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SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Immunotherapy is now a standard of care in solid-tumor oncology following the approvals of CTLA-4 and PD-1 inhibitors. Belzutifan, a small-molecule HIF-2a inhibitor, has recently gained FDA-approval for the treatment of advanced von Hippel-Lindau (VHL) associated renal cell carcinomas. CASE PRESENTATION: A 63-year-old female presented to our hospital with a one-day history of progressive dyspnea. Medical history is significant for metastatic renal cell carcinoma with pulmonary metastasis. Family and social history were noncontributory. Her cancer diagnosis was established in 2019 and had undergone cytoreductive nephrectomy and treatment with axitinib/pembrolizumab. As she had little improvement with immunotherapy, she was enrolled in a clinical trial at Memorial Sloan Kettering. Due to further disease progression, she was transitioned to lenvatinib/everolimus, though the treatment was discontinued due to anorexia and worsening pulmonary symptoms. Further work up revealed that she had ERG, MPL, VHL gene mutations. Thus, she was started on belzutifan two weeks prior to her presentation. Initial vitals were significant for hypoxia on room air that recovered with high flow nasal cannula (40L/80%). Physical examination was remarkable for severe respiratory distress with coarse breath sounds bilaterally. Laboratory studies revealed an acute leukocytosis with a neutrophilic prominence and a chronic metabolic alkalosis. COVID, flu PCR were negative. Chest x-ray demonstrated diffuse bilateral reticulonodular opacities. CTA revealed innumerable pulmonary nodules with areas of mass-like consolidation and a loculated left-sided pleural effusion. She was covered with azithromycin/ceftriaxone along with high-dose steroids and was admitted to the stepdown unit for further management. While in stepdown, she had a left PleurX catheter placed given her large effusion which was complicated by bloody output that required one unit of blood. Despite high-dose steroids, she had persistent hypoxia. As she remained unstable, goals of care discussions were held, which ultimately led to a change in code status to comfort measures. All aggressive measures were discontinued. She was started on comfort medications and ultimately passed away. DISCUSSION: Currently, neoplasms associated with VHL mutations are managed surgically to minimize the risk of metastatic disease. Nearly 70% of all patients with VHL mutations will develop renal cell carcinomas which means most patients undergo numerous surgical procedures. HIF-2a inhibition therefore offers an effective alternative that could reduce surgical burden and offer a new approach to management of VHL-associated disease. However due to its new approval, several adverse effects have yet to be documented. CONCLUSIONS: We report the only known case of Belzutifan-induced hypersensitivity pneumonitis and hope this case will become a useful contribution to the literature. Reference #1: Jonasch E, Donskov F, Iliopoulos O, Rathmell WK, Narayan VK, Maughan BL, Oudard S, Else T, Maranchie JK, Welsh SJ, Thamake S, Park EK, Perini RF, Linehan WM, Srinivasan R;MK-6482-004 Investigators. Belzutifan for Renal Cell Carcinoma in von Hippel-Lindau Disease. N Engl J Med. 2021 Nov 25;385(22):2036-2046. doi: 10.1056/NEJMoa2103425. PMID: 34818478. DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Raj Parikh
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SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Inhaled pulmonary vasodilators such as epoprostenol (IE) and nitric oxide have been used to treat refractory hypoxemia due to COVID-19 by improving ventilation-perfusion mismatch. One undesirable consequence of this therapy is increased left atrial pressures and risk of pulmonary edema due to systemic vasodilation. The concomitant use of diuretics could mitigate this side effect thereby optimizing IE’s therapeutic impact. The aim of this study was to assess improvement in oxygenation in spontaneously breathing and mechanically ventilated patients with COVID-19 who received IE alone and those who received both IE and loop diuretic (LD) within 24 hours of each other. METHODS: This is a retrospective case control study approved by the local IRB. Improvement in oxygenation was defined as an improvement in the PaO2/FiO2 (PF) ratio by at least 10% within the 24 hours following therapy. SpO2/FiO2 (SF) ratio was used as a surrogate in cases where arterial blood gas trend was not available. Data was analyzed using SPSS version 26 and chi-square analysis was used to compare the 2 groups. RESULTS: A total of 80 patients with COVID-19, confirmed through RT-PCR, received IE from October 2020 to February 2022. Patients were stratified into 2 groups: combination therapy with IE and LD (IE-LD;n = 34;42.5%) vs IE alone (n = 46;57.5%). Improvement in oxygenation was seen in 82.4% IE-LD patients, which was a statistically significant difference compared to19.6% IE patients (z = 5.568, p <.00001). Hospital length-of-stay was comparable (19.6 days in IE-LD, 25.0 days in IE;p = 0.13) but there was a trend towards decreased in-hospital mortality (64.7% in IE-LD, 82.6% in IE only). The eventual need for mechanical ventilation in spontaneously breathing patients (52.9% in IE-LD, 56.3% in IE;p = 0.85) and mean ventilator days in intubated patients (14.3 days in IE-LD, 16.6 days in IE;p = 0.61) were not statistically different between the 2 groups. CONCLUSIONS: IE is a valuable rescue therapy in cases of refractory hypoxemia due to Covid-19 as previous studies have shown that approximately half of all patients will show improvement in oxygenation. In our study, 43 out of 80 patients had an increase in PF or SF ratio of at least 10% and the majority of these received combination therapy rather than IE alone, suggesting that LD is an effective adjunct to IE. CLINICAL IMPLICATIONS: The role of inhaled pulmonary vasodilators in management of Covid-19 is well-documented as they have been shown to delay intubation in spontaneously breathing Covid-19 patients. Despite the small sample size and retrospective design, our study reports that using LD to minimize inadvertent effects of pulmonary edema when administering IE, can further improve oxygenation in this population. Thus, more studies investigating this combination therapy are warranted. DISCLOSURES: No relevant relationships by Kristine Bessette No relevant relationships by Raj Parikh No relevant relationships by Michael Perkins No relevant relationships by Mari-Elena Pino No relevant relationships by Saimir Sharofi
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SESSION TITLE: Imaging Across the Care Spectrum SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory coronavirus 2 (SARS-CoV-2) has led to approximately 474 million cases and a devastating 6 million deaths worldwide, to date. Despite a relatively low incidence of secondary bacterial infections in COVID-19 patients, the frequency of empiric treatment with antibiotics is as high as 60 to 100%, highlighting a lack of stringent antibiotic stewardship. This promotes the development of multidrug resistant microorganisms. The purpose of this study was to evaluate the utility of the procalcitonin (PCT) biomarker in identifying the development of hospital acquired pneumonia (HAP) in COVID-19 patients. METHODS: We conducted a single center retrospective study of COVID-19 patients admitted between March 2020 to March 2021. COVID-19 patients who developed HAP during their index hospitalization were compared to those who did not develop HAP. Included in the study were COVID-19 positive patients who received empiric antibiotics for < 48 hours and had at least one PCT value ≥ 48 hours since admission. Exclusion criteria included patients with conditions that could affect PCT values including chronic kidney disease stage 5 and above, malignancy and elevated bilirubin levels. Patients with positive microbiology data < 48 hours of admission and those receiving antibiotic therapy prior to admission were excluded as well. All data was analyzed via SPSS. RESULTS: The median age of the cohort was 65 years. There was no difference in demographics in those who had HAP compared to those who did not. Median Charlson comorbidity index (CCI) (3,2;p=0.6) PCT (0.16, 0.13;p=0.91), ferritin (707, 659.5;p=0.48), and C-reactive protein (CRP) (10.56, 6.78;p=0.19) within 48 hours of admission did not differ significantly between the groups either. Notably, PCT (0.09,0.47;p=0.01) and CRP (3.37, 6.59, p=0.01) 48 hours after admission were significantly higher in COVID-19 patients who developed HAP. However, when PCT and CRP were included in multivariate logistic regression, neither remained a significant predictor of HAP. The odds ratios of PCT and CRP 48 hours after admission were 1.25 (95% CI:0.85-1.8;p=0.27) and 1.08 (95% CI:0.95-1.23;p=0.22), respectively. CONCLUSIONS: Our study did not show a significant difference in the median CCI, PCT, CRP and ferritin obtained within 48 hours of admission in patients who developed HAP versus those who did not. However, PCT and CRP obtained 48 hours after admission, were higher in patients who developed HAP. CLINICAL IMPLICATIONS: The data support the use of PCT and CRP as potential tools to predict the development of concomitant HAP in COVID-19 patients and as guides for antibiotic stewardship in this patient population. DISCLOSURES: No relevant relationships by Mythri Anil Kumar No relevant relationships by Tara McLaughlin No relevant relationships by Raj Parikh No relevant relationships by Meher Singha