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1.
Front Oncol ; 12: 1014786, 2022.
Article in English | MEDLINE | ID: covidwho-2080208

ABSTRACT

Background: The SARS-CoV-2 pandemic has slowed down cancer prevention and treatment strategies; consequently, cancer patients are prioritized to get the COVID-19 vaccines. Being constantly threatened by a new outbreak, the dive within the immunogenicity response is of great value; nonetheless, evaluating the side effects of these vaccines on fragile patients will assure their adherence to the vaccination protocol. Objectives: This study sets out to investigate the adverse events reported about the vaccine according to its doses and types, and to compare the prevalence and severity of toxicities across two subgroups of cancer patients, those who received the injection during active therapy cycles, and those who have not started the therapy yet at vaccination time, moreover, this paper examines the will and commitment of this population to the vaccination schemes. Methods: This is an observational, retrospective, cohort study, in which we conducted a semi-constructed interview with 415 random solid cancer patients treated at the National Institute of Oncology in Morocco. The assessment of adverse events was carried out with a standardized scale. Results: Eleven months after the launch of the campaign, 75.2% of patients received at least one dose of the vaccine. Altogether, the analysis demonstrates a significant difference between the adverse effects reported post the second dose compared to the first one (p=0.004; odds ratio=2 [95% CI: 1.23 - 3.31]). Besides, the results indicate an increase in the rank of the severity of systemic events (p<0.001, r=0.28) after the second dose, but not for the local events (p=0.92, r=0.005). In the adjusted subgroup analysis, no effect was detected linking active therapy with the occurrence of toxicity (p=0.51, v=0.04) as well as with the level of severity reported after both; the first and second dose. Due to the fear of interactions with the therapy, we noticed a significant trend to delay the booster dose among the participants who completed the initial vaccine protocol. Conclusion: A considerable body of evidence exists to persuade cancer patients to take the Coronavirus vaccines, and to also follow their vaccination schemes under the supervision of their treating physicians.

2.
Blood ; 140(3):236-252, 2022.
Article in English | Web of Science | ID: covidwho-2070701

ABSTRACT

The coronavirus infectious disease (COVID-19) shows a remarkable symptomatic heterogeneity. Several risk factors including advanced age, previous illnesses, and a compromised immune system contribute to an unfavorable outcome. In patients with hematologic malignancy, the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is significantly reduced explaining why the mortality rate of hematologic patients hospitalized for a SARS-CoV-2 infection is about 34%. Active immunization is an essential pillar to prevent SARS-CoV-2 infections in patients with hematologic malignancy. However, the immune response to SARS-CoV-2 vaccines may be significantly impaired, as only half of patients with hematologic malignancy develop a measurable antiviral antibody response. The subtype of hematologic malignancy and B cell-depleting treatment predict a poor immune response to vaccination. Recently, antiviral drugs and monoclonal antibodies for pre-exposure or postexposure prophylaxis and for early treatment of COVID-19 have become available. These therapies should be offered to patients at high risk for severe COVID-19 and vaccine nonresponders. Importantly, as the virus evolves, some therapies may lose their clinical efficacy against new variants. Therefore, the ongoing pandemic will remain a major challenge for patients with hematologic malignancy and their caregivers who need to constantly monitor the scientific progress in this area.

3.
Archives of Pediatric Infectious Diseases ; 10(4) (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2067103

ABSTRACT

Background: Given that immunocompromised patients are more at risk for the infection of SARS-CoV-2, epidemiological data are critical for assessing the corresponding prevalence among health care workers (HCWs) and patients at health centers. Objective(s): This study aims to investigate the prevalence of SARS-CoV-2 infection among the staff of two hospitals that take care of immunocompromised patients, including pediatrics and adults with special medical conditions. Method(s): This cross-sectional study includes all HCWs of the two hospitals;Abu Ali Sina Transplant Hospital (AASTH) and Amir al-Momenin Burn Injury Hospital (AABIH) in Shiraz, southern Iran, conducted from April 11, 2020, to June 16, 2021. The TaqMan real-time PCR assay was used to assess the SARS-CoV-2 infection rate in the suspected HCWs. Result(s): Out of 1232 sampled HCWs, 694 (56%) were female. Two hundred sixty-five samples (21.5%) and 967 samples (78.5%) were prepared from AABIH, and AASTH, respectively. The results showed that 30% (373) of the clinically suspected employees had positive test results. There was a significant correlation between the risk of exposure to COVID-19 patients and the PCR positivity rate, which could be explained by the fact that 58% of the infected HCWs were in a high-risk group, 20% medium-risk, and the remaining 22% were low-risk (P < 0.0001). The rates of positive cases in females were higher than that among male counterparts (P < 0.05). Conclusion(s): In order to protect health care workers and reduce the prevalence and transmission of diseases, deficiencies must be identified and eliminated. Copyright © 2022, Author(s).

4.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P67, 2022.
Article in English | EMBASE | ID: covidwho-2064480

ABSTRACT

Introduction: Tracheostomy is often performed in patients with a prolonged course of endotracheal intubation to minimize sedation, facilitate ventilator weaning, or to address other clinical complexities. However, the clinical benefit of tracheostomy during severe COVID-19 infection is not fully understood. Method(s): A retrospective single-system, multicenter observational cohort study was performed on patients intubated in the setting of COVID-19 infection in the University of Pennsylvania Health System during 2020 and 2021. Patients who received intubation alone were compared with patients who received intubation and subsequent tracheostomy. Data analyses included patient demographics, comorbidities, and hospital course. Result(s): Of 777 patients, 452 were male (58.2%) and 325 were female (41.8%) with a mean age of 62.2+/-15.4 years. A total of 185 (23.8%) patients underwent tracheostomy, and the mean time from endotracheal intubation to tracheostomy was 17.3+/-9.7 days. Medical comorbidities were associated with undergoing tracheostomy, including immunocompromise (odds ratio [OR]=5.2;P<.0001), current smoker (OR=3.3;P=.0034), cardiovascular disease (OR=2.2;P<.0001), and diabetes mellitus (OR=1.5;P=.0344). Tracheostomy was associated with a significantly longer hospital length of stay (57.5+/-32.2 days vs 19.9+/-18.1 days;P<.0001). However, patients who underwent tracheostomy were significantly less likely to expire during their hospitalization than those who did not undergo tracheostomy (OR=2.79;P<.0001). Conclusion(s): The difference in in-hospital mortality between COVID-19 patients who received intubation and those who received both intubation and tracheostomy suggests an association between tracheostomy and improved outcomes in the setting of severe COVID-19 infection.

5.
American Journal of Transplantation ; 22(Supplement 3):598-599, 2022.
Article in English | EMBASE | ID: covidwho-2063361

ABSTRACT

Purpose: Therapies for COVID-19 in immunocompromised (IC) patients (pts), including transplant (tx) pts, are limited. We describe our experience with ALVR109, an allogeneic, partially HLA-matched T-cell product, given through emergency investigational new drug (eIND) application to 4 consecutive IC pts with protracted COVID-19. Method(s): To measure SARS-CoV-2 viral loads, SARS-2 RNA was quantified by RT-PCR (N gene) in plasma and saliva. ALVR109 was manufactured for Allovir at Baylor College of Medicine. Result(s): Between May and October 2021, ALVR109 was given to 4 IC pts with COVID-19 (details in Table 1). 2 pts had lymphoma (1 post auto-tx) and 2 had lung tx. All pts had SARS-CoV-2 RNA detected in plasma (viremia) in the weeks leading up to ALVR109 administration. Infusions (20-40 million cells (MC) per dose) were well-tolerated with no adverse events. Prior to ALVR109, pts 1 and 3 had progressive COVID-19 and ongoing SARS-CoV-2 viremia despite monoclonal antibodies (mABs) and remdesivir. Following ALVR109 administration both patients had a decrease in viremia with marked clinical improvement in pt 1, but both eventually died from their underlying disease. Viral loads (plasma/saliva) and functional scores for pt 1 are shown in the figure. Autopsy of pt 3 showed no evidence of SARS-CoV-2 infection by lung in-situ hybridization (ISH). Pts 2 and 4 received ALVR109 as adjunctive therapy to mABs and remdesivir;viremia continued to decline following ALVR109 and both pts survived and were discharged home. Conclusion(s): This initial experience suggests a potential role of ALVR109 in the treatment of IC and tx pts with COVID-19. SARS-CoV-2-specific T-cells appear to be safe and may control viremia in IC pts. Larger studies are needed to confirm this observation, define the best candidates for ALVR109, and determine optimal timing of administration. (Table Presented).

6.
Chest ; 162(4):A2565-A2566, 2022.
Article in English | EMBASE | ID: covidwho-2060965

ABSTRACT

SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Aspergillus is a group of opportunistic endemic fungal species that causes pathology within the respiratory tract and sinuses of individuals with predisposing factors, such as immunosuppression. While less frequently discussed, aspergillosis thyroiditis represents the most common fungal thyroiditis. We present a case of this condition that was misdiagnosed as amiodarone induced thyrotoxicosis. CASE PRESENTATION: A 54-year-old male was evaluated in outpatient pulmonary clinic after a chest CT revealed new upper lobe mass-like pleural based infiltrates with accompanying symptoms of dyspnea on exertion and fevers. His medical history was significant for orthotopic heart transplant 6 months ago due to a combination of non-ischemic cardiomyopathy with further decompensation from COVID-19 infection. After transplant, he was diagnosed with thyrotoxicosis secondary to amiodarone that was being treated with prednisone and methimazole. Given the concern for infection on imaging, he was admitted to the hospital and underwent urgent bronchoscopic evaluation. During the procedure, he was noted to have severe extrinsic tracheal compression. His neck imaging was consistent with a nodular goiter. The BAL revealed Aspergillosis fumigatus and he was subsequently treated with isavuconazium. Given the compression on the trachea and persistent dyspnea, the decision was to pursue total thyroidectomy. Surgery occurred 2 months after treatment was initiated for the Aspergillosis and with improvement on serial chest CTs. Pathologic examination of the thyroid tissue revealed extensive invasive aspergillus with abscesses involving both lobes. DISCUSSION: Aspergillus infection leading to disseminated disease typically occurs in individuals that have a compromised immune system such as seen in malignancy, solid organ transplant, chronic steroid use, and poorly controlled diabetes mellitus. Recently, it has been cited that up to 15% of hospitalized COVID-19 patients requiring intensive care develop aspergillus infection. After initial aspergillosis infection has been established, the thyroid gland is a site for dissemination due to its rich vascular supply. In addition, due to the angioinvasive properties of the pathogen, the fungus can breakdown tissue planes and easily travel from its site of origin. Thereby a primary infection in the respiratory tract can lead to dissemination to the neck structures due to its proximity. When thyroid invasion occurs, the common complaints are neck pain and swelling. Thyroid laboratory findings encompass the full spectrum including hyperthyroidism, hypothyroidism, and euthyroid. Given these non-specific findings, clinicians need to be conscious of this disease entity. CONCLUSIONS: In patients with immunocompromising conditions, findings of neck pain, swelling, and abnormal thyroid laboratory values should broaden the differential for clinicians to include aspergillosis thyroiditis. Reference #1: Alvi, Madiha M et al. "Aspergillus thyroiditis: a complication of respiratory tract infection in an immunocompromised patient.” Case reports in endocrinology vol. 2013 (2013): 741041. doi:10.1155/2013/741041 Reference #2: Marui, Suemi, et al. "Suppurative thyroiditis due to aspergillosis: a case report.” Journal of Medical Case Reports 8.1 (2014): 1-3. Reference #3: Kuehn, Bridget M. "Aspergillosis Is Common Among COVID-19 Patients in the ICU.” JAMA 326.16 (2021): 1573-1573. DISCLOSURES: No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Kristen Bussa Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting f e Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee No relevant relationships by Haresh Mani No relevant relationships by Mary Beth Maydosz No relevant relationships by Alan Nyquist No relevant relationships by Anju Singhal No relevant relationships by Amy Thatcher

7.
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

8.
Chest ; 162(4):A1776, 2022.
Article in English | EMBASE | ID: covidwho-2060859

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: The most reported fungal infections in patients with COVID-19 include aspergillosis, invasive candidiasis, and mucormycosis. We hereby present a case of a male who developed acute pulmonary histoplasmosis (APH) after COVID-19 infection. CASE PRESENTATION: 51-year-old male with PMHx of COVID-19 infection 3 weeks ago presenting with worsening shortness of breath. Patient had a complicated hospital course with COVID-19 treated with high doses of methylprednisolone. Patient was local to Arizona and lived on a ranch with livestock. CT chest suggestive of multilobar pneumonia and bilateral pleural effusions (Image 1). Coccidiomycosis serology came back negative. Urinary Histoplasma galactomannan antigen came back positive. The diagnosis of APH after COVID-19 infection was established. Patient was started on voriconazole. His symptoms significantly improved. Patient was discharged to skilled nursing facility with outpatient infectious disease follow-up. DISCUSSION: The current literature on APH in the setting of COVID-19 infection is limited. The few proposed mechanisms are: 1. Liberal use of high dose steroids in COVID-19 leading to reactivation of latent H. Capsulatum. 2. Systemic inflammation in COVID-19 causes interstitial lung damage permitting conidia to proliferate leading to acute infection. The Histoplasma urine antigen test is highly sensitive in the diagnosis of APH, especially in immunocompromised patients like our patient. With this case we would like to increase awareness of the possibility of rare fungal infections like APH in patients with COVID-19, as timely diagnosis and appropriate management can lead to improved outcomes. CONCLUSIONS: Rare fungal infections following COVID-19 have been documented and timely diagnosis and management are imperative to improve patient outcomes. Reference #1: Macedo, Priscila M, et al. APH following COVID-19. Case Report J.Fungi 2021 DISCLOSURES: No relevant relationships by Ali Raja no disclosure on file for Yamin Saddouk;No relevant relationships by Parita Soni No relevant relationships by Lyndie Wilkins Parker

9.
Chest ; 162(4):A1764, 2022.
Article in English | EMBASE | ID: covidwho-2060857

ABSTRACT

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: COVID-19 Associated Pulmonary Aspergillosis (CAPA) is a subset of invasive pulmonary aspergillosis occurring in patients actively infected with or recovering from COVID-19. It has mostly been described in immunocompromised or severely ill patients requiring invasive mechanical ventilation[1-6]. The authors report a case of CAPA infection in an ambulatory and immunocompetent patient with prior lung resection. CASE PRESENTATION: A 20-year-old male presented to a Comprehensive Cancer Center for fever and hemoptysis. He carried a diagnosis of metastatic germ cell tumor to his lungs, status post left upper-lobe wedge resection. He had completed bleomycin, etoposide, and cisplatin (BEP) chemotherapy one year earlier. He was recently diagnosed with COVID-19 one month prior to admission and treated as an outpatient with monoclonal antibodies. He reported ongoing cough productive of clear sputum since his diagnosis, which had worsened over the previous two days and was now blood-tinged. He had been afebrile for weeks before noting new fevers over the same period. Physical examination was notable for fever to 38.6°C and lungs clear to auscultation. His labs were significant for a WBC of 14.5 K/mcl (82.5% neutrophils), Cr 2.1 mg/dL (baseline 1.5 mg/dL), and normal platelets and coagulation studies. Serum Aspergillus galactomannan was normal. Repeat SARS-CoV-2 PCR was negative. Chest x-ray was unchanged. V/Q scan showed no evidence of pulmonary embolism. Non-contrast CT chest performed on hospital day #4 revealed a partial opacification and increased wall thickness of patient's largest left upper lobe surgical cavitation (see Image 1). A bronchoscopy was performed day #6, with bronchoalveolar lavage (BAL) galactomannan >5.56 (normal <0.5)7;fungal culture was significant for septate hyphae. He was started on voriconazole with improvement in his symptoms and discharged day #9. DISCUSSION: Immunocompromised patients with prolonged neutropenia, solid-organ or stem cell transplants, and patients with advanced AIDS are at highest risk of contracting PA[8-9]. ARDS secondary to viral pneumonia is also a common precipitant in immunocompetent patients[1-6,10,11]. The exact mechanism of this association remains unknown, but it is postulated to occur due to multiple factors, including host immune dysregulation[1,2], widespread exposure to corticosteroids[1,2], concomitant lung disease[1], and viral-induced lymphopenia[2]. We report a case of an immunocompetent patient with prior lung resection recovering from COVID-19 who experienced a secondary worsening of symptoms ultimately found to have CAPA to further highlight the link between these conditions. CONCLUSIONS: While many of CAPA case reports describe patients with typical risk profiles for CAPA, this case suggests that clinicians should consider structural lung disease alone in an otherwise immunocompetent, ambulatory individual to be a potential risk factor. Reference #1: See Image 2 for full list of references. DISCLOSURES: No relevant relationships by Raphael Rabinowitz No relevant relationships by Matthew Velez

10.
Chest ; 162(4):A1000, 2022.
Article in English | EMBASE | ID: covidwho-2060747

ABSTRACT

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Nocardiosis is a rare bacterial infection, which frequently affects immunocompromised patients. It can present as an acute, subacute, or chronic pulmonary infection with non-specific symptoms, such as fever, cough, dyspnea, weight loss, and hemoptysis. CASE PRESENTATION: A 34-year-old female with a history of chronic granulomatous disease and hidradenitis suppurativa on adalimumab presented to the ED with fever, shortness of breath, and productive cough of 2 days. Her vitals were T 101F, BP 66/48, HR 148, RR 42, and SPO2 94% on room air. On exam, she was cachectic, with bilateral crackles and rales in the right lung base. Extremities were cold, with trace pitting edema was present on bilateral lower extremities. COVID-19 PCR was negative. Despite fluid resuscitation, she remained hypotensive and was started on norepinephrine. Blood cultures were collected, and broad-spectrum antibiotics and an antifungal agent were initiated. Chest CT demonstrated bilateral multifocal consolidation with surrounding ground-glass opacities and complete consolidation of the right lower lobe. Due to worsening respiratory distress and tachypnea, and lack of improvement with non-invasive ventilation, she was intubated, placed on mechanical ventilation, and admitted to the Medical ICU. On hospital day 1, due to the patient's immunosuppression, unresolving shock, and radiographic findings, a bronchoscopy with bronchoalveolar lavage (BAL) was performed. On hospital day 2, a transthoracic echocardiogram showed LV ejection fraction of 20-25% with severe global hypokinesis of the LV. ACS workup had been unremarkable, with mildly elevated troponin and no ischemic changes on EKG. She was initiated on cardiac inotropes. On hospital day 3, BAL culture revealed Nocardia cyriacigeorgica. TMP-SMX and ceftriaxone were started for severe pulmonary nocardiosis. On hospital day 11, she was liberated from mechanical ventilation, and by hospital day 14, she was weaned off all pressors and inotropes. Approximately 4 weeks after admission, repeat TTE showed recovery of LV ejection fraction (55-60%) and she was discharged with a prolonged course of TMP-SMX and IV ceftriaxone, with duration to be determined at outpatient infectious disease follow-up. DISCUSSION: We discuss a unique case of severe pulmonary nocardiosis, presenting with ARDS and cardiogenic shock. To the best of our knowledge, this is the first case of a patient with pulmonary nocardiosis presenting with stress cardiomyopathy reported in the literature. While the pathophysiology is not well understood, theorized mechanisms include catecholamine excess, coronary artery spasm, microvascular dysfunction. CONCLUSIONS: This case highlights the need for a broad differential diagnosis in patients presenting with ARDS and cardiogenic shock and illustrates the value of clinical bronchoscopy in patients with unique presenting features. Reference #1: Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun;22(6):891-903;quiz 904-5. doi: 10.1093/clinids/22.6.891. PMID: 8783685. Reference #2: Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005 Feb 10;352(6):539-48. doi: 10.1056/NEJMoa043046. PMID: 15703419. Reference #3: Park JH, Kang SJ, Song JK, Kim HK, Lim CM, Kang DH, Koh Y. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest. 2005 Jul;128(1):296-302. doi: 10.1378/chest.128.1.296. PMID: 16002949. DISCLOSURES: no disclosure on file for D. Clark Files;No relevant relationships by Nisha Patel No relevant relationships by Meehir Shah

11.
Chest ; 162(4):A954, 2022.
Article in English | EMBASE | ID: covidwho-2060740

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: SARS-CoV-2 pandemic has shown rare and varied presentations of known pathology and infectious processes. We discuss the case of a patient developing bronchial tree ulcerations in the backdrop of SARS-CoV-2 and superimposed infections. CASE PRESENTATION: This was a 59-year-old male with past medical history of B-cell lymphoma, diagnosed with SARS-CoV-2 infection. He was admitted with shortness of breath and increased oxygen requirement. In brief, his hospital course included bilevel positive airway pressure noninvasive ventilation along with steroids, baricitinib and therapeutic anticoagulation. His clinical status worsened to severe acute respiratory distress syndrome and he progressed to mechanical ventilation. While on the ventilator he was treated with paralysis and proning. Due to worsening hypoxia and secretions, he underwent bronchoscopy showing copious thick mucoid white patches and secretions in trachea extending to the right and left mainstem bronchi and extensive mucus plugging. Baricitinib was discontinued and he was placed on empiric micafungin, broad spectrum antibiotics while results were pending. He required repeat bronchoscopy for therapeutic suctioning of recurrent copious thick white secretions with mucus plugging. Cultures resulted as aspergillus fumigatus and micafungin was switched to voriconazole. Two weeks later, in an ongoing prolonged intubated state, he developed cuff leak requiring tube exchange and repeat bronchoscopy, which showed development of multiple bilateral ulcerations with central necrosis and sloughing in the right and left bronchial tree. Repeat lab evaluation of the bronchoscopy samples now resulted in growth of nocardia along with aspergillus species. DISCUSSION: Ulceration of bronchial tree may be seen in malignant lesions, autoimmune conditions, poisoning or toxicology cases. Occurrence of pulmonary ulcerations are rare in infectious cases as sequalae in the SARS-CoV-2 pandemic. Patient's immunocompromised state, with history of B-cell lymphoma, prolonged steroid and JAK inhibitor administration, predisposes to higher propensity of infections. Bronchial tree ulceration also leads to suspicion of viral infections such as herpes, varicella which were found to be negative from bronchial samples. It remains difficult to ascertain if the prolonged aspergillus infection led to progression of white plaques into ulcerations, or the newly diagnosed secondary infection of nocardia caused bronchial tree ulcers. Historically, aspergillus has been associated with blackened ulcerations as opposed to the findings here. Also, patient had been receiving treatment with voriconazole for 2 weeks prior to diagnosis of ulcers, therefore raising suspicion for a rare nocardial etiology as well. CONCLUSIONS: Prolonged intubation in immunocompromised patients may lead to superimposed nocardial and aspergillus infections causing airway ulcerations and increased mortality. Reference #1: Judson MA, Sahn SA. Endobronchial lesions in HIV-infected individuals. Chest. 1994;105(5):1314-1323. doi:10.1378/chest.105.5.1314 Reference #2: Abdel-Rahman N, Izhakian S, Wasser WG, Fruchter O, Kramer MR. Endobronchial Enigma: A Clinically Rare Presentation of Nocardia beijingensis in an Immunocompetent Patient [published correction appears in Case Rep Pulmonol. 2016;2016:1950463]. Case Rep Pulmonol. 2015;2015:970548. doi:10.1155/2015/970548 DISCLOSURES: No relevant relationships by Habiba Hussain No relevant relationships by Matthew Sehring

12.
Chest ; 162(4):A755, 2022.
Article in English | EMBASE | ID: covidwho-2060683

ABSTRACT

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Human cytomegalovirus (CMV) is a herpesvirus with a high prevalence that causes latent disease in immunocompetent hosts. It is an important opportunistic infection with a variety of clinical manifestations, including pneumonia, in immunocompromised patients.[1] CASE PRESENTATION: A 45-year-old man with no past medical history presented with fever and dyspnea and was positive for coronavirus disease 2019 (COVID-19). He developed acute respiratory distress syndrome (ARDS) and was intubated 13 days after presentation, but developed refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation (ECMO) (cannulated 16 days after presentation). He received a 5-day course of remdesivir and 10 days of dexamethasone 6 mg daily. His course was complicated by acute renal failure requiring continuous renal replacement therapy, septic shock due to a pseudomonal ventilator-associated pneumonia, right ventricular failure, heparin induced thrombocytopenia, and right pneumothorax requiring chest tube thoracostomy. After 4 weeks of ECMO there was lung recovery with ECMO sweep gases <1L/minute, improved radiographic appearance and tidal volumes, and decannulation was anticipated. However, he subsequently developed profound shock of unknown etiology with a rapid worsening of his lung function requiring increased ECMO support. Care was withdrawn at ECMO day 46 due to multiorgan failure. Pathology of his lungs at autopsy showed prominent intranuclear viral inclusions and positive immunohistochemistry in alveolar macrophages consistent with a diagnosis of CMV pneumonia. DISCUSSION: While CMV typically causes latent disease it can reactivate in the setting of immunosuppression and/or critical illness.[1] Patients with severe COVID-19 frequently are treated with immunosuppressive therapies, such as corticosteroids, anti-interluekin-6 therapies, and JAK inhibitors. Due to this immunosuppression, opportunistic infections have been reported in these patients.[2] It can be difficult to differentiate COVID-19 pneumonia from other respiratory infections based on imaging and lab studies alone, especially in patients with prolonged mechanical ventilation and with severe parenchymal disease requiring ECMO support. Little is known about the incidence of CMV and COVID-19 coinfection. There are several cases of biopsy-proven CMV pneumonia in immunocompromised critically ill patients with COVID-19, but this is the first reported case in an immunocompetent patient. CONCLUSIONS: This case highlights the need to maintain a high degree of suspicion for CMV pneumonia in patients with severe COVID-19 pneumonia who receive immunosuppressive therapies. While the diagnosis was made at autopsy in this case, it may be possible to arrive at an earlier diagnosis with CMV polymerase chain reaction (PCR) assays sent from the serum and bronchoalveolar lavage (as lung biopsies are usually impractical in ARDS). Reference #1: de la Hoz RE, Stephens G, Sherlock C. Diagnosis and treatment approaches of CMV infections in adult patients. J Clin Virol. 2002 Aug;25 Suppl 2:S1-12. doi: 10.1016/s1386-6532(02)00091-4. PMID: 12361752. Reference #2: Abdoli A, Falahi S, Kenarkoohi A. COVID-19-associated opportunistic infections: a snapshot on the current reports [published online ahead of print, 2021 Aug 23]. Clin Exp Med. 2021;1-20. doi:10.1007/s10238-021-00751-7 DISCLOSURES: No relevant relationships by Nancy Law No relevant relationships by Mazen Odish No relevant relationships by Robert Owens No relevant relationships by Travis Pollema No relevant relationships by Alyssa Self No relevant relationships by Cassia yi

13.
Chest ; 162(4):A625, 2022.
Article in English | EMBASE | ID: covidwho-2060650

ABSTRACT

SESSION TITLE: Unusual Pneumonias SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Cytomegalovirus (CMV) is an important infectious organism in the morbidity and mortality of immunocompromised patients. CMV is a known cause of pneumoina in transplant patients, such as lung transplant recepients. Pneumocytis Jiroveci Pneumonia (PCP) is also a known risk factor for potentially life-threatening infections in immunocompromised patients. In this , we are presenting a rare case of an immunocompromised patient who had penumonia caused by a concurrent CMV and PCP infections. CASE PRESENTATION: A 53 year-old female patient with history of Rheumatoid Arthritis treated with immunomodulating medications admitted for Shortness of breath, fatigue and tiredness but no fever. COVID-19 and influenza infections (PCR) tests were both negative. At presentation, her WBC was 9900. CT with contrast of her chest showed no embolism, but multi-focal widespread groundglass opacities. Blood culture was negative, MRSA screen was negativetoo, but Fungitell test was positive (with a value of more than 500) and serum LDH test was elevated to 382. CMV quantitaive PCR was elevated to 10,000 copies. A bronchoscopy was done and CMV PCR Bronchoalveolar lavage (BAL) is detected at 650 copies/ ml. A BAL EBV PCR tests was negative. Pneumocystis Jiroveci pneumonia was detected on BAL Direct fluorescent antibody test (DFA). CMV retinitis has been ruled out by an ophthalmology exam. Patient was diagnosed with concurrent CMV and PCP pneumonia infection and her respiratory status worsened mandating a brief ICU stay. Treatment was started with Bactrim, Valganciclovir and Ganciclovir with progressive improvement. In a follow up appointment at the infectious diease clinic two months later, the patient condition improved but was still in need for supplemental oxygen through nasal canula. DISCUSSION: A concurrent CMV and PCP microorganisms lung infection is rare, but patient with underlying immunocompromise constitue a major risk factor for that. CONCLUSIONS: Patients with underlying immuncompromise conditions are at risk of many infections with grave morbidity and mortality risks. Though it is a rare to have a concurrent CMV and PCP lung infection, a patient treated with immunomodulating medications including methotrexate, prednisone and rituximab was a culprit for severe infection. Reference #1: Peghin, M., Hirsch, H. H., Len, Ó., Codina, G., Berastegui, C., Sáez, B., Solé, J., Cabral, E., Solé, A., Zurbano, F., López-Medrano, F., Román, A., & Gavaldá, J. (2016). Epidemiology and immediate indirect effects of respiratory viruses in lung transplant recipients: A 5-year prospective study. American Journal of Transplantation, 17(5), 1304–1312. https://doi.org/10.1111/ajt.14042 DISCLOSURES: No relevant relationships by MohD Ibrahim

14.
Chest ; 162(4):A612-A613, 2022.
Article in English | EMBASE | ID: covidwho-2060647

ABSTRACT

SESSION TITLE: TB and TB-Involved Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary Aspergillus infection has a wide array of manifestations. Chronic Pulmonary Aspergillosis is an uncommon progressive respiratory disease, with the Subacute Invasive Pulmonary Aspergillosis form, one of the most challenging to manage. Typically it presents with rapidly progressive infection (of less than 3 months) in mild to moderately immunocompromised patients with underlying structural lung disease. We herein report the case of a 69-year old female with post-tuberculous cavity with disease progression, in approximately 6 weeks, associated with Aspergillus infection. CASE PRESENTATION: Patient is a 69-year old African American female, never smoker, with known history of Type 2 Diabetes Mellitus and previously treated mycobacterium tuberculosis with residual small right upper lobe cavity (measuring approximately 35 x 40 mm). She was being followed in our outpatient thoracic oncology clinic with serial imaging for surveillance, CT Chest initially every 3 - 6 months then annually thereafter with PET scan as clinically indicated. The cavity remained relatively unchanged for approximately 5 years. In October 2021, her CT Chest had revealed a stable cavity, even despite SARS-CoV-2 Pneumonia infection the previous year. The following month she was admitted to an outside hospital for hyperglycemia with notable significant increase in size of the right upper lobe cavity to 69 x 72 mm with surrounding nodularity. She completed a course of antibiotics and was seen in our clinic 3 months post discharge with a repeat CT Chest which now revealed a mass like area of consolidation with large area of lucency and superimposed fungus ball (now measuring 80 mm x 70mm). She underwent Electromagnetic Navigational Bronchoscopy with transbronchial biopsy and right upper lobe bronchoalveolar lavage. BAL culture identified Aspergillus niger, with no other pathogens (including acid fast bacilli isolated) or malignant cells observed. Biopsy revealed marked mixed inflammation and fungal hyphae. Patient is currently undergoing long-term oral antifungal therapy with plan for close surgical follow-up. DISCUSSION: The diagnosis of Chronic Pulmonary Aspergillosis requires a combination of clinical, radiological and histopathological characteristics present for atleast 3 months for diagnosis. This includes the presence of one or more cavities on thoracic imaging, evidence of aspergillus infection or an immunological response to aspergillus as well as excluding alternative diagnoses. Advances in diagnostic tools have improved early diagnosis and subsequent management as noted in our case. Surgical resection is recommended for simple aspergilloma, however rapidly progressive disease processes are recommended to be managed as invasive aspergillosis. CONCLUSIONS: Post-tuberculosis chronic pulmonary aspergillosis is an emerging disease with significant associated morbidity and likely health burden. Reference #1: Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management David W. Denning, Jacques Cadranel, Catherine Beigelman-Aubry, Florence Ader, Arunaloke Chakrabarti, Stijn Blot, Andrew J. Ullmann, George Dimopoulos, Christoph Lange European Respiratory Journal Jan 2016, 47 (1) 45-68;DOI: 10.1183/13993003.00583-2015 Reference #2: Bongomin F. Post-tuberculosis chronic pulmonary aspergillosis: An emerging public health concern. PLoS Pathog. 2020;16(8):e1008742. Published 2020 Aug 20. doi:10.1371/journal.ppat.1008742 DISCLOSURES: No relevant relationships by Omotooke Babalola No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Sulaiman Tijani

15.
Chest ; 162(4):A605-A606, 2022.
Article in English | EMBASE | ID: covidwho-2060646

ABSTRACT

SESSION TITLE: Chest Infections in Immunocompromised Patients Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection caused by Pneumocystis jirovecii. HIV-negative patients with PCP are primarily individuals receiving immunosuppressive therapy for other disease processes. In rare instances, PCP could be an initial manifestation of underlying defected or suppressed cell-mediated immunity that needs to be diagnosed to prevent morbidity and mortality. CASE PRESENTATION: 75-year-old female with a history of hypertension and hypothyroidism presented to the emergency department for evaluation of cough, fever, and shortness of breath gradually worsening over the last few weeks. She received outpatient treatment with no improvement. She was vaccinated against covid-19. On presentation, the temperature was 103F, heart rate was 108 bpm, blood pressure was 163/93 mm Hg, and oxygen saturation was 86% on room air. Hemogram showed leukocytosis with left shift with elevated inflammatory markers. Chest X-ray revealed bilateral ground glass opacities. She was started on broad-spectrum antibiotics, but symptoms worsened over the next few days. CT chest showed diffuse bilateral ground glass opacities with prominent interstitial markings. BAL obtained from bilateral upper lobes was lymphocyte predominant with pneumocystis jirovecii diagnosed on Gomori methenamine silver (GMS) staining. She was started on PCP-directed antibiotics with intravenous glucocorticoids, and workup for an underlying immunodeficiency was started. Subsequent BATS biopsy revealed diffuse organizing alveolar damage, with possible associated acute interstitial pneumonia pattern. This could be a rare manifestation of PCP or a primary presentation in the appropriate clinical setting. Autoimmune panel, leukemia, and lymphoma panel came back negative. AFB smear, HIV, EBV, CMV, HTLV I/II also returned negative. The lymphocyte subset panel revealed a CD4 count of 205 and a subsequent count a few days later of 64 with decreased total IgG. The patient was treated with high dose steroids for an extended period along with treatment for PCP however continued to decline clinically. The patient and family eventually decided to pursue comfort care. DISCUSSION: The predisposition to PCP in patients is primarily due to a decrease in cell-mediated immunity regardless of HIV infection. In our patient, the etiology of idiopathic CD4+ T cell lymphocytopenia cannot be determined due to the lack of serial laboratory data measurement. One of the proposed etiologies of ICL is systemic persistent immune activation in the setting of exogenous mRNA, the current technology that is being widely used for vaccine development. CONCLUSIONS: In this era of biotechnology, with advancements in immunosuppressive therapy and mRNA-based vaccines, increased awareness around the potential immune system activation and potential downstream complications needs to be further highlighted to raise awareness among physicians. Reference #1: Li, Y., Ghannoum, M., Deng, C., Gao, Y., Zhu, H., Yu, X., & Lavergne, V. (2017). Pneumocystis pneumonia in patients with inflammatory or autoimmune diseases: usefulness of lymphocyte subtyping. International Journal of Infectious Diseases, 57, 108-115. Reference #2: Pardi, N., Hogan, M. J., Porter, F. W., & Weissman, D. (2018). mRNA vaccines - a new era in vaccinology. Nature reviews. Drug discovery, 17(4), 261–279. https://doi.org/10.1038/nrd.2017.243 Reference #3: Vijayakumar, S., Viswanathan, S., & Aghoram, R. (2020). Idiopathic CD4 Lymphocytopenia: Current Insights. ImmunoTargets and therapy, 9, 79–93. https://doi.org/10.2147/ITT.S214139 DISCLOSURES: No relevant relationships by Santhosh Gheevarghese John No relevant relationships by Konstantin Golubykh No relevant relationships by Iuliia Kovalenko No relevant relationships by Maidah Malik No relevant relationships by Hafiz Muhammad Siddique Qurashi No relevant relationships by Taj Rahman No rel vant relationships by Tabinda Saleem

16.
Chest ; 162(4):A562-A563, 2022.
Article in English | EMBASE | ID: covidwho-2060632

ABSTRACT

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pneumocystis jirovecii pneumonia (PJP) remains a significant cause of morbidity and mortality in the immunocompromised population. It can be difficult to discern the radiographic imaging of COVID-19 from PJP. This case describes a noncompliant HIV positive male with remote history of PCP pneumonia and COVID-19 pneumonia who presents with simultaneous recurrence of both disease processes. CASE PRESENTATION: A 45-year-old male with PMH of HIV/AIDS noncompliant on ART (CD4+ 10) presented for evaluation of exertional dyspnea and productive cough for the past 2 weeks. Of note, patient had a history of covid-19 pneumonia about 15 months ago when he was treated with remdesivir and steroids and required supplemental oxygen support. He was also admitted about 8 months prior for PJP pneumonia and underwent treatment with steroids and TMP-SMX for 21 days also requiring supplemental oxygen support. During this presentation, initial vital signs showed: T 36.5 C HR 98 BP 112/63 RR 20 saturating 95% breathing ambient air. ABG on presentation showed PaO2 65 while breathing room air. Physical exam suggested bilateral crackles diffusely with chest radiography significant for increased interstitial markings bilaterally. CT chest showed bilateral groundglass changes suggestive of inflammatory process. He was initially started on antibiotic coverage with azithromycin, ceftriaxone, and TMP-SMX as the initial differential included PJP recurrence since he was noncompliant on secondary prophylaxis after recent infection. He was also started on steroids due to low PaO2. SARS-CoV-2 PCR returned positive however, the low CD4+ count, and a positive serum B-D-glucan assay prompted us to schedule a bronchoscopy to evaluate for PJP pneumonia. BAL showed positive silver stain along with bronchial wash was elevated PCR for PJP (5.6 million copies/mL). A diagnosis of concurrent COVID-19 pneumonia and PJP pneumonia was made. Patient did not receive remdesivir during this admission since his oxygenation began to improve during the hospitalization. Patient was discharged on appropriate regiment for PJP pneumonia and continued steroid taper. He was seen as a follow-up in outpatient clinic about 2 months later compliant on his ART regimen and secondary PJP prophylaxis (CD4 120). DISCUSSION: If it wasn't for the serum B-D-glucan, we likely would not have pursued further causes for hypoxia in an otherwise COVID-19 positive patient with characteristic radiographic findings. The sheer co-incidence and concurrent nature of presentation of these two disease processes make our case extremely unique. Going forward, it is reasonable to keep PJP in the differential when treating a hypoxic immunocompromised patient even if an alternative cause for hypoxia is present. CONCLUSIONS: Herein we present a case of a patient with remote history of COVID-19 pneumonia and PJP pneumonia now presenting with a simultaneous co-infection. Reference #1: Mouren, D., Goyard, C., Catherinot, E., Givel, C., Chabrol, A., Tcherakian, C., Longchampt, E., Vargaftig, J., Farfour, E., Legal, A., Couderc, L. J., & Salvator, H. (2021). COVID-19 and Pneumocystis jirovecii pneumonia: Back to the basics. Respiratory medicine and research, 79, 100814. https://doi.org/10.1016/j.resmer.2021.100814 Reference #2: Huang, L., Cattamanchi, A., Davis, J. L., Boon, S. d., Kovacs, J., Meshnick, S., Miller, R. F., Walzer, P. D., Worodria, W., & Masur, H. (2011). HIV-associated Pneumocystis pneumonia. Proceedings of the American Thoracic Society, 8(3), 294–300. https://doi.org/10.1513/pats.201009-062wr Reference #3: Tasaka, S. (2015). pneumocystis pneumonia in human immunodeficiency virus–infected adults and adolescents: Current concepts and Future Directions. Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine, 9s1. https://doi.org/10.4137/ccrpm.s23324 Group, T. R. C. (2020). Dexamethasone in hospitalized patients with covid-19. (2021). New England Journal of Medicine, 384(8), 693–704. https://doi.org/10.1056/nejmoa2021436 KOLDITZ, M., HALANK, M., BANDT, D., SPORNRAFT-RAGALLER, P., & HÖFFKEN, G. (2009). Early recurrence ofPneumocystis jirovecipneumonia in two HIV-infected patients: Linking infection relapse and immune reconstitution syndrome. Respirology, 14(6), 910–912. doi:10.1111/j.1440-1843.2009.01583.x Mussini C, Pezzotti P, Antinori A, Borghi V, Monforte Ad, Govoni A, De Luca A, Ammassari A, Mongiardo N, Cerri MC, Bedini A, Beltrami C, Ursitti MA, Bini T, Cossarizza A, Esposito R;Changes in Opportunistic Prophylaxis (CIOP) Study Group. Discontinuation of secondary prophylaxis for Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients: a randomized trial by the CIOP Study Group. Clin Infect Dis. 2003 Mar 1;36(5):645-51. doi: 10.1086/367659. Epub 2003 Feb 12. PMID: 12594647. DISCLOSURES: No relevant relationships by Mourad Ismail No relevant relationships by Carlos Palacios No relevant relationships by Rutwik Patel

17.
Chest ; 162(4):A537, 2022.
Article in English | EMBASE | ID: covidwho-2060622

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Persistent acute symptoms of coronavirus disease 2019 (Covid-19) have been previously described in patients receiving immunosuppression, and have additionally been associated with the development of new variants of the SARS-CoV-2 virus. Here follows a report of a similar case which eventually responded to treatment with antiviral and monoclonal antibody therapies. CASE PRESENTATION: The patient is a 51 year old male with a past medical history of bilateral optic neuritis (treated with rituximab), polysubstance use disorder, bipolar disorder, and hypertension. He initially presented to the emergency department in January 2022 with symptoms of shortness of breath, cough, and worsening fatigue over the preceding 3-4 weeks. On presentation he required intubation for hypoxia. A PCR test for SARS-CoV-2 returned positive and he was initiated on treatment with intravenous dexamethasone and antibiotics for presumed community acquired pneumonia. He was extubated 4 days later, but remained hospitalized for a further 6 weeks due to recurrent fevers and a persistent supplemental oxygen requirement. Due to concern for viral-induced cryptogenic organizing pneumonia he was started on high-dose intravenous steroids. However, he developed escalating oxygen requirements resulting in a second intubation to facilitate bronchoscopy, results of which were non-diagnostic. Serum testing for SARS COV2 IgG antibody, 10 weeks after the initial onset of his symptoms, returned negative, therefore he was then treated with a 5 day course of remdesivir, as well as monoclonal antibody therapy with casirivimab-imdevimab. He additionally underwent a VATS lung biopsy for definitive tissue diagnosis, which revealed interstitial inflammation with patchy fibroblastic linear nodules, consistent with diffuse alveolar damage. He was extubated and had improvement in his oxygen requirements and respiratory function, and was planned for discharge to pulmonary rehabilitation almost 3 months after his initial presentation. DISCUSSION: Patients receiving immunosuppression remain at risk for persistent symptoms, prolonged hospitalization, and increased morbidity and mortality, when infected with SARS-CoV-2. Notably, the patient described here had received only 2 doses of an FDA-approved COVID-19 vaccine at the time of his infection, and was being treated with rituximab for optic neuritis, with his last infusion being approximately one month before the onset of his symptoms. Such prolonged, symptomatic infection from SARS-CoV-2 remains a clinical concern, especially due to its association with the development of new viral variants, and further research into appropriate treatment for these patients continues to be investigated. CONCLUSIONS: This case demonstrates an immunocompromised patient with persistent symptoms of Covid-19 who eventually responded to treatment with the antiviral remdesivir, as well as monoclonal antibodies. Reference #1: Choi B, Choudhary MC, Regan J, et al. Persistence and evolution of SARS-CoV-2 in an immunocompromised host. N Engl J Med 2020;383:2291-2293. DISCLOSURES: No relevant relationships by Vivek Sinanan

18.
Chest ; 162(4):A495, 2022.
Article in English | EMBASE | ID: covidwho-2060611

ABSTRACT

SESSION TITLE: Severe and Unusual Blastomycosis Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: The diagnosis of blastomycosis is often delayed due to its non-specific symptoms and imaging findings. Clinicians must have a high clinical index of suspicion to diagnose blastomycosis in a timely manner, especially in the setting of the current COVID-19 pandemic. CASE PRESENTATION: A healthy 44-year-old male presented to an urgent care center with complaints of cough, fevers, and malaise. CT scan of the chest revealed a left upper lobe mass concerning for rounded bacterial pneumonia versus malignancy. He was found to be COVID-19 positive. The patient was sent home with steroids and antibiotics. Three months later, a repeat CT scan of the chest was obtained which revealed progression of the consolidation and prompted further evaluation at the hospital. On presentation, he reported a persistent cough, weight loss, and the development of multiple painful nodules on his extremities and trunk within the past week. A skin lesion was biopsied. A bronchoscopy was also performed for biopsy and brushing. Biopsy of the skin lesion as well as specimens collected from the bronchoscopy resulted positive for Blastomyces. MRI of the brain demonstrated multiple enhancing lesions concerning for septic emboli. He was started on amphotericin B for treatment of disseminated blastomycosis with central nervous system (CNS) involvement. Repeat imaging of the brain and chest about 3 weeks after initiation of therapy showed interval decrease in the size of the lesions. He was then transitioned to oral itraconazole and discharged home. DISCUSSION: Blastomycosis is an endemic fungal infection that can affect immunocompetent and immunocompromised hosts. It tends to infect immunocompetent hosts more so than other invasive fungal infections. Symptoms can range from asymptomatic to rapidly progressive acute respiratory distress syndrome (ARDS). Disseminated blastomycosis has been reported in 20-50% of patients (1). In the above case, an immunocompetent patient developed pulmonary and dermatologic manifestations concerning for disseminated blastomycosis. Though he had no recent travel, occupational exposures, or contact with any construction work, the patient was living in an endemic area for Blastomyces. It is difficult to definitively ascertain if the patient already had pulmonary blastomycosis when he was diagnosed with COVID-19, but his extrapulmonary manifestations clearly developed after the diagnosis. Earlier detection and treatment of the pulmonary blastomycosis may have prevented the dissemination of the disease. CONCLUSIONS: This case serves as a reminder to consider other infectious etiologies, like endemic fungal infections, in the midst of the COVID-19 pandemic to prevent delays in treatment and progression of these diseases. Reference #1: McBride JA, Gauthier GM, Klein BS. Clinical Manifestations and Treatment of Blastomycosis. Clin Chest Med. 2017 Sep;38(3):435-449. doi: 10.1016/j.ccm.2017.04.006. Epub 2017 Jun 12. PMID: 28797487;PMCID: PMC5657236. Reference #2: Cafardi J, Haas D, Lamarre T, Feinberg J. Opportunistic Fungal Infection Associated With COVID-19. Open Forum Infect Dis. 2021 Jan 18;8(7):ofab016. doi: 10.1093/ofid/ofab016. PMID: 34621913;PMCID: PMC7928619. DISCLOSURES: No relevant relationships by Shannon Burke No relevant relationships by Abigail Go No relevant relationships by Jen Minoff No relevant relationships by David Stoeckel

19.
Chest ; 162(4):A494, 2022.
Article in English | EMBASE | ID: covidwho-2060610

ABSTRACT

SESSION TITLE: Procedures in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumocystis jirovecii pneumonia (PJP) is known to cause potentially life-threatening pneumonia in patients on immunosuppressive therapy. Here we describe a case of an elderly man on low dose methotrexate with PJP pneumonia initially mistaken for drug induced pneumonitis. CASE PRESENTATION: A 79 year old man with T-cell large granular lymphocytic leukemia on methotrexate, indeterminate colitis on azathioprine and sulfasalazine and interstitial lung disease was admitted for 3 week history of worsening dyspnea, lethargy and cough. On arrival his oxygen saturation was 87% on room air, requiring 5 liters oxygen via nasal canula. Lung examination was notable for bilateral crackles. Laboratory studies showed white blood cell count 12.4k/μL, lactate 2.7mmol/L, procalcitonin 0.137ng/mL, lactate dehydrogenase(LDH) 925 IU/L, 1,3 β-D glucan elevated at 154pg/mL. Infectious work up including COVID-19 testing was unremarkable. Chest radiograph showed bilateral diffuse interstitial infiltrates (figure 1) and computed tomography (CT) scan showed peripheral reticular changes and patchy ground glass opacities bilaterally (figures 2;3). He was initially treated for possible bacterial pneumonia;then with 125mg of methylprednisolone for presumed methotrexate induced pneumonitis without improvement. He underwent bronchoscopy with bronchoalveolar lavage(BAL) gram stain showing numerous histiocytes and scattered lymphocytes;no infectious organisms were isolated. PJP PCR from BAL came back positive and trimethoprim-sulfamethoxazole (TMP-SMX) was started. Despite maximum therapy he deteriorated clinically, transitioned to comfort care and expired. DISCUSSION: Diagnosis of PJP is made by visualization of cystic or trophic forms in respiratory tissue obtained via biopsy, BAL or sputum. Fungal burden is typically lower in non-HIV patients with PJP, and may result in negative BAL or sputum stain. Thus PCR testing is a useful diagnostic tool. Positive PCR alone cannot distinguish between colonization and active disease, and should be performed when clinical suspicion is high. 1,3 β-D glucan and LDH are nonspecific markers that help in presumptive diagnosis. First line therapy for PJP is TMP-SMX, with atovaquone, dapsone and pentamidine available as alternative therapies. Duration of therapy should be at least 21 days. Adjunctive corticosteroids show survival benefit in HIV-infected individuals. In severely hypoxic patients, corticosteroids are beneficial if started within 72 hours of antibiotic initiation. Their use in non-HIV PJP cases remains controversial. CONCLUSIONS: This case highlights the risk of PJP with long term methotrexate therapy. Cough, hypoxemia and bilateral interstitial infiltrates should prompt work-up for PJP. Timely recognition and early treatment are crucial to prevent mortality. Further studies are needed to assess the efficacy and provide guidelines for primary prophylaxis in this population. Reference #1: Wilson JW, Limper AH, Grys TE, Karre T, Wengenack NL, Binnicker MJ. Pneumocystis jirovecii testing by real-time polymerase chain reaction and direct examination among immunocompetent and immunosuppressed patient groups and correlation to disease specificity. Diagn Microbiol Infect Dis. 2011 Feb;69(2):145-52. doi: 10.1016/j.diagmicrobio.2010.10.021. PMID: 21251557;PMCID: PMC6855182. Reference #2: Salzer HJF, Schäfer G, Hoenigl M, Günther G, Hoffmann C, Kalsdorf B, Alanio A, Lange C. Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis jirovecii Pneumonia. Respiration. 2018;96(1):52-65. doi: 10.1159/000487713. Epub 2018 Apr 10. PMID: 29635251 DISCLOSURES: No relevant relationships by Rutendo Jokomo-Nyakabau No relevant relationships by Richard Swaney No relevant relationships by Manasa Velagapudi

20.
Chest ; 162(4):A480, 2022.
Article in English | EMBASE | ID: covidwho-2060605

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: Exposure to anti-CD20 treatment affects B cell functions involved in anti-COVID immunity and impacts the clinical course of infection. We present two patients with persistent respiratory symptoms and persistent SARS-COv-2 PCR positivity months after initial infection. The aim of presenting these cases is to highlight how exposure to Rituximab can result in patients having significantly prolonged SARS-CoV-2 infections that may require special treatment compared to immunocompetent patients. CASE PRESENTATION: Patient A is a 46-year-old man with a history of marginal zone lymphoma, who was treated with six cycles of bendamustine with rituximab and monthly maintenance rituximab. He has been hypoxic for 7 months after COVID infection with ground glass opacities on imaging, elevated CRP of 58.4, positive PCR, undetectable CD3/CD4 and low cycle threshold of 28, suggesting rapid active viral replication. COVID IGG was negative. T cell subsets counts were undetectable. IgG 351, IgA 59, IgM less than 10. He was treated with a 10-day course of Remdesevir and steroids. Given lack of humoral immunity, he was given convalescent plasma. At discharge he developed positive COVID IgG and remained COVID positive by PCR. He had complete resolution of hypoxia. Patient B is a 68-year-old man with a history of chronic lymphocytic leukemia, who was treated with six years of rituximab maintenance therapy, last rituximab was three years ago. He was diagnosed with SARS-CoV-2 three months prior to admission with worsening hypoxia. He remained PCR positive with persistent respiratory symptoms. At readmission his imaging showed ground glass opacities, CRP 6.6 and cycle threshold was 27.8. The follow studies were abnormally low:IgG 541, IgA 25, IgM 14, absolute CD3 171, absolute CD4 68. He was treated with remdesivir, steroids, granulocyte colony stimulating factor and sotrovimab. Despite these therapies, his hypoxia worsened, and he pursued comfort care. DISCUSSION: There are reports of patients receiving B cell depleting therapy who have persistent shedding of viable SARS-CoV. Persistent viral infection may be suspected in patients with relapsing symptoms, elevated CRP, D-dimer and active ground glass changes imaging. Low T cell subsets and low immunoglobulin levels indicate a CD20 related impairment of adaptive immunity. Time to viral clearance appears to be prolonged compared to general population in immunocompromised patients. There is some published experience using convalescent plasma in this setting. SARS-CoV-2 viremia has been demonstrated to predict adverse outcomes. Median cycle threshold has been shown to be lower, reflecting a high viral load comparable with acute infectious phase of COVID. CONCLUSIONS: To achieve stable clinical responses this subset of patients may benefit from early administration of combination regimens, including both passive immunotherapy and prolonged antiviral treatment. Reference #1: Furlan A, Forner G, Cipriani L, Vian E, Rigoli R, Gherlinzoni F, Scotton P. COVID-19 in B Cell-Depleted Patients After Rituximab: A Diagnostic and Therapeutic Challenge. Front Immunol. 2021 Nov 3;12:763412. doi: 10.3389/fimmu.2021.763412. PMID: 34804051;PMCID: PMC8595333. DISCLOSURES: No relevant relationships by Cheryl Augenstein Primary Investigator relationship with Boehringer Ingelheim Please note: 2/2022-2/2024 Added 04/01/2022 by A. Thanushi Wynn, value=Grant/Research Support

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