Airspace Opacities Research Articles

Baseline chest X-ray in coronavirus disease 19 (COVID-19) patients: association with clinical and laboratory data

PurposeTo assess the reliability of CXR and to describe CXR findings and clinical and laboratory characteristics associated with positive and negative CXR.MethodsRetrospective two-center study on consecutive patients admitted to the emergency department of two north-western Italian hospitals in March 2020 with clinical suspicion of COVID-19 confirmed by RT-PCR and who underwent CXR within 24 h of the swab execution. 260 patients (61% male, 62.8 ± 15.8 year) were enrolled. CXRs were rated as positive (CXR+) or negative (CXR−), and features reported included presence and distribution of airspace opacities, pleural effusion and reduction in lung volumes. Clinical and laboratory data were collected. Statistical analysis was performed with nonparametric tests, binary logistic regression (BLR) and ROC curve analysis.ResultsSensitivity of CXR was 61.1% (95%CI 55–67%) with a typical presence of bilateral (62.3%) airspace opacification, more often with a lower zone (88.7%) and peripheral (43.4%) distribution. At univariate analysis, several factors were found to differ significantly between CXR+ and CXR−. The BLR confirmed as significant predictors only lactate dehydrogenase (LDH), C-reactive protein (CRP) and interval between the onset of symptoms and the execution of CXR. The ROC curve procedure determined that CRX+ was associated with LDH > 500 UI/L (AUC = 0.878), CRP > 30 mg/L (AUC = 0.830) and interval between the onset of symptoms and the execution of CXR > 4 days (AUC = 0.75). The presence of two out of three of the above-mentioned predictors resulted in CXR+ in 92.5% of cases, whereas their absence in 7.4%.ConclusionCXR has a low sensitivity. LDH, CRP and interval between the onset of symptoms and the execution of CXR are major predictors for a positive CXR.

What lies beneath: poking a hole in the diagnosis

A man aged 77 years was referred to the emergency department (ED) of our hospital by his primary physician for evaluation of dyspnoea and hypoxaemia. On presentation to the ED,...

Invasive pulmonary aspergillosis in an immunocompetent, heavy smoker of marijuana with emphysema and chronic obstructive pulmonary disease

Heavy marijuana smoking has been described a predisposing cause of invasive pulmonary aspergillosis in immunocompromised subjects. This article describes a case of invasive pulmonary aspergillosis in an immunocompetent patient with chronic obstructive pulmonary disease, who was not on maintenance oral corticosteroids and who had been smoking 30 joints per day and developed necrotizing pneumonia. Bronchoalveolar lavage culture was positive for Aspergillus Fumigatus. In the absence of clinical-radiographic response to broad spectrum antibiotic and any other positive culture, treatment with voriconazole was initiated, with resolution of lung cavities and airspace opacities and return to baseline clinical status. Repeat bronchoalveolar lavage was negative for Aspergillus Fumigatus. Invasive pulmonary aspergillosis may be considered in the differential diagnosis of necrotizing pneumonia in heavy smokers of marijuana with chronic lung disease.

Generalizability of Deep Learning Tuberculosis Classifier to COVID-19 Chest Radiographs: New Tricks for an Old Algorithm?

Generalizability of Deep Learning Tuberculosis Classifier to COVID-19 Chest Radiographs: New Tricks for an Old Algorithm?

A Curious Case of Confusion in a Patient With Cirrhosis

A Curious Case of Confusion in a Patient With Cirrhosis

P45 Interstitial pneumonitis induced by secukinumab therapy in a patient with psoriatic arthritis

Abstract Background Inhibition of pro-inflammatory interleukin-17A (IL-17A) with secukinumab (an anti-IL-17A antibody) has been utilised in patients with chronic autoimmune disease such as psoriasis seronegative spondyloarthopathies. In mouse models, IL-17A was involved in the development of pulmonary inflammation and progression of fibrosis, with blockade of IL-17A implicated as a potential therapeutic target in such conditions. Here we report a case of, seemingly paradoxical, interstitial lung disease (ILD) secondary to secukinumab therapy in a 61-year-old patient with psoriatic arthritis. Methods Please refer to the results section. Results Initial therapy was with adalimumab achieving good disease control for 9 years, at which point his arthritis began to progress. Secukinumab was commenced with good clinical response from his arthritis, however he developed a persistent cough with blood-stained secretions, and shortness of breath on exertion. A CT thorax was arranged at 21 weeks after initiation of secukinumab, and showed florid bibasal, lingula and middle lobe ground glass density air space opacification. He went on to have bronchoscopy with bronchoalveolar lavage (BAL) and differential cell count. BAL was negative for atypical infection including P. jirovecii, growing upper respiratory tract flora only. Microscopy of BAL showed lymphocytosis in keeping with the diagnosis of drug induced ILD, with no atypical cells. The patient made a significant improvement on withdrawal of secukinumab therapy within 7-8 weeks of cessation - both clinically and radiologically. Conclusion A review of the current literature at this time indicates this is now a third case of secukinumab induced ILD. Given this potentially idiosyncratic reaction we suggest further work may be necessary to understand the underlying immunogenic potential of secukinumab, and an increased awareness as well as vigilance in reporting, to determine those at-risk populations of this phenomenon. Disclosures C. Saleh None. S. Bilgrami None. T. Gatheral None. L. Ottewell None.

Deep Learning Localization of Pneumonia: 2019 Coronavirus (COVID-19) Outbreak.

Deep Learning Localization of Pneumonia: 2019 Coronavirus (COVID-19) Outbreak.

HRCT imaging features in representative imported cases of 2019 novel coronavirus pneumonia.

With the spread of novel coronavirus (2019-nCoV) pneumonia, chest high-resolution computed tomography (HRCT) has been one of the key diagnostic tools. To achieve early and accurate diagnostics, determining the radiological characteristics of the disease is of great importance. In this small scale research we retrospectively reviewed and selected six cases confirmed with 2019-nCoV infection in West China Hospital and investigated their initial and follow-up HRCT features, along with the clinical characteristics. The 2019-nCoV pneumonia basically showed a multifocal or unifocal involvement of ground-glass opacity (GGO), sometimes with consolidation and fibrosis. No pleural effusion or lymphadenopathy was identified in our presented cases. The follow-up CT generally demonstrated mild to moderate progression of the lesion, with only one case showing remission by the reducing extent and density of the airspace opacification.

Chest Radiograph Interpretation with Deep Learning Models: Assessment with Radiologist-adjudicated Reference Standards and Population-adjusted Evaluation.

BackgroundDeep learning has the potential to augment the use of chest radiography in clinical radiology, but challenges include poor generalizability, spectrum bias, and difficulty comparing across studies.PurposeTo develop and evaluate deep learning models for chest radiograph interpretation by using radiologist-adjudicated reference standards.Materials and MethodsDeep learning models were developed to detect four findings (pneumothorax, opacity, nodule or mass, and fracture) on frontal chest radiographs. This retrospective study used two data sets. Data set 1 (DS1) consisted of 759 611 images from a multicity hospital network and ChestX-ray14 is a publicly available data set with 112 120 images. Natural language processing and expert review of a subset of images provided labels for 657 954 training images. Test sets consisted of 1818 and 1962 images from DS1 and ChestX-ray14, respectively. Reference standards were defined by radiologist-adjudicated image review. Performance was evaluated by area under the receiver operating characteristic curve analysis, sensitivity, specificity, and positive predictive value. Four radiologists reviewed test set images for performance comparison. Inverse probability weighting was applied to DS1 to account for positive radiograph enrichment and estimate population-level performance.ResultsIn DS1, population-adjusted areas under the receiver operating characteristic curve for pneumothorax, nodule or mass, airspace opacity, and fracture were, respectively, 0.95 (95% confidence interval [CI]: 0.91, 0.99), 0.72 (95% CI: 0.66, 0.77), 0.91 (95% CI: 0.88, 0.93), and 0.86 (95% CI: 0.79, 0.92). With ChestX-ray14, areas under the receiver operating characteristic curve were 0.94 (95% CI: 0.93, 0.96), 0.91 (95% CI: 0.89, 0.93), 0.94 (95% CI: 0.93, 0.95), and 0.81 (95% CI: 0.75, 0.86), respectively.ConclusionExpert-level models for detecting clinically relevant chest radiograph findings were developed for this study by using adjudicated reference standards and with population-level performance estimation. Radiologist-adjudicated labels for 2412 ChestX-ray14 validation set images and 1962 test set images are provided.© RSNA, 2019Online supplemental material is available for this article.See also the editorial by Chang in this issue.

E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach

Since June, 2019, more than 1000 new cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported in the USA. Patients presented with dyspnoea, cough, and were found to be hypoxaemic with bilateral airspace opacities on chest imaging. Most patients required management in the intensive care unit and steroid therapy. All patients recovered with cessation of vaping, supportive care, and steroid therapy and remained symptom free at follow up. E-cigarette use continues to rapidly escalate in the USA, particularly among youth. Cases were defined as patients admitted to the University of Rochester Medical Center (Rochester, NY, USA) who had used e-cigarettes or another vaping device in the 30 days before presentation, and who had bilateral airspace opacification on chest imaging (CT or x-ray). Case details were obtained via medical record review and patient interviews over the past 3 months including symptomatology, physical exam data, imaging studies, laboratory data, vaping history, and subsequent outpatient follow-up data. In collaboration with the New York State Department of Health, our hospital developed a novel clinical practice algorithm based on statewide physician feedback along with input from experts in environmental health, medical toxicology, infectious disease, epidemiology, and chronic disease prevention. We report 12 cases treated for suspected EVALI at our medical centre between June 6, 2019, and Sept 15, 2019. Ten (83%) patients had dyspnoea, fever, and emesis and nine (75%) had cough. 11 (92%) patients reported the use of e-cigarette cartridges containing tetrahydrocannabinol oil. Although eight (67%) patients required admission to the intensive care unit for hypoxaemic respiratory failure, no deaths occurred. The median hospitalisation duration was 7 days (IQR 7-8). All patients completing follow up (6 [50%]) had resolution of previous chest CT findings and normal spirometry. The clinical algorithm focuses on the key signs and symptoms of EVALI and the importance of ruling out infection and other cardiopulmonary conditions before making a presumptive diagnosis of EVALI. Patients with suspected EVALI in our cohort had life-threatening hypoxaemia, with 67% requiring management in the intensive care unit. Despite the severity of presentation, similar to previous reports of patients with EVALI, most patients improved within 1-2 weeks of initial presentation after vaping cessation and administration of systemic corticosteroids when needed. Almost all (92%) patients with suspected EVALI reported vaping a THC product, making THC containing e-liquids or oils a key focus on the ongoing nationwide investigations into the cause of EVALI. Additional research is required to understand the potential toxins, underlying pathophysiological mechanisms, and identification of susceptible individuals at higher risk for hospitalisation due to EVALI. To our knowledge we present the first clinical practice algorithm for the evaluation and management of EVALI, which will be useful for both acute management and improved accurate reporting of this life-threatening respiratory illness. None.

1790. Single-Center Experience and Lessons Learnt from Management of Nipah Virus Outbreak in India

BackgroundNipah virus (NiV) is re-emerging zoonotic RNA virus belonging to Paramyxoviridae family. Suspecting Nipah virus in a NiV naive tropical area is a challenge. NiV management is further confounded by acute presentation, high mortality, broad species tropism, multiple modes of transmission, difficulty to diagnose and lack of definitive treatment.MethodsRecent NiV outbreak that lasted for approximately 1 month (2–29 May 2018) and resulted in 23 cases with a case-fatality rate of 91%. We present clinical summary and management of five cases managed at Baby Memorial Hospital, Kozhikode, India from May 17, 2018 to May 30, 2018 and were epidemiologically linked to the index case. All patients presented with initial nonspecific prodromal symptoms of fever, muscle pain, watery diarrhea. Median age was 53 years, four were males, median hospital stay was 3 days, median incubation period of was days. Further complications, included encephalitis with viral bronchopneumonia/acute respiratory distress syndrome (ARDS) in 100 %, patients, encephalitis with viral bronchopneumonia/ARDS with myocarditis in 60 %patients, despite attempted therapy with ribavirin all patients developed cardiorespiratory arrest and succumbed to the illness. ResultsHematological Investigations showed normal TLC with a mean of 7,920 cells/ mm3, mild thrombocytopenia (mean 1,57,800) high Hb 16.12(SD1.10), ESR 19 mm/hr, DLC-N 82% high relative neutrophilic cytosis. Normal liver and renal function, Na+ 133 meq/L. CSF analysis showed high opening pressure, 100% lymphocytic pleocytosis, mean CSF sugar 118 mg/100mL, CSF protein 73.6. CT chest -bilateral airspace opacities and ground glassing. Brain FLAIR sequence showed nonspecific hyperintensities in white matter and brainstem correlating with vasculitic changes. Laboratory diagnosis of NiV was made by Real-Time RT–PCR on throat swab, blood, urine and cerebrospinal fluid by Manipal virus research center and National Institute of Virology. Pathological autopsy was done in 2 cases and found noncontributory.ConclusionWe report clinical and public health management experience from one of the three hospitals managing the patients affected with NiV. Managing outbreaks of high infectivity requires persistent organized and committed healthcare interventions Disclosures All authors: No reported disclosures.

Incidence, Risk Factors, and Outcomes of Idiopathic Pneumonia Syndrome after Allogeneic Hematopoietic Cell Transplantation.

Our current knowledge of idiopathic pneumonia syndrome (IPS) predates improved specificity in the diagnosis of IPS and advances in hematopoietic cell transplantation (HCT) and critical care practices. In this study, we describe and update the incidence, risk factors, and outcomes of IPS. We performed a retrospective cohort study of all adults who underwent allogeneic HCT at the Fred Hutchinson Cancer Research Center between 2006 and 2013 (n = 1829). IPS was defined using the National Heart, Lung, and Blood Institute consensus definition: multilobar airspace opacities on chest imaging, absence of lower respiratory tract infection, and hypoxemia. We described IPS incidence and mortality within 120 and 365 days after HCT. We examined conditioning intensity (nonmyeloablative versus myeloablative with high-dose total body irradiation [TBI] versus myeloablative with low-dose TBI) as an IPS risk factor in a time-to-event analysis using Cox models, controlled for age at transplant, HLA matching, stem cell source, and pretransplant Lung function Score (a combined measure of impairment in Forced Expiratory Volume in the first second (FEV1) and Diffusion capacity for carbon monoxide (DLCO)). Among 1829 HCT recipients, 67 fulfilled IPS criteria within 120 days (3.7%). Individuals who developed IPS were more likely to be black/non-Hispanic versus other racial groups and have severe pulmonary impairment but were otherwise similar to participants without IPS. In adjusted models, myeloablative conditioning with high-dose TBI was associated with increased risk of IPS (hazard ratio, 2.5; 95% confidence interval, 1.2 to 5.2). Thirty-one patients (46.3%) with IPS died within the first 120 days of HCT and 47 patients (70.1%) died within 365 days of HCT. In contrast, among the 1762 patients who did not acquire IPS in the first 120 days, 204 (11.6%) died within 120 days of HCT and 510 (29.9%) died within 365 days of HCT. Our findings suggest that although the incidence of IPS may be declining, it remains associated with post-transplant mortality. Future study should focus on early detection and identifying pathologic mediators of IPS to facilitate timely, targeted therapies for those most susceptible to lung injury post-HCT.

LENALIDOMIDE-INDUCED ACUTE EOSINOPHILIC PNEUMONIA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: MDS/MPD (Myelodysplastic Syndrome/Myeloproliferative disorder) overlap syndrome is characterized by dysplasia and cytopenias which prevalence is not known. Lenalidomide is an immunomodulatory drug analogous to thalidomide that is frequently used in myelodysplastic syndrome and also used in cases of Polycythemia Vera. Pulmonary side effects are rare. We present a case of lenalidomide induced acute eosinophilic pneumonia. CASE PRESENTATION: A 76-year-old male with a history of MDS/MPD overlap syndrome, primary and secondary hemochromatosis (transfusion dependent) who recently started lenalidomide was admitted for shortness of breath. He had 2 days of respiratory distress, desaturation (83% room air), new onset of cough and nasal congestion. No history of fever, chills, chest pain, palpitations, no sick contacts. He had chronic fatigue but not worse than baseline. The physical exam was positive for a respiratory distress, a flow systolic murmur and rales at the pulmonary bases. Work up included a negative procalcitonin, negative respiratory viral panel, negative blood cultures. Chest x-ray showed diffuse hazy interstitial and airspace opacity. Chest CT showed ground glass pulmonary infiltrates. His initial management included blood transfusions, diuretics, broad spectrum antibiotics and coverage for PCP and atypical pneumonia, oxygen by nasal canula with 2 Litters. Diuretics were given for suspected pulmonary edema. His Echo showed an ejection fraction of 60-65% and despite effective diuresis, symptoms did not improve. Patient underwent a bronchoalveolar lavage which showed 27% eosinophils, negative gram stain, negative bacterial and fungal cultures. Cytology was negative for malignancy. PCP DFA was negative. A new diagnosis of acute eosinophilic pneumonia was made and patient was treated with steroids and lenalidomide was stopped as well as antibiotics. DISCUSSION: Lenalidomide is becoming a frequently used medication in the last few years due to its new multiple uses approved by the FDA. Pulmonary side effects are rare and acute eosinophilic pneumonia is added to this list. The Naranjo Drug Adverse Drug Reaction Probability Scale was positive for 8 points in our case, making it a probable drug reaction. This is the first case to our knowledge ever reported in MDS/MPD treatment with Lenalidomide. CONCLUSIONS: Lenalidomide is a pharmacologic agent that is linked to multiple but rare pulmonary side effects. Providers should be aware that acute eosinophilic pneumonia can be one of this rare side effects. Reference #1: Toma, Andrew & P. Rapoport, Aaron & Burke, Allen & Sachdeva, Ashutosh. (2017). Lenalidomide-induced eosinophilic pneumonia: Lenalidomide and eosinophilic pneumonia. Respirology Case Reports. 5. e00233. 10.1002/rcr2.233 Reference #2: Mankikian J, Lioger B, Diot E, et al. 2014. Pulmonary toxicity associated with the use of lenalidomide: case report of late-onset acute respiratory distress syndrome and literature review. Heart Lung 43(2):120–123. Reference #3: Naranjo CA, Busto U, Sellers EM, et al. 1981. A method for estimating the probability of adverse drug reactions. Clin. Pharmacol. Ther. 30(2):239–245. DISCLOSURES: No relevant relationships by Mohamad Bitar, source=Web Response No relevant relationships by Fernando Fuentes, source=Web Response No relevant relationships by Shahla Mallick, source=Web Response

NECROTIZING CAVITARY LUNG MASS IN PATIENT WITH AIDS: A RARE MANIFESTATION OF PNEUMOCYSTIS JIROVECII PNEUMONIA

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 infections in immunocompromised hosts encompass a wide differential diagnosis. Of the possible etiologies, Pneumocystis jirovecii presents as a rare cause of necrotizing cavitary pneumonia, particularly in patients with advanced HIV and AIDS. CASE PRESENTATION: A 50-year-old male patient presented with progressively worsening cough productive of green blood-tinged sputum of 2-week duration, associated with pleuritic chest pain, night sweats, and diarrhea. Past medical history was significant for AIDS due to HIV-1 with CD-4 count 73/mm3 not on antiretroviral therapy. He was admitted to an outside hospital two months prior for similar symptoms, and chest x-ray at that time demonstrated no acute process (figure 1A). On presentation he was tachycardic, tachypneic, and afebrile. Oxygen saturation was 98-100% on room air. Physical examination revealed inspiratory crackles on right upper lung field auscultation with associated dullness to percussion, tenderness in the epigastrium and right upper quadrant of the abdomen, and oral thrush. CXR demonstrated diffuse airspace opacification throughout the right upper lobe (RUL), with internal lucent areas consistent with cavitation (figure 1B). A follow-up chest computed tomography (CT) with intravenous contrast demonstrated cavitation of the RUL, with cystic spaces and air fluid levels (figure 2,3). Sputum culture was grossly contaminated with oropharyngeal flora. Three consecutive acid-fast bacilli (AFB) sputum smears were initially negative. Pneumocystis qualitative PCR was positive, with B-D glucan assay (Fungitell) of 239 pg/mL (ref range: <60 pg/mL). Histoplasma urine antigen was negative. Cryptococcus serum testing was negative. A bronchoscopy with bronchoalveolar lavage (BAL) demonstrated findings consistent with necrotizing cavitary pneumonia. Pneumocystis was again identified on qualitative PCR. Anaerobic and aerobic culture, AFB culture, Nocardia, Legionella, and fungal culture were negative. No malignant cells were visualized. After 4 weeks of incubation, the AFB culture from sputum sampling on admission demonstrated Mycobacterium avium complex (MAC) growth in 1 of 3 samples consistent with contamination. DISCUSSION: This case highlights the complexity of cavitary pulmonary lesion diagnosis in an patient with AIDS. The diagnosis of Pneumocystis pneumonia (PCP) was made through sputum and BAL qualitative PCR testing, with fungitell assay testing. The atypical radiographic presentation necessitated exclusion of alternate diagnoses. The possibility of superimposed anaerobic infection was not entirely ruled out, however the location of cavitation with multiple negative cultures on sputum and BAL sampling made this less likely. CONCLUSIONS: Pneumocystis jirovecii can present as a necrotizing cavitary pneumonia, and increased awareness regarding this atypical and rare presentation is critical for accurate diagnosis and prompt management. Reference #1: Gadkowski, LB., Sout, J. Cavitary Pulmonary Disease. Clin Microbiol Rev. 2008 Apr; 21(2): 305-333. https://doi.org/10.1128/CMR.00060-07 DISCLOSURES: No relevant relationships by Odaliz Abreu Lanfranco, source=Web Response No relevant relationships by Sophia Binz, source=Web Response No relevant relationships by Raef Fadel, source=Web Response No relevant relationships by Daniel Ouellette, source=Web Response No relevant relationships by Aula Ramo, source=Web Response

A CASE OF DISSEMINATED NOCARDIA INFECTION IN AN ADULT WITH PANCYTOPENIA

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: Nocardia is an infrequent cause of bacterial infection caused by weakly acid-fast actinomycete Nocardia. It causes opportunistic infections in immunocompromised hosts, including those with lymphomas, malignancies, HIV and those receiving steroids. Here, we present a case of Nocardia lung abscess that progressed to brain abscesses in an immunocompromised state. CASE PRESENTATION: 65-year-old male with history of CKD from glomerulonephritis/p-ANCA vasculitis presented with pancytopenia. He worked as a pipe fitter with significant exposure to soil. He had been treated with prednisone and cyclophosphamide for 7 months, and then switched to azathioprine. There was concern of thrombotic microangiopathy given elevated LDH and presence of schistocytes on peripheral blood smear, however, ADAMST13 level was normal. He received plasma exchanges and started on eculizumab for treatment of presumptive atypical Hemolytic Uremic Syndrome (HUS). Clinical status deteriorated, and he developed worsening anemia, thrombocytopenia and renal function requiring hemodialysis. Thrombocytopenia and renal function failed to improve with eculizumab, and his vasculitis was thought to be the culprit. He was then found to have a pleural effusion, which was drained and revealed exudative fluid with cytology showing acute inflammatory cells. CT chest showed left lower lobe consolidation, left upper lobe airspace opacity and scattered pulmonary nodules. He received supportive blood and platelet transfusions. 25 days later, cultures from pleural fluid grew Nocardia. He had progressive decline in neurological status, and MRI revealed innumerable small enhancing lesions throughout brain and brainstem, likely from Nocardia. Subsequently, he developed seizures and intraparenchymal bleed due to the low platelets. Family eventually opted for comfort care measures only. DISCUSSION: Radiographic findings for Nocardia can be variable, including multifocal disease, nodules, infiltrates or cavitary lesions. Differentiating Nocardia from other filamentous fungi or mycobacteria can be challenging based on radiological finding alone. Pleural effusions can also occur in 10-33% of cases. Dissemination from the lungs can present as bacteremia, empyema, pericarditis, or can involve the CNS. CNS involvement of nocardia most commonly presents as brain abscesses. It has a high morbidity, and the mortality rate can be close to 30% versus 10% for other bacterial abscesses. CONCLUSIONS: We report how an immunocompromised state due to medications can be a reason for the development of Nocardia lung abscess. Failure of early detection and aggressive treatment can result in dissemination of the bacteria. Nocardia may have an indolent presentation and detection may be challenging, but with the risk factors and soil exposure taken into account, it should be considered a differential to help avoid significant morbidity and mortality. Reference #1: Beaman B.L., Burnside J., Edwards B., Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. (1976);134(3):286–289 Reference #2: Saubolle, Michael A., and Den Sussland. “Nocardiosis: Review of Clinical and Laboratory Experience.” Journal of Clinical Microbiology 41.10 (2003): 4497–4501 Reference #3: Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain abscess: Treatment strategies and factors influencing outcome. Neurosurgery. 1994;35:622-31 DISCLOSURES: No relevant relationships by Aqsa Amin, source=Web Response No relevant relationships by Ming-Yan Chow, source=Web Response

A CHALLENGING CASE OF DYSPNEA: ACUTE EXOGENOUS LIPID PNEUMONIA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Dyspnea is a common symptom that generally occurs during exertion and is considered pathological when it occurs at rest. Approximately, 90% of dyspnea is caused by pulmonary diseases making it immensely important that dyspnea be thoroughly evaluated as it can be fatal. And even after thorough evaluation, a clear answer for the etiology of patient’s dyspnea is not quite apparent. We report one such challenging case that after a meticulous collaboration from radiologist, pathologist and pulmonologist, and detailed history taking followed by a detailed work-up to rule out more common fatal causes of shortness of breath patient’s etiology of dyspnea was revealed to be acute exogenous lipid pneumonia (ELP) caused by lipid-based vapor rub (LBVR). CASE PRESENTATION: A 67 year old Japanese male with past medical history of hypertension presented to the hospital with worsening non-productive cough and dyspnea at rest for the past two weeks. He has never had such symptoms in the past. He had also started to self-medicate with a LBVR over the past 2 weeks with minimal relief. He denied smoking tobacco and using recreational drugs. He worked in maintaining air conditioners and heat furnaces for the past 40 years. He did not have birds at home. He denied any sick contacts. He has been up-to-date on his vaccinations. During the hospital stay, he was started on community acquired pneumonia (CAP) treatment and was also diuresed daily after chest x-ray revealed non-specific interstitial and alveolar prominence in both lung bases. Despite CAP and heart failure treatment for 3 days, patient continued to require supplemental oxygen (FiO2 of 40%) to maintain oxygen saturation (SpO2) of 92%. He then underwent computed tomography (CT) of chest which showed multi-focal patchy and confluent ground-glass airspace opacities with interstitial thickening in the lower lobes. Due to these findings on CT and no improvement in oxygen requirements, a bronchoscopy was performed with transbronchial biopsy which showed alveoli filled with lipid laden macrophages consistent with lipid pneumonia. Inspection of airway during bronchoscopy revealed tracheobronchopathia osteochondroplastica. He was discharged home with supplemental oxygen and was asked to cease using the LBVR. Patient followed up out-patient and he no longer had dyspnea at rest. His SpO2 had improved to 96% on room air. DISCUSSION: Chronic ELP usually occurs when lipid-based products are aspirated, or inhaled over an extended period. Acute ELP from inhaling LBVR has never been reported. LBVR products are commonly used to help with cough and congestion, however, it can lead to acute ELP as reported in this case. CONCLUSIONS: The usage of LBVR is often overlooked when acquiring history. This case uniquely sheds light on the tendency of over the counter LBVR to acutely cause exogenous lipid pneumonia making it very important for clinicians to inquire about LBVR usage. Reference #1: Betancourt, SL; Martinez-Jimenez, S; Rossi, SE; Truong, MT; Carrillo, J; Erasmus, JJ (January 2010). "Lipoid pneumonia: spectrum of clinical and radiologic manifestations.". AJR. American journal of roentgenology. 194 (1): 103–9. Reference #2: Kim JY, Jung JW, Choi JC, Shin JW, Park IW, Choi BW (February 2014). "Recurrent lipoid pneumonia associated with oil pulling". The International Journal of Tuberculosis and Lung Disease. 18 (2): 251–2 Reference #3: Moe Bell, Marvin (2015). "Lipoid pneumonia: An unusual and preventable illness in elderly patients“. Canadian Family Physician. 61 (9): 775–777. DISCLOSURES: No relevant relationships by Jalal Damani, source=Web Response

AN UNUSUAL CASE OF DESQUAMATIVE INTERSTITIAL PNEUMONIA RECURRENCE AFTER LUNG TRANSPLANT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Desquamative interstitial pneumonia (DIP) is a form of interstitial lung disease that is characterized by diffuse interstitial infiltrates on chest X-ray, restrictive pulmonary function tests and intra-alveolar accumulation of macrophages. We report a rare case of DIP recurrence after lung transplantation complicated by Aspergillus and Cytomegalovirus (CMV) infection. CASE PRESENTATION: The patient is a 59 year-old male former smoker with a history of Hepatitis C treated in 2006 with Ribavirin and Interferon. He was evaluated for progressive hypoxic respiratory failure requiring bilateral lung transplantation in December 2017. Explanted lung pathology was consistent with end-stage DIP. Post-surgical course was complicated with antibody-mediated rejection requiring intravenous immunoglobulin therapy and plasmapheresis, Aspergillus pneumonia and Cytomegalovirus (CMV) viremia. 14 months later, he presented to hospital with dyspnea and cough. He was hypoxic requiring 2L/min at rest. Computed tomogram (CT) of the chest showed diffuse ground glass opacities bilaterally and a new patchy left basilar airspace opacity. His bronchoscopy and transbronchial biopsy showed a DIP-like injury pattern, focal interstitial fibrosis and chronic bronchiolitis. Respiratory cultures grew Pseudomonas putida for which IV Piperacillin and Tazobactam was given. Laboratory studies showed speckled pattern ANA with a titre of 1:160 and negative anti Ds-DNA, RF, anti-CCP, anti ScL-70, ANCA, SSA/SSB and CPK. HCV RNA was undetected with normal cryoglobulin levels. While he responded to Medrol 32 mg daily and was discharged home without oxygen supplementation, the mechanism for the DIP-like pattern is not well understood. His immunosuppressive regimen post lung transplantation was tacrolimus and mycophenolate. DISCUSSION: In our patient, DIP recurrence post lung transplantation suggests presence of a systemic disease. Though the patient did not show any evidence of connective tissue disease, further workup is pending. The reported association between history of Hepatitis C and DIP in previous case reports may explain this patient’s presentation, however undetected HCV RNA with normal liver function would not support this theory. It is also possible that Aspergillus and CMV infection may have triggered a DIP-like pattern as described in another case post lung and renal transplantation. To our knowledge, this is the second reported case of DIP recurrence after lung transplant. Early recognition and treatment of DIP is essential as it has the most favorable prognosis of all Idiopathic Interstitial Pneumonia subtypes. In cases where DIP occurs in lung transplant patients, opportunistic pathogens might be suspected as causative agents. CONCLUSIONS: It is important to diagnose and treat the underlying etiology that causes DIP so that recurrence after lung transplantation can be prevented. Reference #1: King, M. B., et al. (1997). "Recurrence of desquamative interstitial pneumonia after lung transplantation.” Am J Respir Crit Care Med 156(6): 2003-2005. DISCLOSURES: No relevant relationships by alaa abu-sayf, source=Web Response No relevant relationships by Bathmapriya Balakrishnan, source=Web Response No relevant relationships by Aditya Kotecha, source=Web Response no disclosure on file for Lisa Stagner; No relevant relationships by Krishna Thavarajah, source=Web Response

EOSINOPHILIA AND DYSPNEA: NOT ALWAYS AN ASTHMA EXACERBATION

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: Eosinophilia is a common laboratory finding in patients diagnosed with asthma, however combined with dyspnea and a chronic cough, other diagnoses can be overlooked.. Chronic eosinophilic pneumonia is characterized by a chronic and progressive course similar to worsening asthma with the addition of specific pathologic findings. Here we present a case of a patient with known asthma who presented with progressively worsening cough, shortness of breath and eosinophilia. CASE PRESENTATION: A 46-year-old male with a history of asthma presented to the emergency department (ED) with worsening shortness of breath at both rest and exertion for two months. The patient had associated wheezing, thick yellow sputum and rhinorrhea. At presentation he also noted a two-week history of night sweats with a ten pound weight loss. Prior to presentation the patient underwent a chest x-ray and was treated for two weeks with antibiotics. for presumed pneumonia. The patient then underwent a repeat chest x-ray and was subsequently referred for chest CT. In the ED the patient was noted to have leukocytosis of 34 K/uL with 23.2 K/uL eosinophils (68.2%) Chest X-Ray demonstrated patchy air-space opacities with a predominantly mid to upper lung zone distribution. The patient was started on methylprednisolone, ceftriaxone, and azithromycin for community acquired pneumonia and was seen by the pulmonary and infectious disease consultants. The patient was tested for angiotensin converting enzyme, P-ANCA, Aspergillus, HIV, and tuberculosis, all of which were negative. The patient clinically improved and antibiotic therapy was discontinued. Three days after admission a repeat CXR, showed improved bilateral pulmonary parenchymal abnormalities. The patient’s eosinophilia resolved within three days and the patient continued to clinically improve with a tapering course of steroid therapy. DISCUSSION: Chronic eosinophilic pneumonia (CEP)is characterized by chronic and progressive clinical features and specific pathological findings. The onset of CEP is generally insidious, either subacute or chronic. Accordingly, the symptoms often appear several months before the diagnosis is made. The diagnosis of CEP is based on the association of respiratory symptoms, alveolar or blood eosinophilia, a non-segmental pulmonary infiltration with peripheral predominance involving mainly the upper lobes on chest imaging and the exclusion of other eosinophilic lung diseases. Corticosteroid treatment results in rapid resolution of symptoms, radiologic opacities and peripheral eosinophilia as occurred in our case. CONCLUSIONS: This case demonstrates the need for physicians to broaden their differential diagnoses when considering the etiology of eosinophilia in patients with a history of asthma. Reference #1: https://www.uptodate.com/contents/chronic-eosinophilic-pneumonia?search=chronic%20eosinophilic%20pneumonia&source=search_result&selectedTitle=1∼37&usage_type=default&display_rank=1 DISCLOSURES: No relevant relationships by Jang Chadha, source=Web Response No relevant relationships by Yelenis Fuertes Yanes, source=Web Response No relevant relationships by Nida Hameedi, source=Web Response

Pulmonary Kaposi Sarcoma without Mucocutaneous: Involvement The Role of Sequential Thallium and Gallium Scintigraphy

Kaposi sarcoma (KS) is a vascular-related tumor that has been associated with human immunodeficiency virus (HIV). It commonly involves the skin and lymph nodes, and infrequently involves the lungs. In very rare instances, pulmonary KS can be found in the absence of endobronchial and mucocutaneous involvement. Utilization of sequential thallium and gallium scintigraphy can aid in the diagnosis of pulmonary KS in the absence of mucocutaneous and endobronchial involvement. In this report, we discuss a case of a patient with acquired immunodeficiency syndrome who presented with dyspnea and cough and was found to have subtle pulmonary parenchymal nodular airspace opacities. He underwent negative infectious evaluation, including bronchoscopy. Despite the absence of mucocutaneous findings, sequential positive thallium and negative gallium scintigraphy led to an early diagnosis of pulmonary KS. Pulmonary KS in the absence of mucocutaneous involvement is a rare finding that is exceedingly difficult to diagnose. However, pulmonary KS should be considered in patients with HIV who present with respiratory symptoms even if the typical mucocutaneous manifestations of KS are absent. In such circumstances, sequential thallium and gallium scintigraphy can help differentiate pulmonary KS from other processes such as infections and lymphoma, and assist in establishing an earlier diagnosis.

A RARE CONGENITAL PULMONARY MALFORMATION – PULMONARY SEQUESTRATION: A CASE REPORT

PURPOSE: To show a rare case of congenital pulmonary malformation - pulmonary sequestration. METHODS: Medical record review. RESULTS: A 36-year-old man presented to outpatient clinic with severe cough for one month. Chest x-ray revealed airspace opacities in the right lower lung, suggestive of pneumonia. Antibiotics with ampicillin/sulbactam one week was used but his cough persisted. Laboratory examination revealed a low titer of anti-mycoplasma pneumonia IgG reactivity (12.3 AU/mL). And antibiotics was changed to levofloxacin. After two more weeks antibiotics treatment, his symptoms improved. But the follow-up chest x-ray only showed partial clearing of the previous opacity. Triangular shape opacity was still be found in right lower lung field. Chest CT scan was arranged for further survey. A blood vessel arising from aorta and to the right lower lung mass lesion were found. The image and the pulmonary structure are compatible with pulmonary sequestration. This patient had abdominal pain over the right upper quadrant about 20 months later. Abdominal CT showed the same picture in right lower lung without interval change. CONCLUSIONS: Pulmonary sequestration is a relatively rare congenital pulmonary malformation. There are various manifestations, from asymptomatic to pulmonary infections or hemoptysis. Usually, chest x-ray with patients’ presentation may lead to the possible diagnosis of infection or neoplasm. However, our point is that chest CT scan is the most helpful and gold standard to make a definite diagnosis. CLINICAL IMPLICATIONS: Chest CT scan is the most helpful tool to identify the vascular anatomy and make the diagnosis of pulmonary sequestration.