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1.
J Thorac Cardiovasc Surg ; 2022 Sep 10.
Article in English | MEDLINE | ID: covidwho-2105500

ABSTRACT

OBJECTIVES: Refractory hypoxemia can occur in patients with acute respiratory distress syndrome from COVID-19 despite support with venovenous (VV) extracorporeal membrane oxygenation (ECMO). Parallel ECMO circuits can be used to increase physiologic support. We report our clinical experience using ECMO circuits in parallel for select patients with persistent severe hypoxemia despite the use of a single ECMO circuit. METHODS: We performed a retrospective cohort study of all patients with COVID-19-related acute respiratory distress syndrome who received VV-ECMO with an additional circuit in parallel at Vanderbilt University Medical Center between March 1, 2020, and March 1, 2022. We report demographic characteristics and clinical characteristics including ECMO settings, mechanical ventilator settings, use of adjunctive therapies, and arterial blood gas results after initial cannulation, before and after receipt of a second ECMO circuit in parallel, and before removal of the circuit in parallel, and outcomes. RESULTS: Of 84 patients with COVID-19 who received VV-ECMO during the study period, 22 patients (26.2%) received a circuit in parallel. The median duration of ECMO was 40.0 days (interquartile range, 31.6-53.1 days), of which 19.0 days (interquartile range, 13.0-33.0 days) were spent with a circuit in parallel. Of the 22 patients who received a circuit in parallel, 16 (72.7%) survived to hospital discharge and 6 (27.3%) died before discharge. CONCLUSIONS: In select patients, the additional use of an ECMO circuit in parallel can increase ECMO blood flow and improve oxygenation while allowing for lung-protective mechanical ventilation and excellent outcomes.

2.
Journal of Intensive Medicine ; JOUR
Article in English | ScienceDirect | ID: covidwho-2082984

ABSTRACT

Optimal initial non-invasive management of acute hypoxemic respiratory failure (AHRF), of both coronavirus disease 2019 (COVID-19) and non-COVID-19 etiologies, has been the subject of significant discussion. Avoidance of endotracheal intubation reduces related complications, but maintenance of spontaneous breathing with intense respiratory effort may increase risks of patients’ self-inflicted lung injury, leading to delayed intubation and worse clinical outcomes. High-flow nasal oxygen is currently recommended as the optimal strategy for AHRF management for its simplicity and beneficial physiological effects. Non-invasive ventilation (NIV), delivered as either pressure support or continuous positive airway pressure via interfaces like face masks and helmets, can improve oxygenation and may be associated with reduced endotracheal intubation rates. However, treatment failure is common and associated with poor outcomes. Expertise and knowledge of the specific features of each interface are necessary to fully exploit their potential benefits and minimize risks. Strict clinical and physiological monitoring is necessary during any treatment to avoid delays in endotracheal intubation and protective ventilation. In this narrative review, we analyze the physiological benefits and risks of spontaneous breathing in AHRF, and the characteristics of tools for delivering NIV. The goal herein is to provide a contemporary, evidence-based overview of this highly relevant topic.

3.
Trends in Anaesthesia and Critical Care ; 2022.
Article in English | ScienceDirect | ID: covidwho-2069712

ABSTRACT

The use of the high-flow nasal cannula (HFNC) for oxygen therapy in patients with acute hypoxemic respiratory failure has increased dramatically in recent years, owing to the numerous advantages it has over the other modalities. The respiratory rate-oxygenation (ROX) index was created as a monitoring tool for the appropriate use of the HFNC. It is gaining popularity as a critical monitoring tool due to its non-invasive nature and the ability to be performed at the bedside. To write this review we searched for the original peer-reviewed journal articles using search engines such as Cochrane Library, Google Scholar, and PubMed for evidence of the utility of this index in clinical practice. Despite having many advantages as well as limitations, the ROX index has been shown to have a moderate but useful predictive value/capacity and diagnostic accuracy in detecting HFNC-assisted oxygen therapy failure or success. Further high-quality prospective studies and trials might bring more clarity regarding performance under variable flow rates of HFNC, the acquisition time intervals, cut-off value/limit, and standardization of the index. The ROX index being a non-invasive, simple, and bedside tool could prove a very promising tool to assess the effectiveness, progress and outcome of the HFNC therapy.

4.
Archives of Disease in Childhood ; 107(Supplement 2):A184, 2022.
Article in English | EMBASE | ID: covidwho-2064027

ABSTRACT

Aims Literature describes that most neonates with SARS-CoV-2 infection are asymptomatic or present with mild symptoWe describe an ex-preterm twin infant, born at 31+5 with birthweight 1600g, who deteriorated with COVID pneumonitis at 34 weeks corrected gestational age. They were an inpatient in a level 3 neonatal centre, with an uncomplicated stay prior to becoming unwell and had never been ventilated in their early neonatal course. Methods They acquired postnatal covid on day 24 of life, and deteriorated over the next 72 hours, escalating from high flow to CPAP then BiPAP, and finally requiring intubation. They were empirically commenced on antibiotics and required sedation and muscle relaxation to manage their worsening respiratory failure. Given their acute respiratory decompensation in the context of COVID, and with negative extended virology and bacterial testing otherwise, they were managed on a presumptive diagnosis of COVID pneumonitis. CXRs were consistent with this diagnosis. Despite further escalation in their ventilation strategies, including high frequency oscillatory ventilation and inhaled nitric oxide, they continued to deteriorate with severe hypoxic respiratory failure. Inotropic support was required to maintain cardiac stability. There was extensive MDT discussion between NICU, PICU and the Infectious Diseases teaDue to the severity of their condition, Remdesivir was commenced and the parents were fully informed of the trial nature of the drug and the guarded prognosis. Hydrocortisone was also commenced. Results Due to ongoing deterioration, the patient was transferred to PICU for ongoing care and consideration of ECMO. However, the infant stabilised and the hydrocortisone that had been commenced was switched to methylprednisolone. The Remdesivir was discontinued after 2 doses due to a worsening in LFTs. The situation was further complicated by COVID isolation guidelines while keeping family centred care at the heart of our approach, working within infection control policies and managing a relatively unfamiliar pathology in the neonatal population. Conclusion The infant progressed well and was extubated onto nasal cannula oxygen on day 40 of life and repatriated to our neonatal unit on day 41 at 37+4 corrected gestational age. They had an uneventful stay in our SCBU, establishing feeding, until discharge with home oxygen at 41+1 weeks corrected gestational age.

5.
American Journal of Transplantation ; 22(Supplement 3):992, 2022.
Article in English | EMBASE | ID: covidwho-2063425

ABSTRACT

Purpose: Lung transplant is the last resort for COVID-19 refractory ARDS. Dual organ transplant is seen as a relative contraindication at many institutions. We describe a case of simultaneous Lung-Kidney transplant (SLK) in a patient with COVID-19 ARDS. Method(s): A 24-year-old patient with no PMH presented to an outside hospital with a week of shortness of breath, cough, and fever. Despite treatment with Remdesivir and dexamethasone, the patient developed hypoxemic respiratory failure with acute renal injury requiring ICU care and intubation, V-V ECMO, and dialysis. Additionally, Intravenous and inhaled Aviptadil were given under emergency use authorization. While oxygenation improved, the patient could not be weaned off ECMO. With a LAS score of 90.29, the patient underwent an SLK transplant on HD 53, requiring standard induction and maintenance immunosuppression therapy. The patient was treated post-operatively for PGD as well as for subclinical AMR. After successful inpatient rehabilitation, the patient was discharged home after four months and had a one-month follow-up on room air and normal creatinine clearance. Result(s): Patients with pre-existing renal dysfunction who have undergone lung transplants have a significantly higher one- and three-year mortality than patients with normal GFR. The patient's survival after SLK was similar to isolated lung transplants at one and five years, according to an analysis of the UNOS/OPTN database. Still, dual organ transplant in the COVID-19 ARDS population is considered a contraindication at many centers, given these patients' critical illness and frailty. However, the frailty in this population is reversible due to the rapid onset of disease in an otherwise previously healthy younger population with minimal comorbidities. Thus, multiorgan transplantation should be considered in such a patient population. Our patient received Aviptadil as part of an EIND to stabilize patients and improve oxygenation while waiting on the transplant list. Conclusion(s): We propose that SLK transplantation should be considered for carefully selected patients with COVID-19 ARDS.

6.
American Journal of Transplantation ; 22(Supplement 3):420, 2022.
Article in English | EMBASE | ID: covidwho-2063366

ABSTRACT

Purpose: Extra-pulmonary organs from donors with SARS-CoV-2 detection during donor evaluation are not accepted by many centers due to theoretical concerns for productive infection and organ injury from COVID-related sequelae. We aimed to compare outcomes for kidney transplantation (KT) from donors with and without SAR-CoV-2 RNA detection, CoVD+ and CoVDneg, respectively. Method(s): We retrospectively reviewed donor data, recipient data and key outcomes for all adult CoVD+ KTs performed at our center between 2/1/2021 and 10/31/2021 and compared such data to all consecutive adult CoVDneg KTs during the same period. Organ selection was by protocol and excluded donors within the 1st 14 days of diagnosed symptomatic infection. No COVID-directed therapies were provided to CoVD+ KT recipients (KTRs). Vaccination was not required in early 2021. Result(s): There were 159 KTs, including 71 (44%) from 41 CoVD+'s with mean follow up 151d (range 35-291d). Of the 41 CoV+ donors, 16 (40%) died of COVID complications, mostly hypoxic respiratory failure, with 4 on VV ECMO. For those dying of COVID, the median time from first SARS-CoV2 RNA detection to donation was 28d (range 16-65). Compared to CoVneg donors, CoV+D's had lower KDPI (mean 31 v 43, mean difference -10.8, 95% CI -18.41 to -3.17, p=0.006), and were more likely DCD (OR 2.41, 95% CI 1.28-0.463, p=0.007). Having a CoV+ donor was not associated with delayed graft function (DGF). On multivariable analysis, CoVD+ was not associated with a higher serum creatinine (Cr) at 1, 3 or 6 months, but DCD was. There was 1 death (from pre-existing interstitial lung disease without SARS-CoV-2 detection from the lower airway) at 4 mo and 1 graft loss at 6 wk post-KT, both in the CoVD+ group. Neither of these KTR's donors had died of a COVID-related cause. Rejection occurred in 3 CoVD+ and 4 CoVneg KTRs. Six (3.7%) KTRs were diagnosed with COVID, all >3 mo post-KT, with 5/6 occurring >6 mo post-KT during peak periods of circulating virus. Conclusion(s): In a large series, kidney transplant outcomes from CoVD+s were similar to CoVDnegs up to 6 months post-transplant. CoVD+ KT recipients likely benefited from lower KDPI organs. We demonstrate safe and successful transplantation of CoVD+ kidneys outside of the peak period of symptomatic SARS-CoV-2 infection. (Figure Presented).

7.
Chest ; 162(4):A2467, 2022.
Article in English | EMBASE | ID: covidwho-2060945

ABSTRACT

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The ROX index (Respiratory rate - OXygenation), obtained by the calculation of SpO2/FiO2/respiratory rate (RR), is a tool previously found to predict intubation in patients with acute hypoxic respiratory failure (AHRF). There is variation in the time intervals described from HFNC to ROX index assessment as well as the cutoff value. This study investigates the role of the ROX index from 12 to 72 hours after HFNC initiation to predict intubation or death while on HFNC in patients with COVID-19 AHRF. METHODS: Adult patients (18 years or older) with confirmed nasopharyngeal PCR SARS-CoV-2 infection who received HFNC therapy between March 1 and July 15, 2020, at Monmouth Medical Center were included. 52 patients were available for analysis. Patients were divided into two groups: those able to be weaned to traditional nasal cannula (group one) and those who were intubated or died while on HFNC (group two). RESULTS: Of the 52 patients evaluated, 28 (54%) required intubation or died while on HFNC (Group two). Group two mortality was 53.85% and overall mortality was 42.31%. A Kaplan-Meier analysis comparing patients whose ROX remained above 4.67 (Group A) with those with ROX <= 4.67 (Group B) within the first 12 hours showed that patients in Group B had a significantly shorter time to the event than those in Group A. CONCLUSIONS: Generally, higher ROX index values are associated with a lower risk of intubation on HFNC in AHRF. In this patient sample, any ROX index less than 4.67 at 12 hours or less than 4.04 at 24 hours was associated with an increased risk of eventual intubation or death while on HFNC. Thus, a low or decreasing ROX index may prompt more frequent reassessment and, if accompanied by other evidence of deterioration, may trigger an escalation of care. CLINICAL IMPLICATIONS: This study shows that the ROX index can stratify patients into low or higher risk for deterioration on HFNC among patients with COVID-19 AHRF. This could help optimize the use of critical care services, minimize PPE use, and promote safety for patients and healthcare workers. Future studies may include prospective analysis of the ROX index and exploration of modalities for monitoring patients receiving non-invasive ventilation. DISCLOSURES: No relevant relationships by Reem alhashemi no disclosure on file for Alvin Buemio;No relevant relationships by Kenneth Granet No relevant relationships by Ikwinder Preet Kaur No relevant relationships by Violet Kramer No relevant relationships by Mohsin Mughal No relevant relationships by Chandler Patton

8.
Chest ; 162(4):A2281, 2022.
Article in English | EMBASE | ID: covidwho-2060930

ABSTRACT

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

9.
Chest ; 162(4):A2241, 2022.
Article in English | EMBASE | ID: covidwho-2060916

ABSTRACT

SESSION TITLE: Pulmonary Manifestations of Infections SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: Diffuse alveolar hemorrhage (DAH) due to an undiagnosed autoimmune condition is rare and can be life-threatening. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been described as a viable rescue therapy in severe cases, providing time to establish a diagnosis and begin remission induction therapy (1). We report a patient who presented during the Omicron surge with hypoxemic respiratory failure due to pulmonary hemorrhage ultimately diagnosed with antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) who was supported with VV-ECMO without systemic anticoagulation. CASE PRESENTATION: A 46-year-old woman presented with subacute fatigue and two days of cough and brown sputum. She was found to have normocytic anemia (hemoglobin 3.5 g/dL), renal failure (serum creatinine 17.4 µmol/L), and bilateral pulmonary infiltrates on chest roentgenogram. Though vaccinated, nasal molecular testing detected SARS-CoV-2. She was intubated for progressive hypoxic respiratory failure and bronchoalveolar lavage fluid was consistent with DAH. She received empiric antibiotics, remdesivir, and pulse dose intravenous methylprednisolone as well as continuous renal replacement therapy and plasma exchange. Due to refractory hypoxemia she was cannulated for VV-ECMO. Systemic anticoagulation was deferred due to concerns that it may exacerbate her underlying pathology and due to a small subcortical bleed seen on computed tomography of the head. Perinuclear ANCA (titer >1:1280) was confirmed by immunofluorescence analysis with elevated myeloperoxidase serologies and cyclophosphamide was initiated. Glomeruli with cellular crescent formation consistent with AAV was later identified on renal biopsy. Her course was complicated by recurrent DAH while tapering steroids and an iliac vein thrombus, extracted during decannulation. Her respiratory failure resolved and she was discharged to rehab. DISCUSSION: Traditionally, VV-ECMO obligates systemic anticoagulation to prevent circuit thrombosis, however this may be viewed as a barrier to its use in patients with prohibitive bleeding risk and may contribute to the therapy's overall morbidity. Some institutions have begun to demonstrate the safety of ECMO with low- or prophylactic doses of anticoagulation (2), but this practice remains controversial. Detection of SARS-CoV-2 posed diagnostic and management challenges and its significance to this case remains uncertain. There are many past examples of infectious triggers for both DAH and AAV, and there is emerging evidence for an association between SARS-CoV-2 and ANCA (3). Concerns regarding the risk of B-cell depletion influenced the selection of remission induction therapy. CONCLUSIONS: In the case described, a patient with severe DAH was successfully supported with VV-ECMO. Withholding systemic anticoagulation did not prevent recurrent bleeding and may have contributed to a deep vein thrombosis. Reference #1: Arnold S, Deja M, Nitschke M, Bohnet S, Wallis S, Humrich JY, Riemekasten G, Steinhoff J, Lamprecht P. Extracorporeal membrane oxygenation in ANCA-associated vasculitis. Autoimmun Rev. 2021 Jan;20(1):102702. doi: 10.1016/j.autrev.2020.102702. Epub 2020 Nov 11. PMID: 33188916. Reference #2: Kurihara C, Walter JM, Karim A, et al. Feasibility of Venovenous Extracorporeal Membrane Oxygenation Without Systemic Anticoagulation. Ann Thorac Surg. 2020;110(4):1209-1215. doi:10.1016/j.athoracsur.2020.02.011 Reference #3: Kadkhoda, K., Laurita, K. Antineutrophil cytoplasmic antibodies and their association with clinical outcomes in hospitalized COVID-19 patients. Cell Death Discov. 7, 277 (2021). DISCLOSURES: No relevant relationships by Nathaniel Nelson No relevant relationships by Radu Postelnicu no disclosure on file for Antonio Velez;

10.
Chest ; 162(4):A2079-A2080, 2022.
Article in English | EMBASE | ID: covidwho-2060895

ABSTRACT

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

11.
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

12.
Chest ; 162(4):A2030-A2031, 2022.
Article in English | EMBASE | ID: covidwho-2060887

ABSTRACT

SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The use of remdesivir in critical care setting has been utilized treatment of covid, but not without risk. Many cases have reported severe cardiac effects with bradycardia being the most common. CASE PRESENTATION: The patient was a 15-year-old female with a history of asthma, hyperinsulinemia who required hospitalization for acute hypoxic respiratory failure secondary to COVID-19 pneumonia. She received ceftriaxone, azithromycin, and a 10-day course of remdesivir (RDV). On her third day of admission, the patient developed significant sinus bradycardic with heart rate nadir of 30-40 bpm but denied any symptoms. She completed her remdesivir course on day five of hospitalization and was discharged on day nine with a heart rate of 47 bpm. She later presented to ED the night of discharge following acute onset of lightheadedness and blurry vision at home secondary to orthostatic hypotension and bradycardia. Her pulse was 48 bpm, temperature 36.1 C, respirations 24/min, blood pressure 119/50 mmHg and SpO2 99% on room air. Her physical exam was unremarkable. EKG showed sinus bradycardia with a PR interval of 124 ms and QTc of 406 ms. Echocardiogram showed normal cardiac anatomy and function. Patient was diagnosed with persistent RDV-associated bradycardia and discharged home with a Holter monitor and cardiology follow-up. Bradycardia resolved by her follow-up visit two weeks later. DISCUSSION: According to the WHO pharmacovigilance database, bradycardia is a relatively new adverse effect and 3.6% of the 2,603 adverse effects reported since the onset of the pandemic, with 2 million RDV doses administered during this time [1]. The mechanism of RDV-associated bradycardia is proposed to be an effect of adenosine triphosphate, an active metabolite, which reduces SA node automaticity via stimulation of vagal nerve, as well as RDV cross-reactivity with mRNA polymerase, leading to cardiotoxicity that usually resolves within 24 hours of medication discontinuation. In our patient's case bradycardia did not resolve until eight days after discontinuation of medication [2]. Review of previously case reports does not identify any association with patient age but could be related to timing of when medication reaches therapeutic window, as many patients had onset of bradycardia on day 3 of treatment [3]. We report a pediatric case of severe acute COVID-19 who developed sinus bradycardia on day 3 of RDV treatment as previously described, but the bradycardia persisted long after the discontinuation of RDV. CONCLUSIONS: With over 50 thousand pediatric COVID-19 hospitalizations to date, this case serves as a timely reminder that medication side effects should be monitored closely, and that more research needs to be done into the effects of RDV on cardiac function in pediatric patients. Reference #1: Jung SY, Kim MS, Li H, Lee KH, Koyanagi A, Solmi M, Kronbichler A, Dragioti E, Tizaoui K, Cargnin S, Terrazzino S, Hong SH, Abou Ghayda R, Kim NK, Chung SK, Jacob L, Salem JE, Yon DK, Lee SW, Kostev K, Kim AY, Jung JW, Choi JY, Shin JS, Park SJ, Choi SW, Ban K, Moon SH, Go YY, Shin JI, Smith L. Cardiovascular events and safety outcomes associated with remdesivir using a World Health Organization international pharmacovigilance database. Clin Transl Sci. 2022 Feb;15(2):501-513. doi: 10.1111/cts.13168. Epub 2021 Oct 31. PMID: 34719115;PMCID: PMC8841455. Reference #2: Touafchia A, Bagheri H, Carrié D, Durrieu G, Sommet A, Chouchana L, Montastruc F. Serious bradycardia and remdesivir for coronavirus 2019 (COVID-19): a new safety concerns. Clin Microbiol Infect. 2021 Feb 27;27(5):791.e5–8. doi: 10.1016/j.cmi.2021.02.013. Epub ahead of print. PMID: 33647441;PMCID: PMC7910147. Reference #3: Rau, Cornelius MPhil;Apostolidou, Sofia MD;Singer, Dominique MD, PhD;Avataneo, Valeria PhD;Kobbe, Robin MD Remdesivir, Sinus Bradycardia and Therapeutic Drug Monitoring in Children With Severe CO

13.
Chest ; 162(4):A1990-A1991, 2022.
Article in English | EMBASE | ID: covidwho-2060882

ABSTRACT

SESSION TITLE: Dirty Jobs: Occupational Lung Diseases SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Hypersensitivity Pneumonitis (HP) is a group of immunologically mediated lung diseases. It develops in susceptible individuals with exposure to provoking antigens along with influence from genetic and environmental factors. There remains no standardized approach for assessing the various forms of HP and the diverse nature of the disease makes it difficult and often underdiagnosed. Cystic disease is not uncommon in HP, but the advanced cystic disease seen in our young patient was unique and likely compounded by her pregnancy as well as a previous illness with COVID-19. CASE PRESENTATION: A 26-year-old female construction worker at 12 weeks gestation, with a past medical history of polysubstance abuse and previous COVID-19 infection ten months prior, presented with progressively worsening dyspnea of 9 months. She was admitted with acute hypoxic respiratory failure due to recurrent right pneumothorax requiring multiple thoracenteses and eventually chest tube placement. CT Chest demonstrated severe cystic interstitial fibrosis with emphysematous changes. Initial lung biopsy showed interstitial fibrosis as a possible sequela of COVID-19. Due to her pregnancy and medical complications, she was transferred to a transplant center where she continued to have recurrent pneumothoraces requiring video-assisted thoracoscopic surgery. Autoimmune workup, HP panel, and extended myositis panel were negative. However, a repeat lung biopsy pointed to subacute HP. Despite steroid and immunosuppressant initiation, her hospital course was complicated by cardiac arrest and brain death. She went on to become an organ donor. DISCUSSION: Diffuse cystic lung diseases are characterized by parenchymal destruction of the airway walls leading to expansion of the distal airspaces forming multi-lobular cysts. A broad differential diagnosis for this exists including infection, Langerhans histiocytosis, lymphangioleiomyomatosis, interstitial pneumonia, and HP. The first step to evaluate HP is a detailed history of potential exposures. Our patient worked in construction and was exposed to commonly demonstrated antigens used in paint, plastic, and wood manufacture. Pregnancy appears to trigger symptoms in some patients, seen in prior case reports. Our patient's symptoms began after her COVID infection. Though not clearly studied, some studies have proposed that dysregulation of COVID - 19 immune response triggers interstitial fibrosis as a long-term sequela. Early diagnosis and treatment with steroids are vital to the treatment and prevention of complications such as recurrent pneumothorax. CONCLUSIONS: Covid-19 is an emerging risk factor for the propagation of various immune-mediated diseases. Progression of disease may occur even after the infection has been cured and limited data is available regarding its relation. Early recognition and treatment can be effective life-saving measures in these patients. Reference #1: Baldi BG, Carvalho CRR, Dias OM, Marchiori E, Hochhegger B. Diffuse cystic lung diseases: differential diagnosis. J Bras Pneumol. 2017;43(2):140-149. Reference #2: Densem C, Niven R, Barber P, Bishop P. Development of cryptogenic fibrosing alveolitis during pregnancy. J R Soc Med. 1998;91(11):591-593. Reference #3: Ambardar SR, Hightower SL, Huprikar NA, Chung KK, Singhal A, Collen JF. Post-COVID-19 Pulmonary Fibrosis: Novel Sequelae of the Current Pandemic. J Clin Med. 2021;10(11):2452. Published 2021 Jun 1 DISCLOSURES: No relevant relationships by Anastasia Brit No relevant relationships by Steven Colby No relevant relationships by Patrick Koo No relevant relationships by Vishruth Vyata No relevant relationships by Harika Yadav

14.
Chest ; 162(4):A1868, 2022.
Article in English | EMBASE | ID: covidwho-2060878

ABSTRACT

SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is an atypical cause of acute hypoxic respiratory failure in adults, however if not identified can prove to be fatal. It can all be a COVID19 mimic during the pandemic. AEP has several causes, such as inhalational drugs, infections and various pharmaceuticals. Often, patients will have an acute respiratory syndrome for less than one-month, pulmonary infiltrates on chest computed tomography (CT) or radiography (CXR), in addition to bronchoalveolar lavage (BAL) with more than 25% of eosinophils. CASE PRESENTATION: A 79 y/o man underwent an elective total knee replacement complicated by acute lower limb ischemia from an occluded bypass graft. He developed methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE) joint and soft tissue infection of the lower extremity. He was prescribed a 6-week course of Daptomycin. He presented about 3 weeks into treatment with shortness of breath. He was initially diagnosed with acute on chronic congestive heart failure (CHF) exacerbation and COVID negative. He was initially treated with diuretics. He developed acute renal failure requiring dialysis and acute hypoxic respiratory failure requiring intubation. CXR revealed bilateral lung infiltrates with BAL having 80% eosinophils, eosinophilia and urinalysis positive for eosinophils. Daptomycin was discontinued and he was started on systemic steroids for a two-week course. He was successfully extubated 5 days after diagnosis of AEP and was subsequently discharged to a rehabilitation facility on lifelong Doxycycline for MRSA prosthetic joint infection prophylaxis. DISCUSSION: AEP related to Daptomycin was first reported in 2007, in a patient that developed the condition after receiving treatment for endocarditis. Daptomycin caused an inflammatory reaction within the lungs, due to an accumulation of the drug within the pulmonary surfactant. Our case report patient met all components for AEP diagnosis, in addition to symptom onset being approximately 3 weeks into treatment. The ultimate treatment for AEP is to stop the reversible cause, if identifiable, along with glucocorticoids and symptomatic support. Prognosis for patients with AEP is excellent when diagnosis is prompt, and usually infiltrates are resolved within 1 month without long term adverse pulmonary effects. Our patient was discharged to an acute rehab facility without supplemental oxygen therapy and continues to improve from functional standpoint. This case a definite cause of AEP from Daptomycin presented as COVID19 pneumonia mimic. It highlights the importance of rapid diagnosis to prevent morbidity and mortality. CONCLUSIONS: The differential in a patient with acute hypoxic respiratory failure is numerous, especially during the COVID19 pandemic. During these challenging times, it is important to think of atypical causes, such as AEP to improve the patient's clinical status. Reference #1: Allen JN, Pacht ER, Gadek JE, Davis WB. Acute Eosinophilic Pneumonia as a Reversible Cause of Noninfectious Respiratory Failure. N Engl J Med. 1989;321:569-574 Reference #2: Hayes Jr. D, Anstead MI, Kuhn RJ. Eosinophilic pneumonia induced by daptomycin. J Infect. 2007;54(4):e211-213. Reference #3: Rachid M, Ahmad K, Saunders-Kurban M, Fatima A, Shah A, Nahhas A. Daptomycin-Induced Acute Eosinophilic Pneumonia: Late Onset and Quick Recovery. Case Reports in Pulmonology. 2017. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zinobia Khan No relevant relationships by Kaitlyn Mehern

15.
Chest ; 162(4):A1821, 2022.
Article in English | EMBASE | ID: covidwho-2060870

ABSTRACT

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Coronavirus disease 2019 (COVID-19) and influenza infections are associated with systemic inflammatory reactions that predispose to Takotsubo cardiomyopathy (TTS). Studies have investigated the epidemiology and clinical features of TTS in COVID-19 and influenza infection, however, there are limited data comparing TTS between patients with COVID-19 and influenza. METHODS: We searched PubMed/Medline, Web of Science, SCOPUS, EMBASE, and Google Scholar until November 1st, 2021, for case reports, case series, and observational cohort studies using these keywords: takotsubo syndrome/takotsubo cardiomyopathy, stress-induced cardiomyopathy, and broken heart syndrome combined with the terms COVID-19 and/or SARS-CoV-2, flu and/or influenza. All the published case reports included in the final analysis were in English and were categorized into patients with ‘COVID-19 + TTS’ and ‘Flu + TTS’. RESULTS: We identified 37 studies describing 64 patients with COVID-19+TTS and 10 case reports describing 10 patients with Flu + TTS. The mean age of patients in the COVID-19 + TTS was similar to the influenza group (69 years). Although women were more disproportionately affected by TTS in both groups, COVID-19 + TTS patients had a higher proportion of men than the Flu + TTS group (44% vs 30%) and previously reported incidence of TTS in men in the general population. Compared to patients with Flu + TTS, COVID-19 + TTS had a longer mean time from testing positive to developing TTS (7.3 days vs. 3.1 days), higher incidence rates of acute respiratory distress syndrome (77% vs. 40%), hypoxemic respiratory failure (86% vs. 60%), more likely to require invasive mechanical ventilation (63% vs. 40%) and higher in-hospital mortality rates (36%, n=23 vs 10%, n=1) CONCLUSIONS: Our systematic review highlights some important differences in the presentation and outcomes of TTS in patients with COVID-19 compared to seasonal influenza. Patients with COVID-19 + TTS had higher rates of respiratory complications and excess all-cause mortality compared to Flu + TTS. In contrast to the general population and patients infected with influenza, TTS tends to affect more men with COVID-19 infection. CLINICAL IMPLICATIONS: Hospitalized patients with COVID-19 who develop TTS appear to have a more severe disease course and poorer outcome compared to hospitalized patients with Flu+TTS. The study findings provide additional knowledge comparing complications between COVID-19 and influenza infections and may contribute to the continued efforts to manage the COVID-19 pandemic. DISCLOSURES: no disclosure on file for Temidayo Abe;No relevant relationships by Thomas Allingham No relevant relationships by Omovefe Edika No relevant relationships by Hammad Khalid No relevant relationships by Ifeoma Ogbuka No relevant relationships by Titilope Olanipekun No relevant relationships by Richard Snyder No relevant relationships by Abhinav Vedire No relevant relationships by Nicholas Wilson

16.
Chest ; 162(4):A1796, 2022.
Article in English | EMBASE | ID: covidwho-2060863

ABSTRACT

SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The most dangerous complication of amiodarone use is amiodarone-induced pulmonary toxicity (AIPT) (1). AIPT has no pathognomonic findings & is therefore diagnosed based on clinical suspicion & exclusion of other possible pulmonary diseases (2) CASE PRESENTATION: A 91-year-old female with history of CHF & atrial fibrillation on amiodarone 200mg once daily for approximately 10 years, presented for worsening shortness of breath for 3 days. On admission vitals were stable & pulse oximetry revealed a SpO2 of 89% on room air which increased to 96% on 4 litres oxygen. Examination revealed decreased breath sounds at bases, bilateral rales right>left. No clinical signs of fluid overload. Chest x-ray (fig 1) showed increased bilateral airspace opacities and computed tomography (CT) of chest (fig 3) revealed diffuse airspace opacities, right > left. Initial lab work was within normal limits. She was admitted with a working diagnosis of acute hypoxemic respiratory failure due to community acquired pneumonia (CAP) versus COVID-19 pneumonia due to high suspicion based on her clinical picture. She received remdesvir, empiric antibiotics and amiodarone was discontinued. COVID-19 PCR was negative, patient did not spike fevers or had any leukocytosis & pneumonia workup was negative. Therefore we now considered AIPT. Gallium scan for AIPT revealed abnormal uptake involving lungs bilaterally consistent with AIPT. Patient was continued on dexamethasone, after which patient's oxygen requirement subsequently decreased & repeat chest x-ray (fig 2 ) showed a significant decrease in bilateral infiltrates on steroids. She was discharged home on 2 litres oxygen & prednisone taper for 4 months. DISCUSSION: The advent of the highly contagious SARS-CoV-2 has made it further essential to diagnose AIPT correctly & to differentiate between these two entities. They have similar & non-specific features which makes this an even a greater challenge. Our elderly patient on long-term amiodarone use represents an at-risk group for AIPT (1). Her clinical picture was non-specific, initially suggesting CAP versus COVID-19 pneumonia. In our case, the consistent gallium scan findings confirmed the diagnosis of AIPT & enabled prompt anti-inflammatory treatment along with cessation of amiodarone which resulted in improved prognosis & outcome. AIPT should be suspected in patients taking amiodarone who have new or worsening symptoms with an insidious onset &/or new infiltrates on chest x-ray. Greater parenchymal activity on gallium scintigraphy scanning & the presence of lung biopsy findings can help further confirm the diagnosis (1) CONCLUSIONS: In the era of the COVID-19 pandemic, it becomes even more challenging to diagnose and differentiate AIPT from SARS-CoV-2 pneumonia, which can have a similar presentation (3). Early recognition of AIPT is critical to prevent or minimize its potentially devastating pulmonary effects. Reference #1: Martin, W. J., & Howard, D. M. (1985). Amiodarone-induced lung toxicity: In vitro evidence for the direct toxicity of the drug. American Journal of Pathology, 120(3), 344–350. Reference #2: Benassi, F., Molardi, A., Righi, E. et al. ECMO for pulmonary rescue in an adult with amiodarone-induced toxicity. Heart Vessels 30, 410–415 (2015). Reference #3: Macera M, De Angelis G, Sagnelli C, Coppola N, Vanvitelli Covid-Group. Clinical Presentation of COVID-19: Case Series and Review of the Literature. Int J Environ Res Public Health. 2020 Jul 14;17(14):5062. DISCLOSURES: No relevant relationships by Nayaab Bakshi No relevant relationships by Navjot Kaur Grewal No relevant relationships by Talha Munir No relevant relationships by Anusha Singhania

17.
Chest ; 162(4):A1773, 2022.
Article in English | EMBASE | ID: covidwho-2060858

ABSTRACT

SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Daptomycin is an antibiotic that exerts its bactericidal effect by disrupting multiple aspects of bacterial cell membrane function. It has notable adverse effects including myopathy, rhabdomyolysis, eosinophilic pneumonitis, and anaphylactic hypersensitivity reactions. CASE PRESENTATION: A 46-year-old male with a history of type 2 diabetes presented with a 1-week history of dyspnea and productive cough. 2 weeks prior, he was started on vancomycin for MRSA osteomyelitis of the right foot, but was switched to daptomycin due to vancomycin induced nephrotoxicity. On presentation he was afebrile, tachycardic 100, hypertensive 183/109, tachypneic to 26, hypoxemic 84% on room air, which improved to 94% on nasal cannula. Chest exam noted coarse breath sounds in all fields and pitting edema of lower extremities were present. Labs showed leukocytosis of 15.2/L, Na of 132 mmol/L, and creatinine 3.20mg/dL (normal 1 month prior). COVID-19 testing was negative. Chest X-ray noted new bilateral asymmetric opacifications. Daptomycin was discontinued on day 1 of admission, he was started on IV diuretics and ceftaroline. Further study noted peripheral eosinophilia. Computed tomography of the chest showed bilateral centrally predominant ground-glass infiltrates with air bronchograms and subcarinal and paratracheal lymphadenopathy. On day 4, he underwent bronchoscopy with bronchoalveolar lavage. Cytology noted 4% eosinophil with 43% lymphocytes. Eventually, oxygen requirements and kidney function returned to baseline. He was discharged on ceftaroline for osteomyelitis DISCUSSION: Daptomycin-induced acute eosinophilic pneumonitis (AEP) often results in respiratory failure in the setting of exposure to doses of daptomycin >6mg/kg/day. It is characterized by the infiltration of pulmonary parenchyma with eosinophils and is often associated with peripheral eosinophilia. AEP has been associated with certain chemicals, non-steroidal anti-inflammatory agents, and antibiotics including daptomycin. Renal dysfunction is associated with an increased risk for developing AEP. The mechanism for daptomycin-induced lung injury is unknown but is believed to be related to daptomycin binding to pulmonary surfactant culminating in epithelial injury. Diagnostic criteria include recent daptomycin exposure, fever, dyspnea with hypoxemic respiratory failure, new infiltrates on chest radiography, BAL with > 25% eosinophils, and clinical improvement following daptomycin discontinuation. Our patient met four out of six criteria;we believe that BAL results were due to discontinuing daptomycin days before the procedure was performed. Sometimes stopping daptomycin is enough for recovery, however, steroids may be beneficial and were used in some of the cases reported in the literature CONCLUSIONS: Clinicians should consider AEP in a patient on Daptomycin presenting with respiratory failure, as timely discontinuation favors a good prognosis Reference #1: Uppal P, LaPlante KL, Gaitanis MM, Jankowich MD, Ward KE. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control. 2016;5:55. Published 2016 Dec 12. doi:10.1186/s13756-016-0158-8 Reference #2: Kumar S, Acosta-Sanchez I, Rajagopalan N. Daptomycin-induced Acute Eosinophilic Pneumonia. Cureus. 2018;10(6):e2899. Published 2018 Jun 30. doi:10.7759/cureus.2899 Reference #3: Bartal C, Sagy I, Barski L. Drug-induced eosinophilic pneumonia: A review of 196 case reports. Medicine (Baltimore). 2018;97(4):e9688. doi:10.1097/MD.0000000000009688 DISCLOSURES: No relevant relationships by Chika Winifred Akabusi No relevant relationships by Shazia Choudry No relevant relationships by Hector Ojeda-Martinez No relevant relationships by Mario Torres

18.
Chest ; 162(4):A1741-A1742, 2022.
Article in English | EMBASE | ID: covidwho-2060855

ABSTRACT

SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pleomorphic carcinoma is a subtype of sarcomatoid carcinomas that represents <1 % of all primary lung neoplasms. This case highlights a recent diagnosis of a patient with pleomorphic carcinoma in the midst of COVID-19 pneumonia. CASE PRESENTATION: A 75 year old female with a 180-pack year smoking history presented to the emergency department with dyspnea and chest discomfort. Vital signs significant for oxygen saturation at 93% on room air. The patient had been admitted to the hospital 7 months prior for acute hypoxemic respiratory failure due to COVID-19 pneumonia. At that point, computed tomography (CT) of the chest showed a right lower lobe 5.5 cm juxtapleural lesion measuring fluid attenuation by Hounsfield units without intralesional enhancement. The lesion was initially thought to be secondary to the patient's COVID-19 pneumonia and was not investigated further. The patient was subsequently lost to follow up. Seven months later the patient presented with worsening shortness of breath. Chest CT revealed large right complex pleural effusion with near complete lung collapse. The patient underwent pigtail catheter placement with partial re-expansion of the lung. Pleural fluid analysis showed an exudative effusion with no malignant cells on cytology. Follow-up CT imaging showed a large mass-like area in the right mid and lower hemithorax. Video assisted thorascopic surgery (VATS) decortication and thoracotomy revealed a right lower lobe abscess and empyema. Pathology samples collected during procedure showed malignant cells of sarcamatoid features found in right lung and intraparenchymal lymph nodes. Histology and immunostaining showed a tumor composed of a component of poorly differentiated adenocarcinoma and more than 10% spindle/pleomorphic cells. Immunostaining showed the poorly differentiated adenocarcinoma component was positive for moc 31, Ber-EP4, cytokeratin AE1/AE3, CAM 5.2, lack TTF-1 and p40. The spindle/pleomorphic component was negative for cytokeratins. DISCUSSION: Pulmonary pleomorphic carcinoma (PC) is a rare, poorly differentiated non-small cell lung cancer (NSCLC) that contains at least 10% spindle and/or giant cells or a carcinoma consisting only of spindle and giant cells. PC has poor response to conventional treatments for NSCLC and subsequently poor 5 year survival. It more common in men and smokers. COVID-19 causes a variety of pulmonary radiographic manifestations, including nodules and mass-like consolidations. Superimposed bacterial infections are also common. Our case, however, highlights the importance of serial radiographic monitoring and, when indicated, tissue sampling to rule out alternative explanations for abnormal CT findings. CONCLUSIONS: Appropriate screening and careful follow up of suspicious lung lesions is vital to ensure prompt diagnosis and treatment of lung malignancy. Reference #1: WHO Classification of Tumours Editorial Board. Thoracic Tumours. In: WHO Classification of Tumours,Earke 5th ed, IARC Publications, 2021. Vol 5. Reference #2: Ito K, Oizumi S, Fukumoto S, Harada M, Ishida T, Fujita Y, Harada T, Kojima T, Yokouchi H, Nishimura M;Hokkaido Lung Cancer Clinical Study Group. Clinical characteristics of pleomorphic carcinoma of the lung. Lung Cancer. 2010 May;68(2):204-10. doi: 10.1016/j.lungcan.2009.06.002. Epub 2009 Jul 3. PMID: 19577320. Reference #3: Maneenil K, Xue Z, Liu M, Boland J, Wu F, Stoddard SM, Molina J, Yang P. Sarcomatoid Carcinoma of the Lung: The Mayo Clinic Experience in 127 Patients. Clin Lung Cancer. 2018 May;19(3):e323-e333. doi: 10.1016/j.cllc.2017.12.008. Epub 2017 Dec 21. PMID: 29454534. DISCLOSURES: No relevant relationships by Rachel Earle No relevant relationships by Samantha Gillenwater No relevant relationships by Miquel Gonzalez No relevant relationships by Sikandar Khan No relevant relationships by Christopher Lau no disclosure submitted for Jinesh Mehta;

19.
Chest ; 162(4):A1635-A1636, 2022.
Article in English | EMBASE | ID: covidwho-2060850

ABSTRACT

SESSION TITLE: Challenges in Lung Tumors SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Patients can have a variety of post Coronovirus induced disease (COVID) associated interstitial lung diseases (ILD) ranging from cystic lung disease to fibrinous organizing pneumonia. However, very little is known about malignancies that have been overshadowed by post COVID associated pulmonary changes. We present one such case of insidious invasive mucinous adenocarcinoma of the lung that was masked by post COVID related changes. CASE PRESENTATION: A 70 year old female with COPD, systolic heart failure and significant tobacco use disorder presented with progressively worsening hypoxemic respiratory failure. She has had 4 hospitalizations in past year all for acute on chronic hypoxemic respiratory failure following COVID. She has been on Supplemental Oxygen 3L/min since her infection with SARS-COV2. Patient was found to have worsening bibasilar ground glass opacities (GGO) on CT of chest over the past 1 year since having COVID. She was treated with several rounds of steroids without any relief. Patient had a PET scan that showed a very avid left upper lobe consolidation. Given these worsening abnormalities and symptoms, she underwent bronchoscopy with transbronchial biopsy guided by the positive PET scan and fluoroscopy. However, during bronchoscopy she had copious secretions which were therapeutically cleared helping relieve some of patient's hypoxemia. All her cultures and Fungitell assay on bronchoalveolar lavage were negative. However, post biopsy pathology came back positive for Invasive Mucinous Adenocarcinoma. Patient was treated with chemo and radiation therapy with good response against her malignancy and significant relief in her hypoxemia. DISCUSSION: COVID associated pneumonia is well known to cause chronic hypoxemic respiratory failure. Post COVID related pulmonary changes range from organizing pneumonia to fungal pneumonia. However, patients should start to recover with time as inflammatory changes resolve on CT scan with adequate steroids or anti-fungals. If patients continue to deteriorate then a prompt work-up that rules out other infections and even malignancies is warranted as seen in our patient. This case brings forth an important consideration for aggressively pursuing an adequate work-up in the face of worsening GGO on the CT and patient's continual deterioration due to her hypoxemic respiratory failure. Our patient was able to be adequately diagnosed with malignancy and was then started on chemotherapy that allowed for adequate control of her hypoxemic respiratory failure and helped improve her quality of life. CONCLUSIONS: Post COVID related pulmonary changes can be from a variety of ILD and infections. However, clinician should be vigilant in considering malignancy as a possible etiology of post COVID related changes and initiate an adequate work-up to help evaluate for cancer that can be masked amongst post COVID related ILD. Reference #1: Beck KS, Sung YE, Lee KY, Han DH. Invasive mucinous adenocarcinoma of the lung: Serial CT findings, clinical features, and treatment and survival outcomes. Thorac Cancer. 2020 Dec;11(12):3463-3472. doi: 10.1111/1759-7714.13674. Epub 2020 Oct 5. Reference #2: Matsui T, Sakakura N, Koyama S, Nakanishi K, Sasaki E, Kato S, Hosoda W, Murakami Y, Kuroda H, Yatabe Y. Comparison of Surgical Outcomes Between Invasive Mucinous and Non-Mucinous Lung Adenocarcinoma. Ann Thorac Surg. 2020 Nov 24:S0003-4975(20)32001-4. doi: 10.1016/j.athoracsur.2020.09.042. Epub ahead of print. Reference #3: Lee MA, Kang J, Lee HY, Kim W, Shon I, Hwang NY, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Spread through air spaces (STAS) in invasive mucinous adenocarcinoma of the lung: Incidence, prognostic impact, and prediction based on clinicoradiologic factors. Thorac Cancer. 2020 Nov;11(11):3145-3154. doi: 10.1111/1759-7714.13632. Epub 2020 Sep 25. DISCLOSURES: No relevant relationships by Danya Ahmed No relevant relationships by David Chambers No rele ant relationships by Jalal Damani No relevant relationships by Deon Ford No relevant relationships by Rachaita Lakra

20.
Chest ; 162(4):A1572, 2022.
Article in English | EMBASE | ID: covidwho-2060842

ABSTRACT

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pulmonary clinicians are all too familiar with the ground-glass and consolidative pulmonary opacities that are the hallmark of COVID-19 pneumonia on imaging. As the pandemic continues, we encounter an ever-growing list of complications of SARS-CoV-2 infection. Pneumatoceles are thin-walled, gas-filled spaces within the lungs that occur in association with pneumonia or chest trauma and typically resolve spontaneously1 but may rupture and cause pneumothorax2. Reports of pneumatoceles due to COVID-19 are uncommon. In this case report, I describe a patient who developed large bilateral pneumatoceles as a complication of COVID-19. CASE PRESENTATION: A 25-year-old male non-smoker with no significant past medical history presented with dyspnea after a lab-confirmed diagnosis of COVID-19 nine days prior. Initial chest radiograph showed multifocal bilateral airspace infiltrates consistent with COVID-19 pneumonia. He was admitted for management of acute hypoxic respiratory failure and treated with dexamethasone, remdesivir, and tocilizumab. He required heated high-flow nasal cannula oxygen up to 60 LPM but did not require CPAP or mechanical ventilation. On hospital day 5 he developed increasing tachypnea and exertional desaturation. CT pulmonary angiogram (CTPA) ruled-out pulmonary embolus but revealed progression of bilateral infiltrates and extensive pneumomediastinum with subcutaneous air in the neck and chest wall, and no clear evidence for pneumothorax. The patient discharged on day 12 with oxygen but returned 2 days later with new onset hemoptysis. CTPA on admission showed new bilateral pneumothoraces and he was transferred to a quaternary hospital for intensive care where bilateral chest tubes were placed. Repeat CT Chest after lung expansion revealed bilateral cystic areas within the lungs initially concerning for necrotizing infection. Bacterial and fungal cultures were negative. Despite resolution of the pneumothoraces and removal of chest tubes, he continued to experience hemoptysis and chest pain. CT Chest demonstrated enlargement of now clearly very large pneumatoceles with air-fluid levels. After conservative management and discharge, a 6-week surveillance CT showed significant decrease in the pneumatoceles but a new moderate-to-large right pneumothorax. Ultimately after 2 more admissions and 90 days since COVID-19 diagnosis, he underwent wedge resection and mechanical pleurodesis for definitive management of secondary pneumothoraces. DISCUSSION: A pneumatocele, especially when large and containing an air-fluid level, may mimic hydropneumothorax, empyema, or pulmonary abscess among other diagnoses. Failure to recognize a pneumatocele and differentiate it from other conditions could lead to inappropriate treatment and cause patient harm3. CONCLUSIONS: It is important to recognize pneumatoceles as a potential complication in the post COVID-19 setting to guide appropriate management. Reference #1: Quigley, M. J., & Fraser, R. S. (1988). Pulmonary pneumatocele: pathology and pathogenesis. AJR. American journal of roentgenology, 150(6), 1275–1277. https://doi.org/10.2214/ajr.150.6.1275 Reference #2: Odackal, J., Milinic, T., Amass, T., Chan, E. D., Hua, J., & Krefft, S. (2021). A 28-Year-Old Man With Chest Pain, Shortness of Breath, and Hemoptysis After Recovery From Coronavirus Disease 2019 Pneumonia. Chest, 159(1), e35–e38. https://doi.org/10.1016/j.chest.2020.07.096 Reference #3: Jamil A, Kasi A. Pneumatocele. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556146/ DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: 2018 to present Added 04/01/2022 by Erin Peterson, value=Honoraria

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