary care provider. He was found to be COVID positive on initial workup, also requiring supplemental oxygen. Other routine laboratory tests did not reveal any significant abnormalities. His shortness of breath worsened and on repeat X-rays his pneumothorax increased in size therefore a chest tube was placed by Cardiothoracic Surgery. Computerized Tomography of the chest revealed moderate right pneumothorax, bilateral diffuse ground glass opacities and pulmonary micronodules [Figure 1]. The patient had mild initial improvement and the chest tube was removed but he had recurrence of the PTX and he underwent urgent Video Assisted Thoracoscopic Surgery (VATS), with right upper lobe wedge resection and talc pleurodesis. A biopsy of the resected lung revealed a benign lung with fibroelastotic scarring, diffusely involving subpleural tissue and prominently extending into and entrapping areas of underlying alveolated tissue, with no inflammation, granulomas or pneumonia noted. Workup for tuberculosis, autoimmune disorders, HIV was negative. He eventually was discharged home with close pulmonology and cardiothoracic surgery follow ups, planned for disease surveillance and malignancy workup. DISCUSSION: PPFE is a rare entity, and classified amongst rare causes of idiopathic interstitial pneumonias (IIP) [1]. It is characterized by upper lobe fibrosis, supleural and parenchymal scarring. It can occur at any age, and the usual presentation is of pneumothorax in a thin male, with a shortened anteroposterior diameter of the chest. Radiographic findings typically include subpleural nodular or reticular opacities in the upper lobes, usually sparing the middle and lower lobes. Pathology reveals increased elastic tissue and dense collagen fibers, along with subpleural fibrosis [2]. Pulmonary function testing reveals a restrictive pattern with reduced diffusion capacity and it is usually resistant to steroids [3]. CONCLUSIONS: PPFE is an uncommon cause of insidious, slowly progressive fibrotic lung disease often limited to the upper lobes. It should be suspected in any person presenting with recurrent pneumothorax or blebs without other known inciting causes. Lung biopsy helps establish the diagnosis. Patients with this condition need close pulmonology follow up to assess progression. Reference #1: Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, Ryerson CJ, Ryu JH, Selman M, Wells AU, Behr J, Bouros D, Brown KK, Colby TV, Collard HR, Cordeiro CR, Cottin V, Crestani B, Drent M, Dudden RF, Egan J, Flaherty K, Hogaboam C, Inoue Y, Johkoh T, Kim DS, Kitaichi M, Loyd J, Martinez FJ, Myers J, Protzko S, Raghu G, Richeldi L, Sverzellati N, Swigris J, Valeyre D;ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013 Sep 15;188(6):733-48. doi: 10.1164/rccm.201308-1483ST. PMID: 24032382;PMCID: PMC5803655. Reference #2: Frankel SK, Cool CD, Lynch DA, Brown KK. Idiopathic pleuroparenchymal fibroelastosis: description of a novel clinicopathologic entity. Chest. 2004 Dec;126(6):2007-13. doi: 10.1378/chest.126.6.2007. PMID: 1559 706. Reference #3: Watanabe K. Pleuroparenchymal Fibroelastosis: Its Clinical Characteristics. Curr Respir Med Rev. 2013 Jun;9(4):299-237. doi: 10.2174/1573398X0904140129125307. PMID: 24578677;PMCID: PMC3933942. DISCLOSURES: No relevant relationships by FNU Amisha No relevant relationships by Perminder Gulani No relevant relationships by Hyomin Lim No relevant relationships by paras malik No relevant relationships by Divya Reddy

A CASE OF ROSAI-DORFMAN DISEASE PRESENTING AS A PULMONARY ARTERY MASS

SESSION TITLE: Pathology Under the Microscope SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Rosai-Dorfman disease (RDD) is a rare, idiopathic, nonmalignant lymphohistiocytic proliferative disorder that presents with lymphadenopathy and less commonly with extranodal involvement (1). This is a case of a patient found to have a pulmonary artery mass and bone lesions consistent with RDD. CASE PRESENTATION: A 33-year-old female with COVID pneumonia presented with one week of dyspnea, myalgias, and chills. She developed hypoxia requiring 2L of supplemental oxygen. Physical exam was benign and without lymphadenopathy. CT angiography demonstrated a well circumscribed 2.3cm x 2.1cm eccentric filling defect concerning for a pulmonary embolism versus vascular mass. She had a normal troponin and brain natriuretic peptide. Echocardiogram showed normal left ventricular ejection fraction and right ventricular size and function. Lower extremity dopplers were negative for acute deep venous thrombosis. Cardiac MRI demonstrated a mass in the posterior aspect of the proximal main pulmonary artery superior to the pulmonic valve measuring 1.9cm x 1.6cm that was consistent with a benign cardiac tumor. Patient was discharged and underwent sternotomy and excision of the mass one week later. Pathology showed histiocytosis consistent with RDD. Post-operatively she developed recurrent fevers and imaging showed bony lesions in her lumbar spine, maxilla, and skull base. Pathology from an IR guided biopsy of the lumbar lesion was suggestive of RDD. DISCUSSION: RDD is a rare, nonmalignant lymphohistiocytic proliferative disorder that usually involves lymph nodes. Concurrent nodal and extranodal involvement has been reported in 43% of cases while isolated extranodal involvement has been reported in 23% of cases. Common extranodal sites include cutaneous, soft tissue, upper respiratory tract, bone, and central nervous system (1). There are only a few cases reported of pulmonary artery involvement. These cases include a patient with RDD invading the pulmonary trunk and aorta who required surgical resection and reconstruction due to impending right ventricular failure (2) and a young woman with RDD causing nearly complete obstruction of the main pulmonary artery resulting in severe pulmonary hypertension and heart failure who required debulking (3). This case demonstrates RDD involving the main pulmonary artery and bones which was incidentally discovered when the patient was hospitalized for COVID pneumonia. RDD has a benign course but when the pulmonary artery is involved, patients often require surgical excision. CONCLUSIONS: RDD is a benign proliferation of histiocytes that most commonly presents with cervical lymphadenopathy. Extranodal involvement has been reported but pulmonary artery involvement is rare. RDD has a benign course, but pulmonary arterial involvement often requires surgical excision. Reference #1: Gaitonde, S. (2007). Multifocal, extranodal sinus histiocytosis with massive lymphadenopathy: an overview. Archives of pathology & laboratory medicine, 131(7), 1117-1121. Reference #2: Prendes, B. L., Brinkman, W. T., Sengupta, A. L., & Bavaria, J. E. (2009). Atypical presentation of extranodal Rosai-Dorfman disease. The Annals of thoracic surgery, 87(2), 616-618. Reference #3: Walters, D. M., Dunnington, G. H., Dustin, S. M., Frierson, H. F., Peeler, B. B., Kozower, B. D., … & Lau, C. L. (2010). Rosai-Dorfman disease presenting as a pulmonary artery mass. The Annals of thoracic surgery, 89(1), 300-302. DISCLOSURES: No relevant relationships by Veena Dronamraju Advisory Committee Member relationship with Nabriva Please note: 1 day Added 03/14/2022 by Rohit Gupta, value=Consulting fee No relevant relationships by MARUTI KUMARAN no disclosure on file for Bilal Lashari;No relevant relationships by Parth Rali No relevant relationships by Stephanie Tittaferrante No relevant relationships by Yoshiya Toyoda

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

DIAPHRAGMATIC PARALYSIS FOLLOWING SECOND DOSE OF THE BNT162B2 MRNA COVID-19 VACCINE

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The vaccines against SARS-CoV-2 or COVID-19 have been shown to be safe and effective at preventing severe disease and death. In a phase 3 trial the BNT162b2 mRNA COVID-19 vaccine showed a 52% and 95% efficacy after the first and second doses, respectively (1). Side effects following vaccination are common but are typically mild and self limited (2). The most common side effects are headache, fever, fatigue, arthralgias and pain at the injection site (2). More severe and devastating side effects have been reported including cerebral venous thrombosis and myocarditis (3) (4). Here we report a case of unilateral diaphragmatic paralysis following the second dose of the BNT162b2 mRNA COVID-19 vaccine. CASE PRESENTATION: The patient was a 56 year old female with a past medical history of reactive airways disease and hypertension who was seen in the pulmonology clinic shortly after receiving her second dose of the BNT162b2 mRNA COVID-19 vaccine. After her second dose she developed burning shoulder pain, erythema and swelling that extended to the neck and axilla. She went to an urgent care and was advised to treat with ice and NSAIDs, she had a chest radiograph performed which was reported to be negative. Her symptoms persisted and she was sent to the emergency room, chest x-ray showed interval development of an elevated left hemidiaphragm. A CT Chest with inspiratory and expiratory films was performed and the left diaphragm was noted to be in the same location during inspiration and expiration consistent with diaphragmatic paralysis. PFT showed a reduction in her FVC, TLC and DLCO compared to 13 years prior. DISCUSSION: Diaphragmatic paralysis is a well described clinical entity that is most often associated with cardiothoracic surgery where hypothermia and local ice slush application are thought to induce phrenic nerve injury (5). It has also been described as a complication of viral infections, including a recent report of unilateral diaphragm paralysis in a patient with acute COVID-19 infection (6). In a case series of 246 patients with amyotrophic neuralgia which can include diaphragm paralysis, 5 patients received a vaccine in the week before developing symptoms (8) Additionally, Crespo Burrilio et al recently described a case of amyotrophic neuralgia and unilateral diaphragm paralysis following administration of the Vaxzevri (AstraZeneca) COVID-19 vaccine (7). This case highlights a potential side effect of the BNT162b2 mRNA COVID-19 vaccine that has not been previously reported CONCLUSIONS: Reference #1: Polack FP, Thomas SJ, Kitchin N. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med. 2020;383:2603–2615. Reference #2: Menni, C., Klaser, K., May, A., Polidori, L., Capdevila, J., Louca, P., Sudre, C. H., Nguyen, L. H., Drew, D. A., Merino, J., Hu, C., Selvachandran, S., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., Modat, M., Joshi, A. D., Mangino, M., … Spector, T. D. (2021). Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. The Lancet. Infectious diseases, 21(7), 939–949. https://doi.org/10.1016/S1473-3099(21)00224-3 Reference #3: Jaiswal V, Nepal G, Dijamco P, et al. Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221074450. doi:10.1177/21501319221074450 DISCLOSURES: No relevant relationships by Jack Mann No relevant relationships by John Prudenti

CHEST-WALL CASTLEMAN DISEASE MIMICKING THYMOMA DROP METASTASIS

SESSION TITLE: Amazing Chest Imaging Findings SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Thoracic Castleman disease is challenging to diagnose and can mimic various lymphoproliferative disorders. Herein we present a case of unicentric thoracic castleman disease co-existing with thymoma, mimicking a thymoma drop metastasis. CASE PRESENTATION: A 50-year-old previously healthy Caucasian female presented to the emergency room with COVID-19 related respiratory symptoms. CTA was consistent with COVID-19 pneumonia and incidentally showed a 4.2 x 3.1 cm mass in the right anterosuperior mediastinum abutting the ascending aorta and superior right atrium, and a 3.3 x 2.1 cm mass in right posterior costophrenic sulcus abutting the right 11th rib raising suspicion for thymoma with a "drop metastases.” CT abdomen/pelvis was unrevealing. For proper staging, US guided biopsy of chest wall mass was performed which showed reactive lymphoid tissue. CT guided biopsy of the mediastinal mass revealed a thymoma. Due to ongoing concern for pleural metastases and possible sampling error with prior biopsy of the costophrenic lesion, she underwent surgical resection of the anterior mediastinal mass and chest wall lesion including part of 11th rib. The chest wall lesion was noted to be extrapleural. Surgical biopsy confirmed WHO grade B1 Thymoma and the chest wall lesion showed hyaline vascular Castleman disease. DISCUSSION: Pleural "Drop” metastasis from a thymoma or thymic carcinoma should be considered in patients with an anterior mediastinal mass and pleural based lesions. Imaging shows one or more pleural nodules or masses, which can be smooth, nodular, or diffuse. [1]. In our case, a basilar, discrete, nodular mass was suspicious for a drop metastasis. At the time of surgery, the lesion was noted to be extrapleural. Unicentric Castleman disease is a benign lymphoproliferative disorder which presents as a homogeneous, well-marginated, highly vascularized enhancing mass commonly involving the mediastinum. These lesions can mimic thymoma, lymphoma, sarcoma, hemangiopericytoma, and neural crest derived neoplasms. Pleural Castleman disease can arise from visceral and parietal pleura with extension into the chest wall or lung fissures and can cause pleural effusion. Intercostal disease can resemble other chest wall masses and cause rib erosions [2]. Chest-wall localization is a rare manifestation of Castleman disease often diagnosed due to non-specific thoracic symptoms such as dyspnea, cough, chest-wall pain or generalized malaise.[3] Complete excision of the lesion is generally curative with cure rate of 95-100%, with recurrence reported with partially resected lesions. CONCLUSIONS: Castleman disease located in the chest wall can present diagnostic and management challenges particularly when present in the context of other lesion with metastatic potential. Reference #1: 1.Benveniste, M.F.K., Rosado-de-Christenson, M.L., Sabloff, B.S., Moran, C.A., Swisher, S.G. and Marom, E.M. (2011). Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma. RadioGraphics, 31(7), pp.1847–1861. Reference #2: 2.Ko, S.-F., Hsieh, M.-J., Ng, S.-H., Lin, J.-W., Wan, Y.-L., Lee, T.-Y., Chen, W.-J. and Chen, M.-C. (2004). Imaging Spectrum of Castleman's Disease. American Journal of Roentgenology, 182(3), pp.769–775 Reference #3: 3. Rena, O., Casadio, C. and Maggi, G. (2001). Castleman's disease: unusual intrathoracic localization. European Journal of Cardio-Thoracic Surgery, 19(4), pp.519–521. DISCLOSURES: No relevant relationships by Peter LaCamera, value=Consulting fee Removed 04/06/2022 by Peter LaCamera No relevant relationships by Peter LaCamera, value=Consulting fee Removed 04/06/2022 by Peter LaCamera No relevant relationships by Alina Wasim

BENIGN PLEURAL SCHWANNOMA WITH PLEURAL EFFUSIONS AND NECROTIZING PNEUMONIA

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

TENSION PNEUMOMEDIASTINUM RESULTING IN OBSTRUCTIVE SHOCK IN COVID-19

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

PULMONARY ARTERY PSEUDOANEURYSM (PAP) AND MASSIVE HEMOPTYSIS AS A COMPLICATION OF MUCORMYCOSIS AND COVID-19 PNEUMONIA

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: PAP is a rare entity that can occur secondary to infection, malignancy, or trauma. Mucormycosis in the setting of Covid-19 pneumonia has been increasingly recognized but PAP has only recently been reported in this setting. CASE PRESENTATION: A 44 year-old man with type 2 diabetes, non-ischemic cardiomyopathy, hypothyroidism, and ulcerative colitis presented with dyspnea and cough in July 2021. He was diagnosed with Covid-19 pneumonia and initially treated with molnupiravir. Eight days later he presented to the emergency room with worsening dyspnea, hypoxemia and diabetic ketoacidosis. He required 3L of oxygen and was intubated for airway protection. CT chest revealed mild bilateral patchy opacities and dexamethasone was started. Unfortunately, persistent fevers and worsening respiratory status ensued and repeat chest CT on hospital day (HD) 8 showed a new large left upper lobe (LUL) cavitary lesion. Cultures ultimately grew Rhizopus microsporus and he was started on amphotericin then isavuconazole after acute kidney injury developed. Dexamethasone was discontinued and interval imaging after ten days showed dramatic growth of the cavitary lesion (9 x 6 x 3 cm) with new extension through the chest wall, infiltrating the intercostal spaces and pectoralis muscle. Due to ventilator dependency a tracheostomy was performed on HD 24. Despite anti-fungal therapy the cavitary lesion persisted, with evidence of osseous destruction of the third and fourth ribs, as well as new fluid collections within the cavity and hilar extension. On HD 46 he was transferred to our institution for Thoracic Surgery and Interventional Radiology (IR) evaluations. Percutaneous drain placement followed by pneumonectomy vs. staged cavernostomy was considered;however, on HD 50, the patient suddenly developed massive hemoptysis. CTA of the chest showed a 1.6 x 1.5 cm PAP with active hemorrhage from the LUL anterior segmental artery with dispersion into the cavity. Urgent coil and glue embolization was successfully performed by IR. Ultimately, thoracic surgical intervention was deemed too high risk and thus he was medically managed with a regimen of isavuconazole, amphotericin, and terbinafine. Hemoptysis did not recur and he was eventually discharged from the hospital and liberated from both mechanical ventilation and tracheostomy. Chest CT 6 months from the initial diagnosis has shown stable to mildly decreased size of the cavitary lesion. DISCUSSION: This is the first case to our knowledge of PAP as a complication of Covid-19 and Mucor superinfection in the United States. Five cases of this combination have been recently reported in other countries. Risk factors for Mucor infection after Covid appear to be uncontrolled diabetes, DKA, and steroid administration. CONCLUSIONS: A high index of suspicion should be maintained in patients with these risk factors, as PAP can present as massive hemoptysis and is often fatal. Reference #1: Hoenigl M, Seidel D, Carvalho A, et al. The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries [ 2022 Jan 25]. Lancet Microbe. 2022;10.1016/S2666-5247(21)00237-8. doi:10.1016/S2666-5247(21)00237-8 Reference #2: Pruthi H, Muthu V, Bhujade H, et al. Pulmonary Artery Pseudoaneurysm in COVID-19-Associated Pulmonary Mucormycosis: Case Series and Systematic Review of the Literature. Mycopathologia. 2022;187(1):31-37. doi:10.1007/s11046-021-00610-9 Reference #3: Coffey MJ, Fantone J 3rd, Stirling MC, Lynch JP 3rd. Pseudoaneurysm of pulmonary artery in mucormycosis. Radiographic characteristics and management. Am Rev Respir Dis. 1992;145(6):1487-1490. doi:10.1164/ajrccm/145.6.1487 DISCLOSURES: No relevant relationships by Kevin Patel No relevant relationships by Clifford Sung

COMMON PRESENTATION WITH AN UNCOMMON ETIOLOGY: THYMOMA-ASSOCIATED AUTOIMMUNE ENCEPHALITIS INDUCED BY COVID-19 BOOSTER VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Thymoma-associated autoimmune encephalitis (TAAE) is an understudied and overlooked diagnosis in patients presenting with abrupt altered mental status. Described as inflammation of brain tissue, autoimmune encephalitis is seen in 5-10 cases per 100,000 across all age groups per year. A rare subtype involves neuronal surface antibodies to alpha-amino-3-hydroxyl-5-methyl-4isoxazolepropionic acid receptors (AMPA-R) encephalitis is seen even less commonly. Given the "unicorn” nature of presenting cases and difficulty of diagnosis, prompt identification and treatment are critical as prolonged courses without treatment are irreversible and deadly. CASE PRESENTATION: A 47-year-old male with no past medical history presented 3 days after a Johnson & Johnson coronavirus-2019 (COVID-19) booster vaccine due to worsening acute altered mental status over the past week. He complained of episodes of fever & chills prior to this. The patient's wife reported abrupt changes in memory and personality. Upon admission, the patient had a Glasgow Coma Scale of 4. The patient was intubated and transferred to the intensive care unit. Intravenous (IV) vancomycin, ceftriaxone and acyclovir was initiated for meningitis. Computed tomography (CT) scan of the head without contrast was unremarkable. Magnetic resonance imaging (MRI) showed enhancements of the right anterior and medial temporal lobe suggesting encephalitis. Cerebrospinal fluid analysis (CSF) revealed lymphocytic pleocytosis. A CT scan of the chest, abdomen and pelvis showed an anterior mediastinal mass measured 1.8 x 2.3 cm (Figure 1). FilmArray Meningitis polymerase chain reaction was negative as well as Herpes Simplex Virus (HSV) 1 and 2. Autoimmune encephalitis antibody was positive for Anti-AMPAR. Pulse dose steroids and intravenous immunoglobulin were initiated but failed. Rituximab was initiated and cardiothoracic surgery completed a thymectomy. DISCUSSION: TAAE is a rare disease, permanently debilitating, and deadly if unrecognized or treatment is delayed. Autoimmune encephalitis is an umbrella disease process seen in 0.00005% of patients per year. AMPA-R positive encephalitis is even less commonly seen with only 22 cases reported between the years 2009 and 2014 [1]. A rapidly progressive cognitive decline or psychiatric disorders are early features of this disease.Our patient had prodromal symptoms of fever and cognitive decline days after receiving his COVID-19 booster vaccine. CONCLUSIONS: Post-vaccine encephalomyelitis has been described in other settings[2]. This patient was free of symptoms prior to the COVID-19 vaccine booster, and demonstrated altered mental status hours after receiving it. This furthers the possibility of an association of the COVID-19 booster vaccine, development of encephalitis, and in this case a thymoma. Despite this, conclusions can not be made on the account of one report, but introduces a new area of focus to study. Reference #1: Höftberger, R., van Sonderen, A., Leypoldt, F., Houghton, D., Geschwind, M., Gelfand, J., Paredes, M., Sabater, L., Saiz, A., Titulaer, M. J., Graus, F., & Dalmau, J. (2015). Encephalitis and AMPA receptor antibodies: Novel findings in a case series of 22 patients. Neurology, 84(24), 2403–2412. https://doi.org/10.1212/WNL.0000000000001682 Reference #2: Huynh, W., Cordato, D. J., Kehdi, E., Masters, L. T., & Dedousis, C. (2008). Post-vaccination encephalomyelitis: literature review and illustrative case. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 15(12), 1315–1322. https://doi.org/10.1016/j.jocn.2008.05.002 DISCLOSURES: No relevant relationships by Matthew Frank No relevant relationships by Justin Ilagan No relevant relationships by Danielle Mahon No relevant relationships by Danielle Mahon No relevant relationships by Harshini Sahani No relevant relationships by Kameron Tavakolian No relevant relationship by Ndausung Udongwo