Airspace Opacities Research Articles

Abstract Sa1106: Computed Tomography Imaging After In-Hospital Cardiac Arrest: An Observational Cohort Study

Introduction/Background: Computed tomography (CT) imaging is a promising method for diagnosing patients after return of spontaneous circulation (ROSC) from cardiac arrest. CT information could alter management, improving patient outcomes. There are data supporting use after out-of-hospital arrests, but use and impact of CT imaging after in-hospital-cardiac arrest (IHCA) has not been investigated. Research Question/Hypothesis: We hypothesize that CT imaging will identify acute pathology, resulting in a change in management. Goals/Aims: Our aim is to describe the rates of use, findings, and consequences of CT imaging after IHCA. Methods/Approach: We screened for the first IHCA on admission between 1/26 2023, and 1/302024 at 3 hospitals. Patients 18 years of age or older who achieved ROSC were included. Information was collected on demographics, type of imaging performed, imaging findings, and whether the findings acutely changed management. A change in management was defined as a subsequent change in medications, procedures, or consultations that would not have otherwise occurred and was specifically performed to reverse, mitigate, or treat the imaging finding, based on review of chart documentation by critical care fellows and medicine residents. Results are reported as counts and percentages. Results: We screened 638 IHCA at 3 hospitals. Of the 201 patients meeting inclusion criteria, 72 (35.8%) died within 24 hours after ROSC. Of those who survived 24 hours, 58 of 129 (45.0%) received CT imaging in the 48 hours after ROSC, 53 (41.1%) received a head CT, 26 (20.2%) received a chest CT, 19 (14.7%) received an abdomen/pelvis CT, and 4 (3.1%) received a CT that was not head, chest, or abdomen/pelvis. The most common findings were ischemic stroke (15), pulmonary airspace opacities (23), and pleural effusion (15). An acute finding (previously unknown) was identified in 32 of 58 scans (55.2%), and there was an acute change in management because of the acute finding in 21 (65.6%) of those patients. For 8 patients (13.8%), the scan identified an acute finding thought to have contributed to the cardiac arrest. Of the 58 patients who received CT imaging, 2 of them (3.4%) suffered cardiac arrest while receiving the CT scan. Conclusions: CT imaging within 48 hours after IHCA frequently identified acute pathology, resulting in a change in management. Complications were seen, although we do not know if these were a result of the CT imaging, related transportation, or other causes.

Chest X-Ray-Based Telemedicine Platform for Pediatric Tuberculosis Diagnosis in Low-Resource Settings: Development and Validation Study.

Tuberculosis (TB) remains a major cause of morbidity and death worldwide, with a significant impact on children, especially those under the age of 5 years. The complex diagnosis of pediatric TB, compounded by limited access to more accurate diagnostic tests, underscores the need for improved tools to enhance diagnosis and care in resource-limited settings. This study aims to present a telemedicine web platform, BITScreen PTB (Biomedical Image Technologies Screen for Pediatric Tuberculosis), aimed at improving the evaluation of pulmonary TB in children based on digital chest x-ray (CXR) imaging and clinical information in resource-limited settings. The platform was evaluated by 3 independent expert readers through a retrospective assessment of a data set with 218 imaging examinations of children under 3 years of age, selected from a previous study performed in Mozambique. The key aspects assessed were the usability through a standardized questionnaire, the time needed to complete the assessment through the platform, the performance of the readers to identify TB cases based on the CXR, the association between the TB features identified in the CXRs and the initial diagnostic classification, and the interreader agreement of the global assessment and the radiological findings. The platform's usability and user satisfaction were evaluated using a questionnaire, which received an average rating of 4.4 (SD 0.59) out of 5. The average examination completion time ranged from 35 to 110 seconds. In addition, the study on CXR showed low sensitivity (16.3%-28.2%) but high specificity (91.1%-98.2%) in the assessment of the consensus case definition of pediatric TB using the platform. The CXR finding having a stronger association with the initial diagnostic classification was air space opacification (χ21>20.38, P<.001). The study found varying levels of interreader agreement, with moderate/substantial agreement for air space opacification (κ=0.54-0.67) and pleural effusion (κ=0.43-0.72). Our findings support the promising role of telemedicine platforms such as BITScreen PTB in enhancing pediatric TB diagnosis access, particularly in resource-limited settings. Additionally, these platforms could facilitate the multireader and systematic assessment of CXR in pediatric TB clinical studies.

Enhancing diagnostic precision for acute chest syndrome in sickle cell disease: insights from dual-energy CT lung perfusion mapping.

Acute chest syndrome (ACS) is secondary to occlusion of the pulmonary vasculature and a potentially life-threatening complication of sickle cell disease (SCD). Dual-energy CT (DECT) iodine perfusion map reconstructions can provide a method to visualize and quantify the extent of pulmonary microthrombi. A total of 102 patients with sickle cell disease who underwent DECT CTPA with perfusion were retrospectively identified. The presence or absence of airspace opacities, segmental perfusion defects, and acute or chronic pulmonary emboli was noted. The number of segmental perfusion defects between patients with and without acute chest syndrome was compared. Sub-analyses were performed to investigate robustness. Of the 102 patients, 68 were clinically determined to not have ACS and 34 were determined to have ACS by clinical criteria. Of the patients with ACS, 82.4% were found to have perfusion defects with a median of 2 perfusion defects per patient. The presence of any or new perfusion defects was significantly associated with the diagnosis of ACS (P = 0.005 and < 0.001, respectively). Excluding patients with pulmonary embolism, 79% of patients with ACS had old or new perfusion defects, and the specificity for new perfusion defects was 87%, higher than consolidation/ground glass opacities (80%). DECT iodine map has the capability to depict microthrombi as perfusion defects. The presence of segmental perfusion defects on dual-energy CT maps was found to be associated with ACS with potential for improved specificity and reclassification.

SAT539 Thyroid Cancer Presenting as Aspiration Pneumonia

Abstract Disclosure: S. Aslam: None. M. Asif: None. I. Nadeem: None. W.J. Khan: None. Background Goiter, most often, is first noticed as a visible neck mass; however, some patients may present with signs and symptoms of hypothyroidism, or hyperthyroidism. Retrosternal extension can cause compression of the trachea, esophagus, and jugular veins resulting in dysfunction of these viscera. CaseA 68-year-old male presented with SOB, and weakness for 5 days. He had SaO2 79% on room air requiring oxygen, RR 28/min, HR 78/min and Temp.101.6 F, BP 94/48 mmHg. The lung exam revealed bilateral rhonchi and coarse crypts. Minimal non-tender nodularity was noted on the thyroid palpation not previously noticed by the patient or his family. Chest x-ray showed bilateral airspace opacities. CT chest revealed a large upper mediastinal mass displacing the trachea and esophagus to the right, a nodule in the left lobe of thyroid, subcarinal and right hilar lymphadenopathy and bilateral dependent consolidative opacities suggesting aspiration pneumonia but no PE. A barium esophagogram showed a 7.5 cm mediastinal mass causing 50% narrowing and displacement of esophagus and compression with left sided deviation of trachea. A barium swallow study was done, and the patient was found to have aspiration with all administered food types due to an abnormal swallowing mechanism. The patient was advised NPO and placed on NG tube feeding to prevent further aspiration. The patient underwent bronchoscopy and EBUS from station 4 lymph node, the pathology of which did not show any malignant cells. However, due to high clinical suspicion of a malignant process, the patient underwent a CT-guided biopsy of the mediastinal mass that showed bland thyroid tissue. Ultrasound of thyroid revealed multiple right and left lobe nodules. TSH and free T4, and calcitonin were WNL. The patient's hypoxia and fever resolved after completion of the antibiotics including ceftriaxone and doxycycline and being nothing per oral within 7 days. Due to persistent dysphagia, he was placed on PEG tube feeding and discharged from the hospital to a nursing home. The patient underwent ultrasound-guided fine needle biopsy of 1 right-sided and 2 left-sided thyroid nodules that resulted as papillary thyroid cancer. He underwent a successful right-sided thoracotomy and removal of large sized thyroid mass. The patient is seeing endocrinology as an outpatient for radioactive iodine and hormone replacement therapy. Conclusion We treated a patient of follicular carcinoma who presented with extrathyroidal symptoms. Retrosternal or ectopic thyroid tumors can present as euthyroid state without obvious enlargement of the normal thyroid gland. A meticulous clinical evaluation should include the differential diagnosis of retrosternal goiter or ectopic thyroid with cancer when treating patients who preset with sign and symptoms concerning for mediastinal disease. Presentation Date: Saturday, June 17, 2023

Chest X-ray’s findings in symptomatic patients positive for coronavirus disease (COVID-19)

Background: The coronavirus disease (COVID) flared-up as pneumonia for an unknown cause in December 2019 in Wuhan, China, and was spread swiftly outside of Wuhan to other countries, later. Objective: To find out the Chest X-ray’s findings in positive cases for Covid-19. Methodology: A cross-sectional study was conducted at Department of radiology, Farooq Hospital Lahore. 150 patients of different age groups were enrolled in this study with convenient sampling technique. We included only those patients in this study who were symptomatic and have positive PCR of Covid-19 virus while the asymptomatic were excluded. Results: All 150 patients were with the history of positive polymerase chain reaction (PCR) of COVID and were symptomatic. 85 (56.7%) males and 65 (43.3%) females were enrolled in this study. Out of 150 patients 54 (63%) patients presented with the history of fever, 103 (68.7%) had history of diabetes, 54 (36%) had history of hypertension, 57 (38%) had history of smoking, 69 (46%) had history of cough, and all patients presented with the history of loss of smell. On X-ray 87 (58%) shows Air Space Opacification, 98 (65.3%) shows Inflammatory Process, 46 (30.7%) shows Ground Glass Appearance, 52 (34.7%) shows Consolidation, 9 (6%) shows Pleural effusion, 15 (10%) has cardiomegaly, 15 (10%) has bronchitis and 8 (5.3%) has pulmonary edema. Conclusion: The chest X-ray is the basic modality for identifying patients with COVID-19 pneumonia and it is especially useful due to its low cost and low radiation exposure. Early changes in the lung parenchyma and consolidation and hazy pattern can be detected and that will help to reduce the rate of hospitalization due to Covid-19. Key words: Chest X-ray, Covid-19, viral infection, pandemic disease, mortality

Can You Establish the Cause of This Patient's Shortness of Breath?

Mr. B is a 56-year-old man diagnosed with metastatic HER2-positive gastroesophageal adenocarcinoma. He received front-line leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX) and trastuzumab for 10 months before restaging imaging revealed progressive disease. He then received second-line trastuzumab deruxtecan. His treatment was complicated by several admissions felt to be unrelated to his cancer therapy. He was discharged after an episode of pneumonia on a steroid taper with prophylactic trimethoprim/sulfamethoxazole. Once he recovered, he was given a fourth dose of chemotherapy. About a week later, wheezes were noticed on physical exam, and he was given a 5-day course of levofloxacin. Around the same time, he also finished his steroid taper. Twelve days after his dose of chemotherapy, he presented to the emergency room with 3 to 4 days of progressive shortness of breath and dry cough following the completion of levofloxacin without symptom improvement. A CT scan showed increasing airspace opacities and multifocal areas of consolidation. Blood, nasal, and sputum cultures were negative. A bronchoscopy was performed that did not reveal findings concerning for capillaritis. He was ultimately diagnosed with drug-induced pneumonitis/interstitial lung disease (ILD). Mr. B continued to experience worsening hypoxic respiratory failure despite continuous IV steroids. He was discharged to an inpatient hospice facility where he passed away 2 weeks later. Drug-induced pneumonitis/ILD should be considered in all patients receiving trastuzumab deruxtecan who develop progressive shortness of breath or other respiratory complaints.

Total Anomalous Pulmonary Venous Return.

Supplemental material is available for this article.

Migratory Pneumonia in Prolonged SARS-CoV-2 Infection in Patients Treated With B-cell Depletion Therapies for B-cell Lymphoma.

To report the clinical and radiological characteristics of patients with underlying B-cell lymphoma and coronavirus disease 2019 (COVID-19) showing migratory airspace opacities on serial chest computed tomography (CT) with persistent COVID-19 symptoms. From January 2020 to June 2022, of the 56 patients with underlying hematologic malignancy who had undergone chest CT more than once at our hospital after acquiring COVID-19, seven adult patients (5 female; age range, 37-71 years; median age, 45 years) who showed migratory airspace opacities on chest CT were selected for the analysis of clinical and CT features. All patients had been diagnosed with B-cell lymphoma (three diffuse large B-cell lymphoma and four follicular lymphoma) and had received B-cell depleting chemotherapy, including rituximab, within three months prior to COVID-19 diagnosis. The patients underwent a median of 3 CT scans during the follow-up period (median 124 days). All patients showed multifocal patchy peripheral ground glass opacities (GGOs) with basal predominance in the baseline CTs. In all patients, follow-up CTs demonstrated clearing of previous airspace opacities with the development of new peripheral and peribronchial GGO and consolidation in different locations. Throughout the follow-up period, all patients demonstrated prolonged COVID-19 symptoms accompanied by positive polymerase chain reaction results from nasopharyngeal swabs, with cycle threshold values of less than 25. COVID-19 patients with B-cell lymphoma who had received B-cell depleting therapy and are experiencing prolonged SARS-CoV-2 infection and persistent symptoms may demonstrate migratory airspace opacities on serial CT, which could be interpreted as ongoing COVID-19 pneumonia.

A Deep Learning Approach for Detecting Covid-19 Using the Chest X-Ray營mages

Real-time detection of Covid-19 has definitely been the most widely-used world-wide classification problem since the start of the pandemic from 2020 until now. In the meantime, airspace opacities spreads related to lung have been of the most challenging problems in this area. A common approach to do on that score has been using chest X-ray images to better diagnose positive Covid-19 cases. Similar to most other classification problems, machine learning-based approaches have been the first/most-used candidates in this application. Many schemes based on machine/deep learning have been proposed in recent years though increasing the performance and accuracy of the system has still remained an open issue. In this paper, we develop a novel deep learning architecture to better classify the Covid-19 X-ray images. To do so, we first propose a novel multi-habitat migration artificial bee colony (MHMABC) algorithm to improve the exploitation/exploration of artificial bee colony (ABC) algorithm. After that, we optimally train the fully connected by using the proposed MHMABC algorithm to obtain better accuracy and convergence rate while reducing the execution cost. Our experiment results on Covid-19 X-ray image dataset show that the proposed deep architecture has a great performance in different important optimization parameters. Furthermore, it will be shown that the MHMABC algorithm outperforms the state-of-the-art algorithms by evaluating its performance using some well-known benchmark datasets.

953: INFLAMMATORY MYOFIBROBLASTIC TUMOR PRESENTING AS A LUNG NODULE: A CASE REPORT

Introduction: Inflammatory Myofibroblastic Tumors are a group of soft tissue neoplasms constituting a mixture of spindle-shaped myofibroblasts or fibroblasts and a variable amount of inflammatory cells with a predilection for the lung often presenting with non-specific symptoms. They represent less than 1% of adult lung tumors. Histopathologic and immunohistochemical analysis of a biopsy specimen is the mainstay of diagnosis. Description: A 30-year-old male presented to the ER with flank pain and episodes of small volume hemoptysis intermittently for the last six years. At presentation, a computed tomography angiography (CTA) of the chest revealed a cavitary nodule of 24 mm at the largest diameter containing rounded soft tissue mass arising adjacent to the right posterior basal segmental bronchus along with adjacent ground glass airspace opacities likely reflecting pulmonary haemorrhage which was confirmed on bronchoscopy revealing fresh blood emanating from the posterior basal segment of the right lower lobe with no endobronchial lesion. Bronchoalveolar lavage (BAL) of the segment was performed with cultures ultimately turning negative. At a later date, a robot-assisted navigational bronchoscopy-guided transbronchial needle aspiration of the lesion was performed. Histopathology results were significant for spindle cells arranged in a storiform to a haphazard pattern. The spindle cells had basophilic cytoplasm and elongated nuclei with fine chromatin. Immunostains of the tumor cells were positive for CD56, CD68, and CD34 (focal), SMA and ALK and negative for cytokeratins AE1/AE3, CK8/18, TTF-1, synaptophysin, chromogranin, S100, desmin, and CD117, SS18-SSX, STAT6, HHV-8, SOX10, CD30, and langerin. These findings supported the diagnosis of an inflammatory myofibroblastic tumor. Discussion: Chest imaging is crucial for early identification. Complete surgical excision provides long-term survival benefits, preventing local recurrence and metastasis. Corticosteroids can be used when the mass is unresectable. If ALK-1 is positive, crizotinib is beneficial in some cases. Our case highlights the need for further investigative studies to establish the natural history of this neoplastic disease and discover appropriate medical management for it.

Community-Acquired Pneumonia: Postpandemic, Not Post-COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic upended our approach to imaging community-acquired pneumonia, and this will alter our diagnostic algorithms for years to come. In light of these changes, it is worthwhile to consider several postpandemic scenarios of community-acquired pneumonia: (1) patient with pneumonia and recent positive COVID-19 testing; (2) patient with air space opacities and history of prior COVID-19 pneumonia (weeks earlier); (3) multifocal pneumonia with negative or unknown COVID-19 status; and (4) lobar or sublobar pneumonia with negative or unknown COVID-19 status. In the setting of positive COVID-19 testing and typical radiologic findings, the diagnosis of COVID-19 pneumonia is generally secure. The diagnosis prompts vigilance for thromboembolic disease acutely and, in severely ill patients, for invasive fungal disease. Persistent or recurrent air space opacities following COVID-19 infection may more often represent organizing pneumonia than secondary infection. When COVID-19 status is unknown or negative, widespread airway-centric disease suggests infection with mycoplasma, Haemophilus influenzae, or several respiratory viruses. Necrotizing pneumonia favors infection with pneumococcus, Staphylococcus, Klebsiella, and anaerobes. Lobar or sublobar pneumonia will continue to suggest the diagnosis of pneumococcus or consideration of other pathogens in the setting of local outbreaks. A positive COVID-19 test accompanied by these imaging patterns may suggest coinfection with one of the above pathogens, or when the prevalence of COVID-19 is very low, a false positive COVID-19 test. Clinicians may still proceed with testing for COVID-19 when radiologic patterns are atypical for COVID-19, dependent on the patient's exposure history and the local epidemiology of the virus.

Interstitial lung disease in a patient with premature aging: Suspected Werner syndrome

Werner syndrome (WS) is a rare inherited autosomal recessive disease that can be diagnosed with cardinal signs without the genetic testing. Some features that are consistent with WS include premature aging, loss, and graying hair, scleroderma-like skin changes. We report a 42-year-old man with cardinal signs of WS who also developed interstitial lung disease (ILD). The patient had past medical history (PMHx) of atypical left femur fracture in his early 30s from unknown causes. Also, he had loss and graying hair, salt-on-pepper skin changes, associated with squeaky voice, muscle wasting, and osteoporosis. He had worsening symptoms of dyspnea on exertion and was found with bilateral diffuse subpleural reticular opacities with slight mid- to lower-lung predominance and mild bronchiectasis without honeycombing or ground-glass airspace opacities on chest computed tomography (CT) scan. Other causes of ILD were excluded as patient routine laboratories and rheumatologic workup was negative. Werner syndrome presents similar features with other telomerase-associated diseases such as mutations of telomerase complexes [telomerase RNA component (TERC) and telomerase reverse transcriptase (TERT)]. Werner syndrome can be difficult to diagnose because it is a rare genetic disease that begins to show symptoms and signs after 10 or 20-year-olds, but the diagnosis is recognized after 30s. Few cases have been reported about the association of WS and ILD, but both diseases are aging diseases. This case might be the first case reported in Puerto Rico of Werner syndrome associated with ILD. Early referral and treatment is important to improve patients’ quality of life and life expectancy by slowing the progression of the disease.

ODP100 Hypoparathyroidism in the Setting of COVID-19: Increasingly Common Phenomenon

Abstract Background Acquired hypoparathyroidism (HPT) in adults is most commonly caused by post-surgical or autoimmune damage to the parathyroid glands. Genetic defects causing abnormal gland development, impaired parathyroid hormone (PTH) production or action are rare and typically diagnosed in childhood. Recent literature suggests surprisingly high prevalence of hypocalcemia in patients with SARS-CoV-2 infection and this finding is associated with poor outcomes. [1] We present a case of new onset HPT in a patient admitted with respiratory failure due to COVID-19. Case presentation A 63-year-old woman with history of obesity, GERD, asthma, presented to the ED with fever, cough, dyspnea, and diarrhea. She was found to have low O2 saturation, CXR revealed multifocal interstitial and airspace opacities. Her PCR SARS-CoV-2 test was positive and she was admitted to ICU. She was incidentally found to have severe hypocalcemia Ca 5.2 mg/dL (8.5 - 10.3 mg/dL), ionized Ca 2.46 mg/dL (4.50 - 5.10 mg/dL), albumin 3.7 g/dL (3.5 - 5. 0 g/dL). She denied any history of neck surgery, radiation or trauma and personal or family history of autoimmune or calcium disorders. Her calcium levels were normal over the past 4 years. She denied symptoms of hypocalcemia prior to presentation and reported leg cramps and finger numbness in the ED. Further work-up revealed PTH 13 pg/mL (15 - 65 pg/mL), 25-OH vitamin D 16 ng/mL (30 - 80 ng/mL), Mg 1.2 mg/dL (1.4 - 2.5 mg/dL), phosphorus 4.9 mg/dL (2.3 - 4.5 mg/dL), bicarbonate 26 mmol/L (22 - 32 mmol/L). Patient was started on Ca (IV and PO), Mg, and vitamin D replacement. PTH reassessment on days 6, 14, and 19 showed persistently low/inappropriately normal PTH (22, 14, and 8 pg/mL respectively) despite normalization of magnesium levels. Patient was discharged on Ca, Mg, and vitamin D supplementation with follow-up in Endocrinology clinic for further evaluation of her hypoparathyroidism progression. Conclusion SARS-CoV-2 infection causes a hypersensitive immune reaction and widespread inflammation. Emerging evidence suggests that this cytokine-mediated reaction and hypoxia associated with COVID-19 can affect the parathyroid glands, resulting in impaired PTH secretion. Furthermore, direct parathyroid tissue invasion and destruction by means of entry via angiotensin-converting enzyme 2 receptors has also been proposed [2]. Hypocalcemia in our patient could be multifactorial, however we believe that COVID-19 induced HPT was the leading mechanism. We hope that further research explores this hypothesis and elucidates the underlying pathophysiology.

USE OF PLASMA EXCHANGE TO TREAT REFRACTORY DIFFUSE ALVEOLAR HEMORRHAGE FROM ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS

USE OF PLASMA EXCHANGE TO TREAT REFRACTORY DIFFUSE ALVEOLAR HEMORRHAGE FROM ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS

ANTISYNTHETASE SYNDROME PRESENTING AS INTERSTITIAL LUNG DISEASE: A CASE OF ANCHORING BIAS DURING THE COVID-19 PANDEMIC

ANTISYNTHETASE SYNDROME PRESENTING AS INTERSTITIAL LUNG DISEASE: A CASE OF ANCHORING BIAS DURING THE COVID-19 PANDEMIC

PRIMARY SJÖGREN SYNDROME AND PULMONARY INVOLVEMENT: UTILITY OF SALIVARY GLAND BIOPSY IN DIAGNOSIS

PRIMARY SJÖGREN SYNDROME AND PULMONARY INVOLVEMENT: UTILITY OF SALIVARY GLAND BIOPSY IN DIAGNOSIS

INTERSTITIAL LUNG DISEASE IN A TODDLER WITH ANTI-MDA5 JUVENILE DERMATOMYOSITIS THAT IMPROVED WITH AGGRESSIVE, EARLY TREATMENT WITH STEROIDS AND MULTIPLE IMMUNOSUPPRESSANTS

INTERSTITIAL LUNG DISEASE IN A TODDLER WITH ANTI-MDA5 JUVENILE DERMATOMYOSITIS THAT IMPROVED WITH AGGRESSIVE, EARLY TREATMENT WITH STEROIDS AND MULTIPLE IMMUNOSUPPRESSANTS

SEVERE COVID-19 COMPLICATED WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

SEVERE COVID-19 COMPLICATED WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

S2748 Necrobiotic Lung Nodules in Patient With Ulcerative Colitis

Introduction: Ulcerative colitis and Crohn’s disease are two forms of inflammatory bowel disease (IBD). 25-40% of IBD patients have extra-intestinal manifestations (EIM). Pulmonary manifestations are one of the rarest forms of EIM, particularly necrobiotic nodules. It is a challenge to diagnose as it presents with symptoms similar to autoimmune, vasculitis, or infectious pathologies. We present a rare case of a patient who was found to have necrobiotic lung nodules during an acute ulcerative colitis flare. Case Description/Methods: 44-year-old male with newly diagnosed ulcerative pancolitis, presented with diarrhea and hematochezia for 8 weeks and 4 weeks of leg ulcers. He denied any other symptoms. 4 months ago, he was started on high dose steroids and switched to vedolizumab, however began to relapse after steroids were tapered. On admission, vitals significant for tachycardia at 118 bpm. Physical exam was significant for lower extremity ulcers consistent with pyoderma gangrenosum. Labs significant for leukocytosis (16,500/µL), Hg of 6.8, and elevated CRP at 160.26. Findings were suggestive of IBD flare and he also underwent chest x-ray which showed multifocal nodular airspace opacities, which appeared to have developed cavitations. CT chest revealed bilateral pulmonary nodules. He underwent infectious, autoimmune and vasculitis work up including HIV, tuberculosis, bacterial, viral, endocarditis, ANA, ANCA as well as fungal serologies which were all negative. He had CT guided biopsies, which were suggestive of necrobiotic lung nodules. Repeat CT chest showed interval improvement in solid and cavitary nodules. Given extensive negative infectious work up and improvement with steroids and infliximab, his presentation was consistent with necrobiotic lung nodules secondary to uncontrolled inflammatory bowel disease. (Figure) Discussion: We describe a rare case of necrobiotic lung nodules as an extra-intestinal manifestation of uncontrolled ulcerative colitis. Histologically, these nodules are sterile aggregates of neutrophils, that can cavitate and have a high degree of resemblance to pyoderma gangrenosum in cases of IBD. Few cases of necrobiotic lung nodules with IBD have been reported and most of them had respiratory symptoms but our case did not present with respiratory manifestations. In conclusion, necrobiotic lung nodules should be considered as a differential diagnosis of lung nodules in patients with IBD while excluding any infectious etiologies as mandatory before starting treatment with steroids and biologics.Figure 1.: CT guided biopsy suggestive of necrobiotic lung nodule.

S3210 Unraveling Extrapulmonary Sarcoidosis in a Patient With Unexplained Cholestatic Liver Injury

Introduction: Sarcoidosis is an autoimmune condition characterized by non-caseating granulomas most commonly in the lungs and hilar lymph nodes. We report a case of sarcoidosis presenting as hepatomegaly and cholestatic liver injury. Case Description/Methods: A 46-year-old female with end stage renal disease, latent tuberculosis (TB) and daily use of herbal teas, who had multiple hospitalizations over a 6-month period with similar presentation, presented with right upper quadrant pain and jaundice. Examination revealed pulsatile abdomen and jugular venous distention. During each admission, she had elevated alkaline phosphatase and total bilirubin to a peak of 2003 U/L and 37.4 mg/dL respectively, with otherwise normal liver enzymes. Infectious workup and tumor markers were negative. On her second admission, she had rapid improvement in her lab abnormalities and symptoms after initiating steroids for treatment of Bell’s palsy, otherwise, on other admissions she had slow improvement with ursodeoxycholic acid. Initial ultrasound abdomen, magnetic resonance cholangiopancreatography, and triphasic computed tomography (CT) liver showed hepatomegaly, otherwise unremarkable. She had two liver biopsies which revealed sinusoidal congestion and dilation, hepatocellular and sinusoidal fibrosis consistent with chronic venous outflow obstruction and few non-necrotizing granulomas. Repeated transthoracic echocardiogram eventually showed mild tricuspid and pulmonary insufficiency. Right heart catheterization showed mild pulmonary hypertension and hemodynamics not suggestive of a cardiac cause of liver disease. In a last attempt to locate tissue for biopsy, a CT chest, abdomen and pelvis was obtained and showed airspace opacities within the left lower lobe likely related to inflammatory process and an area of enhancement at the junction of segment 5 and 6 of the liver that could relate to hepatic sarcoid. She was started on Prednisone 40mg daily for presumed hepatic sarcoid and Rifampin 600mg daily for latent TB. She will undergo bronchoscopy with biopsy and renal biopsy to further establish a unifying diagnosis (Figure). Discussion: After an extensive workup was found to be negative, sarcoidosis became the top differential given non-caseating granulomas on liver biopsy, nerve palsy, renal disease, mild pulmonary hypertension and response to steroids. Lack of pulmonary involvement is an uncommon presentation in sarcoidosis, occurring in 5-9% of cases overall. Hepatic sarcoidosis occurs in 11-80% of cases and is mostly asymptomatic.Figure 1.: Hepatomegaly with heterogeneous enhancement. There is an area of increased enhancement at the junction of segment 5 and 6 (arrow) of the liver which is nonspecific, but could relate to hepatic sarcoidosis given clinical picture.