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1.
International Journal of Innovation and Learning ; 32(3):305-321, 2022.
Article in English | Web of Science | ID: covidwho-2070789

ABSTRACT

Core diagnostic and physical examination skills in neurology are fundamental for aspiring physicians. Merging theory with practical activities is an efficient way to strengthen the learning process. However, SARS-CoV-2 pandemic hard tested the possibility to perform them. This article aims at describing/evaluating the way Humanitas University managed this issue implementing innovative flipped-learning-based activities. The five-day neurology lab was re-designed aiming at avoiding unnecessary contacts, maximising skills acquisition and meeting students' needs, satisfaction, expectations. Mandatory SARS-CoV-2 serology/swab testing before activities' beginning assured every student's safety. Student's satisfaction assessment, performed through two online questionnaires, showed that the new organisation of the neurological lab received significantly higher appreciation compared to previous year's activities. Flipped-learning-based activities helped grasping the essence of different neurological syndromes and the required skills to recognise them. In view of this, we believe that flipped-learning-based activities could constitute a powerful innovative method to build solid knowledge in the neurology field.

2.
Flora ; 27(2):276-285, 2022.
Article in English | EMBASE | ID: covidwho-2067059

ABSTRACT

Introduction: Vaccination plays an important role in all strategic actions against the COVID-19 pandemic. Despite the high safety and efficacy of vaccination, side effects of the vaccines may also occur. The purpose of this study was to evaluate the clinical and sonographic findings and short-term results of cervical and axillary lymphadenopathy after the BNT-162b2 mRNA vaccine. Materials and Methods: The patients who received at least one dose of BNT-162b2 mRNA vaccine between July-September 2021 and were detected to have ipsilateral axillary and cervical lymphadenopathy related closely to the vaccination period, were included in the study. Clinical characteristics, sonographic findings of lymphadenopathies, and short-term results were analyzed retrospectively. Results: A total of 13 patients [six females (46.2%), seven males (53.8%)] were evaluated in the present study. Mean age of the patients was 41.9 years (min-max= 20-56). Median time-lapse between vaccination and presentation to hospital was six days, and seven (53.8%) patients presented with symptoms and findings after the first dose, and six patients (46.2%) after the second dose. Three (23.1%) axillary lymphadenopathies, and 10 (76.9%) cervical lymphadenopathies were detected. Sonographic examination revealed lymphadenopathies predominantly oval morphology (69.2%), asymmetric cortical thickening (61.5%), and hilar-type vascularization (69.2%). Mean time of regression was found 19.2 days (min-max= 10-35). Conclusion: Ipsilateral cervical and axillary lymphadenopathies may occur because of vaccines against COVID-19. The sonographic findings of these lymphadenopathies may not be distinguished clearly from malignant lymph nodes;and for this reason, close clinical and radiological follow-up would be appropriate to elucidate the process.

3.
American Journal of Transplantation ; 22(Supplement 3):868-869, 2022.
Article in English | EMBASE | ID: covidwho-2063539

ABSTRACT

Purpose: Telemedicine is an essential part of healthcare delivery and has grown exponentially during the COVID-19 pandemic. Data on optimal utilization and implementation of telemedicine in SOT care remain limited. We aimed to evaluate patient, provider and clinic staff perspectives on telemedicine use and potential barriers in SOT clinics. Method(s): We prospectively enrolled adults seen via telemedicine (video or telephone) in SOT clinics at a single academic transplant center between 9-10/2021. Patients completed a survey administered either online or phone following their visit. Providers and clinic staff involved in telemedicine completed online surveys. Surveys were tailored to patient, provider and clinic staff to assess specific concerns, barriers and satisfaction with telemedicine. Result(s): Survey response rate was 21% (175/853) for patients, 57% (70/122) for providers and 31% (20/64) for clinic staff. 95% of visits were video and seen in liver (39%), kidney (40%), lung (16%) and heart transplant (5%) clinics. Patients were male (51%) with a median age of 62, English-speaking (95%) and had some college experience (84%). Patient and provider descriptions of telemedicine use are shown in Figure 1. Patients were not concerned with privacy (86%), lack of physical exam (76%), audio/video difficulties (89% and 93%) or help with setup (82%). Most were satisfied with the ease of video visit (85%) and quality of care (80%). Compared to in-person visits, patients felt their telemedicine visit was similar (66%) if not better (16%). Among providers, most were satisfied with ease of video visits (74%) and quality of care (60%), but 48% were dissatisfied with telephone visits. Providers spent time assisting patients (72%) or required help from staff to aid patients (7%) with visits;90% noted functioning of software/hardware before visits as crucial to improving telemedicine use. Among clinic staff, 50% reported additional time spent aiding patients with initial visit setup due to needing to instruct how to use telemedicine software (60%) and providing additional instructions to caregiver(s) (20%). Conclusion(s): Telemedicine via video is an effective and convenient method of healthcare delivery across the continuum of SOT care according to patients, providers and clinic staff. However, concerns about time assisting with setup were noted by providers and staff. Additional resources and support are needed to improve navigation of telemedicine for patients and to improve efficiency with telemedicine for providers and staff. (Figure Presented).

4.
American Journal of Transplantation ; 22(Supplement 3):795-796, 2022.
Article in English | EMBASE | ID: covidwho-2063407

ABSTRACT

Purpose: Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine has the potential to facilitate care delivery/ coordination for donors. We aimed to understand center practices and provider attitudes and perceived barriers of telemedicine services for living kidney donation. Method(s): We conducted a national survey of multidisciplinary providers from 194 U.S. active adult living donor kidney transplant centers in 2020. The survey was distributed with an online link from 2/18/2021 to 5/13/2021, and up to two reminders were provided. The target population included nephrologists, surgeons, nurse coordinators, social workers or independent living donor advocates, and psychiatrists or psychologists. We used descriptive statistics and analysis of variance. Result(s): Two hundred ninety-three providers from 128 unique centers responded to the survey, a center representation rate of 66.0%, reflecting 82.9% of U.S. practice by donor volume and 91.5% of U.S. states/territories. Most centers (70.3%) will continue using telemedicine beyond the COVID-19 pandemic. Video only was mostly used for donor evaluation by nephrologists, surgeons, psychiatrists or psychologists. Telephone and video were mostly used by social workers, while no mutual modality was used by coordinators. Vital signs and weight were obtained largely using self-reported measures or a local provider/primary care physician, and a physical exam was mostly completed at a subsequent in-person visit to the transplant center. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation for potential donors. These attitudes were consistent across provider roles (p>0.05). Providers were favorably disposed to use telemedicine beyond the pandemic for donor evaluation and followup care. Out-of-state licensing and reimbursements were key regulatory barriers. Conclusion(s): These findings help inform clinical practice and policy expanding telemedicine services to enhance access to living donation and may be extended to other medical specialties.

5.
Clinical Toxicology ; 60(Supplement 2):121, 2022.
Article in English | EMBASE | ID: covidwho-2062721

ABSTRACT

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

6.
Journal of the American Academy of Dermatology ; 87(3 Supplement):AB220, 2022.
Article in English | EMBASE | ID: covidwho-2061395

ABSTRACT

Introduction: White piedra is a rare superficial mycosis caused by the genus Trichosporon. Its prevalence is higher among tropical climates and predominantly affects children and women. Less than 17 cases have been described in Mexico, none of them in the Northeast region. We present the first case reported in this zone. Case presentation: A 27-year-old otherwise healthy woman presented to our clinic with a 1-month history of asymptomatic pseudonits on her scalp hair. Physical evaluation revealed numerous small white concretions over the majority of the hair shafts. At trichoscopic inspection, multiple white-yellowish ovoid nodules were observed. Direct microscopic examination with 20% potassium hydroxide (KOH) and blue cotton showed nodules composed of arthroconidia and hyphae over the hair shaft. Additionally, fungal culture was positive for Trichosporon inkin, confirming the diagnosis of white piedra. Treatment was initiated with ketoconazole shampoo and systemic itraconazole with favorable response. Discussion(s): Since the first case description by Beigel in Germany, most white piedra cases have been reported in tropical and humid climates. This mycosis typically affects females and subjects under 15 years of age. Some risk factors include poor hygiene, excess humidity, diabetes, and long, curly hair. In our case, the patient had curly hair and she constantly tied her hair up wet as she worked as a full-time nurse in a COVID-19 reference center. In our country, 50% of previous reported cases are from nontropical regions. Although infrequent in cosmopolitan areas in Northeast Mexico, white piedra should be considered in the differential diagnosis of pseudonits. Copyright © 2022

7.
Chest ; 162(4):A1320, 2022.
Article in English | EMBASE | ID: covidwho-2060986

ABSTRACT

SESSION TITLE: Challenges in Cystic Fibrosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pulmonary involvement in Systemic Lupus Erythematosus (SLE) is seen in 30-50% of patients (most commonly Nonspecific Interstitial Pneumonitis) but cystic lung disease is extremely rare (1). Lymphoid interstitial pneumonia (LIP) is an inflammatory lung disease that is characterized by infiltration of lymphocytes and plasma cells (2), and associated with lung cysts. Oftentimes, it is associated with HIV, lymphoma, and primary Sjogren's Syndrome (SS) (2), however there are rare reports of LIP associated with SLE (1). We present a case of a young male with incidental lung cysts who was found to have a new diagnosis of SLE. CASE PRESENTATION: A 24-year-old male with a past medical history of premature birth at 5 months and prior mild COVID-19 infection presented with 3 weeks of abdominal pain, nausea, vomiting, fever, and unintentional 15-pound weight loss. He endorsed dry mouth, frequent cavities, and a new rash involving his chest, face, and lower extremities. Physical exam was significant for malar rash and dry mucous membranes. Labs revealed pancytopenia, sedimentation rate 61 mm/hour and C-reactive protein 5.54 mg/L. Computed tomography (CT) of the chest showed several thin-walled cysts in all bilateral lung lobes (predominant in right upper lobe) and bilateral axillary lymph nodes [Figure 1]. CT abdomen and pelvis was unremarkable. Autoimmune work-up resulted in a positive antinuclear antibody >1:1280, double stranded DNA antibody elevated at 34, elevated SSA and SSB antibodies (>8.0 and 1.4 respectively), and decreased Complement 3 (59.5 mg/dl) and 4 (10.1 mg/dl) levels. Peripheral smear, right axillary lymph node and bone marrow biopsies were negative for malignancy. He was started on prednisone and Plaquenil with symptomatic improvement. There is high suspicion of LIP given the clinical and radiological findings. He will follow up in clinic to obtain PFTs and schedule a lung biopsy. DISCUSSION: Interstitial lung disease in SLE presents in middle-aged patients at a later part of their disease course, with a female preponderance (2,3). An initial presentation of SLE and secondary SS in a young male and associated cystic lung disease is rare. The suspicion for LIP in association with SLE is high in our patient given variable size and distribution of lung cysts and coexisting secondary Sjogren's syndrome, although no ground glass or nodular opacities were found on CT chest as reported in typical LIP (3). Though this patient has no pulmonary symptoms, cysts/LIP in SLE tend to progress and have a high incidence of developing lymphomas, gammaglobulinemia and amyloidosis (2,3). CONCLUSIONS: It is important to establish a histopathological diagnosis and obtain baseline PFTs to monitor pulmonary disease manifestations. In addition to controlling the primary disease with antirheumatic drugs, steroids have been found to be useful in acute pulmonary flares (2). Reference #1: Maeda R, Isowa N, Miura H, Tokuyasu H. Systemic lupus erythematosus with multiple lung cysts. Interact Cardiovasc Thorac Surg. 2009 Jun;8(6):701-2. doi: 10.1510/icvts.2008.200055. Epub 2009 Mar 12. PMID: 19282324. Reference #2: Yood RA, Steigman DM, Gill LR. Lymphocytic interstitial pneumonitis in a patient with systemic lupus erythematosus. Lupus. 1995 Apr;4(2):161-3. doi: 10.1177/096120339500400217. PMID: 7795624. Reference #3: Filipek MS, Thompson ME, Wang PL, Gosselin MV, L Primack S. Lymphocytic interstitial pneumonitis in a patient with systemic lupus erythematosus: radiographic and high-resolution CT findings. J Thorac Imaging. 2004 Jul;19(3):200-3. doi: 10.1097/01.rti.0000099464.94973.51. PMID: 15273618. DISCLOSURES: No relevant relationships by Matthew Fain No relevant relationships by Christina Fanous No relevant relationships by Rathnavali Katragadda No relevant relationships by CHRISELYN PALMA

8.
Chest ; 162(4):A2480-A2481, 2022.
Article in English | EMBASE | ID: covidwho-2060951

ABSTRACT

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The incidence of acute pericarditis is 3.32 per 100,000 person-years (11). Patone et. Al, found that 0.001% had acute pericarditis after a dose of the COVID-19 vaccine, while 11.9% were COVID-19 positive (11). 1.5% of patients with COVID- 19 developed new onset pericarditis and six-month all-cause mortality was 15.5% (2). CASE PRESENTATION: 48-year-old male with no known past medical history who presented with acute onset of sharp, left-sided chest pain and associated with dyspnea on exertion. He was not vaccinated for COVID-19 and denied being around any sick contacts. On physical examination he was afebrile, normotensive and saturating 99% on room air. EKG initially showed diffuse ST elevations in leads II,III, aVF, V2-V6. Initial high sensitivity trop was <6. He was incidentally found to be COVID positive. Initial echocardiogram was not suggestive of wall motion abnormalities or pericardial effusions. He was not initiated on management for COVID-19 pneumonia as he was asymptomatic and on room air. He was started on colchicine 0.6 mg BID and ibuprofen 400 TID for pericarditis treatment and symptoms resolved on follow up. DISCUSSION: COVID-19 causing pericarditis is relatively rare and our patient presented with pericarditis and no associated respiratory symptoms. The clinical signs of pericarditis include: a pleuritic or sharp chest pain relieved by leaning forwards, a pericardial friction rub auscultated near the left sternal border and EKG changes including diffuse ST elevations or PR depressions seen in the leads I,II,III, aVL, aVF and the precordial leads V2-V6 (3). The common complications seen with pericarditis are pericardial effusion, cardiac tamponade, and constrictive pericarditis (1). A common etiology for pericarditis is a viral illness which can be seen to precede the cardiac symptoms and be seen as flu-like symptoms or as gastrointestinal symptoms. Treatment is with colchicine and NSAIDs. Aspirin has been the drug of choice in patient's who present with pericarditis following a myocardial infarction, solely because the other NSAIDs have been studied and shown to interfere with myocardial healing (3)(4). NSAIDs were believed to be harmful in patient's diagnosed with COVID, due to upregulation of ACE2 receptors in multiple sites which is used by SARS-COV-2 as a point of entry into cells (9). Drake et. Al, looked at patients with COVID-19 pneumonia, and found use of NSAIDs did not play any significant role in mortality (10). First-line therapy for pericarditis is NSAIDs and colchicine. Second line therapy can be with corticosteroids and refractory therapy is generally with intravenous human immunoglobulins, Azathioprine or anti-IL1 agents such as Anakinra (12). CONCLUSIONS: COVID 19 continues to present with varying levels of comorbidities. Timely diagnosis and intervention of pericarditis precipitated by COVID-19 can lead to near complete recovery and prevent fatal outcomes. Reference #1: Dababneh E, Siddique MS. Pericarditis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431080/ Reference #2: Buckley BJR, Harrison SL, Fazio-Eynullayeva E, Underhill P, Lane DA, Lip GYH. Prevalence and clinical outcomes of myocarditis and pericarditis in 718,365 COVID-19 patients. Eur J Clin Invest. 2021 Nov;51(11):e13679. doi: 10.1111/eci.13679. Epub 2021 Sep 18. PMID: 34516657;PMCID: PMC8646627.1 Reference #3: Little WC, Freeman GL. Pericardial disease. Circulation. 2006 Mar 28;113(12):1622-32. doi: 10.1161/CIRCULATIONAHA.105.561514. Erratum in: Circulation. 2007 Apr 17;115(15):e406. Dosage error in article text. PMID: 16567581. DISCLOSURES: No relevant relationships by Atika Azhar No relevant relationships by Berty Baskaran No relevant relationships by Andres Cordova Sanchez No relevant relationships by Harvir Gambhir No relevant relationships by Hanish Jai

9.
Chest ; 162(4):A2478, 2022.
Article in English | EMBASE | ID: covidwho-2060950

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: Pneumomediastinum is the presence of air or other gas in the mediastinum which can be due to trauma related to mechanical ventilation or spontaneous in preexisting lung diseases. Here, we present the case of Covid-19 pneumonia, who developed pneumomediastinum without any trauma or other risk factors. CASE PRESENTATION: A 56-year-old male COVID unvaccinated with a history of essential hypertension presented to the ED with shortness of breath and worsening cough for one week. He was living with his father, who was admitted to the ICU and receiving treatment for COVID pneumonia. The patient appeared to be in respiratory distress. His initial vital signs were temperature of 99.6 F, respiratory rate of 26 breaths per minute, blood pressure 125/71 mm Hg, heart rate 109 beats per minute with a regular rhythm, and oxygen saturation of 50% while he was breathing ambient air. Pulmonary examination revealed use of respiratory accessory muscle and widespread bilateral coarse rhonchi on auscultation. The rest of the physical examination was within normal limits. RT- PCR COVID -19 test was positive. The blood gas analysis reported respiratory alkalosis. Inflammatory markers were elevated: erythrocyte sedimentation rate (35.2 mg/L), C-Reactive Protein (17.70 mg/dL), Ferritin (1108.1 ng/mL), Lactate Dehydrogenase (813 U/L), Lactate (2.4 mg/dL), D-Dimer (35.20 mg/L) and Troponin High Sensitivity-236.6 ng/L. His CBC, electrolytes, and kidney function were normal. Chest X-ray showed Pneumomediastinum with dense basilar predominant consolidation. CT Angio Chest with contrast reported Pneumomediastinum likely from the left central airway source and bilateral dense ground glass consolidation. An echocardiogram showed an ejection fraction of 60-65%, no valvular abnormalities. He was placed on vapotherm(Oxygen 40L/min) with 100% FiO2. He was given Dexamethasone 6mg for ten days, Remdesivir, Barcitinib, and a 7-day course of Azithromycin and Ceftriaxone for community-acquired pneumonia. He was advised to practice prone positioning for 12 hours or more per day. Pulmonology, Infectious Disease, and Cardiology were consulted. Gradually, his oxygen requirement was weaned down and Pneumomediastinum resolved on serial chest x rays. He was discharged on home oxygen in a clinically stable condition. DISCUSSION: Pneumomediastinum in viral pneumonia is rare. The exact mechanism is unknown. Covid-19 pneumonia causes diffuse alveolar wall damage, which might cause air leakage into the mediastinum. The development of pneumomediastinum is an ominous sign in these patients. Fortunately, our patient did not worsen and was weaned off high flow oxygenation requirement. CONCLUSIONS: Few isolated reported cases of pneumomediastinum in a COVID-19 patient have been associated with life-threatening complications. It should be used as a prognostic marker, and close monitoring of these patients is advisable. Reference #1: Damous, S.H.B., dos Santos Junior, J.P., Pezzano, Á.V.A. et al. Pneumomediastinum complicating COVID-19: a case series. Eur J Med Res 26, 114 (2021) DISCLOSURES: No relevant relationships by Saad Ansari No relevant relationships by Akshit Chitkara No relevant relationships by Sudeshna Ghosh No relevant relationships by Femina Patel

10.
Chest ; 162(4):A2387, 2022.
Article in English | EMBASE | ID: covidwho-2060941

ABSTRACT

SESSION TITLE: Variety in Risk Factors and Treatment of VTE SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The year of 2020 will be a year never forgotten when the COVID-19 pandemic began. The healthcare system is going into a crisis facing a disease that is unknown and overwhelming. Companies were frantic to find a solution to help prevent so many unnecessary deaths. Pfizer mRNA COVID-19 vaccine was granted emergency use by the FDA after proving efficacy in early trials. Many side effects were unknown and discovered as time went on. Unprovoked isolated pulmonary embolisms are rare. CASE PRESENTATION: A 24 year old male with no significant past medical history presented to the emergency department due to shortness of breath, hemoptysis and chest pain. He denied any family history or personal history of clotting disorders. He received the mRNA COVID-19 Pfizer vaccine 5 days prior to symptom onset. He describes it as constant sharp pain with varying intensity that he rates a 6/10 and can reach a 10/10 pain exacerbated with lying flat and deep breathing. He also states he has been coughing up a teaspoon amount of blood with this chest pain. Physical examination revealed reduced breath sounds in the left lower lobe. Patient was hemodynamically stable. Labs were stable and hemoglobin was stable throughout the hospital course. Fibrinogen was elevated and hypercoagulable work-up was negative. CTA of chest was performed and revealed left-sided pulmonary emboli involving the left lower lobe with pulmonary infarction. Therefore, he was managed by Eliquis. DISCUSSION: Pfizer released a safety and efficacy report of the BNT162b2 mRNA Covid-19 Vaccine. Many of the common side effects reported were pain at the injection site, fatigue, headache, and fever [1]. Adverse events that were reported were shoulder injury, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia [1]. Isolated PE in a young healthy patient was never reported as an adverse event from the Pfizer safety and efficacy report. Severe acute respiratory syndrome-coronavirus-2 has been proven to increase the risk of venous thromboembolism because it is a prothrombotic virus [2]. Vaccination reports of pulmonary embolism are increasing, however, isolated PE without a DVT is still very underreported and rare. The literature states that a lot of patients that are having PE after mRNA vaccine also have associated thrombocytopenia, however, this is not what this patient demonstrates [3]. A total of 43, 548 participants were observed for the safety and efficacy report of the Pfizer COVID-19 report and not a single patient demonstrated an isolated pulmonary embolism event [1]. CONCLUSIONS: This case is a demonstration of a rare occurrence of isolated PE with no evidence of DVT in such close proximity to receiving the mRNA COVID-19 Pfizer vaccination.There are few reports of pulmonary embolism in healthy patients with no history of clotting disorders and further data are needed to support this association. Reference #1: Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 Reference #2: Hesam-Shariati S, Fatehi P, Abouzaripour M, Fathi F, Hesam-Shariati N, Hesam Shariati MB. Increased pulmonary embolism in patients with COVID-19: a case series and literature review. Trop Dis Travel Med Vaccines. 2021;7(1):16. Published 2021 Jun 12. doi:10.1186/s40794-021-00145-3 Reference #3: Muster V, Gary T, Raggam RB, Wölfler A, Brodmann M. Pulmonary embolism and thrombocytopenia following ChAdOx1 vaccination. Lancet. 2021;397(10287):1842. doi:10.1016/S0140-6736(21)00871-0 DISCLOSURES: No relevant relationships by Muhammad Azaz Cheema No relevant relationships by Morcos Fahmy No relevant relationships by Christina Gearges No relevant relationships by Asma Iftikhar

11.
Chest ; 162(4):A2354, 2022.
Article in English | EMBASE | ID: covidwho-2060939

ABSTRACT

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Deep vein thrombosis (DVT) formation is widely recognized as Virchow's Triad of hypercoagulability, venous stasis, and endothelial injury. Based on this definition, congenital aberrations of the inferior vena cava (IVC) such as atresia or coarctation classify as major risk factors to incite a DVT (1). A congenital IVC anomaly with evidence of post-COVID-19 vaccination hypercoagulability (2) suggests a risk association with thrombotic episodes. We present a case of congenital IVC interruption with development of a DVT nine days after Pfizer COVID-19 booster administration. While it is known that IVC anomalies may contribute to DVT development (1), there is scarce data identifying a COVID-19 mRNA vaccine as a direct source of massive DVT in a young adult. CASE PRESENTATION: A 28 year old male with a history of repaired coarctation of the aorta presented with severe right thigh pain that began days after the Pfizer COVID-19 booster. Four days prior, an outpatient ultrasound (US) was negative for DVT. Physical exam revealed a dusky right foot with good distal pulses. Sensation was intact throughout. The left lower extremity (LE) had no edema or tenderness. An US of the right LE showed a DVT extending from the common femoral vein to the posterior tibial vein and DVT of the greater saphenous and deep femoral vein. Left LE US showed an anterior tibial DVT. Attempted thrombolysis was made with tissue plasminogen activator therapy and thrombectomy. Given the patient's atretic IVC anatomy, some residual clot remained in the common iliac vein, and was treated with anticoagulation therapy. After two extensive surgical lyses and aggressive medical lysis, the DVT's were resolved and the patient slowly improved. Upon follow up, he is feeling much better with no further pain. Ultimately this patient will require lifelong anticoagulation and may require an IVC stent to prevent future thrombotic events. DISCUSSION: Coarctation of the aorta is a common congenital heart defect and is often coupled with additional cardiovascular anomalies (1). In our patient, imaging showed a small and near-occluded IVC, which predisposed him to vasculitic events. There is no literature describing a massive DVT in a young adult patient within days of an mRNA COVID-19 vaccine. While these thrombotic events are rare (2), this report portrays one case in which the Pfizer COVID-19 mRNA vaccine may have prompted a vascular event in a susceptible patient. CONCLUSIONS: It has been previously established that congenital IVC anomalies may contribute to increased risk of DVT (1). In this case, we observe an association of the mRNA COVID-19 vaccine with massive DVT in a young male. While this is not meant to discourage patients with congenital IVC anomalies from receiving the COVID vaccine series, it prompts the need for open discussion with healthcare providers to discuss possible adverse effects. Reference #1: Chee, Y.-L., Culligan, D.J. and Watson, H.G. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. British Journal of Haematology. 2001;114:878-880. doi.org/10.1046/j.1365-2141.2001.03025.x Reference #2: Bilotta C, Perrone G, Adelfio V, et al. COVID-19 Vaccine-Related Thrombosis: A Systematic Review and Exploratory Analysis. Front Immunol. 2021;12:729251. doi:10.3389/fimmu.2021.729251 Reference #3: Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. The Lancet. 2001;357(9254):441. doi.org/10.1016/S0140-6736(00)04010-1 DISCLOSURES: No relevant relationships by Melanie Krongold no disclosure on file for Majed Samarneh;No relevant relationships by Elena Tran No relevant relationships by Lakshmi Sheetala Vijaya

12.
Chest ; 162(4):A2350, 2022.
Article in English | EMBASE | ID: covidwho-2060937

ABSTRACT

SESSION TITLE: Rare Cases with Masquerading Pulmonary Symptoms SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Paget-Schroetter (PS) syndrome, also known as venous thoracic outlet syndrome, is a primary thromboembolic sequela of compression of the subclavian vein. CASE PRESENTATION: A previously healthy 24 year old male presented with shortness of breath and cough. He had recently been exposed to COVID. He denied fever, diarrhea, vomiting, leg swelling, and rashes. On physical exam he was tachycardic, had no murmurs or JVD, and was CTAB with no wheezing or rales. Labs were significant for a WBC of 17k, and troponin of 0.033. CTA of the chest showed multiple filling defects in the pulmonary arteries consistent with Pulmonary Embolism (PE). He was started on a heparin drip. All COVID testing was negative. Lower extremity venous doppler ultrasounds (US) were negative for DVT. His respiratory status improved, and he was discharged on apixaban with the diagnosis of PE provoked by possible COVID infection. He returned approximately 2 months later with exertional dyspnea and upper extremity swelling and was found to have recurrent PE despite having been compliant with his apixaban. Upper extremity venous doppler US was significant for DVT in his right subclavian vein. He was placed on warfarin. At this time his hypercoagulable workup was also negative. Symptoms persisted despite being on warfarin with outpatient monitored INR. A venogram was ordered to evaluate upper torso blood flow. The venogram was remarkable for high-grade stenosis of the right subclavian vein. This finding led to the consideration of thoracic outlet syndrome aka Paget-Schroetter (PS). DISCUSSION: PS is a rare clinical entity that results from stress placed on the endothelium of the subclavian vein as it passes between the junction of the first rib and the clavicle. It can predispose otherwise healthy patients to recurrent venous thromboembolisms that are refractory to anticoagulation. The clinical features usually include upper extremity swelling and pain which is exacerbated by repetitive or strenuous exercise. Venous collaterals can also be seen in some patients. Evaluation should include some form of upper extremity Doppler and a CT/MR venogram or venography to make the final diagnosis. Treatment may involve anticoagulation, thrombolysis, and/or surgical decompression. Best results are seen with early thrombolysis and surgical decompression. If caught early and treated appropriately, PS has a good outcome with few long-term sequela. CONCLUSIONS: Our goal was to describe a patient with an uncommon cause for recurrent venous thromboembolisms that were refractory to anticoagulation. Our patient's presentation of PS serves to describe many aspects of the disease process, evaluation, diagnosis, and management as seen in the case presentation. The patient's demographic fit the epidemiological profile age of 20s-30s with typical imaging findings and pertinent negative workup which would lead providers to this rarer diagnosis. Reference #1: Saleem T, Baril DT. Paget Schroetter Syndrome. [Updated 2022 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482416/ Reference #2: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. Reference #3: Karl A. Illig, Adam J. Doyle, A comprehensive review of Paget-Schroetter syndrome, Journal of Vascular Surgery, Volume 51, Issue 6, 2010,Pages 1538-1547,ISSN 0741-5214, https://doi.org/10.1016/j.jvs.2009.12.022. DISCLOSURES: No relevant relationships by Jonathan Marks No relevant relationships by Zachary Stachura

13.
Chest ; 162(4):A2274, 2022.
Article in English | EMBASE | ID: covidwho-2060929

ABSTRACT

SESSION TITLE: Challenges in Asthma SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Asthma is a chronic illness affecting 334 million people worldwide[1]. Asthma affects the respiratory gas exchange, which plays a significant role in acid-base balance. Acid-base disorders in asthma involve respiratory alkalosis, respiratory acidosis, and AG acidosis[2]. CASE PRESENTATION: A 37 years old Hispanic male with a PMH of intermittent asthma presents with progressive dyspnea for three days, worse with activity and decreases with rest. He reported no [cough, fever, rhinorrhea, chest pain]. No orthopnea. He is vaccinated for COVID ( 2 Pfizer doses), has no sickness exposure, and works as a driver. The patient is not a smoker. Physical Exam: Blood pressure 124/72 mmHg. Heart Rate 100 PPM. Temperature 97.1 F.Respiratory Rate 21BPM.SPO2 90% General appearance: acute distress with nasal flaring. Heart: Normal S1, S2. RRR. Lung: Poor air entry with diffuse wheeze bilaterally. He was placed on a 6 LPM NC. CBC and differential were unremarkable. He was started on methylprednisone, Ceftriaxone, and azithromycin. The patient was started on inhaled Salbutamol and Budesonide. Chest X-ray was unremarkable, Chemistry was unremarkable except for elevated Lactic acid 4.7, There was no concern for reduced tissue perfusion or hypoxia, with no evidence of an infectious process because both viral and bacterial causes for pneumonia were excluded, and antibiotics were stopped. A serial lactic acid level trend was 4.5/4.3/ 4.1/ 4 on the first day, while on the next day, it was 3.1/ 2.9/ 2.7/ 2.5/ 3.5, we stopped trending his lactic acid level. He improved and was discharged on an oral taper steroid and inhaled steroids with a B2 agonist. DISCUSSION: There are two types of Lactic acidosis in patients with asthma: 1- Type-A results from impaired oxygen delivery to tissues and reduced tissue perfusion in severe acute asthma may be accompanied by reduced cardiac output. 2- Type B where oxygen delivery is normal, but the cellular function is impaired due to increased norepinephrine in plasma, increasing metabolic rate and lactate production, drugs like beta-agonists increase glycogenolysis leading to an increased pyruvate concentration;pyruvate is converted to lactic acid. B2 agonist increases lipolysis and increases Acetyl CoA, this increase in Acetyl CoA inhibits the conversion of pyruvate to Acetyl CoA, increasing pyruvate which will be converted to lactic acid[2], Theophylline is a non-selective 5'-phosphodiesterase inhibitor and potentiates the activity of ß-adrenergic agents by increasing the intracellular concentration of cAMP, Glucocorticoids are also known to increase the ß-receptor's sensitivity to ß-adrenergic agonists. CONCLUSIONS: Providers are increasingly challenged by hyperlactatemia,it is not harmful but elevated Lactic acid levels and clearance rate is used for prognostication,hyperlactatemia might be misleading,and all possible causes of elevated lactic acid levels must be explored. Reference #1: 10.5334/aogh.2412 Reference #2: https://doi.org/10.3390/jcm8040563 Reference #3: Edwin B. Liem, Stephen C. Mnookin, Michael E. Mahla;Albuterol-induced Lactic Acidosis. Anesthesiology 2003;99:505–506 doi: https://doi.org/10.1097/00000542-200308000-00036 DISCLOSURES: No relevant relationships by Vasudev Malik Daliparty No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib No relevant relationships by MATTHEW YOTSUYA

14.
Chest ; 162(4):A2250, 2022.
Article in English | EMBASE | ID: covidwho-2060920

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: Amyloidosis of the respiratory tract is rare. We present a case of tracheobronchial amyloid presenting as multifactorial cough with syncope. CASE PRESENTATION: The patient is a 65-year-old man with history of hypertension, hyperlipidemia, and allergic rhinitis who presented to the ED after a syncopal event. Two weeks prior, he had a new-onset myalgias and severe persistent cough, not resolving with over-the-counter medications. During a coughing paroxysm, he experienced a brief loss of consciousness. On arrival, his vital signs and physical exam were within normal limits except for Mallampati II, BM of 38.8 kg/m2. Basic laboratory testing was also unremarkable except for troponin T of 251 nl/dL and NT-ProBNP of 1181 pg/mL. NP swab for Sars-CoV-19 (PCR), Influenza A and B were not detected. CT of the chest revealed an area of circumferential mural soft tissue thickening in the left lower lobe bronchi. Cardiac MRI showed an area of subepicardial delayed enhancement, suggestive of myocardial inflammation or edema. Flexible bronchoscopy confirmed that the left lower lobe bronchus and proximal subsegmental bronchi had an infiltrative process with a friable, erythematous irregular mucosal surface. Forceps biopsy sampling and staining with Congo red, sulfate Alcian blue and Trichome stain were positive for amyloid deposits. Immunostain revealed predominantly CD3 positive T-Cells. Mass spectometry showed AL (lamda)-type amyloid deposition. GMS and AFB stains were negative. Telemetry showed 2-3 second pauses, correlated with episodes of cough. DISCUSSION: Amyloidosis is a disorder caused by misfolding of proteins and fibril accumulation in the extracellular space. It can present as a diffuse or localized process to one organ system. Several patterns of lung involvement have been described: nodular pulmonary, diffuse alveolar-septal, cystic, pleural, and tracheobronchial amyloidosis. Tracheobronchial amyloidosis is usually limited and not associated with systemic disease or hematologic malignancy. It can be asymptomatic, or can present with cough, dyspnea or signs of obstruction, including postobstructive pneumonia. Congo Red stained samples reveal green birefringence under polarized light microscopy. Further analysis of proteins usually reveals localized immunoglobulin light chains (AL). Cough syncope is due to increased intrathoracic pressure, decreased venous return and cardiac output, stimulation of baroreceptors, decreased chronotropic response, arterial hypotension and decreased cerebral perfusion. Our patient presented with multifactorial cough (possible viral infection, upper airway cough syndrome, amyloidosis) causing sinus pauses and syncope, on underlying myocarditis. CONCLUSIONS: Amyloid infiltration of the respiratory system is rare, but it should be considered in the differential diagnosis of airway disorders, nodular or cystic lung diseases, and pleural processes. Reference #1: Milani P, Basset M, Russo F, et al. The lung in amyloidosis. Eur Respir Rev 2017;26: 170046 [https://doi.org/10.1183/16000617.0046-2017]. Reference #2: Utz JP, Swensen SJ, Gertz MA. Pulmonary amyloidosis. The Mayo Clinic experience from 1980 to 1993. Ann Intern Med. 1996 Feb 15;124(4):407-13. doi: 10.7326/0003-4819-124-4-199602150-00004 Reference #3: Dicpinigaitis PV, Lim L, Farmakidis C. Cough syncope. Respir Med. 2014 Feb;108(2):244-51. doi: 10.1016/j.rmed.2013.10.020. Epub 2013 Nov 5. PMID: 24238768. DISCLOSURES: No relevant relationships by Amarilys Alarcon-Calderon No relevant relationships by Ashokakumar Patel

15.
Chest ; 162(4):A2248-A2249, 2022.
Article in English | EMBASE | ID: covidwho-2060919

ABSTRACT

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder characterized by low serum IgG, IgA and/or IgM, and poor specific antibody production. CVID is estimated to affect as many as 1 in 25,000 individuals. Chronic lung disease is a common problem in patients with CVID. About 10-20% of patients have lymphocytic infiltrates and/or sarcoid-like granulomas, with several histological findings, termed granulomatous and lymphocytic interstitial lung disease (GLILD). CASE PRESENTATION: Patient is a 61-year-old Caucasian woman with a history significant for CVID in remission who presented to the Pulmonary Clinic with a chief compliant of dyspnea of exertion (DOE). Patient was not suffering from any respiratory complaints until the diagnosis of severe COVID-19 pneumonia 4 months prior. For the following months, patient was slowly improving but was still suffering from severe DOE that has negatively impacted her quality of life. Patient has a remote history of smoking, having quit 10 years ago. Patient denied any joint pain, stiffness, swelling, skin rash, muscle ache, or weakness. No known history of SLE, Rheumatoid Arthritis, or other collagen vascular disorders had been reported. Patient denied any exposure to birds. Physical exam was significant only for bilateral basal rales with no wheezing or crackles. No skin rash, joints deformities, or clubbing was noticed. Laboratory studies revealed ESR was 17 with a CRP of 10.6. Negative ANA, SM, RNP, and SSA/SSB antibodies. Her Immunoglobulins levels were low with IgG 382 (nl > 610) and IgA < 2 (nl > 85). Her PFT revealed severe restrictive process with TLC 46% of predicted and severe reduction in DLCO at 35%. CT chest revealed diffuse central groundglass opacities, and interstitial thickening with traction bronchiectasis. Lung biopsy via VATS revealed lung parenchymal with focal, noncaseating granulomas, foci of focal interstitial lymphocytic infiltration and fibrosis;features consistent with Granulomatosis-Lymphocytic Interstitial Lung Disease (GLILD). Systemic steroid initiated and for the following weeks patient reports significant improvement in DOE. Her PFT at 3 month follow up showed significant improvement in FVC (5% increase), TLC (11% increase), and DLCO (5% increase). DISCUSSION: The respiratory manifestations of CVID follow two main mechanisms: injury due to acute or recurrent infections and damage due to poorly understood immune-mediated processes. Severe COVID-19 results in dysregulated immune and inflammatory response that can worsen an underlying lung disease. Previous cases have been reported about CVID with GLILD complicated with COVID-19 infection but not vice versa. CONCLUSIONS: To our knowledge, this is a rare case of CVID complicated by GLILD triggered by recent COVID-19 infection. However, little is known about the association between COVID-19 infection and GLILD and further investigation is needed. Reference #1: Ho HE, Mathew S, Peluso MJ, Cunningham-Rundles C. Clinical outcomes and features of COVID-19 in patients with primary immunodeficiencies in New York City. J Allergy Clin Immunol Pract. 2020;S2213–2198(20):31102–8. Reference #2: Prasse A, Kayser G, Warnatz K. Common variable immunodeficiency-associated granulomatous and interstitial lung disease. Curr Opin Pulm Med. 2013;19:503–9. Reference #3: Cunningham-Rundles C, Bodian C. Common variable immunodeficiency: clinical and immunological features of 248 patients. Clin Immunol. 1999;92:34–48. DISCLOSURES: No relevant relationships by husam nayef No relevant relationships by Arshia Vahabzadeh No relevant relationships by Zaid Yaqoob No relevant relationships by Mohammad Zalt

16.
Chest ; 162(4):A2224, 2022.
Article in English | EMBASE | ID: covidwho-2060913

ABSTRACT

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

17.
Chest ; 162(4):A2186, 2022.
Article in English | EMBASE | ID: covidwho-2060908

ABSTRACT

SESSION TITLE: Systemic Diseases Causing Pulmonary Havoc SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: In the coronavirus disease 2019 (COVID-19) era, the etiology of interstitial lung disease (ILD) should remain broad to ensure accurate diagnosis and the proper treatment of patients. Vital to the art of medicine is taking a comprehensive history, and anchoring on a common diagnosis such as COVID-19 can result in early dismissal of alternate etiologies that physicians have an obligation to explore. CASE PRESENTATION: A 58-year-old male with a history of diabetes, hypothyroidism, and hypertension presented to the emergency department (ED) with dyspnea and fever. Initial CT chest imaging was significant for reticular and fibrotic changes with peripheral ground-glass and solid nodular opacities, some with areas of central clearing. Despite negative PCR testing, he was diagnosed with COVID-19 and discharged on oxygen with pulmonary follow-up. He continued to have arthralgias, proximal muscle weakness, low-grade fevers, and weight loss. He re-presented to the ED and was admitted for hypovolemia and further exploration into a potential autoimmune etiology of his symptoms. Labs were significant for a creatine kinase of 3,381 U/L, positive autoimmune antibodies [ANA (1:320), Jo-1 (>8.0 U), and SS-A/Ro (1.4 U)], and elevated ESR and CRP (30 mm/hr and 81 mg/L). Repeat CT revealed persistent parenchymal changes. Bronchoscopy was performed without anatomical abnormalities, and bronchoalveolar lavage (BAL) fluid was normal in appearance and negative for infectious etiologies. Though the patient was a farmer and possessed risk factors for hypersensitivity pneumonitis, lack of lymphocytic predominance on BAL, negative hypersensitivity panel, and uncharacteristic CT findings helped exclude this diagnosis. The patient was diagnosed with antisynthetase syndrome and treated with pulse dose intravenous solumedrol before transitioning to prednisone with resolution of muscle weakness and radiographic improvement in lung infiltrates. Muscle biopsy was deferred given the rapid clinical response and serum markers consistent with the diagnosis. DISCUSSION: Antisynthetase syndrome is a rare cause of ILD and often presents with myositis, arthritis, skin changes, Raynaud's phenomenon, and fever [1]. These symptoms, combined with the aminoacyl-tRNA synthetase antibody—most commonly the Jo-1 antibody—help confirm the diagnosis [2]. Due to a lack of established diagnostic criteria, muscle biopsy is often used to exclude other causes of myositis [3]. The ILD associated with antisynthetase syndrome is a significant cause of morbidity and mortality, and delay in diagnosis can lead to progression of lung injury. CONCLUSIONS: Chest imaging findings in COVID-19 are nonspecific, and post-COVID lung disease often presents similarly to other ILDs [1]. Because of this, history and physical exam remain crucial tools to reflect on alternate diagnoses for ILD and will continue to be necessary as we evolve through this COVID-19 era. Reference #1: Devi HG, Pasha MM, Padmaja MS, Halappa S. Antisynthetase Syndrome: A Rare Cause for ILD. Journal of Clinical and Diagnostic Research : JCDR. 2016;10(3):OD08. doi:10.7860/JCDR/2016/16872.7361 Reference #2: Cavagna L, Trallero-Araguás E, Meloni F, et al. Influence of Antisynthetase Antibodies Specificities on Antisynthetase Syndrome Clinical Spectrum Time Course. Journal of Clinical Medicine. 2019;8(11). doi:10.3390/jcm8112013 Reference #3: Schmidt J. Current Classification and Management of Inflammatory Myopathies. J Neuromuscul Dis. 2018;5(2):109-129. doi: 10.3233/JND-180308. PMID: 29865091;PMCID: PMC6004913. DISCLOSURES: No relevant relationships by Dustin Norton No relevant relationships by Alyssa Simon No relevant relationships by Kang Rui Xiang

18.
Chest ; 162(4):A2177, 2022.
Article in English | EMBASE | ID: covidwho-2060907

ABSTRACT

SESSION TITLE: Systemic Diseases Causing Pulmonary Havoc SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Choriocarcinoma is the most common type of gestational trophoblastic neoplasm (GTN) and can occur in association with any pregnancy [1]. The main risk factors are advanced or very young maternal age, ethnicity, ectopic pregnancy, abortion, and prior molar pregnancy. The most common sites of choriocarcinoma metastasis are lungs, liver, and brain [2]. This case describes a patient with choriocarcinoma that presented with hemoptysis. CASE PRESENTATION: The patient is a 22 year-old G2P1 female presenting at 36 weeks-gestation with one week of hemoptysis. She denied any other symptoms. On presentation, she was tachycardic. Physical examination demonstrated bibasilar crackles. Admission chest x-ray revealed diffuse bilateral infiltrates (Fig 1). Hs-troponin was elevated to 144 ng/L;however, EKG did not show ischemic changes. Cultures were obtained prior to empirically initiating antibiotics. Despite antibiotic treatment, hemoptysis worsened over her course and oxygen requirements increased. Infectious workup was negative. CT obtained for pulmonary embolism revealed bilateral patchy airspace opacities in lungs, suspected due to multifocal pneumonia (Fig 2). AFB smear and quantiferon were negative. After an emergent C-section for increased oxygen requirements, bronchoscopy with BAL was obtained and demonstrated diffuse alveolar hemorrhage. BAL was only positive for mildly increased CD4:CD8 ratio. Transbronchial biopsy was aborted due to bleed risk. Subsequent right lobe wedge biopsy confirmed metastatic choriocarcinoma. Her serum human chorionic gonadotropin (ß-hCG) level was found to be 20,713 milli-international units/mL. DISCUSSION: The etiology of hemoptysis was initially thought to be secondary to pneumonia. Differential diagnoses also included an acute COVID infection, alveolar hemorrhage, tuberculosis in a recently-immigrated patient, myocarditis, autoimmune etiology, and malignancy. Patient's risk factors included a prior miscarriage. Rarely, bleeding can occur as a result of metastatic lesions and may result in abdominal pain, hemoptysis, melena, or evidence of increased intracranial pressure from intracerebral hemorrhage [2]. Patients, such as the one described in this case, can exhibit pulmonary symptoms of dyspnea, cough, and chest pain caused by lung metastases. Upon closer examination of the CT scans, several of the opacities are nodular and consistent with GTN. Patients treated with surgery, chemotherapy, or a combination of both demonstrated similar treatment outcomes;chemotherapy may still be the preferred option. The overall cure rate in treating these tumors is currently > 90% [2]. CONCLUSIONS: GTN, although rare, should be considered as a differential diagnosis in women with a pregnancy history and risk factors that present with the primary symptom of hemoptysis. High index of suspicion and awareness of these neoplasms are necessary for timely diagnosis. Reference #1: Savage P. Winter M. Parker V. et al. Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study. BJOG. 2020;127: 1102-1107 Reference #2: Lurain, J., 2010. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology, 203(6), pp.531-539. DISCLOSURES: No relevant relationships by Crystal Ajja No relevant relationships by Heba Osman No relevant relationships by James Rowley

19.
Chest ; 162(4):A2159-A2160, 2022.
Article in English | EMBASE | ID: covidwho-2060903

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: Pulmonary cavitary lesions can have varying etiologies. Among these, Lemierre syndrome is an uncommon disease which usually presents with symptoms of upper respiratory tract infection with unilateral neck pain, tenderness or swelling. In recent years, antibiotic stewardship for upper respiratory illnesses has led to its delayed diagnosis resulting in possible increased morbidity and mortality. There have been few reported cases of pulmonary cavitary lesions as the initial presentation of Lemierre syndrome. Our patient presented with incidental bilateral pulmonary cavitary lesions, which led to a diagnosis of Lemierre syndrome. CASE PRESENTATION: A 30-year-old gentleman with no significant past medical history visited urgent care for reproducible chest pain following motor vehicle accident. Chest x ray obtained for suspected rib fracture showed bilateral patchy and rounded opacities, confirmed by CT as bilateral cavitary nodules and consolidation. He was referred to our hospital for further care. Two weeks prior, following administration of COVID booster vaccine, he had developed fever, sore throat, tender lump behind left ear, left jaw and anterior left neck. Most symptoms self resolved in 3-5 days except persistent fever. On arrival, patient was febrile to 102F and hemodynamically stable. Physical examination revealed dry mucous membranes and erythematous pharynx. Labs were significant for leukocytosis of 24.5uL with bandemia and elevated inflammatory markers. Three sets of blood cultures were drawn and empirically started on vancomycin and piperacillin/tazobactam. Echocardiogram ruled out heart valve vegetations. CT angiography of neck showed intraluminal thrombi in left internal jugular vein. Blood cultures finalized to Fusobacterium nucleatum and antibiotics were tapered to metronidazole. Due to persistent fever, anticoagulation was initiated with apixaban 5mg twice daily. Pan CT showed improvement in size of many pulmonary septic emboli. After 48 hours of patient being afebrile, he was discharged on antibiotics and apixaban for at least 4 weeks until surveillance CT angiography showed non progression of thrombus. DISCUSSION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein which presents within 1-3 weeks following upper respiratory tract infections with multi-system complications. Management involves prolonged antibiotic course with use of anticoagulation and vein stripping still being debated. Our patient came to the hospital with an incidental finding of bilateral cavitary pulmonary lesions which went on to be diagnosed as Lemierre syndrome from positive blood cultures and CT angiography findings. CONCLUSIONS: Lemierre syndrome is an uncommon disease with mortality up to 18%. A call out to health care providers to keep a low threshold for its diagnosis in patients with initial presentation of bilateral pulmonary cavitary lesions, warranting prompt management. Reference #1: Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore). 1989 Mar;68(2):85-94. PMID: 2646510. Reference #2: Golpe R, Marín B, Alonso M. Lemierre's syndrome (necrobacillosis). Postgrad Med J. 1999 Mar;75(881):141-4. doi: 10.1136/pgmj.75.881.141. PMID: 10448489;PMCID: PMC1741175. Reference #3: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484. DISCLOSURES: No relevant relationships by Sumukh Arun Kumar No relevant relationships by Megna Machado No relevant relationships by Sushmita Prabhu No relevant relationships by PAWINA SUBEDI No relevant relationships by Mithil Gowda Suresh No relevant relationships by Bradley Switzer

20.
Chest ; 162(4):A2083, 2022.
Article in English | EMBASE | ID: covidwho-2060896

ABSTRACT

SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration can affect ventilation-oxygenation dynamics causing significant morbidity and mortality in children and adults. Patient presentation can range from asymptomatic to life-threatening hypoxia. A thorough history and physical examination helps in narrowing differential diagnosis and provision of timely management. A myriad of complications can occur from aspirated Foreign body including recurrent pneumonia, lung abscess, obstructive emphysema, and death. Here we present a case of a patient with recurrent pneumonia from a chronically aspirated foreign body. CASE PRESENTATION: 37-year-old male with past medical history of a recent COVID-19 infection and bronchus intermedius endobronchial mass (squamous metaplasia on biopsy 2009) who presented with fever, chest pain, worsening dyspnea. Initial workup was consistent with severe sepsis. A CT chest showed complete collapse, cavitation in right lower lobe and presence of right bronchus stent. Patient was treated with IV fluids and antibiotics during the hospitalization. He underwent bronchoscopy for airway examination and bronchoalveolar lavage. Airway exam showed a large endobronchial mass in the bronchus intermedius. Endobronchial biopsies were taken, followed by tissue debulking using flexible forceps and cryoprobe. A yellow plastic foreign object was then visualized dislodged in the right lower lobe. This was successfully removed with grasping forceps. Patient had to be extubated and be reintubated to remove foreign object in one piece as it did not fit the endotracheal tube. Post debulking, bronchus intermedius and right lower lobe were patent and procedure was completed. Our patient responded well to treatment he was ultimately transitioned to oral antibiotics and discharged home with outpatient follow up. Repeat bronchoscopy 6 weeks later showed normal airways. DISCUSSION: Our case illustrated the importance of thorough investigation while treating patients with recurrent pneumonia, and this sometimes should include bronchoscopy with airway exam. In our case a bronchoscopy was done several years ago, however the foreign body was not identified as the cause of the endobronchial lesion. A lingering foreign body in the long run has significant morbidity as seen in our case despite appropriate treatment with antibiotics patient continued to have recurrent post obstructive pneumonias. Bronchoscopy remains the gold standard in definitive diagnosis and management of foreign body. Since the refinement of bronchoscopy and debulking, the rate of mortality from foreign body aspiration has been remarkably reduced. CONCLUSIONS: In summary patients with history suggestive of potential foreign body aspiration presenting with recurrent pneumonias at a particular anatomical location should prompt physicians to perform diagnostic bronchoscopy, which remains the gold standard for diagnosing of foreign body aspiration Reference #1: Foreign Body Aspiration Natan Cramer;Noel Jabbour;Melissa M. Tavarez;Roger S. Taylor. DISCLOSURES: No relevant relationships by Maria Abril No relevant relationships by Bilal Bangash No relevant relationships by Imran Tarrar

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