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1.
Gastroenterology ; 162(7):S-854, 2022.
Article in English | EMBASE | ID: covidwho-1967377

ABSTRACT

Background: Optimizing management of gastroesophageal reflux disease (GERD) is important to preserve graft function after lung transplantation as patients with GERD are at higher risk of rejection. Patients with COVID-19 associated respiratory failure undergoing lung transplantation is an emerging subset of patients in which GERD pre- or post-transplant is not well characterized. Aim: To evaluate the prevalence and adverse effects of GERD both pre- and post-transplant in patients undergoing lung transplantation for severe COVID-19 infection. Methods: A retrospective review was conducted at a single academic medical center with a large multi-organ transplant program. All patients undergoing lung transplant due to COVID-19 from 2020-2021 were included in the study, with attention to pre- and post-operative physiological testing for GERD. Results: Seventeen patients were identified who had undergone lung transplant for COVID-19. All patients were male;52.9% (9/17) were Hispanic, 35.3% (6/17) Caucasian and 11.8% (2/17) Black. Median age was 50 (24- 70 years) with median time to transplant from documented infection of 131 days. A prehospitalization GERD diagnosis was found in 29.4% (5/17) patients, and two patients (11.8%) were taking prescribed proton-pump inhibitor (PPI) prior to their COVID-19 associated hospitalization. No patient underwent pre-transplant GERD testing, although three patients did undergo upper endoscopy for GI bleeding prior to transplant. Post-transplant, all patients were immediately treated with PPI per institutional protocol. 70.5% (12/17) patients reported post-transplant foregut symptoms including heartburn, regurgitation, dysphagia, early satiety, abdominal bloating/cramping, nausea and vomiting. All 17 patients had at least one symptomdriven foregut study such as a gastric emptying study, barium esophagram, upper endoscopy, esophageal manometry or pH testing. Three patients were referred for anti-reflux surgery (ARS) based on results of testing, including delayed gastric emptying, abnormal pH testing and bronchoscopy findings concerning for aspiration pneumonia. All three underwent Toupet fundoplication with or without hiatal hernia repair;one was performed early (< 3 mo) posttransplant, two occurred late (> 6 mo), and none had complications or symptom-based recurrence of reflux. Discussion: In this large single-center series of COVID-19 associated respiratory failure and lung transplant, pre-operative reflux testing could not be performed;however, post-transplant GERD symptoms were still routinely assessed and evaluated, prompting management with ARS in a small subset of patients, both early and late posttransplant, with resolution of GERD symptoms. Long-term outcomes of this unique group and comparison with others requiring transplant will necessitate further investigation to assess impact of GERD on allograft dysfunction.

2.
Indian J Pathol Microbiol ; 65(3): 713-715, 2022.
Article in English | MEDLINE | ID: covidwho-1964253

ABSTRACT

The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to an increased incidence of fungal infections. However, pulmonary infections are rare. COVID-associated pulmonary aspergillosis has been reported; however, there is no prior report of tracheobronchial aspergillosis with endobronchial aspergilloma as per the authors' literature search. We report such a case of a 65-year-old male with radiology and biopsy-proven endobronchial aspergilloma upon a background of tracheobronchial and pulmonary aspergillosis after having recovered clinically from severe COVID-19 disease.


Subject(s)
Aspergillosis , COVID-19 , Pulmonary Aspergillosis , Aged , COVID-19/diagnosis , Humans , Male , Pandemics , Pulmonary Aspergillosis/complications , Pulmonary Aspergillosis/diagnosis , SARS-CoV-2 , Tomography, X-Ray Computed
3.
BMJ Open Respir Res ; 9(1)2022 07.
Article in English | MEDLINE | ID: covidwho-1962326

ABSTRACT

Lung cancer is the single biggest cause of cancer death. The diagnostic pathway can be complex, including specialist cancer diagnostics that are not performed at every hospital. One such example is endobronchial ultrasound (EBUS), a day-case bronchoscopic procedure used for nodal staging and tissue diagnosis. In this proof-of-concept pilot in Greater Manchester, we tested a novel digital EBUS booking platform. This platform was accessible across multiple acute care trusts and provided visibility of all available EBUS appointments, allowing referring teams to book directly into the appropriate slot. During a 6-month pilot, 193 EBUS procedures were booked through this new single-queue platform. The median waiting times reduced by 2 days from 9 to 7 days (22% reduction and saving approximately 386 days in total) and reduced variation in waiting times by 1 day from 5 to 4 days (20% reduction). 98% of patients who completed an experience of care survey felt the process was 'very well' or 'well' organised and 77% felt the most important factor in deciding where to have their EBUS was the earliest possible appointment regardless of travel. This proof-of-concept pilot has shown improvements in cancer waiting times with significant future potential in delivering specialist cancer diagnostics.


Subject(s)
COVID-19 , Lung Neoplasms , Bronchoscopy , Humans , Lung Neoplasms/diagnosis , Lung Neoplasms/pathology , Neoplasm Staging , Pandemics
4.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927930

ABSTRACT

RATIONALE The COVID-19 pandemic led to rapid changes in care-delivery for intensive care unit (ICU) patients, due to factors including high ICU strain, shifting team member roles, and changes in care locations. As these changes may have not only impacted patients with COVID-19 but also critically ill patients without COVID-19, we assessed changes in common ICU practices for mechanically ventilated patients without COVID before and after the start of the COVID-19 pandemic. METHODS We used the Premier Healthcare Database to identify mechanical ventilated ICU patients in the US from January 1, 2016 - December 31, 2020. Patients were excluded if they had an ICD-10 diagnosis of COVID-19 (U07.1) or if they were admitted to a hospital that did not contribute data for all five years. We assessed annual rates of common ICU imaging studies (chest CT scan, chest x-ray, lower extremity doppler ultrasound), bedside diagnostics (electrocardiogram, electroencephalogram), and bedside procedures (arterial line, central venous catheterization, bronchoscopy) and annual mortality rates. We used interrupted time series analysis, adjusted for seasonality and autocorrelation where present, to evaluate trends in ICU practices prior to the pandemic (March 2016 - February 2020), at the onset of the pandemic (April 2020) and as the pandemic progressed (April 2020 - December 2020). March 2020, as the US transitioned into the pandemic, was excluded from the analysis. RESULTS We identified 584,393 mechanically ventilated patients without COVID- 19 at 509 hospitals. Trends in ICU procedures and mortality are illustrated in Figure 1. At the onset of the pandemic, use of chest x-ray (-35.6% [-53.5 to -17.8%, p<0.001]), electrocardiogram (-14.8% [-21.9 to -7.6%, p<0.001]), and bronchoscopy (-1.2% [-1.8 to -0.6%, p<0.001]) decreased;rates of lower extremity doppler (-1.8% [-4.1 to -0.5%, p=0.12]), electroencephalogram (-0.8% [- 1.7 to 0.1%, p=0.09]), arterial lines (-0.09 [-1.0 to 0.9%, p=0.85]) and central venous catheters (+0.2 [-1.3 to 1.7%, p=0.77]) did not significantly change;use of chest CT increased 2.6% (0.9 to 4.3%, p=0.001). With the exception of chest CT, arterial lines, and central venous catheters, trends in all other measured procedures increased as the pandemic progressed, compared with pre-pandemic trends. There was no significant trend change in mortality at the onset of the pandemic or during the pandemic. CONCLUSIONS Multiple practice patterns changed among patients without COVID-19 early during the pandemic. However, no change in mortality was seen during this time. These findings warrant further investigation to determine their impact on patientcentered outcomes.

5.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927853

ABSTRACT

Introduction:Immunocompromised individuals, such as those with HIV and low CD4 counts, are at increased risk for opportunistic infections. Although uncommon, these patients can be infected with multiple organisms, making diagnosis and management challenging for clinicians. Mortality remains high, as the data on initiating and adjusting antimicrobials when there is concern for co-infection is lacking. We present a case of Pneumocystis jiroveci (PCP) and cytomegalovirus (CMV) coinfection resulting in severe hypoxic respiratory failure and death. Case Report:A 38-year-old male with no past medical history presented with fever, dyspnea, and nonproductive cough. Vital signs were notable for a fever of 102.3°F, respiratory rate of 24, and oxygen saturation of 77% on room air. Physical examination revealed an ill-appearing male with bilateral rhonchi who became dyspneic with minimal conversation. Laboratory studies were significant for an elevated c-reactive protein, erythrocyte sedimentation rate, ferritin and lactate dehydrogenase. CT chest demonstrated bilateral ground glass opacities with multifocal consolidations. The patient was admitted for hypoxic respiratory failure secondary to suspected COVID pneumonia, despite negative testing. By hospital day 4, the patient had shown little improvement. Further work-up revealed that he was HIV positive with a CD4 count of 5, so he was empirically started on oral trimethoprim-sulfamethoxazole (TMPSMX) for presumed PCP pneumonia. On hospital day 9, the patient underwent endotracheal intubation for worsening hypoxia and subsequent bronchoscopy for further evaluation. PCP PCR confirmed the diagnosis, and the patient was transitioned to intravenous TMP-SMX. Still with minimal improvement, micafungin was added as potential salvage therapy. After 12 days of TMPSMX, treatment was changed to clindamycin/primaquine. CMV PCR from the bronchoalveolar lavage fluid came back positive at this time, so ganciclovir was added to the regimen. Despite multiple antimicrobials, the patient continued to decline. He was deemed not to be a candidate for ECMO given his profoundly immunocompromised status and ultimately died. Discussion:This case highlights the difficulties clinicians have in managing severely immunocompromised patients who worsen despite appropriate care. Little data exists providing guidelines on when to change to second and/or third-line agents in treating PCP pneumonia. Additionally, further studies need to be completed to delineate in whom empiric antimicrobials should be initiated early when co-infection is a possibility. ECMO may serve a purpose in this patient population given that lung rest is necessary to allow healing, but only a few cases of its use exist at this time.

6.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927838

ABSTRACT

Introduction: Mucormycosis is a rare invasive opportunistic fungal infection caused by Zygomycetes. [1,2] It is associated with worse outcomes in immunocompromised patients.[3,4] Invasive pulmonary infections can lead to bronchial necrosis from angioinvasion.[1,3] Here, we present a case of invasive pulmonary mucormycosis (IPM) caused by Rhizopus spp, resulting in tracheo-esophageal fistula. Case : An 18-year-old male with uncontrolled type 1 diabetes was admitted to the intensive care unit for diabetic ketoacidosis (DKA) and acute hypoxia due to COVID 19 pneumonia requiring ventilatory support. Chest imaging showed bilateral opacities. He was treated with dexamethasone for COVID 19 and broad-spectrum antibiotics for superimposed bacterial pneumonia. Clinical course was complicated by acute respiratory distress syndrome and pneumomediastinum. Computed tomography of the chest showed large pneumomediastinum with air leak within the distal thoracic trachea. Bronchoscopy revealed a disfigured main carina with erosions (figure 1), a tracheo-esophageal fistula, necrotic blood-tinged left mainstem bronchus tissue, and a necrotic pus-filled superior segment of the right lower lobe. Left mainstem bronchial tissue specimen culture grew Rhizopus and Klebsiella spp. Liposomal amphotericin was initiated. Given his poor prognosis, the patient's family refused aggressive thoracic surgical intervention and pursued palliative care. Discussion: Rhizopus spp is the most common cause of mucormycosis in immunocompromised populations.[6] IPM is the second most common clinical form reported after the central nervous system.[3,6] Typically, IPM lesions are localized, and invasive presentations are infrequent. Rarely, IPM can cause invasive disease by angioinvasion, obstructing blood flow, and ischemic tissue necrosis.[6] Airway tissue necrosis can lead to fistulas between the airway and adjacent structures, including pleura, pericardium, and mediastinum.[2,3,4,5] Published clinical literature review revealed only a few cases due to IPM. Common predisposing factors include diabetes, DKA, and immunosuppressive medications, as observed in our patient.[3] Lobar bronchi are the usual locations of endobronchial erosions, with a predilection for the upper lobes.[3] In contrast, the left mainstem bronchus and right lower lobe were involved in the case presented here. In addition to antifungal treatment, surgical debridement is the mainstay of therapy due to necrosis.[7] The survival rate is between 35-46% in medically managed compared to 51-90% in surgically treated patients.[3]Conclusion: IPM is a life-threatening invasive disease associated with high mortality rates. Clinicians should suspect it in immunocompromised patients, including diabetes. The clinical history may include uncontrolled diabetes, recent DKA, and infections predisposing patients to develop superimposed fungal infections. The concurrent use of systemic steroids may also contribute to worse outcomes. (Figure Presented).

7.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927837

ABSTRACT

Introduction: The Fungitell assay is an in vitro diagnostic test for the qualitative detection of (1-3)-beta-D-Glucan (BDG) in serum. It can be particularly useful in early diagnosis of fungal infections that would otherwise take weeks to finalize in culture.Description:This is a case of a 73 year old Filipino female with a history of diffuse large B-cell lymphoma status post RCHOP therapy, currently maintained on Ritixumab, and rheumatoid arthritis treated with Methotrexate who was admitted to the hospital with increasing shortness of breath for several weeks. In the Emergency Department she was hypoxic and required 2 liters of oxygen via nasal cannula and with 92% oxygen saturation. Her vital signs were otherwise normal. She was afebrile and WBC was 9.4. She had a negative respiratory viral PCR which included COVID-19. Infectious work up including sputum culture and urine antigens were also sent. A CT chest was performed and showed bilateral ground glass opacities suspicious for atypical pneumonia.There was concern for drug toxicity from Methotrexate which was subsequently suspended. A bronchoscopy and bronchoalveolar lavage (BAL) was performed to rule out infection prior to starting steroids for suspected pneumonitis. Cell count from the BAL revealed low neutrophils. There was negative growth over the next 48 hours. Steroids were initiated at 1 mg/kg daily and patient was discharged home with close outpatient follow up scheduled. A fungitell (serum beta D glucan) that was collected from the BAL had resulted after the patient was discharged home. The level returned very elevated (>500). The patient was contacted and she reported that her symptoms did not improve with the steroids. She was still requiring up to four liters of oxygen at home. She was asked to return to the hospital to work up an undiagnosed fungal or PJP pneumonia. A repeat bronchoscopy was performed and a PJP PCR was tested on the BAL. This returned positive. She was started on Bactrim for 14 days to treat PJP pneumonia. She was weaned down to 2 liters of oxygen and was doing well from a pulmonary standpoint at her outpatient follow up visit 2 weeks later. Discussion: The Fungitell assay test in this case was crucial to help guide us to the correct diagnosis. In patients who are immunocompromised, physicians should utilize specialty testing such as Fungitell when it is available. Compared to microbial fungal culture, Fungitell results faster, has a higher sensitivity and a higher negative predictive value. (Figure Presented).

8.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927821

ABSTRACT

Introduction: Pulmonary Hamartomas are the most common benign tumors of lungs. Hamartomas are usually asymptomatic and are incidentally diagnosed on chest imaging. Symptomatic cases usually involve endobronchial mucosa. We describe a case of a symptomatic patient who was noted to have a right upper lobe collapse by an endobronchial lesion. This lesion was confirmed to be a cartilaginous hamartoma and was definitively treated by electrosurgical by Argon plasma (APC). Description: A 37 year old obese male active smoker presented to the ER for worsening Shortness of air (SOA) for two weeks. He had dry cough for similar duration without any fevers. On physical examination he was afebrile with normal vital signs but without hypoxia and otherwise normal physical examination. Labs revealed normal white cell count. A COVID test was negative. CT chest showed an endobronchial lesion obstructing the right upper lobe (RUL) with some internal fat density measuring at least 1.5cm causing complete collapse of RUL. No mediastinal or hilar adenopathy was noted. A flexible bronchoscopy showed a pedunculated smooth lesion arising from RUL bronchus anteriorly occluding the RUL bronchus. FNA of the lesion did not show any malignant cells. Using electrosurgery by APC the lesion was removed en bloc. A histopathology showed findings of cartilaginous hamartoma. A follow up Chest X-ray showed improvement in RUL atelectasis. Discussion: Pulmonary hamartomas are the most common benign pulmonary tumors and comprise 6% of solitary pulmonary nodules. Mostly detected on chest imaging as an incidental finding however CT chest has characteristic finding of pop corn shaped calcifications, fat density. Symptomatic cases are usually endobronchial and can be definitively treated with endoscopic techniques.

9.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927820

ABSTRACT

Introduction: Primary tracheal tumors are rare with an incidence of 0.2/100,000 persons, accounting for 0.6% of all pulmonary tumors. Only 10-20% of these tumors are benign with the most common being recurrent respiratory papillomatosis. Other benign tracheobronchial tumors include hamartoma, fibroma, lipoma and hemangioma among others. Due to the slow growing nature of these tumors, patients may present with progressive exertional dyspnea, cough and recurrent pneumonia, though rarely these tumors are identified incidentally in asymptomatic patients. This case describes a patient with an who underwent successful resection with flexible bronchoscopy and snare electrocautery. Case Report: A 66-year-old male with a history of former tobacco use was admitted to the medical intensive care unit (ICU) in 11/2020 with COVID-19 pneumonia, and incidentally found to have a tracheal tumor noted on CT imaging. His ICU course was complicated by submassive pulmonary embolism, pneumothorax requiring chest tube, and acute hypoxemic respiratory failure requiring heated high-flow nasal cannula. He was successfully discharged to home after 4 weeks and evaluated in the ambulatory clinic for follow-up 2 months later. Review of his imaging from an outside facility demonstrated a 1-cm polypoid lesion arising from the right tracheal wall (Figure 1A). Pulmonary function testing demonstrated a moderate restrictive defect with normal flow-volume loops. He was referred to interventional pulmonology for further evaluation and management. Flexible bronchoscopy revealed a 50% partially obstructing polypoid mass 6-cm distal to the vocal cords (Figure 1B). The mass was excised using snare electrocautery with subsequent cryotherapy for destruction of abnormal tissue at the base of the lesion and argon plasma coagulation for hemostasis. Pathology revealed tracheal lipoma. Repeat flexible bronchoscopy 12 weeks later revealed no evidence of recurrence at the site of the previously resected tracheal lipoma (Figure 1C). Discussion: Among benign tracheobronchial tumors, lipoma is an extremely rare diagnosis representing only 3-9% of cases. Airway lipomas very rarely involve the trachea and are infrequently found incidentally in asymptomatic patients. Epidemiological risk factors are thought to include male gender, obesity, middle age, and smoking. Flexible tracheobronchoscopy remains the gold standard for diagnosis, also allowing for excisional treatment with electrocautery, cryotherapy, or laser therapy. Given the rare incidence of these tumors, follow-up evaluation is recommended, though to-date there are no reports of local recurrence after bronchoscopic treatment. This case highlights the importance for diagnostic evaluation of incidental tracheobronchial tumors given the rare incidence of benign diagnoses.

10.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927819

ABSTRACT

Post-intubation tracheal stenosis (PiTS) is a complication that occurs in 10-22% of patients after prolonged intubation or tracheostomy. Predisposing factors include localized infection, soft tissue trauma, granulation at the site of stoma, hypotension, tracheal cartilage damage, and metabolic disorders. Despite advances in the design of endotracheal tubes and cuffs, PiTS continues to remain an undesired consequence that warrants increased attention, especially in the COVID pandemic, which has led to increased number of tracheostomies and intubations. Consequently, prompt diagnosis and management is imperative to improve patient survival and quality of life. Herein, we present a 52-year-old male with history of tracheostomy in the setting of prolonged intubation from intraparenchymal hemorrhage with subsequent decannulation who was admitted for the management of pulmonary embolism. His course was complicated by encephalopathy and acute hypercapnic respiratory failure requiring intubation. In the intensive care unit, the patient was extubated after improvement in his respiratory and mental status, however developed shortness of breath and the feeling of impending doom a few hours after extubation. Chest radiograph was obtained and suggested tracheal stenosis (Image-1A). Given this finding, follow-up urgent chest computed tomography demonstrated severe lateral collapse of the subglottic space with critical tracheal stenosis (Image-1B). There was >90% cross sectional area reduction at the site of greatest stenosis (Image-1C). The measured area at the site of greatest stenosis was noted at 0.32 cm2 (average tracheal area is 2.8-3.4 cm2). His tracheal stenosis was suspected to be secondary to his history of tracheostomy. Given these findings, patient was reintubated for airway protection and urgently underwent rigid bronchoscopy. Initially, argon plasma coagulation was used in between stenotic areas, however there was minimal improvement in the airway, requiring a silicone 18 x 14 x 14 cm Y-stent to be placed. Since stent placement, patient has required frequent bronchoscopies to assist with mucus and secretion clearing. The remainder of his hospital course was benign. PiTS is an infrequent yet important complication that clinicians must consider in individuals with a history of prolonged intubation who have sudden difficulty breathing postextubation. Prompt recognition is required to manage these patients effectively. Factors considered in the management include location, length, and the severity of the stenosis. Therefore, if 1) critical stenosis is suspected, 2) the facility is capable of resection and reconstruction, and 3) the patient has minimal comorbidities, surgery should be considered. Otherwise, bronchoscopy with stent placement can be performed.

11.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927818

ABSTRACT

Introduction: The COVID-19 pandemic has increased the prevalence of single-use bronchoscopes outside the operating room, where they had previously been employed primarily as intubation adjuncts. However, direct comparisons of the performance of these bronchoscopes has been limited. In this study, we describe our initial experience studying operator perception of how well multiple different bronchoscopes are able to engage difficult airway segments in an ex-vivo model. Methods: Nine faculty and fellows from the Pulmonary and Critical Care Division at UCSD were recruited to complete an airway survey of an ex-vivo model using three single use bronchoscopes (Olympus H-SteriScope, Ambu A-Scope 4, Verathon GlideScope B-Flex). This survey included engagement into traditionally difficult airway segments (RB1, RB6, LB1/2 and LB6) with and without a tool in the working channel. Immediately after completing these bronchoscopies, participants were directed to complete an anonymous survey rating each bronchoscopes ease of maneuverability into the difficult segments on a scale of 1-100 with a higher number representing a more favorable rating. The participant's ability to successfully engage each of these segments was also recorded. Results: Participants rated the ability to maneuver into difficult airway segments with a tool in the working channel by the Olympus singleuse bronchoscope (97.2 [94.3-100]) and Ambu single-use bronchoscope (84.7[74.2-95.2]) higher than the GlideScope single-use bronchoscope (49.3[36.3-64.3]) (Table 1). Additionally, a greater number of participants were able to successfully engage the selected difficult airway segments using the Olympus and Ambu single-use bronchoscopes both with and without a tool in the working channel when compared to the GlideScope single-use bronchoscope (Table 2 and Table 3). Conclusions: In this singlecenter study, the Olympus H-SteriScope and Ambu A-Scope 4 single-use bronchoscopes had a higher perceived maneuverability and were better able to engage difficult airway segments than the GlideScope B-Flex single-use bronchoscope. Further studies are needed to compare these single-use bronchoscopes to reusable bronchoscopes.

12.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927786

ABSTRACT

Introduction: Pneumonic-type lung adenocarcinoma (P-ADC) exhibits a pattern of lung cancer that is radiologically like pneumonia1. It may be misdiagnosed and represents a diagnostic challenge in the setting of progressive respiratory failure. We report a case of P-ADC which presented with rarely described extensive diffuse air-space consolidation. Case Presentation: This is a 74-year-old female with a history of Crohn's disease on Mesalamine, Diabetes Mellitus, Hypertension, Hyperlipidemia and former smoker of 40 pack years admitted to the ICU for hypoxic respiratory failure requiring 100% O2 via HFNC. Twenty-two months prior to admission the patient underwent an EBUS following abnormal low dose lung cancer screening CT (Figure 1A-B). The CT demonstrated left infrahilar consolidation and multiple ground-glass nodules. The EBUS with biopsy/brushings of the mass in addition to bronchoalveolar lavage (BAL) were negative. She was lost to follow-up due to the COVID-19 pandemic. Two weeks prior to admission she was admitted for cough and dyspnea, treated for a community acquired pneumonia following CT showing excessive nodular opacities with left dense consolidations. On day of admission the patient presented from outpatient PFT with hypoxemia requiring 8LPM O2 and saturation of 90%, admitted to ICU on HFNC. Associated symptoms were recent unintentional 20 lbs weight loss and fatigue. CT imaging was remarkable for progressive, fulminant left lung consolidation and contralateral lung nodules (Figure 1C-D). The patient underwent a bedside bronchoscopy which showed normal anatomy and copious thin clear secretions. BAL samples showed malignant cells favouring nonsmall cell carcinoma. Further CT guided FNA showed the tumor cells were consistent with adenocarcinoma and positive for TTF1/Napsin A, negative for p40, and KRAS mutation detected. The patient was started on methylprednisolone, Carboplatin and Pemetrexad and discharged home on 6 LPM oxygen. The patient was shortly after re-admitted for a post obstructive pneumonia and progressive hypoxemic respiratory failure, she transitioned to hospice care and passed away during the hospitalization. Conclusion: P-ADC is uncommon and often misdiagnosed due to unusual presentation mimicking infectious and inflammatory diseases2. It is unclear whether P-ADC represents an extreme form, later stage, or entirely different entity of lung cancer and large airspace consolidations are rarely reported3. Lesions of pneumonia type that extend beyond one lobe on CT are associated with microscopy involvement of both lungs and pathologic correlation shows that CT is unable to reveal multifocality in a high percentage of cases which makes the extend of multifocal consolidations in this case rarely described4-6. (Figure Presented).

13.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927763

ABSTRACT

Airway abnormalities may be due to a multitude of conditions. Symptoms do not occur until there is very significant narrowing, and therefore these conditions are often incidentally found. It is important to consider a broad differential.This case is a 47 year old woman with history of mild intermittent asthma and chronic sinusitis who presented to the emergency department with four weeks of malaise, shortness of breath, cough, and two days of hemoptysis. On CT imaging she was found to have tracheal wall thickening, calcifications and projections along the trachea, as well as extensive right upper and middle lobe, and lingular ground glass opacities as seen in figure 1. With hindsight, similar tracheal abnormalities were noted on chest x-ray in 2019. During admission, ENT was consulted and she was noted to have saddle nose deformity. Nasal biopsy was performed and revealed evidence of chronic inflammation, but no other abnormalities. Extensive workup was performed including rheumatologic workup with mildly positive ANA, mildly elevated ESR and CRP, negative ANCAs, MPO, PR3, RF. Bronchoscopy was pursued and direct visualization of nodules were noted along the anterior and lateral aspects of the trachea, as well as narrowing of the right upper lobe segmental bronchi, also seen in figure 1. Bronchoalveolar lavage cultures revealed Citrobacter freundii complex, Group G beta hemolytic streptococcus, Providencia rettgeri, Enterococcus avium, Pseudomonas aeruginosa, Klebsiella pneumoniae, in addition to rhinovirus and COVID-19. Biopsy was not performed due to patient intolerance of the procedure and desaturation. Ultimately, the pulmonary infiltrates were felt to be a separate process from the tracheal nodules. She improved clinically, and was discharged on antibiotic therapy with a plan for close outpatient follow up.Tracheobronchopathia osteochondroplastica (TO) is a rare condition. Imaging is often the first clue, as symptoms come late in disease course. The differential diagnosis of imaging findings consistent with TO include relapsing polychondritis, granulomatosis with polyangiitis, amyloidosis, along with a host of others. Diagnosis of TO often requires multidisciplinary involvement to evaluate other etiologies,and ultimately bronchoscopy for direct visualization. (Table Presented).

14.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927727

ABSTRACT

Introduction: Daptomycin is an antibiotic approved by FDA in 2003 with an excellent coverage for Gram positive cocci including methicillin resistant Staph. Aureus and vancomycin resistant Enterococci.Acute Eosinophilic Pneumonia(AEP) is a rare but potentially fatal complication of daptomycin is characterized by febrile illness, Hypoxemia,Diffuse Bilateral pulmonary infiltrates and BAL with >25% eosinophils. Case Report: 79 Y/O M with the CKD stage 4 and hypertension presented to the hospital with fever, dry cough and worsening shortness of breath after a recent hospital admission for MRSA bacteremia.Patient was admitted 1 week before presentation for symptoms of pyelonephritis and was found to have MRSA bacteremia for which he was discharged on IV daptomycin for 6 weeks. On admission,patient was febrile with hypoxic to 81%. Labs did show leukocytosis with mild peripheral eosinophilia.PCR for respiratory viruses including covid was negative.Chest X ray was done, which was consistent with multifocal Pneumonia which was followed by Chest CT scan which demonstrated new bilateral dense ground-glass and consolidative opacities.Given concerns for aspiration pneumonia, fungal infections or eosinophilic pneumonitis,pulmonology was consulted for possible bronchoscopy.Bronchoscopy with BAL was done the next day.BAL revealed a WBC of 260/μL with 45% eosinophilic predominance. Given the bronchoscopy results,his symptoms were attributed to Daptomycin related eosinophilic pneumonia.Patient was started on 40mg oral prednisone for a total of 4 weeks with rapid taper.Over the hospital course, his symptoms completely resolved. Discussion: The prosed mechanism involves presentation of drug or drug-hapten combination by the macrophages to the T helper cell results in interleukin-5 release which along with macrophage released eotaxin, results in eosinophilic migration to lungs.The criteria for to diagnose AEP due to daptomycin consist of 4 components which includes febrile illness,hypoxemia,diffuse bilateral pulmonary infiltrates and BAL with >25% eosinophils.Peripheral eosinophilia may not be present in all cases. It is also possible that daptomycin, a renally excreted drug, persists in the lungs of patients with renal dysfunction as seen in our patient and as such may lead to higher incidence of daptomycin induced AEP.In most cases, a short course of steroids(2-3 weeks)is sufficient for complete resolution of symptoms. Conclusion: Daptomycin induced AEP is increasingly seen in patients with high doses of drug and underlying renal dysfunction,and not related to therapy duration as it can occur as early as day 3 of treatment and as late as week 6 of treatment course. Bronchoscopy with BAL should be considered in all cases suspected. (Figure Presented).

15.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927726

ABSTRACT

Cocaine use has a significant public health impact, causing over 1.2 million ER visits annually. Cocaine can cause a wide range of pulmonary pathology, including diffuse alveolar hemorrhage (“Crack Lung”), barotrauma, bronchiectasis, granulomatous disease, and pulmonary vascular disease. Acute eosinophilic pneumonia (AEP) is a rare and potentially life-threatening complication of cocaine use that can be successfully treated if identified. We describe a case of persistent fevers, hypoxemia, and air space opacities due to AEP related to cocaine use.A 34-year-old male with a history of polysubstance abuse was found unresponsive, apneic, and surrounded by vomitus at a party, where he had smoked marijuana and cocaine and injected heroin. Upon hospital arrival, he was hypotensive and severely hypoxic and was intubated. He had severe rhabdomyolysis, lactic acidosis, acute kidney injury, and acute liver injury. His chest radiograph demonstrated diffuse bilateral alveolar infiltrates. COVID-19 was ruled out. Sputum cultures grew Klebsiella and E. Coli;Streptococcus Pneumoniae urine antigen was positive. He received IV fluids, vasopressors, and broad spectrum antibiotics for septic shock and aspiration pneumonia in the setting of drug overdose. His septic shock and hypoxemia improved, allowing tracheostomy and gastrostomy to be performed. Despite prolonged courses of antibiotics, he had persistent fevers, worsening infiltrates on chest radiograph, and persistent hypoxemia. CT imaging demonstrated diffuse, bilateral ground glass opacities and consolidations, with reticulation and interlobular septal thickening. Viral, bacterial, and fungal cultures collected via bronchoscopy were negative, however, cell count revealed 315 WBC / mm3, with 27% eosinophils. He was started on methylprednisolone 80mg IV every eight hours and had resolution of fevers and improvement in oxygenation and infiltrates. 1 month after discharge, he was decannulated and did not require supplemental oxygen. DiscussionThis case highlights an important aspect of assessing fever in the ICU despite broad spectrum antibiotics in patient with drug overdose. In the above , bronchoscopy unmasked an eosinophilic pneumonia allowing a rapid transition to trach collar and prevention of progression to pulmonary fibrosis. (Figure Presented).

16.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927725

ABSTRACT

Introduction: The known etiologies of acute eosinophilic pneumonia (AEP) have grown recently, culminating in the creation of the term drug-induced AEP 3. One of the newer causes of druginduced AEP is Daptomycin, which has grown in popularity for its use in treating methicillin-resistant staph aureus (MRSA) infections. As a result, the Food Drug Administration created the following criteria to diagnosis Daptomycin-induced AEP: 1) concurrent exposure to Daptomycin, 2) fever, 3) dyspnea with increased oxygen requirement or requiring mechanical ventilation, 4) new infiltrates on imaging, 5) bronchoalveolar lavage (BAL) with >25% eosinophils and 6) clinical improvement following Daptomycin withdrawal. Given this statement, we present a case of Daptomycin-induced AEP. Case Presentation: A 45-year old female presented to the ER with a complaint of shortness of breath for four days. She had recently been diagnosed with Covid-19 with concomitant globicatella bacteremia and discharged 17 days ago with home oxygen (requiring 3L) and to complete 2 weeks of IV Daptomycin. In the ER, a CT Angio Chest was obtained showing bilateral airspace opacities with no evidence of thromboembolism. She was also noted to be saturating at 92% while on 15L Venturi-mask. The patient was started on broad-spectrum antibiotics and cultures were obtained. Her condition worsened and a bronchoscopy with bronchoalveolar lavage (BAL) was performed, however there was inadequate specimen to run cytology. Due to worsening status despite antibiotics, the patient was started on methylprednisolone 80 mg three times a day. After initiation of steroids, the patient's respiratory status returned to baseline and repeat imaging showed improvements of opacities. Complete infectious and autoimmune workups were complete ruling out other etiologies. The patient was discharged with a steroid taper and repeat CT imaging ordered, but never done. Discussion: Though we were unable to obtain a BAL specimen, we are confident of our diagnosis. Our patient not only had a known inciting factor, but also had resolution of symptoms with withdrawal of Daptomycin and initiation of steroids. Our case study highlights two important points about the disease. First, AEP should be on the differential for patients with a complaint of shortness of breath with a known inciting factor. Secondly, it should be noted that while our patient was unable to meet all criteria created by the FDA, this should not rule out the diagnosis. It is important to be proactive in treatment if clinical suspicion is high.

17.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927722

ABSTRACT

Palbociclib, abemaciclib and ribociclib are cyclin-dependent kinase 4/6 (CDK 4/6) inhibitors used in the current treatment of HR-positive, HER2-negative metastatic breast cancer.1.2 As CDK 4/6 inhibitors are becoming more common it is important to be aware of some potentially fatal side effects. A 54-year-old woman with stage III breast cancer with prior mastectomy currently on hormonal and immunotherapy with anastrozole, ribociclib and goserelin presented with fever and shortness of breath. The patient became febrile with a negative COVID-19 test, and was treated for community acquired pneumonia. The fevers persisted despite antibiotics. CBC notable for leukopenia and uptrending absolute eosinophil count of 280 cells per microlitre. A chest CT scan revealed scattered, predominantly peripheral ground glass opacities in the bilateral upper, bilateral lower, and right middle lobes not present on prior imaging. A diagnostic bronchoscopy with BAL revealed 140 white-blood cells, 4 polys, 60 lymphocytes, 30 monocytes and 6 eosinophils. Flow cytometry yielded predominantly T-cells, abundant macrophages and inflammatory Infectious work up including PCP PCR, gram stain, fungal and AFB culture were negative. Ribociclib was discontinued and the patient improved symptomatically with return to baseline level of function. Reports of CDK 4/6 inhibitor drug-associated lung injury are limited There has been only one case report outside of clinical trials of Ribociclib pneumonitis.7 As these drugs become more commonly used, it is important for clinicians to be aware of this potentially fatal drug associated lung injury. Treatment with drug cessation has varying responses from recovery like in our patient to death.

18.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927720

ABSTRACT

Introduction Eosinophilic pneumonia is a class of lung diseases characterized by accumulation of eosinophils in the lung. Chronic eosinophilic pneumonia (CEP) is diagnosed through radiographic imaging and bronchoalveolar lavage (BAL) with elevated eosinophil count (>25%) in the setting of pulmonary symptoms for more than 2 weeks. While CEP is often an idiopathic disease, it may also be caused by medications, illicit substances, or infections. Identifying the trigger is imperative for successful treatment. A 71-year-old man presented with fever and chronic shortness of breath that started after COVID-19 infection (6 months prior to presentation). Medical history was also significant for multiple myeloma, asthma, hypertension, type 2 diabetes, coronary artery disease, chronic kidney disease, and Alzheimer's dementia. Current medications included bortezomib, pomalidomide, aspirin, clopidogrel , donepezil, tramadol and insulin. Lenalidomide was discontinued 3 months prior due to generalized skin rash and high peripheral eosinophilia (19%). On presentation, physical exam revealed mild respiratory distress, bibasilar crackles, and bilateral pedal edema. Long COVID Syndrome was suspected. He was started on antibiotics and diuretics with no improvement. Labs revealed mild peripheral eosinophilia. Chest X-ray showed diffuse bilateral reticular nodular opacities predominantly on the right. CT chest revealed reticulonodular infiltrates in both lungs predominantly in the right upper lobe with small pleural effusion. Bronchoscopy with BAL was negative for infection but revealed 28% eosinophils. Pomalidomide was discontinued and oral prednisone started. Discussion: CEP is part of a group of eosinophilic lung diseases characterized by abnormal accumulation of eosinophils in the lung tissue. Symptoms include dyspnea and cough in the majority of cases, but may also include fever, sinusitis, rhinitis, fatigue and weight loss. The radiographic hallmarks are bilateral alveolar infiltrates peripherally predominantly in the upper lobes and may be ground glass or consolidation. The presence of an elevated eosinophil count (>25%) in a BAL confirms the diagnosis. Though often idiopathic, identification of possible causes is important for proper management. In our case, the patient has multiple risk factors including possible Long COVID Syndrome and malignancy. Medications such as bortezomib, lenalinomide and pomalidomide have been known to cause diffuse lung injury. To the best of our knowledge there is one case report illustrating Lenalinomide related CEP. History of asthma is present in most cases of idiopathic CEP. Our patient had multiple potential triggers for CEP. We suspect that CEP was medication-related in this case. (Figure Presented).

19.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927702

ABSTRACT

Introduction: Acute interstitial pneumonia (AIP) also known as Hamman-Rich Syndrome is an uncommon, acute, and rapidly progressive idiopathic pulmonary disease that often leads to acute respiratory distress syndrome (ARDS). We present a case of a 52-year-old male who developed this condition. Case: A 52-year-old male with no past medical history presented to the emergency department with a 3-day history of progressively worsening dyspnea, dry cough, and chills. Prior to symptom onset, he was in his usual state of health but did report having polyarthralgia mainly involving large joints with no other associated symptoms. He denied a history of sick contacts including COVID exposure, sexually transmitted infections, incarceration, intravenous drug abuse, or travel to tuberculosis endemic countries. He denied tobacco use and any other form of illicit drug use. On physical examination, he was afebrile, tachycardic, and hypoxic on room air. He appeared to be in no respiratory distress and chest was clear to auscultation. There were no joint abnormalities, skin rashes, or lymphadenopathy. Lab workup revealed elevated D-Dimer (2140 ng/mL), CRP (50 mg/L), lactate dehydrogenase (296 IU/L), ferritin (578 ng/mL). His SARSCoV2 PCR was negative. Chest X-ray and CT chest both revealed right pleural effusion and diffuse reticular and ground-glass opacities. He underwent thoracentesis and fluid analysis revealed lymphocytic exudate with negative cultures. Antibiotics and steroids were initiated. He underwent a complete rheumatologic workup including myositis panel, due to concern for possible autoimmune etiologies and it was negative. His respiratory status worsened, and he eventually required intubation. At this point given unclear etiology, he underwent bronchoscopy with transbronchial cryobiopsy. Cryobiopsy revealed evidence of organizing phase of diffuse alveolar damage (Figure 1) and in the setting of negative cultures, COVID-19 and autoimmune panel, there was a growing concern for acute interstitial pneumonia. The patient was started on pulse dose of steroids and transferred to a transplant center for lung transplantation evaluation. Discussion: Acute interstitial pneumonia is a rare idiopathic clinicopathological condition that is characterized clinically by rapid onset of respiratory failure in patients with no past medical history of pre-existing lung disease. Histopathological findings are identical to those of diffuse alveolar damage. Closely resembling ARDS, it is frequently confused with other clinical entities characterized by rapidly progressive interstitial pneumonia. Considering this a high index of suspicion is required to diagnose these patients and institute appropriate management as mortality is as high as 70%. (Figure Presented).

20.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927701

ABSTRACT

INTRODUCTION: E-cigarette or vaping associated lung injury (EVALI) is an uncommon complication of e-cigarettes or vaping. 96% of these cases require hospitalization. The condition is especially associated with tetrahydrocannabinol (THC) products, frequent use, and is found primarily in young adults. “Dabbing” refers to the process of heating THC containing oils or waxes with butane solvents to vaporize cannabinoids for inhalation. CASE REPORT: An obese 20-year-old college male with a history of prematurity and anxiety presented with cough, dyspnea, nausea, vomiting and diarrhea that began 3 days prior. He reported smoking marijuana, but denied vaping. Multiple PCR tests for SARS-CoV-2 were negative. Initial chest radiograph demonstrated multifocal pneumonia. He was hypoxic on presentation requiring two liters of oxygen via nasal cannula. Broad spectrum antibiotics for pneumonia and steroids were initiated. Oxygen requirements rapidly increased and humidified high flow oxygen was instituted and escalated to 60 liters per minute and 90 % FiO2. He remained hypoxic, prompting intubation 48 hours from presentation. His ventilatory settings were steadily escalated to a positive end expiratory pressure of 15 cm H2O with 100% FiO2. Despite this, the patient had oxygenation saturations as low as 57% requiring transition to venovenous extracorporeal membrane oxygenation (VV-ECMO). Computed tomography angiography ruled out pulmonary embolism but redemonstrated extensive alveolar and interstitial infiltrates bilaterally. Bronchoscopy with alveolar lavage was performed with negative cultures and cytology. Blood cultures were also negative and antibiotic therapy was stopped. Extensive laboratory investigation for autoimmune vasculitis was performed and found to be negative. Discussion with family revealed that the patient regularly inhaled concentrated THC wax with butane as a solvent. Treatment continued with high dose intravenous steroids and supportive care. The patient received a total of 5 days of ventilator support after which he was extubated, and an additional 5 days of VV-ECMO. At discharge, the patient required 2 liters of continuous oxygen at rest and 4 liters with activity. He was otherwise asymptomatic and at his baseline level of function. He was discharged on daily steroids with taper and close outpatient follow up. DISCUSSION: While the majority of hospitalized patients with EVALI require intubation, the necessity of VV-ECMO utilization represents a rare severe presentation. Dabbing remains a rare cause of acute respiratory distress syndrome and EVALI, however, dabbing is emerging as a trend among young adults and represents an under-investigated cause of severe inhalational lung injury.

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