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1.
NeuroQuantology ; 20(10):7542-7549, 2022.
Article in English | EMBASE | ID: covidwho-2067317

ABSTRACT

Background: CT is based on the fundamental principle that the density of the tissue passed by the x-ray beam can be measured from the calculation of the attenuation coefficient. Using this principle, CT allows the reconstruction of the density of the body, by a two-dimensional section perpendicular to the axis of the acquisition systemThe role of chest CT imaging in the management of patients with COVID-19 has evolved since the onset of the pandemic. Specifically, the description of CT scan findings, use of chest CT imaging in various acute and subacute settings, and its usefulness in predicting chronic disease have been defined better.In April 2020, the Fleischner Society released a multinational expert consensus statement that offered guidance to physicians on the use of thoracic imaging in various health care environments. The Society of Thoracic Radiology, the American College of Radiology, and the Radiological Society of North America offered additional guidance for the use of both plain chest radiography and CT imaging for patients suspected to have COVID-19. The GGO often lacks a rounded configuration. These opacities may lack a peripheral distribution. An atypical appearance is uncommonly associated with COVID-19 pneumonia and is more indicative of an alternate diagnosis, including bacterial pneumonia with or without cavitation, and tree-in-bud branching centrilobular nodules. The indeterminate pattern is observed mainly in elderly patients and is the most challenging.

2.
Archives of Disease in Childhood ; 107(Supplement 2):A359-A360, 2022.
Article in English | EMBASE | ID: covidwho-2064045

ABSTRACT

Aims To describe a case of 3 weeks old neonate presenting with severe pulmonary hemorrhage due to COVID-19 infection and its outcome. Methods We report an interesting case of pulmonary hemorrhage presenting at a young age of 3 weeks, in a previously healthy neonate who was infected with COVID-19 virus;Literature review and investigation results are included. This is a 3-week-old female, a product of full-term pregnancy and an uneventful perinatal course. She was admitted from the emergency department initially as a case of late neonatal sepsis, where a full septic workup was done. Her presenting complaints were low-grade fever and a blocked nose for one day. She was hemodynamically stable in the emergency department except for tachycardia secondary to fever, which improved once the fever was controlled. Her initial blood workup, including blood gas and CSF study, was reassuring (table 1a). Her COVID PCR was positive with a CT value of 17.77. She was treated with IV antibiotics and supportive management. Later that day, the patient developed cardiopulmonary arrest, CPR was initiated, and the patient was intubated. The patient was found to have pulmonary hemorrhage as evident by the fresh blood coming out of the endotracheal tube and the chest X-Ray findings of ground-glass opacities and dense consolidation (figure 1). After initial brief stabilization, the patient started deteriorating requiring escalation of respiratory support to HFOV. The patient continued to deteriorate and developed bilateral pneumothorax requiring bilateral chest tube insertion. After chest tube insertion, there was a mild transient improvement in oxygenation. The patient was put on the maximum ventilatory settings, but she kept having frequent desaturation, requiring frequent manual bag to tube ventilation. Later, she started developing progressive hypotension, that required support with maximum doses of inotropes. Her urine output started decreasing, for which frusemide were started with no response. Blood investigations showed severe DIC picture (table 1b and 1c). She was empirically covered with Meropenem and Vancomycin along with Remdesivir and Dexamethasone for COVID 19 pneumonia. Eventually, the child developed progressive desaturation, hypotension, and poor perfusion. Shortly after that, she developed cardiac arrest and was declared dead. Results The clinical picture of COVID 19 infection is more indistinct in children than in adults, with the most common symptoms being fever, cough, dyspnea, and malaise. In the few published cases of COVID-19 in the neonate, the presentation was that of late neonatal sepsis;interestingly, the lung involvement was not described as frequently as in older age groups. Pulmonary hemorrhage has been reported in adults but rarely in children. Some reports in adults suggested that patients with COVID infection had an increased inflammatory state that led to the development of vasculitis and pulmonary hemorrhage. Up to our knowledge, this is the youngest age at which a patient with COVID-19 infection developed pulmonary hemorrhage with no other underlying cause of it. Conclusion While many of the cases of COVID infection in children are mild, fatal complications like pulmonary hemorrhage can be present. Adding new challenges to the management of this viral infection.

3.
Clinical Toxicology ; 60(Supplement 2):121, 2022.
Article in English | EMBASE | ID: covidwho-2062721

ABSTRACT

Background: Palytoxin poisoning is an uncommon exposure in the US, and is most frequently encountered amongst hobbiests and professionals in the aquarium industry. The toxin is produced by the microalgae Ostreopsis as well as the coral Palythoa toxica. Discovered in Hawaii, the name limu-make-o-Hana translates to "seaweed of death from Hana." Palytoxin interrupts Na+/ K+ ATPase pump, resulting in widespread cellular dysfunction. Persons are at highest risk when cleaning a fish tank housing the coral that produces palytoxin, resulting in cutaneous or inhalational exposure. We present a case of palytoxin inhalational exposure with computed tomography (CT) imaging. Case report: A 41-year-old male presented to the emergency department (ED) with dyspnea, cough, and wheezing after cleaning his saltwater fish tank. He reported that he maintains Zoanthid corals in his home saltwater fish tank and typically wears personal protective equipment when cleaning the tank. He had taken off his mask directly after using hot water to clean the tank, and quickly developed shortness of breath. He contacted Poison Control and was instructed to take loratadine with initial improvement in his symptoms. He then developed decreased appetite, nausea, and chills. The following day, in addition to these symptoms, he developed a fever of 102.5 degreeF and an oxygen saturation of 88% measured with an at-home pulse oximeter. He then proceeded to the ED where he was found to be hypoxic to 91% on room air, tachycardic to 120 bpm, hypotensive to 93/ 70mmHg, febrile to 100.9 degreeF and tachypneic at a respiratory rate of 30. Physical exam revealed clear lung sounds. Application of supplemental oxygen at 2 L resulted in improvement in his oxygen saturation and his hypotension and tachycardia responded to intravenous fluids. Significant laboratory results included WBC count of 20.4 with bands of 14%, elevated lactate of 2.4mmol/L, elevated D-dimer of 0.48 mug/mL and a negative COVID PCR test. CTA thorax revealed patchy ground-glass opacities in the bilateral upper and lower lobes with mosaicism. The patient received doxycycline in addition to broad spectrum antibiotics due to concern for inhalational marine toxicity. He was also started on 60mg prednisone, inhaled steroids, and bronchodilators for symptomatic treatment, with improvement in his symptoms. During his hospitalization, a respiratory viral panel was negative for common viruses associated with atypical pneumonia including influenza, coronavirus, metapneumovirus, rhinovirus, enterovirus, adenovirus, parainfluenza, bocavirus, Chlamydophila pneumoniae, and Mycoplasma pneumonia. His dyspnea gradually improved and he was weaned off supplemental oxygen prior to discharge home on hospital day 2. Discussion(s): It is unclear what changes are expected on thoracic imaging in patients with inhalational palytoxin exposure. Chest radiographs in two previous cases displayed scattered infiltrates, and a chest CT in another case showed pleural based consolidations. The ground-glass mosaicism suggests that a more diffuse reactive airway process after an inhalational palytoxin insult. Conclusion(s): Patients with inhalational palytoxin exposure may be found to have reactive airway symptoms along with ground glass opacities with mosaicism on CT imaging.

4.
Chest ; 162(4):A2571-A2572, 2022.
Article in English | EMBASE | ID: covidwho-2060966

ABSTRACT

SESSION TITLE: Pulmonary Issues in Transplantation Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: We describe two unvaccinated lung transplant recipients (LTRs) with mild COVID-19 and prolonged SARS-CoV-2 colonization who presented with recrudescence of symptoms due to superinfection. CASE PRESENTATION: Case 1: A 57-year-old LTR (August 2018) presented to the emergency room (ER) in July 2020 with headache, positive SARS-CoV-2 nasopharyngeal swab-PCR result, and elevated D-Dimer. He recovered at home and tested negative for SARS-CoV-2 on day 28. He presented to the ER again in October 2020 with chest pain. At this time, evaluation revealed a positive SARS-CoV-2 nasopharyngeal swab-PCR result, positive SARS-CoV-2 IgG (index 3.41), leukocytosis, and elevated inflammatory markers. Of note, nasopharyngeal swab was also positive for rhinovirus. Imaging showed new mild bibasilar ground-glass opacities. Patient was treated with remdesevir, convalescent plasma, and pulse corticosteroid. His SARS-CoV-2 PCR test was negative on day 3 of the remdesevir regimen;he remains clear of SARS-CoV-2 and rhinovirus to date, with complete clinical and radiologic recovery (Figure 1, Case 1). His immunosuppression was unchanged. Case 2: A 75-year-old LTR (July 2016) with pancytopenia presented for a sick visit in May 2020 with cough and fever. His SARS-CoV-2 nasal wash-PCR test was positive;imaging was unremarkable. He was sent home on pulse corticosteroid and levofloxacin. A week later in June 2020, he presented to the ER with worsening cough. At this time, evaluation revealed positive SARS-CoV-2 IgG (index 7.58), leucopenia, thrombocytopenia, elevated inflammatory markers, and new radiographic bibasilar ground-glass opacities (Figure 1, Case 2). His condition improved with intravenous antibiotics and corticosteroids. He consistently tested positive for SARS-CoV-2 in nasal wash samples for 3 months, with the first negative test in September 2020. He was hospitalized in January 2021 for neutropenic fever, P. Aeruginosa (PsA) infection in bronchoalveolar lavage (BAL), and anti-PsA antibodies in the serum. At this time, he also had SARS-CoV-2 colonization in BAL despite negative PCR results of nasal wash samples. His condition improved with 14 days of antibiotics. He was stable at his last follow-up. DISCUSSION: Both patients had an initial episode of mild COVID-19 pneumonitis, appropriate seroconversion, and prolonged viral colonization in the respiratory tract. Immunosuppression may have predisposed to rhinovirus and PsA superinfection in case 1 and 2, respectively. CONCLUSIONS: A high index of suspicion for superimposed infections in LTRs recovering from COVID-19 is warranted. Reference #1: 1. Hogan JI, Kotton CN. A Call for Caution in the Immunocompromised: Coronavirus Disease 2019 Associated With Mortality in a Vaccinated Lung Transplant Recipient. Open Forum Infect Dis. 2021 Nov 10;8(12):ofab557. DISCLOSURES: No relevant relationships by Hesham Abdelrazek No relevant relationships by Ashwini Arjuna No relevant relationships by Bhuvin Buddhdev No relevant relationships by Deepika Razia No relevant relationships by Rajat Walia, value=Honoraria Removed 04/04/2022 by Rajat Walia No relevant relationships by Rajat Walia, value=Honoraria Removed 04/04/2022 by Rajat Walia No relevant relationships by Rajat Walia, value=Honoraria Removed 04/04/2022 by Rajat Walia No relevant relationships by Rajat Walia, value=Honoraria Removed 04/04/2022 by Rajat Walia No relevant relationships by Rajat Walia, value=Honoraria Removed 04/04/2022 by Rajat Walia

5.
Chest ; 162(4):A2545-A2546, 2022.
Article in English | EMBASE | ID: covidwho-2060958

ABSTRACT

SESSION TITLE: Signs and Symptoms of Chest Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaping products have been rapidly gaining popularity, with studies showing increasing use, even among school-going children and adolescents. E-cigarette or Vaping Associated Lung Injury (EVALI) is defined as respiratory failure within 90 days of e-cigarette use with pulmonary infiltrates on imaging, in the absence of infectious or alternative causes of respiratory failure.[1] Vitamin E acetate, a thickening agent in THC containing e-cigarettes, is thought to be the main causative agent of EVALI and has been found in the bronchoalveolar lavage samples in almost all cases of EVALI.[2] However, diagnosing EVALI in this era of COVID -19 is a challenge due to striking similarities in clinical symptoms and imaging findings. CASE PRESENTATION: A 32-year-old male with anxiety and polysubstance abuse, presented with headache, cough, low-grade fevers and chills of 1 week. In the ED, he was febrile to 102 F and hypoxic to 89% on room air and was started on 3 liters of oxygen. Labs showed leukocytosis and elevated inflammatory markers. Urine toxicology was positive for THC. Chest X-ray showed bilateral interstitial opacities. CT angio of the chest showed bilateral ground glass opacities. Despite 2 negative PCR tests, suspicion for COVID was high and the patient was initially started on dexamethasone and other supplements, along with antibiotic coverage for a possible bacterial etiology. Despite this, respiratory symptoms and hypoxia continued to worsen. Infectious work up including blood, sputum cultures with AFB staining, urine streptococcus and legionella tested negative. The patient however now revealed the regular use of THC containing vape and procuring the THC oil from a new street vendor. This prompted us to suspect vaping induced chemical pneumonitis. He was restarted on steroid therapy with methylprednisolone and within 1 week, had symptomatic improvement and resolution of hypoxia. The patient was eventually discharged on prednisone taper over 7-10 days. DISCUSSION: Our patient was initially treated for COVID pneumonia despite repeated negative PCR tests, as findings were suggestive of SARS-COV-2 infection. Fortunately, the patient eventually revealed about regular use of THC-oil vapes, making us consider a diagnosis of vaping induced chemical pneumonitis. The mainstay of treatment is steroid therapy and cessation of e-cigarette use. The severity of the pandemic has led to a low threshold for suspecting COVID, causing increased anchoring and availability bias, and potentially under-diagnosing conditions like EVALI which resemble COVID infection.[3] CONCLUSIONS: While it is important to have a low threshold for suspecting COVID-19, considering other mimics of COVID is prudent for providing treatment in an appropriate and timely manner. Detailed inquiry of e-cigarette use, particularly THC-oil containing vapes, duration of use and source of procurement, goes a long way in diagnosing of EVALI. Reference #1: EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review Lydia Winnicka, MD and Mangalore Amith Shenoy, MD PMCID: PMC7351931 PMID: 32246394 Reference #2: Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study Denitza P Blagev 1, Dixie Harris 2, Angela C Dunn 3, David W Guidry 2, Colin K Grissom 4, Michael J Lanspa 5 PMID: 31711629 DOI: 10.1016/S0140-6736(19)32679-0 Reference #3: EVALI: A Mimicker of COVID-19 Mitchell M. Pitlick, MD,a Daenielle K. Lang, MD,a Anne M. Meehan, MBBCh, PhD,b and Christopher P. McCoy, MDb, PMCID: PMC8006188 PMID: 33817560 DISCLOSURES: No relevant relationships by Kaushik Darbha No relevant relationships by Rashmikant Doshi No relevant relationships by Ishan Sahu No relevant relationships by sara samad

6.
Chest ; 162(4):A2486, 2022.
Article in English | EMBASE | ID: covidwho-2060952

ABSTRACT

SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Post COVID pulmonary complications can be attributed to severe inflammatory response that can result in pulmonary fibrosis. It is somewhat predictable in patients with severe illness, advanced age and comorbidities. However, a little is known about pulmonary complications in younger patients with mild illness followed up at outpatient clinics. We aim to shed light on post COVID pulmonary complications in patients who did not require hospitalization but had significant outpatient visits. METHODS: This study is based upon a retrospective chart review of patients who presented to Pulmonology Clinic at Cayuga Medical Associates with respiratory symptoms associated with COVID-19 disease. Mild illness was defined as symptoms of dyspnea on exertion or fatigue or shortness of breath that have not required oxygen and lasted for less than or equal to two months. Moderate illness was defined as symptoms of mild illness lasting for more than two months without oxygen supplementation. Severe illness was defined as hypoxia requiring home oxygen. We have excluded the patients who were hospitalized for COVID pneumonia. RESULTS: Of 23 patients (56.52% female) with COVID illness seen at Pulmonology Clinic in one-year duration, 13.04% had COPD, 26.09% had asthma and 21.74% had OSA. Median age was 33 with mean BMI 27.61.13.04% were current smokers. 39.13% required a PFT among which 77.78% had normal results. 21.74% of the total patients who never had OSA as an underlying diagnosis, required sleep study, among which 60% had mild OSA and 20% had severe OSA. 13.04% were already on oral steroids for other diseases. Majority of the patients had normal chest x-ray findings. 39.13% had CT chest, majority of which showed normal findings and few with diffuse ground glass opacities. 8.70% developed palpitations along with respiratory symptoms. At six months follow up, 43.48% had mild illness who were managed with conservative management such as incentive spirometry, deep breathing techniques, prone positioning and as needed short acting bronchodilator treatments. 43.48% had moderate illness who were treated with short course of oral steroids in addition to conservative management. 13.04% had severe illness who required home oxygen up to 2 L for two months maximum. Most common pulmonary complaint was dyspnea on exertion, seen in 43.48%. 17.39% had fatigue. 21.74% had sleep apnea symptoms. Median duration of symptoms was two months. CONCLUSIONS: Our study outlines the incidence of post COVID pulmonary complications in patient group where these complications are least expected. CLINICAL IMPLICATIONS: Post COVID pulmonary complications appear to be of significant concern in patients visiting outpatient clinics. The heterogeneity in management of those complications needs a serious attention. The feasibility and implementation strategy of post COVID-19-care-clinic with proper management guidelines should be brought to streamline practice. DISCLOSURES: No relevant relationships by Sameer Acharya No relevant relationships by Ali AKRAM No relevant relationships by Samjhauta Bhattarai No relevant relationships by Lavanya Kodali

7.
Chest ; 162(4):A2443, 2022.
Article in English | EMBASE | ID: covidwho-2060944

ABSTRACT

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Point of care ultrasound used by the provider is rapidly expanding in internal medicine. Thrombus in transit (TIT) is defined on ultrasound as mobile echogenic material temporarily present in the right heart chambers to the pulmonary circulation via the tricuspid valve or systemic circulation via an atrial septal defect. In this case, we were able to identify echogenic material traversing the tricuspid valve into the pulmonary circulation, which confirmed the diagnosis of pulmonary embolus [1] CASE PRESENTATION: This is a 71-year-old female with a history of hypertension who presented to the emergency room with 4-day pleuritic chest pain, productive cough, fever, and exertional dyspnea. She was hemodynamically stable, afebrile, tachycardic, and tachypneic. Initial diagnostic workup demonstrated elevated cardiac enzymes and creatinine, ground-glass opacities on chest CT, positive COVID PCR, and sinus tachycardia with nonspecific T wave abnormalities. Given her renal insufficiency, CTA was initially held off. The patient was found to have right lower extremity deep venous thrombosis, and a heparin infusion was started while waiting for a V/Q scan. Shortly after admission, she had a syncopal episode after using the bathroom. CPR was initiated for suspected cardiac arrest, and a bedside ultrasound demonstrated a sizeable mobile thrombus in the right atrium traversing the tricuspid valve into the right ventricle. Given this finding, we elected to move forward with CTA chest, and this study confirmed extensive bilateral PE with right heart strain. DISCUSSION: TIT is a rare emergency in PE (4%) with a staggering mortality rate twice as high as PE without TIT [2]. The gold standard for diagnosis of PE is CT angiogram, and early echocardiography is a cornerstone in diagnosis and risk stratification. However, patients similar to the one discussed in this care may present with conditions preventing timely utilization of these tools. POCUS allows for the rapid assessment and implementation of time-sensitive treatments. Historically, it has been a must-have skill set among ER and critical care physicians. Only 35% of internal medicine residency programs have fully integrated formal diagnostic POCUS within the past decade despite increasing interest among trainees. The expeditious medical decision made for our patient was possible following a focused echocardiogram performed by an internal medicine resident. In patients with massive PE, only 35% of echocardiograms obtained within 24 hours were done in the ER, and still, 1 in 6 happened after 6 hours [3]. CONCLUSIONS: As with any operator-dependent skill, proficiency in POCUS is a prerequisite for reliable findings and time-sensitive medical decision-making. POCUS only becomes a lifesaving tool in experienced hands. Hence, it is imperative that internal medicine residency programs consider this tool an essential component of resident training. Reference #1: Arboine-Aguirre L, Figueroa-Calderón E, Ramírez-Rivera A, et al. Thrombus in transit and submassive pulmonary thromboembolism successfully treated with tenecteplase. Gac Med Mex. 2017;153(1):129–33. Reference #2: Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. doi:10.1016/s0002-9149(97)00162-8 Reference #3: Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. doi:10.1016/s0735-1097(03)00479-0 DISCLOSURES: No relevant relationships by Varinder Bansro No relevant relationships by Olayiwola Bolaji No relevant relationships by clarence findley No relevant relationships by Faizal Ouedraogo

8.
Chest ; 162(4):A2300, 2022.
Article in English | EMBASE | ID: covidwho-2060934

ABSTRACT

SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Covid 19 virus has impacted nearly 450 million people across the globe;ranging from an asymptomatic carrier state to respiratory symptoms, cardiovascular symptoms, hematologic manifestations and multiorgan failure to death. Thrombotic events are one of its devastating complications. CASE PRESENTATION: A 66 year old man with a history of diabetes mellitus, hypertension and 30 pack years smoking history presented to the emergency room with hypoxia and altered mental status. On exam, his GCS was 8/15 and oxygen saturation was 85% on room air. He was subsequently intubated. CTA chest demonstrated bilateral diffuse ground glass opacities and left pulmonary embolism (PE). CT abdomen and pelvis showed multifocal infarcts in the right kidney with findings suggestive of renal artery thrombosis. Initial platelet count was 80,000/ul with creatinine of 3.9 mg/dl and creatine kinase (CK) of 3977 u/l. His INR was 1.4. Patient was not a candidate for thrombolysis given his thrombocytopenia. He was started on intravenous (IV) heparin and given IV hydration. On day 3 of his admission, he developed dry gangrene of the toes. Ankle brachial index of the right lower extremity (LE) was 1.16 and left LE was 0. Duplex ultrasonography of left LE showed mid to distal popliteal artery thrombus occluding below knee popliteal and tibial arteries. Echocardiogram showed ejection fraction of 55% and bubble study was negative for any intra atrial or pulmonary shunting. On day 4 of his admission, he developed oliguria and his gangrene got worse. His platelet counts decreased to 36,000/ul. Other pertinent labs showed INR 1.2, PT 15.3, PTT 34, D dimer 14.82, fibrinogen 498, CK 6434 mg/dl, hemoglobin 13.2 g/dl, haptoglobin 243 mg/dl and LDH 1041 U/l. Given his poor prognosis in the setting of ventilator dependent respiratory failure, multiple thrombosis and kidney failure requiring hemodialysis, the family decided to withdraw care. DISCUSSION: There are multiple hypotheses of thrombus formation in Covid 19 infection such as interleukin 6 and other cytokines induced endothelial injury, angiogenesis and elevated prothrombotic factors such as factor VIII and fibrinogen. Our patient had PE, renal artery thrombosis and popliteal artery thrombosis. Despite being on full dose anticoagulation, he developed gangrene of the toes. His lab results were not consistent with disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and he was not known to have any baseline hypercoagulable disorder. He did not have any intra cardiac shunts. Hence, it is most likely Covid 19 induced multiple arterial and venous thrombosis. CONCLUSIONS: The treatment of Covid 19 related thrombosis has become very challenging especially in the setting of multiple clots. It is crucial to have large multicenter studies to investigate vascular complications of Covid-19 and to formulate management strategies to ensure good patient outcomes. Reference #1: https://www.nejm.org/doi/full/10.1056/nejmoa2015432 Reference #2: https://journal.chestnet.org/article/S0012-3692(21)01126-0/fulltext DISCLOSURES: No relevant relationships by Devashish Desai No relevant relationships by Swe Swe Hlaing no disclosure on file for Jean Marie Koka;No relevant relationships by Hui Chong Lau No relevant relationships by Subha Saeed No relevant relationships by Anupam Sharma No relevant relationships by Muhammad Moiz Tahir

9.
Chest ; 162(4):A2258, 2022.
Article in English | EMBASE | ID: covidwho-2060923

ABSTRACT

SESSION TITLE: Autoimmune Diseases Gone Wild: Rare Cases of Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Immunoglobulin G4-related disease (IgG4-RD) is a complex entity related to autoimmune dysfunction and inflammation that can cause mass-like lesions and fibrosis of a variety of organs, including pancreas and/or lungs. IgG4-RD in the lung can have diverse clinical and radiographic presentations. We present a case of suspected IgG4-RD that manifested as idiopathic pancreatitis and interstitial lung disease that mimicked coal workers' pneumoconiosis. CASE PRESENTATION: A 72 year-old male with a decades-long coal mining history and a presumptive diagnosis of coal-worker's pneumoconiosis was admitted to the hospital for necrotizing pancreatitis. There was no evidence of gallstones, elevated triglycerides, history of alcohol use or medication known to precipitate pancreatitis. Two years prior, a presumptive diagnosis of coal-worker's pneumoconiosis had been reached largely on the basis of history and chest imaging (Figure 1) showing a progressive massive pulmonary fibrosis pattern. His hospital course was protracted and complicated by nosocomial COVID-19 treated with remdesivir and a 10-day course of dexamethasone. He then had persistent hypoxemia that worsened after dexamethasone was discontinued. Empiric high-dose methylprednisolone was given and the hypoxemia improved dramatically. However, the hypoxemia and pancreatitis repeatedly worsened with significant dose decrease. Inpatient CT chest showed worsening interstitial reticulation and ground-glass opacities superimposed on prior fibrosis (Figure 2). Serum IgG subclass levels were checked;IgG4 and IgG4:IgG ratio were mildly elevated at 93mg/dL and 0.09, respectively. In the setting of idiopathic pancreatitis, pulmonary fibrosis, and steroid-sensitive hypoxemia, he was diagnosed with probable IgG4-RD involving pancreas and lungs. An association between inhaled occupational exposures and development of IgG4-RD has been observed. To confirm the diagnosis of pulmonary IgG4-RD, a tissue biopsy will be necessary. He is now discharged from hospital on a long steroid taper. DISCUSSION: A serum IgG4 level >125mg/dL or an IgG4:total IgG ratio >0.08 support the diagnosis, as does clinical response to steroids. However, these criteria are nonspecific and will be in the normal range in a substantial minority of cases. Lymphocytes and a predominance of IgG4-positive plasma cells infiltrating fibrotic tissue in involved organs are pathologic hallmarks of IgG4-RD. Lung involvement in patients with pancreatitis due to IgG4-RD is common and likely under recognized. CONCLUSIONS: Pulmonary involvement in IgG4-RD can show a wide array of radiographic patterns, but that seen in this case with pseudotumor and fibrosis is among the most commonly reported. Given the overlap in risk factors and radiographic appearance between IgG4-RD and pneumoconiosis, vigilance for IgG4-RD is warranted. Reference #1: Hirano K., Kawabe T., Komatsu Y., et al. High-rate pulmonary involvement in autoimmune pancreatitis. Internal Medicine Journal. 2006;36(1):58–61. doi: 10.1111/j.1445-5994.2006.01009.x Reference #2: Kamisawa T, Zen Y, Pillai S, Stone JH. IgG4-related disease. Lancet. 2015 Apr 11;385(9976):1460-71. doi: 10.1016/S0140-6736(14)60720-0. Epub 2014 Dec 4. PMID: 25481618. Reference #3: de Buy Wenniger, L. J., Culver, E. L., & Beuers, U. (2014). Exposure to occupational antigens might predispose to IgG4-related disease. Hepatology (Baltimore, Md.), 60(4), 1453–1454. https://doi.org/10.1002/hep.26999 DISCLOSURES: No relevant relationships by Jordan Minish, source=Web Response No relevant relationships by Robert Ousley, source=Web Response No relevant relationships by Meagan Reif, source=Web Response No relevant relationships by Derek Russell, source=Web Response

10.
Chest ; 162(4):A2245, 2022.
Article in English | EMBASE | ID: covidwho-2060918

ABSTRACT

SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rapidly progressive interstitial lung disease (RP-ILD) is a rare and potentially fatal manifestation of dermatomyositis (DM) and has considerable impact in terms of the prognosis. CASE PRESENTATION: A 52-year-old male demonstrated DM-typical rash, fever, mialgias, and mild muscle weakness 3 months after asymptomatic COVID-19 infection. Two weeks later dysphonia and progressive dyspnea appeared. Lung CT scan showed the picture of organizing pneumonia. His COVID-19 PCR test was negative multiple times. Laboratory tests revealed the following numbers: ALT 210 IU/L, AST 748 IU/L, LDH 613 IU/L, CPK 1165 IU/L, ferritin 1145ϻg/l, CRB 11 mg/l. The patient was tested positive for anti-Ro52 antibodies, while anti-synthetase and scleroderma-associated antibodies were not discovered. Anti-melanoma differentiation-associated gene 5 (MDA5) test was not available due to the lack of the necessary test systems in the country. The patient was diagnosed with DM. Combined immunosuppressive therapy was administered, including: oral prednisolone 60 mg per day and 720 mg intravenously, dexamethasone 64-24 mg intravenously per diem, ciclosporin 200 mg и cyclophosphamide 600 mg, and 3 plasmapheresis sessions followed by an intravenous immunoglobulin. As a result of the therapy, muscle weakness disappeared and CPK levels returned to normal limits, however dyspnea progressed and ferritin levels hit 3500ϻg/l. After the following 3 weeks of intensive combined immunosuppressive therapy, the patient demonstrated symptoms of severe respiratory failure (RF). CT scan showed multiple traction bronchiectasis, wide areas of ground glass opacity, pneumomediastinum and subcutaneous emphysema of a neck and supraclavicular regions. Ciclosporin was replaced with tofacitinib with the dose of 10 mg per diem, IL-6 inhibitor (olokizumab 256 mg) was injected intravenously, massive broad-spectrum antibiotic therapy was administered. RF progressed and the patient was put on mechanical ventilation. The patient died of acute RF and sepsis a week later. DISCUSSION: RP-ILD is a common manifestation of severe MDA5+ DM, which is also associated with necrotizing vasculitis and amyopathic/hypomyopathic muscle involvement. In this case acute ILD in a patient with typical DM could also have been provoked by previous COVID-19 infection. CONCLUSIONS: The courses of disease for COVID-19 and MDA5+ DM have several similarities, which means it can be the same for their pathogenesis and clinical manifestations. In spite of early screening and intensive immunosuppressive therapy in such cases, the prognosis of patients with DM and RP-ILD is still poor and is associated with high mortality. Reference #1: Wang G, Wang Q, Wang Y, et al. Presence of Anti-MDA5 Antibody and Its Value for the Clinical Assessment in Patients With COVID-19: A Retrospective Cohort Study. Front Immunol. 2021 Dec 20;12:791348. doi: 10.3389/fimmu.2021.791348. PMID: 34987516;PMCID: PMC8720853. DISCLOSURES: No relevant relationships by Lidia Ananyeva No relevant relationships by Maria Aristova No relevant relationships by Liudmila Garzanova No relevant relationships by Anna Khelkovskaya-Sergeeva No relevant relationships by Dmitry Kulikovsky

11.
Chest ; 162(4):A2237, 2022.
Article in English | EMBASE | ID: covidwho-2060915

ABSTRACT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: ANCA-associated vasculitis (AAV) is a systemic disease that causes inflammation of small vessels in various organs, such as the lungs, kidneys, and nervous system. We report a case of AAV following SARS-CoV-2 infection. CASE PRESENTATION: A 64-year-old female from Albania with no known medical history, presented with intermittent low-grade hemoptysis and fever for 1 week prior to admission. She had chills, myalgias, fatigue, and poor appetite 6 weeks prior. On arrival, she was febrile (101F), and hypoxic (Spo2 92% on 3L O2). Labs were significant for anemia [Hb 6.8 g/dl], acute kidney injury (AKI) [Cr 2.5 mg/dl]. She was found to be Positive for Sars-CoV-2 by PCR. Chest X-Ray showed patchy bilateral airspace opacities with peripheral and lower lobe predominance, concerning for atypical pneumonia (Fig 1). Urinalysis was significant for proteinuria (2+) and hematuria (2+). CT (Computed Tomography) thorax showed extensive bilateral airspace disease (dense consolidations and ground-glass opacities) favoring multifocal infection and mediastinal lymphadenopathy(Fig 2). Due to the chronicity of her symptoms and atypical imaging for viral pneumonia, other diagnoses were explored including bacterial superinfection, Tuberculosis, and autoimmune disease. Sputum studies were negative for infections including Acid Fast Bacilli. Workup revealed elevated Antimyeloperoxidase antibodies (MPO) and positive COVID-19 Ig G. She was started on methylprednisolone 1g for AAV. Renal biopsy revealed pauci-immune glomerulonephritis with features of cellular crescent consistent with microscopic polyangiitis (Fig 3). Follow-up CT chest showed improved airspace abnormalities and mediastinal lymphadenopathy. After induction therapy with Rituximab was initiated, she continued to recover and was discharged home. DISCUSSION: The pathogenesis of AAV is believed to be an aberrant pathogenic autoimmune response that follows an initial insult which can include infections. SARS-CoV-2 has been associated with the emergence of autoimmune diseases in susceptible patients(1). The proposed mechanism is linked to elevated levels of circulating neutrophil extracellular traps (NETs) observed in covid infection. These NETS are covered with proteins including neutrophilic enzymes which can activate complement pathways causing tissue destruction and vasculitis. The diagnosis of new-onset AAV can be challenging in COVID-19 patients as symptoms and clinical manifestations of both diseases can overlap. AAV should be considered strongly in patients who are currently infected or have been infected with SARS-CoV-2 and present with atypical or non-resolving pneumonia and other organ involvement such as AKI to avoid permanent organ damage. CONCLUSIONS: The presence of non-resolving or atypical pneumonia and AKI in a patient with SARS-CoV-2 should prompt evaluation of immunological markers to assess or rule out AAV for early diagnosis and treatment. Reference #1: Caso F, Costa L, Ruscitti P, Navarini L, Del Puente A, Giacomelli R, Scarpa R. Could Sars-coronavirus-2 trigger autoimmune and/or autoinflammatory mechanisms in genetically predisposed subjects? Autoimmun Rev. 2020;19(5):102524. doi: 10.1016/j.autrev.2020.102524 DISCLOSURES: No relevant relationships by Tarik Al-Bermani No relevant relationships by Anant Jain No relevant relationships by Ian Kaplan No relevant relationships by Alina Kifayat No relevant relationships by Lisa Paul

12.
Chest ; 162(4):A2224, 2022.
Article in English | EMBASE | ID: covidwho-2060913

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Epiglottitis is an inflammation of the epiglottis which can be life-threatening in the absence of prompt intervention. Although primarily a pediatric condition, streptococcus pneumonia has been identified as a common pathogen in adults. SARS-CoV 2 has been known to affect a multitude of systems including the upper respiratory tract, but rarely the epiglottis. CASE PRESENTATION: A 66-year-old female with a past history of hypertension, and hypothyroidism presented with acute onset pharyngodynia and dysphagia with a feeling of throat closing up due to swelling and difficulty speaking. She had a recent COVID-19 diagnosis and was doing well except for mild fatigue. Upon presentation, she was hemodynamically stable. Physical exam revealed posterior pharyngeal edema without any exudate, mildly edematous uvula, and no stridor. Laboratory data was pristine except for elevated inflammatory markers. Rapid streptococcal test and MRSA swab were negative. Sputum culture showed usual respiratory flora and blood cultures were negative. A neck CT showed diffuse edema without any evidence of abscess. Laryngoscopy performed by the ENT surgeon revealed diffuse edema including epiglottitis. Emergent intubation revealed supra and epiglottis edema sparing the vocal cords. The patient was given Decadron and Benadryl to help with the edema along with clindamycin and subsequently transferred to ICU for further care. She was treated with Ceftriaxone for 7 days due to a chest X-ray finding of pneumonia. As for COVID 19 treatment, she received a course of Remdesivir and Decadron. Decadron was given at an increased interval to reduce edema around the epiglottis. Her ICU course was complicated with hypotension requiring intermittent vasopressor support, and acute kidney injury from ischemic acute tubular necrosis which slowly improved. Repeat CT chest showed bibasilar consolidations with peripheral ground-glass opacities. In view of hospital-acquired pneumonia, she was started on Ertapenem. Her clinical condition improved and she was successfully extubated. She was shifted to the floors from where she was discharged without any further complications. DISCUSSION: There are only two other reported cases of COVID 19 epiglottitis. The patient's advanced age and obesity were non-modifiable risk factors, but the COVID-19 infection played a role. The virus can lead to excessive upregulation of the host inflammatory response through repeat epithelial and endothelial damage leading to a cytokine storm, which may be responsible for this presentation. A great level of attention is to be maintained while attending to these patients given the multitude of systems that can be affected. CONCLUSIONS: COVID-19 is a potential cause of life-threatening acute epiglottitis. Early suspicion and direct visualization of the epiglottis is the key to success for early management. Reference #1: Emberey J, Velala SS, Marshall B, et al. Acute Epiglottitis Due to COVID-19 Infection. Eur J Case Rep Intern Med. 2021;8(3):002280. Published 2021 Mar 3. doi:10.12890/2021_002280 Reference #2: Smith C, Mobarakai O, Sahra S, Twito J, Mobarakai N. Case report: Epiglottitis in the setting of COVID-19. IDCases. 2021;24:e01116. doi: 10.1016/j.idcr.2021.e01116. Epub 2021 Apr 7. PMID: 33842206;PMCID: PMC8025537. DISCLOSURES: No relevant relationships by Arunava Saha

13.
Chest ; 162(4):A2203, 2022.
Article in English | EMBASE | ID: covidwho-2060911

ABSTRACT

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatous polyangiitis (GPA), previously known as Wegener's granulomatosis, is a rare syndrome characterized by inflammation of small and medium sized vessels. The clinical presentation can be very heterogenous and differentiation from an infectious disease can be challenging initially. Here, we present a case of a young male presenting with respiratory symptoms during the pandemic, presumed to have coronavirus disease 2019 (COVID-19) though after extensive workup was later diagnosed with GPA. CASE PRESENTATION: A 19-year-old male presented to the emergency department (ED) with complaints of low-grade fever and dry cough for one week. He reported having abdominal pain, fatigue, loss of appetite and polyarthralgia. An outpatient upper gastrointestinal endoscopy revealed gastritis and duodenitis. In the ED, his vitals included a temperature of 101.8°F, blood pressure of 115/65mmHg, heart rate of 99/min, respiratory rate of 18/minute and oxygen saturation of 99% on room air. COVID-19 testing was negative. A computerized tomography of the chest revealed extensive ground glass opacities. He was presumptively diagnosed with COVID-19 and started on dexamethasone therapy along with azithromycin for atypical pneumonia. However multiple tests for SARS-CoV-2 were negative. Another consideration was COVID-19 induced multisystem inflammatory syndrome given the patients young age. Infectious workup included negative testing for human immunodeficiency virus, Legionella, tick borne diseases and mycoplasma. As febrile episodes continued, he developed microcytic anemia, microscopic hematuria, and petechial rash on his ankles. Antinuclear antigen screen was negative, but C-antineutrophil cytoplasmic and anti-proteinase-3 antibodies were positive. Renal biopsy revealed GPA. He was prescribed pulse dose steroids and transitioned to immunotherapy. DISCUSSION: GPA is a challenging diagnosis given multiple system involvement, though early identification and initiation of treatment are important to prevent long term sequalae. In our case, acute onset febrile illness and pulmonary ground glass opacities led to repeated COVID-19 testing potentially delaying the diagnosis. Ultimately, the correct diagnosis was made and confirmed on renal biopsy. We believe our case highlight the importance of keeping a broad differential and considering vasculitis in these situations for prompt diagnosis. CONCLUSIONS: GPA can often mimic respiratory infectious processes, a high index of suspicion is necessary for timely diagnosis. Reference #1: Selvaraj V, Moustafa A, Dapaah-Afriyie K, et alCOVID-19-induced granulomatosis with polyangiitis. BMJ Case Reports CP 2021;14:e242142 Reference #2: Qurratulain, Q., Ahmed, A., & Jones, Q. (2021). Lesson of the month: Severe granulomatosis with polyangiitis (GPA): a diagnostic challenge during the COVID-19 pandemic. Clinical Medicine, 21(1), 79. DISCLOSURES: No relevant relationships by Aamna Khan No relevant relationships by Usama Sadiq No relevant relationships by Rehan Saeed

14.
Chest ; 162(4):A2195, 2022.
Article in English | EMBASE | ID: covidwho-2060910

ABSTRACT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Both COVID-19 infection and sarcoidosis have been associated with long-term systemic complications with current research attempting to link these two diseases based on inflammatory properties. This case presents a patient with previously biopsy proven asymptomatic sarcoidosis who progressed to symptomatic sarcoidosis following severe COVID-19 infection. CASE PRESENTATION: A 58-year-old previously active female with known asymptomatic, biopsy proven pulmonary sarcoidosis presented to hospital in February 2021 with severe COVID-19 pneumonia requiring treatment with Decadron and Remdesivir. She was discharged home on room air but continued to have fatigue, shortness of breath, wheezing and coughing. Due to persistent respiratory symptoms and new onset vomiting with anorexia, she sought evaluation in the emergency department in July 2021. She was febrile with blood work significant for leukopenia and thrombocytopenia. She was found to have Anaplasmosis and despite adequate treatment continued to have persistent hypoxia with oxygen saturation of 82%. CT chest showed new areas of bilateral upper lobe predominant ground glass opacities and ill-defined soft tissue density in the subcarinal region. She was started on inhalers and underwent bronchoscopy with negative infectious disease work-up. She was discharged home on both inhalers and oral prednisone. Upon subsequent follow-up with pulmonology, she reported significant improvement in respiratory symptoms. Repeat CT chest after two of months of oral prednisone showed near resolution of all previous findings. After three of months of steroids, she began a prolonged steroid taper of one month. She reported absence of respiratory symptoms off of steroids. DISCUSSION: Current research is focusing on patients at greater risk of developing symptomatic sarcoidosis due to Th17 cells and the specific cytokines these cells produce. Several case reports suggest correlation between the inflammatory cascade induced by sarcoidosis and COVID-19 infection. One such case report suggests that COVID-19 infection can be a trigger for developing symptomatic pulmonary sarcoidosis. Our patient would be the first reported case of biopsy proven previously asymptomatic sarcoidosis developing into symptomatic sarcoidosis following severe COVID-19 infection. CONCLUSIONS: Therefore, COVID-19 infection may not only predispose individuals to developing pulmonary sarcoid but may also contribute to the progression of once asymptomatic sarcoid to symptomatic sarcoid. Reference #1: Capaccione, K. M., McGroder, C., Garcia, C. K., Fedyna S., Sagi, A., & Salvatore, M. M. (2022). Covid-19-induced pulmonary sarcoid: A case report and review of the literature. Clinical Imaging, 83, 152-158. https://doi.org/10.1016/j.clinimag.2021.12.021 Reference #2: Chen, Edward S. "Reassessing Th1 versus Th17.1 in Sarcoidosis: New Tricks for Old Dogma.” The European Respiratory Journal, vol. 51, no. 3, 2018, p. 1800010. Reference #3: Xu, Zhe, et al. "Pathological Findings of COVID-19 Associated with Acute Respiratory Distress Syndrome.” The Lancet Respiratory Medicine, vol. 8, no. 4, 2020, pp. 420–422. DISCLOSURES: No relevant relationships by Skylar Hartmann No relevant relationships by Jessica Wiseman

15.
Chest ; 162(4):A2190, 2022.
Article in English | EMBASE | ID: covidwho-2060909

ABSTRACT

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: Eosinophilia is the most commonly reported adverse event following administration of the Pfizer/BioNTech vaccine, accounting for 237 of 372 events (63.7%). Eosinophilic pneumonia has been described noted in 3 of all reported cases. CASE PRESENTATION: We present the case of a 73 year-old male presented to his PCP with a 3 week history of nonproductive cough and wheezing. He completed a 2-shot series of BNT162b2 mRNA (Pfizer/BioNTech) COVID vaccine 1 week prior to symptom onset. He had no history of respiratory symptoms, smoking, sick contacts, recent travel, chemical or biological exposures. On presentation, he was afebrile, tachycardic and required 3LPM supplemental oxygen to maintain peripheral oxygen saturation (SpO2) above 94%. Laboratory findings noted leukocytosis (13,200/mL) and eosinophilia at 5% (Absolute Eosinophil Count (AEC): 580 cells/L). Respiratory viral panel, procalcitonin, ESR and D-dimer were negative. Chest CT scan was unremarkable. He was treated with azithromycin, prednisone and inhaled bronchodilators with improvement in hypoxia. 2 weeks later, he reported intermittent dyspnea during a pulmonary clinic visit. Pulmonary function testing was normal (FEV1/FVC: 76%;FVC: 3.67L (90% predicted);FEV1: 2.80L (88% predicted). IgE level was normal and eosinophilia had resolved. 6 months after initial symptom onset, the patient received his third BNT162b2 mRNA vaccine dose. 2 weeks after vaccination, he presented to the ED with severe dyspnea, wheezing and cough with yellow sputum. He also noted a new itchy, erythematous bilateral forearm rash and painless oral ulcers. On exam, he was afebrile, tachypneic with SpO2 of 93% on 4LPM supplemental oxygen and audibly wheezing with a prolonged expiratory phase. Laboratory studies noted elevated creatinine and leukocytosis (23,100/mL) with marked eosinophilia (29.5 %, AEC: 6814 cells/L). Chest CT scan revealed a 2 cm rounded ground-glass opacity in the right upper lobe. (Figure 1.) Further workup revealed a weakly positive antihistone antibody (1:4 titer). IgE, ANA, ANCA, SS-A/B, anti-CCP, and complement levels were normal. Intravenous methylprednisolone treatment was initiated with rapid improvement in dyspnea, eosinophilia and renal function. A transbronchial biopsy (Figure 2.) of the RUL lung lesion revealed organizing pneumonia with mixed inflammatory infiltrate. Bronchoalveolar lavage analysis revealed elevated WBC (432 cells/L) with neutrophilic predominance (85%). Patient was discharged home on a prednisone taper with resolution of symptoms. DISCUSSION: Subsequent allergy work up did not indicate any apparent etiology of hypereosinophilia. Testing for strongyloides, coccidiosis and aspergillosis were also negative. A final diagnosis of BNT162b2 mRNA vaccine related pulmonary eosinophilia was made. CONCLUSIONS: Additional study is warranted into eosinophilic disease associated with the BNT162b2 mRNA vaccine. Reference #1: 1. United States Department of Health and Human Services (DHHS), Public Health Service (PHS), Centers for Disease Control (CDC) / Food and Drug Administration (FDA), Vaccine Adverse Event Reporting System (VAERS) 1990 - 03/11/2022, CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/vaers.html on Mar 11, 2022 1:18:37 PM DISCLOSURES: No relevant relationships by Matthew Haltom No relevant relationships by Nikky Keer No relevant relationships by Thekrayat Khader No relevant relationships by Muthiah Muthiah

16.
Chest ; 162(4):A2176, 2022.
Article in English | EMBASE | ID: covidwho-2060906

ABSTRACT

SESSION TITLE: Critical Systemic Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatosis with polyangiitis (GPA) is a necrotizing granulomatous vasculitis affecting small-to-medium sized blood vessels. GPA is highly associated with antineutrophil cytoplasmic antibodies (ANCAs) and often triggered by environmental factors such as medications and infectious agents. Tracheobronchial stenosis and diffuse alveolar hemorrhage are serious complications of GPA. CASE PRESENTATION: A 35-year-old Caucasian male with a history of chronic sinusitis requiring balloon sinuplasty and recent tympanostomy had presented multiple times to the emergency room due to dyspnea and cough with pinkish sputum production. This was associated with sore throat and fever, which were attributed to his COVID-19 infection and treated with supportive care. Due to persistent drainage through his tympanostomy he was prescribed levofloxacin by his ENT specialist. After the second dose of levofloxacin, he developed Raynaud's phenomenon, diffuse purpuric lesions and swelling over his lower extremity, eyelids, and elbows. Four days later he developed worsening hemoptysis and dyspnea for which he was admitted for further evaluation. Laboratory findings were remarkable for peripheral eosinophilia, elevated ESR 19mm/hr, CRP 9.2mg/dl, c-ANCA 1:320 titer, positive proteinase-3 antibodies and normal p-ANCA titers. Urinalysis with microscopic hematuria. Chest CT scan showed ground glass opacity, consolidative infiltrate with subpleural sparing and minimal left bronchial stenosis. Bronchoscopy suggestive of diffuse alveolar hemorrhage. Limited lung biopsy showed ulcer and granulation tissue with abundant eosinophils, but no granulomatous inflammation noted. Pulse dose steroids and Rituximab were initiated, and rapid clinical improvement was noted. Patient was discharged on prednisone taper and Pneumocystis jiroveci prophylaxis. DISCUSSION: We believe that GPA may have been triggered by recent COVID-19 infection and levofloxacin use. Mild peripheral blood and tissue eosinophilia (<12%) has been described in GPA, however it is a rare finding. GPA and eosinophilic granulomatosis with polyangiitis (EGPA) are both ANCA vasculitis that involve lungs and kidneys. GPA presents with sinusitis, alveolar hemorrhage and high titers of PR-3 antibodies. EGPA presents with a history of atopic, asthma and high titers of myeloperoxidase-ANCA along with abundant peripheral eosinophils. Our patient best fits the diagnostic criteria for GPA with eosinophilia variant rather than EGPA. Our patient had no history of asthma or atopic disease and p-ANCA was normal, which also points away from EGPA. CONCLUSIONS: Clinicians should recognize the differential diagnosis for eosinophils in ANCA vasculitis. Early diagnosis of ANCA vasculitis and initiation of appropriate treatment is important to decrease morbidity and mortality. Reference #1: Potter MB, Fincher RK, Finger DR. Eosinophilia in Wegener's Granulomatosis. Chest 116: 1480-1483, 1999 Reference #2: Krupsky, Meir et al. Wegener's Granulomatosis With Peripheral Eosinophilia. CHEST, Volume 104, Issue 4, 1290 - 1292 Reference #3: Kitching AR, Anders HJ, et al. ANCA-associated vasculitis. Nat Rev Dis Primers. 2020 Aug 27;6(1):71. doi: 10.1038/s41572-020-0204-y. PMID: 32855422. DISCLOSURES: No relevant relationships by Afoma King No relevant relationships by Joshuam Ruiz Vega No relevant relationships by Krishna Shah no disclosure on file for Milos Tucakovic;

17.
Chest ; 162(4):A2163, 2022.
Article in English | EMBASE | ID: covidwho-2060904

ABSTRACT

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Fat embolism is a syndrome that can occur during orthopedic procedures or fractures of the long bones, especially the femur and tibia. It can affect multiple organs, including the brain, skin, and lungs, causing the triad of altered mentation, petechiae, and hypoxemia. Here, we present a case of a 54-year-old woman at risk for graft versus host disease (GVHD) who presented with dyspnea a few weeks after an orthopedic procedure. Initial chest radiograph was notable for parenchymal infiltrates, and she was initially treated with antibiotics without improvement. CASE PRESENTATION: A 54-year-old woman with a history of leukemia, stem cell transplantation years ago, GVHD (skin liver, ocular, oral, joints (not lung), with clinical and cytogenetic remission underwent total hip arthroplasty. Two weeks later, she developed lethargy and dyspnea and presented to the emergency department. She was found to have an elevated WBC of x19.5 k/ul (normal 4.1-9.3k/uL) with a left upper lobe consolidation on the chest radiograph (Figure 1). She was treated empirically for pneumonia and discharged with a 7-day course of levofloxacin. Despite completing the course of antibiotics, her dyspnea worsened, and she presented to the emergency department two weeks later with worsening hypoxemia. Computed tomography (CT) of the chest showed bilateral diffuse ground-glass opacities (GGOs) with patchy consolidations in a broncho-vascular distribution (Figure 2). She was negative for COVID-19, Influenza A, B and Legionella urinary antigen. The differential diagnosis included infection and GVHD among others. She underwent bronchoalveolar lavage (BAL). The Gram stain and the culture did not suggest an infection. Pathology from BAL returned significant for reactive bronchial and squamous cells with lipid-laden macrophages. She was started on steroids. Her clinical status improved dramatically, and she was eventually discharged. At a 3-month follow-up her symptoms had improved. Her CT scan also showed significant improvement (Figure 3). DISCUSSION: Our case highlights the successful diagnosis of fat embolism in the lungs in a patient with complicated medical history. Fat embolism usually presents as ground glass opacities. However, the diagnosis was more challenging in this case due to a significant time lapse between her surgery and her presentation to the hospital. She also lacked the other common signs of fat embolism including altered mentation and skin changes. Therefore, other etiologies, such as GVHD, bacterial or viral infection were initially strongly considered. CONCLUSIONS: The diagnosis of fat embolism syndrome condition should still be suspected despite a delay from the initial surgery. Diagnosis in immunocompromised patients requires a detailed workup to rule out other etiologies. Reference #1: Johnson, M. J., & Lucas, G. L. (1996). Fat embolism syndrome. Orthopedics, 19(1), 41-49. Reference #2: Newbigin, K., Souza, C. A., Torres, C., Marchiori, E., Gupta, A., Inacio, J., … & Peña, E. (2016). Fat embolism syndrome: state-of-the-art review focused on pulmonary imaging findings. Respiratory medicine, 113, 93-100. Reference #3: Swiatek, K., Kordic, G., & Jordan, K. (2018). An Unlikely Presentation of Fat Embolism Syndrome. Chest, 154(4), 686A. DISCLOSURES: No relevant relationships by Raheel Anwar No relevant relationships by Boris Medarov

18.
Chest ; 162(4):A2072, 2022.
Article in English | EMBASE | ID: covidwho-2060894

ABSTRACT

SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Peripheral pulmonary nodule biopsy can be challenging based on its location and size. Robotic bronchoscopy is augmenting peripheral navigation, allowing for approximation of peripheral nodules. The diagnostic yield is variable and is primarily dependent upon operator experience, selection of biopsy equipment and nodule texture. Hard pulmonary nodules are difficult to biopsy with a needle, brush and forceps. We report a case of utilizing combined disposable 1.1 mm cryoprobe and robotic bronchoscopy to diagnose a right lower lobe nodule. CASE PRESENTATION: A 83-year-old woman with a remote history of non-Hodgkin's lymphoma presented with dyspnea and fatigue. 18F-FDG PET/CT revealed a 2.7 cm hypermetabolic nodule with central photopenia in the right lower lobe (RLL) along with patchy bilateral ground-glass opacities related to COVID-19 infection. After a few weeks, robotic navigation was used for approximation of the RLL superior segment nodule. Under fluoroscopic and radial guidance with circumferential signal, 6 forcep biopsies and 5 fine needle aspirations with 21-gauge needle yielded a non-diagnostic sample. A decision was made to utilize a 1.1 mm disposable cryoprobe, which was inserted through the opening made by the forceps into the target lesion. Six cryo biopsies were obtained with 4-6 seconds freeze time. Minimal bleeding was encountered and no pneumothorax occurred. Histopathological examination revealed necrotizing granulomatous inflammation. DISCUSSION: To the best of our knowledge, this is the first reported case of combination 1.1 mm disposable cryoprobe biopsy with robotic bronchoscopy. Interventional pulmonologists are primarily using cryo probe for mechanical tumor debulking and peripheral lung biopsy for diagnosis of interstitial lung disease. The use of a 1.1 mm cryoprobe under robotic guidance allows for well-preserved tissue samples and possibly boosting diagnostic yield. The advantage of the 1.1 mm cryoprobe lies with its size and excellent flexibility. The robotic platform also corrects for any unwanted deflection. One limitation of using a flexible cryoprobe is its blunt tip, requiring an additional step in gaining access to nodules located outside the airway with either the biopsy needle or forceps. Future improvements in cryoprobe design with a sharp tip may address this limitation. CONCLUSIONS: Combining 1.1 mm disposable cryoprobe with robotic bronchoscopy is safe and can be considered as an adjunct to conventional biopsy, allowing for well-preserved tissue. Further prospective studies to evaluate its performance and safety is warranted. Reference #1: Kho SS, Chai CS, Nyanti LE, et al. Combination of 1.1 mm flexible cryoprobe with conventional guide sheath and therapeutic bronchoscope in biopsy of apical upper lobe solitary pulmonary nodule. BMC Pulm Med. 2020. 158(20). doi.org/10.1186/s12890-020-01199-3 Reference #2: Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047 Reference #3: Sahajal Dhooria, Inderpaul Singh Sehgal, Ashutosh NA Digambar Behera, Ritesh Agarwal. Diagnostic Yield and Safety of Cryoprobe Transbronchial Lung Biopsy in Diffuse Parenchymal Lung Diseases: Systematic Review and Meta-Analysis. Respiratory Care. 2016. 61(5):700-712. doi.org/10.4187/respcare.04488 DISCLOSURES: No relevant relationships by Sailendra Chundu No relevant relationships by Moiz Javed No relevant relationships by Abid Khokar No relevant relationships by Ali Saeed No relevant relationships by Andrew Talon No relevant relationships by Melinda Wang

19.
Chest ; 162(4):A2040-A2041, 2022.
Article in English | EMBASE | ID: covidwho-2060891

ABSTRACT

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

20.
Chest ; 162(4):A2006-A2007, 2022.
Article in English | EMBASE | ID: covidwho-2060886

ABSTRACT

SESSION TITLE: Occupational and Environmental Lung Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We describe a case of acute progression of chronic hypersensitivity pneumonitis (HP) in an adult, previously misdiagnosed as COPD for 13 years due to severe emphysematous changes seen on imaging. He was also found to have acutely worsened disease as a result of Covid-19. CASE PRESENTATION: A 64-year-old male presented to the pulmonary clinic with dyspnea on minimal exertion. He reported respiratory complaints for 13 years, treated with 2 L/min of oxygen overnight, and budesonide-formoterol and tiotropium inhalers. These complaints were previously associated with brief occupational mold exposure and possible COPD. His respiratory distress worsened one year ago when he was hospitalized for Covid-19. On discharge, his oxygen requirement had increased to 6 L/min. CT chest showed air-trapping in the mid-zones bilaterally, mosaic attenuation, and peri-bronchial thickening. PFTs showed an FEV1 33% and FVC 55% of predicted, consistent with severe obstruction and reduction in lung volume. As the patient was a lifetime non-smoker, alternative diagnoses were pursued. Alpha-1 antitrypsin levels and immunologic testing, including scleroderma and myositis panels, were within normal limits. Positive findings included CCP IgG/IgA antibodies at 96 units and HP panel positive for pigeon serum antibodies. Prompted by this testing, the patient revealed that he had parakeets in his home for the past 15 years. He also reported significant symptom improvement on occasions that he took a course of steroids. Based on these findings, a diagnosis of chronic fibrotic hypersensitivity pneumonitis with bronchiolitis obliterans was considered. The patient's severe airflow obstruction and respiratory failure precluded surgical lung biopsy. Empiric management was initiated with 30 mg of prednisone daily with a slow taper and instruction to eliminate exposure to exotic birds. DISCUSSION: HP is commonly caused by inhalation of and sensitization to an aerosolized environmental antigen;a common subtype is bird fancier's lung due to repetitive exposure of avian antigen. Continuous antigen exposure increases the risk for development of fibrosis, which was also seen in our patient. The most commonly described radiologic findings in HP are ground-glass opacities, ill-defined centrilobular nodules, and focal areas of air trapping resulting in mosaic attenuation and fibrosis. More than 20% lymphocytosis on bronchoalveolar lavage is also a sensitive tool in detecting alveolitis. The relationship between Covid-19 and disease progression in HP is not well studied. CONCLUSIONS: Chronic hypersensitivity pneumonitis from avian antigens, or Bird fancier's lung, can present with severe emphysematous changes on CT imaging, along with obstructive pattern of PFTs. This should be an important differential, especially in patients who are non-smokers. Covid-19 causes disease progression in HP, this relationship needs to be further explored. Reference #1: Funke M., Fellrath J.-M. Hypersensitivity pneumonitis secondary to lovebirds: a new cause of bird fancier's disease. Eur. Respir. J. 2008;32:517–521. DOI: 10.1183/09031936.00108507 Reference #2: Pereira C., Gimenez A., Kuranishi L., Storrer K. Chronic hypersensitivity pneumonitis. J. Asthma Allergy. 2016;9:171–181. DOI: 10.2147/JAA.S81540 Reference #3: C.S. Glazer, C.S. Rose, D.A. Lynch Clinical and radiologic manifestations of hypersensitivity pneumonitis J. Thorac. Imag., 17 (4) (2002), pp. 261-272. DOI: 10.1097/00005382-200210000-00003 Morell F, Roger A, Reyes L, Cruz MJ, Murio C, Muñoz X Bird fancier's lung: a series of 86 patients. Medicine (Baltimore). 2008;87(2):110-130. DOI: 10.1097/MD.0b013e31816d1dda DISCLOSURES: No relevant relationships by Momina Amjad No relevant relationships by Amit Chopra No relevant relationships by Rafeh Safdar

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