Acute Onset Shortness Of Breath Research Articles

Saddle Pulmonary Embolus Treated With Bilateral Emergent Aspiration Pulmonary Thrombectomy

A 77 year old man with recurrent lower extremity thrombosis presented with acute onset shortness of breath and new onset hypoxemia three days after prostatectomy for adenocarcinoma of the prostate. He had been off anticoagulation during the perioperative period. In addition to his new diagnosis of prostate cancer he also had a remote history of treated non-invasive melanoma. Based on this presentation he was at high risk of developing thromboembolic disease. Computed tomography angiogram (CTA) of his chest confirmed a large saddle pulmonary embolus, echocardiogram was positive for new right ventricular wall motion dyskinesis and lower extremity ultrasound revealed bilateral acute and chronic deep vein thrombosis. Given his high bleeding risk, hypoxia and elevated troponin I, he underwent emergent successful aspiration pulmonary thrombectomy. This case is of interest to hospitalists and intesivists as it provides an overview of the current invasive management of pulmonary embolus in the acute setting when systemic anticoagulation is contraindicated. Emergent Aspiration Pulmonary Thrombectomy can restore pulmonary artery flow and cardiopulmonary hemodynamics. A collaborative team based approach that involves the emergency department, intensive care unit, interventional teams and hospitalists is favored.

Delayed pulmonary embolism occurring six months after a mild COVID infection: A case report

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a globally impactful disease. Venous Thromboembolism (VTE), particularly pulmonary embolism is common in the acute stages. Occurrence after initial recovery remains rare. We report a 43-year-old man who was admitted following acute onset shortness of breath six months after mild SARS-CoV-2 infection. Computed Tomography Pulmonary Angiogram revealed a bilateral pulmonary embolism. No other risk factors for VTE were identified. This case report raises concern over a persistent pro-coagulopathy state caused by the SARS-Cov-2 virus even after recovering from the initial infection.

LIVING WITH EHLERS-DANLOS SYNDROME: FOLLOWING A YOUNG BOY THROUGH HIS UPS AND DOWNS ON HIS JOURNEY INTO ADULTHOOD

SESSION TITLE: Genetic and Developmental Disorders Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Ehlers-Danlos syndromes (EDS) are a group of genetic diseases manifesting as various forms of connective tissue disease. Amongst the 13 subtypes, vascular EDS (vEDS) is due to autosomal dominant inheritance of mutated COL3A1 gene, affecting the production of type III collagen. We present a case of a young boy with vEDS from the time of diagnosis and his survival into young adulthood.CASE PRESENTATION: A 25-year-old man presented to pulmonary clinic with the following history: at the age of 16, he presented to a pediatric pulmonary clinic for acute onset shortness of breath, chest tightness, and hemoptysis with a recent elbow tendon and brachial artery rupture following minor trauma. He has no family history of pulmonary diseases. His physical exam was notable for translucent skin, joint hypermobility, long fingers with clinodactyly, acrocyanosis, and no wheezing. Computed tomography scan of the lungs revealed a large cavitary nodule and diffuse smaller lung nodules bilaterally surrounded by ground-glass opacities without lymphadenopathy. Pulmonary function test (PFT) did not show any abnormalities. Biopsy of the lung nodule showed nonspecific inflammation. Extensive rheumatologic markers were all negative. Due to continued hemoptysis, he underwent wedge resection of his left lower lobe, which was complicated by a left pneumothorax that was conservatively managed. Pathological evaluation revealed alveolar hemorrhage with foci of wall destruction. Genetic evaluation finally revealed a heterogenous mutation in COL3A1 gene; he was diagnosed with vEDS. Since the time of diagnosis, he has had recurrent episodes of hemoptysis and three episodes of spontaneous pneumothoraces which required chest tube and talc pleurodesis bilaterally. Subsequent chest imaging and PFTs revealed progressive emphysematous changes with significant bullae, cystic bronchiectasis, and obstructed flow with decreased diffusion capacity, causing persistent dyspnea on exertion. 9 years since the diagnosis, he still has intermittent hemoptysis and chest pain that prompts him to seek frequent emergent medical attention, putting a significant strain on his quality of life.DISCUSSION: VEDS is a rare genetic disease with the frequency of de novo mutations as high as 51%. While gaining a diagnosis poses a challenge in the absence of family history, the burden of this disease stems from the management of its complications. Patients continue to suffer from the physical and psychological strain caused by recurrent complications. Because of its association with catastrophic acute viscus and vascular rupture, vEDS has the worst prognosis of all subtypes.CONCLUSIONS: This case highlights the challenge in diagnosing vEDS caused by a de novo mutation and managing its recurrent complications. Understanding the natural history of vEDS and its complications is crucial for supporting patients and providing an effective management plan.Reference #1: Byers PH, Belmont J, Black J, De Backer J, Frank M, Jeunemaitre X, Johnson D, Pepin M, Robert L, Sanders L, Wheeldon N. Diagnosis, natural history, and management in vascular Ehlers-Danlos syndrome. Am J Med Genet C Semin Med Genet. 2017 Mar;175(1):40-47. doi: 10.1002/ajmg.c.31553. PMID: 28306228.Reference #2: Legrand A, Devriese M, Dupuis-Girod S, Simian C, Venisse A, Mazzella JM, Auribault K, Adham S, Frank M, Albuisson J, Jeunemaitre X. Frequency of de novo variants and parental mosaicism in vascular Ehlers-Danlos syndrome. Genet Med. 2019 Jul;21(7):1568-1575. doi: 10.1038/s41436-018-0356-2. Epub 2018 Nov 26. PMID: 30474650.Reference #3: Pepin M, Schwarze U, Superti-Furga A, Byers PH. Clinical and genetic features of Ehlers-Danlos syndrome type IV, the vascular type. N Engl J Med 2000;342:673–680.DISCLOSURES: No relevant relationships by Hadya ElshakhNo relevant relationships by Rammohan GumpeniNo relevant relationships by Stephen KarbowitzNo relevant relationships by Christina Jee Ah RheeNo relevant relationships by Fizza Sajid SESSION TITLE: Genetic and Developmental Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Ehlers-Danlos syndromes (EDS) are a group of genetic diseases manifesting as various forms of connective tissue disease. Amongst the 13 subtypes, vascular EDS (vEDS) is due to autosomal dominant inheritance of mutated COL3A1 gene, affecting the production of type III collagen. We present a case of a young boy with vEDS from the time of diagnosis and his survival into young adulthood. CASE PRESENTATION: A 25-year-old man presented to pulmonary clinic with the following history: at the age of 16, he presented to a pediatric pulmonary clinic for acute onset shortness of breath, chest tightness, and hemoptysis with a recent elbow tendon and brachial artery rupture following minor trauma. He has no family history of pulmonary diseases. His physical exam was notable for translucent skin, joint hypermobility, long fingers with clinodactyly, acrocyanosis, and no wheezing. Computed tomography scan of the lungs revealed a large cavitary nodule and diffuse smaller lung nodules bilaterally surrounded by ground-glass opacities without lymphadenopathy. Pulmonary function test (PFT) did not show any abnormalities. Biopsy of the lung nodule showed nonspecific inflammation. Extensive rheumatologic markers were all negative. Due to continued hemoptysis, he underwent wedge resection of his left lower lobe, which was complicated by a left pneumothorax that was conservatively managed. Pathological evaluation revealed alveolar hemorrhage with foci of wall destruction. Genetic evaluation finally revealed a heterogenous mutation in COL3A1 gene; he was diagnosed with vEDS. Since the time of diagnosis, he has had recurrent episodes of hemoptysis and three episodes of spontaneous pneumothoraces which required chest tube and talc pleurodesis bilaterally. Subsequent chest imaging and PFTs revealed progressive emphysematous changes with significant bullae, cystic bronchiectasis, and obstructed flow with decreased diffusion capacity, causing persistent dyspnea on exertion. 9 years since the diagnosis, he still has intermittent hemoptysis and chest pain that prompts him to seek frequent emergent medical attention, putting a significant strain on his quality of life. DISCUSSION: VEDS is a rare genetic disease with the frequency of de novo mutations as high as 51%. While gaining a diagnosis poses a challenge in the absence of family history, the burden of this disease stems from the management of its complications. Patients continue to suffer from the physical and psychological strain caused by recurrent complications. Because of its association with catastrophic acute viscus and vascular rupture, vEDS has the worst prognosis of all subtypes. CONCLUSIONS: This case highlights the challenge in diagnosing vEDS caused by a de novo mutation and managing its recurrent complications. Understanding the natural history of vEDS and its complications is crucial for supporting patients and providing an effective management plan. Reference #1: Byers PH, Belmont J, Black J, De Backer J, Frank M, Jeunemaitre X, Johnson D, Pepin M, Robert L, Sanders L, Wheeldon N. Diagnosis, natural history, and management in vascular Ehlers-Danlos syndrome. Am J Med Genet C Semin Med Genet. 2017 Mar;175(1):40-47. doi: 10.1002/ajmg.c.31553. PMID: 28306228. Reference #2: Legrand A, Devriese M, Dupuis-Girod S, Simian C, Venisse A, Mazzella JM, Auribault K, Adham S, Frank M, Albuisson J, Jeunemaitre X. Frequency of de novo variants and parental mosaicism in vascular Ehlers-Danlos syndrome. Genet Med. 2019 Jul;21(7):1568-1575. doi: 10.1038/s41436-018-0356-2. Epub 2018 Nov 26. PMID: 30474650. Reference #3: Pepin M, Schwarze U, Superti-Furga A, Byers PH. Clinical and genetic features of Ehlers-Danlos syndrome type IV, the vascular type. N Engl J Med 2000;342:673–680. DISCLOSURES: No relevant relationships by Hadya Elshakh No relevant relationships by Rammohan Gumpeni No relevant relationships by Stephen Karbowitz No relevant relationships by Christina Jee Ah Rhee No relevant relationships by Fizza Sajid

Donath-landsteiner hemolytic anemia with erythrophagocytosis and platelet phagocytosis in peripheral smear: Rare findings

The Donath-Landsteiner (DL) hemolytic anemia or paroxysmal cold hemoglobinuria (PCH) is a rare subtype of autoimmune hemolytic anemia (AIHA). We report here a case of a 22-year-old young female who presented with acute onset shortness of breath. Routine hematological investigation revealed erythrophagocytosis and platelet phagocytosis by monocytes in peripheral blood smear, which are rarely reported in AIHA, especially the DL. The unusual blood smear findings directed the pathologists to initiate workup for hemolytic anemia that yielded positive results in direct Coombs test C3d (Complement) and direct DL test. The findings confirmed the case as DL hemolytic anemia. To the best of our knowledge, this is the first report of both erythrophagocytosis and platelet phagocytosis in peripheral blood smear in PCH.

A Rare Occurrence of Postural Hypotension in a COVID-19 Patient

The SARS-CoV-2 infection has presented itself with typical presentations like other viral infections and atypical presentations as well. Many of the clinical associations are established and still, researches are ongoing. It is still an evolving disease and is an area of research at present time. We present a rare case of postural hypotension in a 49-years-old COVID-19 patient. We admitted a 49-year-old diabetic male patient with a history of acute onset shortness of breath, cough and fever. The patient was diagnosed case of a COVID-19 infection and was admitted with mild to moderate symptoms. The patient maintained his normal saturation on oxygen. The patient developed an unusual symptom of postural hypotension during his hospital stay and it was managed with a conservative approach. The development of postural hypotension in a COVID-19 patient is reported very rarely. Given the fact that postural hypotension is an important and specific disease entity, this association presents an active area of research in the present era.

Chronic myeloid leukaemia presenting as acute pulmonary thromboembolism

Abstract Myeloproliferative neoplasms are associated with increased viscosity and thrombosis most commonly leading to splanchnic vein thrombosis and Budd Chiari syndrome. Pulmonary thromboembolism is a rare possibility. Chronic Myeloid Leukaemia commonly present with anaemia, splenomegaly. In cases presenting with thrombosis, leucocytosis is generally observed. Eosinophilia is also a rare presentation of CML. Here we present a case of young male presented with unprovoked Acute Pulmonary Embolism and eosinophilia. On evaluation found to be having Philadelphia Chromosome positive and improved on treatment with Tyrosine Kinase Inhibitors. This case highlights the importance of consideration of pulmonary embolism as one of cause of acute onset shortness of breath especially when there are suggestive ECG changes and emphasises the need for evaluation of cause of Acute thromboembolism.

Case Report on Nursing Management of a Client with Hiatus Hernia

A hiatus hernia occurs when a portion of the stomach protrudes into the chest cavity. It enters through the same entrance through which the food tube (oesophagus) travels to the stomach. A case of an 39-year-old male with a history of diabetic presented to the emergency room with acute onset shortness of breath, epigastric pain and chest pain. The stomach bulges up into the chest through that opening in a hiatal hernia (also known as a hiatus hernia). The client was having burning sensation in epigastric region since from 2-5 year, acid reflux after taking food, heartburn, nausea, regurgitation, vomiting, and abdominal pain and irritation. After the physical examination, history collection and investigations he was diagnosed as case of hiatus hernia.The study's main focus is on professional management and excellent nursing care, which may be able to give the holistic care that hiatus hernia requires while also efficiently treating the difficult case. Following a complete recovery, the patient's multidisciplinary health care team works together to help the patient reclaim his or her prior level of independence and contentment.

PRIMARY INTRATHORACIC SYNOVIAL SARCOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Synovial sarcomas (SS) are a rare group of malignancies, seen in 0.17 per 100,000 persons, accounting for 7% of all soft tissue sarcomas. These malignant tumors most commonly present as a tumor of the extremities. While they have a high propensity for metastasis to bone and lung, primary intrathoracic malignancy is rare. We present a case of a patient who presented with acute onset shortness of breath, diagnosed with primary synovial sarcoma of the lung. CASE PRESENTATION: A 22-year-old male with no past significant medical history presented with a four-week history of right upper quadrant abdominal pain and acute onset chest pain radiating to his shoulder with associated dyspnea. On arrival to emergency department, patient was tachycardia, otherwise vitally stable. Labs were notable for leukocytosis. Chest x-ray showed a moderate right-sided pleural effusion with associated opacity of the lower hemithorax. A chest tube was placed however no fluid was evacuated. A CT of the chest was obtained which showed a right lower lobe hemithorax, a right lower lobe pleural-based nodule measuring 2x2 x 1.6 cm, and a lesion within the right hemithorax measuring 20x17.9x19.3 cm. The patient was taken for video-assisted thoracoscopic surgery for surgical exploration and chest tube placement. Patient was found to have large tumor invading whole right chest with compression on mediastinal structures including the heart, lung, and IVC. Biopsies were taken. Patient developed acute respiratory distress and obstructive shock and was intubated and placed on vasopressor support. Preliminary pathology was revealing of synovial sarcoma. Operative findings revealed a large right pleural and posterior mediastinal mass invading the right lower lobe through the diaphragm into the peritoneal space and liver capsule. He underwent thoracotomy with excision and resection of the thoracoabdominal and mediastinal tumor, total pulmonary decortication, wedge resection of right lower and middle lobe, and reconstruction of diaphragm. The patient was successfully extubated three days post operatively and soon after discharged home. Post-operative CT showed no definite evidence of gross residual disease. The patient received 3 cycles of doxorubicin/isofosfamide following discharge. DISCUSSION: Reports of primary thoracic SS are rare. Diagnosis is often delayed because of the benign radiographic appearance and indolent nature of these tumors; sequelae of disease often do not manifest until tumor burden is great enough to cause mass effect. Though standard of care is chemotherapy, the patient in this case required emergency palliative resection due to cardiovascular compromise. CONCLUSIONS: Though soft tissue sarcomas account for less than 0.1% of all malignant thoracic neoplasms, it should be considered in the differential for thoracic malignancies as delay in diagnosis could be consequential to patient outcome. REFERENCE #1: Javad Parvizi, Gregory K. Kim, Chapter 218 - Synovial Sarcoma, Editor(s): Javad Parvizi, Gregory K. Kim, High Yield Orthopaedics, W.B. Saunders, 2010, Pages 455-456, ISBN 9781416002369, https://doi.org/10.1016/B978-1-4160-0236-9.00230-3. REFERENCE #2: Nedra Joseph, Samantha St. Laurent, Jeanenne Joy Nelson, Shan Zheng, and Heide Stirnadel-Farrant. Journal of Clinical Oncology 2019 37:15_suppl, e22535-e22535 DISCLOSURES: No relevant relationships by Neiha Kidwai, source=Web Response

UNILATERAL CRYSTAL METHAMPHETAMINE LUNG

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Methamphetamine is a drug manufactured from ephedrine and pseudoephedrine mixed with ingredients such as ammonia, lithium, iodine, and phosphorous but adulterants such as alcohol, acetone, and energy drinks have also been used. Smoking is the most common form of abuse with complications such as eosinophilic pneumonia, alveolar hemorrhage, acute interstitial pneumonia, and pulmonary fibrosis. We present an atypical methamphetamine-induced lung injury. CASE PRESENTATION: A 57-year-old female with a 40-pack year smoking history and polysubstance abuse presented with acute onset shortness of breath. On admission, she was hypoxic requiring 25 liters of high flow oxygen. On examination, the patient was afebrile with normal blood pressure. Chest auscultation revealed wheezing, most prominent in the left lung fields, while the rest of the systemic examination was unremarkable. Laboratories showed leukocytosis, normal liver, and renal function test. Sputum culture had no bacterial growth and Covid-19 PCR negative. Urine toxicology was positive for methamphetamine. Contrast CT chest showed diffuse interstitial thickening and ground-glass opacities throughout the right lung but normal left lung parenchyma with narrowing of the distal left mainstem bronchus by an endobronchial mass. The patient's hypoxemia improved with Methylprednisolone. Bronchoscopy showed a left mainstem lesion with near-complete obstruction of the left upper and lower lobes with biopsy revealing squamous cell carcinoma. There was normal airway mucosa on the right lung segments and scant inflammation without malignant cells on biopsy. The patient underwent successful tumor debulking with follow-up PET CT demonstrating decreased but persistence of alveolar septal thickening on the right lung with FDG positive mediastinal lymph nodes. The patient was weaned off supplemental oxygen 4 weeks later. DISCUSSION: Diagnosis of Methamphetamine-induced lung injury depends on the history of recent use, ground-glass opacities on imaging, and exclusion of other infections which was fulfilled by our patient but with the question of left lung sparing. Crystalline particles range in size from less than 250 nm-10 μm, with clusters as large as 80 μm where the obstructing mass may have prevented the flow of the drug vapor. Methamphetamine has also been postulated to release early response cytokines including TNF-alpha and IL-6 leading to recruitment of neutrophils and free radicals release causing acute lung injury. The management is mainly supportive with empiric steroids with improvement via impeding this inflammatory cascade. CONCLUSIONS: Our case demonstrates multiple learning points including particle size factor in passage through an obstructed airway, response to steroids supporting in settings of acute inflammation, and the persistence of residual lung disease on imaging in contrast to clinical improvement 4 weeks post-exposure. REFERENCE #1: Javed A, Nasrullah A, Malik K (February 08, 2021) A Rare Case of Methamphetamine-Induced Lung Injury During the Ongoing COVID-19 Pandemic. Cureus 13(2): e13215. doi:10.7759/cureus.13215 REFERENCE #2: Kinner SA, Degenhardt L. Crystal methamphetamine smoking among regular ecstasy users in Australia: increases in use and associations with harm. Drug Alcohol Rev. 2008 May;27(3):292-300. doi: 10.1080/09595230801919452. PMID: 18368611. REFERENCE #3: Lin SS, Chen YC, Chang YL, Yeh DY, Lin CC. Crystal amphetamine smoking-induced acute eosinophilic pneumonia and diffuse alveolar damage: a case report and literature review. Chin J Physiol. 2014 Oct 31;57(5):295-8. doi: 10.4077/CJP.2014.BAC201. PMID: 25241990. DISCLOSURES: No relevant relationships by Uchit Thapa, source=Web Response

Pulmonary Embolism as a Rare Complication of Clomiphene Therapy: A Case Report and Literature Review

Background Pulmonary embolism (PE) is a medical emergency. Certain medications like oral contraceptives and hormone replacement therapies have been associated with PE. Clomiphene citrate is a selective estrogen receptor modulator, approved for treating infertility in females, but is being used as an off-label therapy in treating male hypogonadism. Very rarely, clomiphene can cause pulmonary embolism. Case Report. A 56-year-old gentleman presented with acute onset shortness of breath and chest discomfort. Upon further workup, he was found to have large volume pulmonary embolism. He was prescribed clomiphene citrate (CC) 2 years ago for hypogonadism. He was started on anticoagulation with improvement in his symptoms, and clomiphene was discontinued. Conclusion Pulmonary embolism is a rare but potential complication of clomiphene therapy. In male patients with suspected hypogonadism, the risk of serious thromboembolic complications should be discussed before prescribing CC. Patients on CC have to be carefully monitored for serious side effects.

1438 The Past, Present and Future Management of Complex Chyle Fistulae

Abstract Background Chyle leak/fistula is a rare complication of oesophageal surgery, usually consequent on an unintended breach of the thoracic duct, its tributaries, or the cisterna chyli. For high volume persistent leaks further surgery has been the traditional approach, however two cases have resulted in a new management approach at this Centre. Case Series The first patient, a 49-year-old, developed high volume drain output post three stage oesophagectomy. His jejunostomy feeding was discontinued, total parenteral nutrition and a somatostatin analogue, were commenced. Despite these measures, the drain output remained >1.5litres per day and an exploratory thoracotomy was performed. The second patient, an 81-year-old underwent a transhiatal-oesophagectomy. On postoperative day 10 he developed acute onset shortness of breath, CXR demonstrated a large left sided pleural effusion. CT thorax demonstrated multiloculated complex pleural effusions. US guided pig tail drain was placed in the largest targetable effusion. The fluid was chylous in appearance. In both cases, an interventional radiological approach, not previously performed at this centre, provided definitive management. Lymphangiography was performed via injection of 1mL of Lipoidol® every 5 minutes into the inguinal lymph nodes to identify the cisterna chyli. A guidewire was advanced via the cisterna chyli with coils and glue used to embolize the leaking tracts. Discussion The lessons from this experience provide an algorithm for the management of chyle leaks, that will change practice at this centre. Embolization or disruption of thoracic duct and cisterna chyli leaks will be first line therapy for complex chyle leaks, with surgery reserved for where this fails.

Pseudo‐Wenckebach

A 47-year-old man with an implanted dual-chamber pacemaker was transferred to the emergency department with acute onset shortness of breath. He had tachycardia, with a heart rate of 123 beats/min in a regularly irregular rhythm. His respiratory rate was 30 breaths/min, and oxygen saturation was 88% with 15-L oxygen via a mask with a nonrebreathing reservoir. The chest X-ray showed bilateral perihilar airspace opacity with dilatation of the main pulmonary artery. An electrocardiogram (Fig. 1A) showed wide-complex tachycardia with regularly irregular RR intervals induced by progressive prolongation of the AV interval. Based on the clinical presentation, a diagnosis of acute pulmonary edema was made. This progressive prolongation of the AV delay is often called “pseudo-atrioventricular Wenckebach.” The pseudo-Wenckebach occurs when the sinus rate exceeds the programmed maximum tracking rate, but the P–P interval is longer than the total atrial refractory period to avoid an abrupt decrease of the ventricular rate that results in circulatory disruption.1, 2 When physicians find irregular P–Q interval, the pseudo-Wenckebach is sometimes mistaken for pacing failure. Therefore, emergency physicians should know this phenomenon. After recovery within a day on nitrates and diuretics, the electrocardiogram (Fig. 1B) showed a normal pacing rhythm. Approval of Research Protocol: Not applicable. Informed Consent: Not applicable . Registry and the Registration No. of the study/Trial: Not applicable. Animal Studies: Not applicable. Conflict of Interest: None declared.

ATRIAL FLUTTERS AS AN INITIAL PRESENTATION OF LUNG CANCER CAUSING MALIGNANT PERICARDIAL EFFUSION

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pericardial effusion is a devastating cardiac condition, resulting from various etiology. Cardiac arrhythmia is an uncommon presentation of pericardial effusion, while atrial fibrillation is the most common arrhythmia found in this condition. Atrial flutter, as an initial presentation of malignant pericardial effusion, has not yet been reported. We presented a case of an elderly man with atrial flutter from malignant cardiac effusion from a newly diagnosed lung cancer. CASE PRESENTATION: An 81-year-old man, with chronic obstructive pulmonary disease and hypertension, presented with acute onset shortness of breath. He used albuterol MDI but his symptoms were not improved. On evaluation, he had heart rate 179 beats per minute (bpm), blood pressure 172/118 mmHg without pulsus paradoxus, and respiratory rate of 26. He had good mental status and did not have jugular venous distention. Lungs exam was normal. Heart exam revealed tachycardia without murmur. His blood test was unremarkable. His ECG showed atrial flutter with rapid ventricular rate and 2:1 block. He received intravenous Diltiazem 20 mg and his heart rate decreased to 90. Point of care ultrasound (POCUS) showed large pericardial effusion without tamponade physiology and no signs of pulmonary edema. Computed tomography (CT) chest illustrated large pericardial effusion with new left upper lung mass. Cytology from pericardial effusion revealed squamous cell carcinoma. He was diagnosed as malignant pericardial effusion from advance stage squamous cell lung cancer. His hospital course was complicated with septic shock and eventually death. DISCUSSION: Lung cancer is the most common metastasis cancer to the heart and pericardium because of the proximity of the tumor to the heart [1]. There are several possible explanations of malignant pericardial effusion pathogenesis. First, it can be a result of cardiac lymphatic drainage occlusion by the tumor [2]. Second, local or hematogenous spread of the tumor lead to venous blood flow obstruction and an increase in hydrostatic pressure causing pericardial effusion [3]. Third, neoplastic pericardial involvement stimulates an overproduction of pericardial fluid [3]. Pericardial effusion in cancer patients may arise from complications of treatment, including chemotherapy and radiation, and hypoalbuminemia from malignancy-related cachexia. Cytology analysis of pericardial fluid and pericardial biopsy should be performed to confirm the diagnosis. Management includes pericardiocentesis, pericardial window, pericardial sclerosis, and radiation therapy. CONCLUSIONS: We presented a rare case of atrial flutter secondary to malignant pericardial effusion from newly diagnosis of advanced-stage lung cancer. Clinicians should have pericardial effusion as a differential diagnosis of patients with atrial flutter as this is a catastrophic condition, requiring urgent management. Reference #1: DeCamp MM, et al. Malignant effusive disease of the pleura and pericardium. Chest. 1997;112(4 Suppl):2915-2955. Reference #2: Chiles C, et al. Metastatic involvement of the heart and pericardium: CT and MR imaging. Radiographics. 2011;21(2):438-449. Reference #3: Scheinin SA, Sosa-Herrera J. Cardiac tamponade resembling an acute myocardial infarction as the initial manifestation of metastatic pericardial adenocarcinoma. Methodist Debakey Cardiovasc J. 2014; 10:124–128. DISCLOSURES: No relevant relationships by Nehad Shabarek, source=Web Response No relevant relationships by Kulachanya Suwanwongse, source=Web Response

SUBCUTANEOUS EMPHYSEMA WITH AIRWAY COMPROMISE FOLLOWING OCCULT GI MICROPERFORATIONS CAUSED BY FOREIGN-BODY INGESTION

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Traumatic pharyngeal perforation leading to subcutaneous emphysema following ingestion of sharp foreign objects is well described in the literature. We present the case of a man who presented in respiratory distress with evidence of extensive subcutaneous emphysema who was subsequently diagnosed with occult pharyngeal microperforations. CASE PRESENTATION: A 76-year-old man with a history of essential hypertension, type 2 diabetes mellitus, schizophreniform disorder, and multiple myeloma presented to the hospital with acute onset shortness of breath, facial swelling, dysphagia, and fever. Clinically, the patient was in respiratory distress, with evidence of stridor and with palpable crepitus extending over his neck and face. Neck and chest (Figure 1) CT showed soft tissue emphysema throughout his face and neck that extended into the mediastinum. Indirect laryngoscopy revealed diffuse pharyngeal wall and epiglottic edema, with an inability to visualize the glottis and without evidence of mural tears. The patient underwent an emergent tracheostomy given the concerns for airway compromise. Based on the initial concern of possible necrotizing fasciitis, the patient received broad spectrum antibiotics. Intraoperative biopsies of the laryngopharynx showed extensive necrosis and acute inflammation without bacterial growth. Given to the patient’s rapid clinical improvement a decision was made to hold off on emergent debridement. Barium swallow demonstrated no evidence of gastrointestinal perforation. One week after admission, the patient had a bowel movement in which he was observed to have passed numerous nuts, bolts, screws, and keys from his rectum. Abdominal imaging was performed and showed that further objects were traversing through the colon (see Figures 2–3). On questioning, the patient admitted to having ingested these objects in an attempt to aid his chronic constipation. At this point, it was determined that the consumption of these foreign bodies led to transient esophageal microperforations causing initial airway compromise. DISCUSSION: Our patient underwent traumatic pharyngeal perforation which is well described in the literature, secondary to ingestion of sharp foreign objects. Although initially it was thought that the presentation was due to a necrotizing infection, the patient’s improvement after airway management and negative culture data went against this interpretation. The subsequent passage of foreign objects and confirmatory imaging allowed us to make the final diagnosis of occult pharyngeal microperforations. CONCLUSIONS: This case emphasizes the need to approach patients based on their clinical appearance. It is important to maintain a broad differential based on the clinical presentation and to have a high index of suspicion once other possible causes have been excluded. Reference #1: Lynn De Roeck, Lauranne Van Assche, Veronique Verhoeven, Ina Vrints, Jana Van Thielen, Thierry Tondu & Filip Thiessen (2019) Progressive subcutaneous emphysema of unknown origin: a surgical dilemma, Acta Chirurgica Belgica, 119:4, 251-253, DOI: 10.1080/00015458.2018.1438560 DISCLOSURES: No relevant relationships by Jason Bofinger, source=Web Response no disclosure on file for Calli Dogon; No relevant relationships by Shahrzad Zonoozi, source=Web Response

Pulmonary Thromboembolism in COVID-19: Initial Experience from India

Pulmonary thromboembolic complications are increasingly being recognised in Coronavirus Disease 2019 (COVID-19) infections. Most of the cases of Pulmonary Embolism (PE) are often missed in presence of non-specific symptoms. The present report is about a 90-year-old COVID-19 positive male, asymptomatic on presentation, with no prior co-morbidities who developed acute onset shortness of breath along with elevated D-dimer levels four days post admission. Subsequently, a Computed Tomography Pulmonary Angiogram (CTPA) was done which revealed segmental and sub-segmental thromboembolism in upper and middle lobar branches of right pulmonary artery along with bilateral lower lobe ground-glass opacities consistent with COVID-19 pneumonia. As the patient was haemodynamically stable, he was managed conservatively on low molecular weight heparin and subsequently discharged on oral anti-coagulants. This report highlights the need for prompt evaluation of symptoms such as dyspnoea in COVID-19 patients and to rule out thromboembolic complications in them. In resource limited countries such as India with most of the COVID-19 centres having limited access to CT scans, triaging patients based on clinical suspicion and serially rising D-dimer levels may help identify those with thromboembolic complications.

CAN CEMENT TAKE OUR BREATH AWAY? AN INTERESTING CASE OF PULMONARY EMBOLISM AFTER KYPHOPLASTY

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pulmonary cement embolism (PCE) refers to embolization of polymethyl methacrylate into the lungs. Patients are most often asymptomatic, but reports have been made were patients present symptomatically after PCE. We report a case of a 61-year-old man who had a vertebral kyphoplasty and presented 2 days later with acute onset respiratory distress and found to have a fatal PCE in the setting of multiple comorbidities. CASE PRESENTATION: 61-year-old male with medical history of HIV, DM, HTN, ESRD on HD, presented with worsening back pain. The back pain started after a mechanical fall. Imaging revealed a T12 burst fracture.Patient underwent an uncomplicated kyphoplasty of T11, T12, L1 vertebrae, did well post-operatively and was discharged. Patient presented back to ED on same day of discharge with complaints of acute onset shortness of breath. On arrival, Patient appeared in severe respiratory distress. His physical examination was remarkable for decreased breath and crackles bilaterally. Due to increased work of breathing, he was intubated and placed on mechanical ventilation in the ED. Initial CXR showed increased hyperdense perihilar opacities. The clinical presentation was concerning for embolic vertebroplasty material (IMG1). This was confirmed with a CTA (IMG2) which reported extensive vertebroplasty cement embolism to the pulmonary arteries and enlargement of the pulmonary arteries. Patient was admitted to the ICU for mechanical ventilation and open cardiac surgery to remove cement from the lungs was considered, but patients status continued to deteriorate in the following 24 hours. He was hemodynamically unstable requiring large doses of vasopressors and requiring immediate hemodialysis. Patient had an episode of PEA arrest after which family decide to withdraw care. DISCUSSION: In this case, a Chest X ray showed pulmonary infiltrates and an increase in perihiliar opacities compatible with embolic vertebroplasty at the ER after 72 hours post procedure. Although most patients remain asymptomatic according to different authors, it has been reported cases in which patients develop symptoms months, and even until 10 years after procedure. PCE after kyphoplasty is a complication that happens according to different series as low as 3.5% up to high as 28.6% . Percutaneous kyphoplasty has been reported with less possibility to develop Pulmonary cement embolism than vertebroplasty. The presence of comorbidities in a patient of the older age increased the possibilities of fatal outcome in this patient. CONCLUSIONS: Percutaneous kyphoplasty one of the main complications of this procedure has been the development of PCE which if detected early with a high index of suspicion has an overall good prognosis. In those patients with serious co-morbidities and kyphoplasty, closer monitoring should be done in order to detect the onset of symptoms and to provide adequate treatment to avoid fatal outcomes. Reference #1: M.I. Syed, S. Jan, N.A. Patel, A. Shaikh, R.A. Marsh, R.V. Stewart. Fatal Fat Embolism after Vertebroplasty: Identification of the High-Risk Patient. American Journal of Neuroradiology Feb 2006, 27 (2) 343-345. Reference #2: Dash A, Brinster DR. Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty. Annals of Thoracic Surgery. 2011;91(1):276–278 Reference #3: Nishant Sinha, Vivek Padegal, Satish Satyanarayana,and Hassan Krishnamurthy Santosh. Pulmonary cement embolization after vertebroplasty, an uncommon presentation of pulmonary embolism: A case report and literature review DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response no disclosure on file for Yash Jobanputra; No relevant relationships by Purva Sharma, source=Web Response

ACUTE PULMONARY GRAFT VS HOST DISEASE RESPONDING TO IBRUTINIB THERAPY

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Acute graft versus host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT) usually involves the liver, skin and gut and lung involvement is rare. We report a case of acute GVHD with respiratory failure developing 18 months post allogeneic HSCT that was successfully treated with Ibrutinib. CASE PRESENTATION: A 58-year old male with relapsed small lymphocytic lymphoma (SLL) following matched, sibling-donor allogeneic HSCT complicated by chronic GVHD presented with acute onset shortness of breath following completion of slow corticosteroid taper. He presented 18 months post-transplant with a one-week history of progressive dyspnea, anorexia, weight loss, diarrhea, lower extremity edema, dizziness and lethargy. Dyspnea rapidly progressed to acute hypoxemic respiratory failure requiring high-flow oxygen therapy (HFOT). CT chest progressed from right middle and lower lobe ground glass opacities on admission to bilateral multi-lobar parenchymal opacities (Figure 1). Oxygen requirements progressed in spite of broad-spectrum antibacterial and antifungal therapy; he underwent bronchoscopy with transbronchial biopsy that showed chronic interstitial inflammatory infiltrate with scattered T cells, with no evidence of SLL/CLL (Figure 2). Microbiological testing, including bronchoalveolar lavage fluid cultures, was negative. The diagnosis of acute GVHD was made and the patient was started on high-dose IV methylprednisolone on hospital day (HD) 9. After 5 days, he remained on HFOT; he received tocilizumab and was started on ibrutinib on HD 14. By HD 18, his pulmonary status had significantly improved. By HD 22, he was off supplemental oxygen, and by HD 23, his chest CT demonstrated resolution of lung opacities. DISCUSSION: Non- infectious lung complications (NILC) is a nonspecific term that includes pulmonary edema, diffuse alveolar haemorrhage, idiopathic pneumonia syndrome, post-transplant lymphoproliferative disorder and many other pulmonary complications that can occur in patients post HSCT (1). Acute GVHD is one of the complications responsible for severe morbidity and often, mortality. As per the 2014 NIH consensus criteria, diagnosis of acute GVHD depends on clinical manifestations, not to the temporal relationship with transplantation (2). The clinical course of acute GVHD typically mimics steroid-responsive cryptogenic organizing pneumonia; however in certain cases, it may be refractory to even high doses of steroids. Our patient’s clinical improvement following initiation of immunomodulatory therapies including tocilizumab and ibrutinib, provides support for using these novel agents. CONCLUSIONS: Ibrutinib is a tyrosine kinase inhibitor that has been shown to benefit patients with chronic GVHD (3). Our case highlights its use with a positive outcome in acute GVHD refractory to steroids. Reference #1: Pena E, Souza CA, Escuissato DL, Gomes MM, Allan D, Tay J, et al. Noninfectious pulmonary complications after hematopoietic stem cell transplantation: practical approach to imaging diagnosis. Radiographics. 2014;34(3):663-83. Reference #2: Jagasia MH, Greinix HT, Arora M, Williams KM, Wolff D, Cowen EW, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Staging Working Group report. Biol Blood Marrow Transplant. 2015;21(3):389-401.e1. Reference #3: Miklos D, Cutler CS, Arora M, Waller EK, Jagasia M, Pusic I, et al. Ibrutinib for chronic graft-versus-host disease after failure of prior therapy. Blood. 2017;130(21):2243-50. DISCLOSURES: No relevant relationships by Divyansh Bajaj, source=Web Response No relevant relationships by Nancy Hardy, source=Web Response No relevant relationships by Van Holden, source=Web Response No relevant relationships by Shreya Kanth, source=Web Response No relevant relationships by Akshay Kohli, source=Web Response No relevant relationships by Laura Malone, source=Web Response Consultant relationship with Medtronic Please note: $1001 - $5000 Added 03/17/2019 by Edward Pickering, source=Web Response, value=Consulting fee Consultant relationship with Medtronic Please note: $1001 - $5000 Added 03/13/2019 by Ashutosh Sachdeva, source=Web Response, value=Consulting fee Unrestricted education grant relationship with Olympus Please note: $1001 - $5000 Added 03/13/2019 by Ashutosh Sachdeva, source=Web Response, value=Grant/Research Support

A Case of Sarcoidosis Presenting as Refractory Arrhythmias: Quieting the Storm

Introduction Sarcoidosis is a multisystem granulomatous disorder of unknown etiology. Cardiac sarcoidosis can manifest as conduction abnormality, ventricular tachycardia (VT), heart failure or sudden cardiac death. Although well studied in the literature, we present an uncommon case of arrhythmia as a presenting manifestation of this disease. Case 45-year-old female with no significant past medical history presented with acute onset shortness of breath and palpitations. Initial transthoracic echocardiogram revealed an ejection fraction of 50%. Electrophysiology (EP) study showed a chemically inducible accelerated idioventricular rhythm with right bundle morphology. Left heart catheterization showed angiographically normal vessels and cardiac MRI showed no regional wall motion abnormalities or abnormal delayed enhancement. Patient presented to the hospital again due to recurrence of arrhythmia, found to be VT. Nuclear medicine whole body PET scan showed perfusion defects consistent with cardiac sarcoidosis. A mediastinal lymph node biopsy demonstrated focal non-granulomatous inflammation. Patient was initiated on anti-arrhythmics and underwent a single-chamber ICD placement. She continued to have episodes of wide QRS tachycardia, and was evaluated by Advanced Heart Failure for refractory arrhythmias. Decision-making Patient was initially managed with Amiodarone and a beta-blocker. Due to unstable VT, she was taken to EP lab where a focal origin of the VT was successfully found in the basal anterolateral endocardial left ventricle and at the base of one of the papillary muscles. Ablations were performed in these areas with reduction in VT rate. Patient was also discovered to have complete atrioventricular block. Subsequently, she developed recurrence of arrhythmia and was admitted again for VT management. Patient was taken back to the EP lab for an endocardial and epicardial ablation. A focal VT source was found in the apical lateral left ventricle. Due to proximity of the phrenic nerve to the site, no ablations were performed. However, due to recurrence of arrhythmia, she was taken back to the lab for a third ablation in the epicardial area with resulting success. Antiarrhythmics were changed to Flecainide which has since suppressed her VT. Patient has been maintained on Methotrexate, Hydroxychloroquine, and Prednisone for continued sarcoid therapy. We are using periodic F-FDG PET imaging to monitor the severity of myocardial inflammation. Based on patient's clinical status and PET imaging, we have determined the time to wean immunosuppressant agents. Conclusion Cardiac sarcoidosis affects at least 25% of sarcoidosis patients and accounts for substantial mortality and morbidity.Ventricular arrhythmias may be the presenting symptom of cardiac sarcoidosis and are challenging to treat. Risk stratification through proposed techniques such as advanced cardiac imaging and EP studies is integral in this population. Recognition of sarcoidosis as a possible etiology of arrhythmias through integration of clinical and imaging findings can lead to appropriate lifesaving treatments.

Uvular angioedema in a patient on angiotensinreceptorblocker

A 62-year-old Caucasian man presented to emergency room with complaints of acute onset shortness of breath (dyspnoea) and swelling of neck for 1 day. His medical history included hypertension, coronary...

Pneumomediastinum in a Heavy Weightlifter.

The presence of air in the mediastinal cavity (i.e., pneumomediastinum) is an uncommon condition. It is usually precipitated by an event such as penetrating trauma, barotrauma or increased intrathoracic pressure caused by severe vomiting or coughing. We present the case of a 32-year-old man who developed pneumomediastinum as a result of heavy weightlifting.LEARNING POINTSPneumomediastinum should be considered in the differential diagnosis of acute onset shortness of breath and chest pain.Pneumomediastinum can be precipitated without any obvious trauma as in cases of increased coughing/vomiting or heavy weightlifting.It is generally managed conservatively and resolves spontaneously.