Bilateral Airspace Opacities Research Articles

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

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

MYCOBACTERIUM SHIMOIDEI: A RARE NONTUBERCULOUS INFECTION IN A US PATIENT

MYCOBACTERIUM SHIMOIDEI: A RARE NONTUBERCULOUS INFECTION IN A US PATIENT

A CASE OF MICROSCOPIC POLYANGIITIS (MPA) FOLLOWING SARS-COV-2 INFECTION

A CASE OF MICROSCOPIC POLYANGIITIS (MPA) FOLLOWING SARS-COV-2 INFECTION

DEXAMETHASONE-INDUCED HICCUPS IN A PATIENT WITH COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dexamethasone has been shown to reduce 28-day mortality in patients with severe COVID-19 pneumonia who required oxygen supplementation or invasive mechanical ventilation according to the RECOVERY trial. With the global COVID-19 pandemic, we are seeing increasing use of dexamethasone. This may lead to increased incidence of side effects as well. One of the side effects of dexamethasone therapy is hiccups which can range in presentation from mild and transient to persistent, causing distress and impaired quality of life. CASE PRESENTATION: A 59-year-old male with past medical history of type 2 diabetes mellitus and hypertension presented to the hospital with chief complaint of shortness of breath. Vitals were remarkable for acute hypoxic respiratory failure, improved with oxygen supplementation. Computerized tomography (CT) of the chest with contrast both showed bilateral airspace opacities. COVID-19 PCR was positive. Patient was diagnosed with COVID-19 pneumonia and started on remdesevir and dexamethasone. On day 3 of therapy, patient endorsed having hiccups without aggravating or relieving factors. These hiccups were suspected to be secondary to dexamethasone after initial evaluation. Gabapentin therapy was planned for relief, but patient's hiccups resolved after 24 hours. Patient completed the remaining dexamethasone therapy without incident. DISCUSSION: This brief case highlights the importance of recognizing dexamethasone induced hiccups as a clinical entity that may increase in incidence given increasing utility of dexamethasone in patients with severe COVID-19 pneumonia. Previous studies described this phenomenon in patients who were prescribed dexamethasone for chemotherapy induced nausea. They noticed that rotating dexamethasone with prednisolone in patients who developed hiccups significantly reduced the hiccups intensity. The hiccups were thought to be due to dexamethasone being more permeable to and crossing the blood brain barrier to stimulate the hiccups reflex arc in the midbrain. For patients with COVID-19 who meet criteria for dexamethasone, it may be prudent to continue with dexamethasone despite hiccups if quality of life is not significantly impaired due to lack of convincing evidence regarding efficacy of other steroids in COVID-19. Therapies such as gabapentin, metoclopramide and baclofen have been proposed for hiccups that are significantly affecting quality of life. Dexamethasone induced hiccups usually resolve upon discontinuing the drug. As such, most patients usually require reassurance or brief pharmacotherapy for hiccups. CONCLUSIONS: Dexamethasone may cause hiccups during the course of therapy for severe COVID-19 pneumonia. These hiccups are usual transient and resolve upon discontinuation of the drug. REFERENCE #1: Lee GW, Oh SY, Kang MH, Kang JH, Park SH, Hwang IG, Yi SY, Choi YJ, Ji JH, Lee HY, Bruera E. Treatment of dexamethasone-induced hiccup in chemotherapy patients by methylprednisolone rotation. Oncologist. 2013;18(11):1229-34. doi: 10.1634/theoncologist.2013-0224. Epub 2013 Oct 9. PMID: 24107973;PMCID: PMC3825309. DISCLOSURES: No relevant relationships by Muhammad Hasib Khalil, source=Web Response

VAPING CAN BREAK YOUR HEART

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Electronic cigarette or vaping product use-associated lung injury (EVALI) is potentially life-threatening disease that has become increasingly recognized over the last years. However, the extra-pulmonary manifestations of this disease are not as well described. We present a patient who simultaneously developed acute EVALI and stress induced cardiomyopathy. CASE PRESENTATION: A 35-year-old female with a recent heavy vaping history presented to hospital via EMS due to disorganized behavior. Her past medical history was notable for polysubstance abuse and an extensive neuropsychiatric history. Her vital signs were notable for sinus tachycardia, hypotension and hypoxia with an oxyhemoglobin saturation 65%. Her physical exam was notable for cyanosis, rales to pulmonary auscultation and use of accessory muscles. She was intubated and started on empiric antibiotics for community acquired pneumonia, and vasopressors. A computer tomography pulmonary angiography (CTPE) was negative for acute pulmonary embolism but showed scattered bilateral airspace opacities with dependent consolidations (fig 1.). Relevant laboratory on admission included procalcitonin 28.17, WBC count 12.9 and troponin 1.58. SARs-COV-2, serum blood cultures, legionella antigen, streptococci pneumoniae antigen and HIV were negative. Urine toxicology was positive for cannabinoids. Bronchoalveolar lavage later demonstrated 50,000 TNC with neutrophil predominance. EKG showed sinus tachycardia and nonspecific ST depression. Echocardiogram revealed severe diffuse hypokinesis with left ventricular ejection fraction (LVEF) of 13%. During her ICU course she continued on mechanical ventilation with lung protective strategy, systemic glucocorticoids and antibiotics. Vasopressors were subsequently weaned off. Repeated echocardiogram on ICU day five demonstrated a recovered LVEF at 55%. Patient's hypoxemia improved, and she was successfully extubated on ICU day eight. DISCUSSION: Pulmonary injury is the most well described clinical manifestation of EVALI, however a large majority of these patients also present with gastrointestinal symptoms and malaise, suggesting a systemic disease process. Our patient had newly reduced LVEF suggestive of stress induced cardiomyopathy which consequently improved with standard and supportive care. CONCLUSIONS: It is important to maintain a high index of suspicion of secondary organ damage, as prompt diagnosis and treatment of EVALI associated cardiac dysfunction can have an impact in short- and long-term prognosis. REFERENCE #1: Kligerman S, Raptis C, Larsen B, Henry TS, Caporale A, Tazelaar H, Schiebler ML, Wehrli FW, Klein JS, Kanne J. Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology. 2020 Mar;294(3):491-505. doi: 10.1148/radiol.2020192585. Epub 2020 Jan 28. PMID: 31990264. DISCLOSURES: No relevant relationships by David barounis, source=Web Response No relevant relationships by Xavier Fonseca, source=Web Response No relevant relationships by Dana Mueller, source=Web Response

S2452 A Rapidly Fatal Case of Fulminant Hepatic Failure From Streptococcus salivarius Bacteremia

INTRODUCTION: Bacteremia can prove fatal in those presenting with fulminant hepatic failure (FHF). Clinical suspicion of infection must be on the differential as the only symptoms on presentation may be general deterioration or worsening encephalopathy. CASE DESCRIPTION/METHODS: 63-year-old male with history of chronic lymphocytic leukemia (CLL) (baseline leukocytosis 32,000/mm3) presented for fever and acute dyspnea that started 1 day prior to admission associated with 3 to 4 days of myalgias and fatigue. In the emergency department, he was initially febrile (100.4⁰F), tachycardic (heart rate 130 bpm), and hypertensive (164/83 mmHg). The patient had markedly elevated transaminases (AST >6000 IU/L and ALT >3300 IU/L), lactic acid (3.1 mmol/L), creatinine (5.28 mg/dL), leukocytosis (35,000/mm3), and procalcitonin (20.9 ng/mL) with a King’s College Criteria score of 2. He rapidly declined and was intubated within four hours of presentation and started on continuous renal replacement therapy (CRRT). Broad-spectrum antibiotic coverage with vancomycin and piperacillin/tazobactam was initiated. His leukocytosis rapidly increased to 122,000/mm3 and determined not to be related to CLL. An abdominal ultrasound showed coarsened hepatic echotexture with borderline hepatomegaly, mild splenomegaly, and patent portal vasculature. Extensive viral work up was negative, to include SARS-CoV-2. He remained profoundly acidotic requiring four vasopressors and continuous bicarbonate infusions despite CRRT due to FHF and inability to clear lactate. Given his poor prognosis, he was transitioned to comfort measures with compassionate extubation and went into asystolic arrest 51 hours after presentation. Blood cultures resulted posthumously and were positive for Streptococcus salivarius. DISCUSSION: In cases of FHF, infection may precipitate the initial presentation and contribute to death in 10% of fatal cases. Up to 80% of fatal FHF cases caused by bacterial infection are diagnosed less than 24 hours before death. Clinical features, such as fever or leukocytosis, can be poor indicators of bacterial infection considering these may be absent in up to 30% of cases though severity of hepatic encephalopathy and SIRS score >1 can be predictive of bacteremia. Gram positive organisms can be seen in 44-70% of isolates. Rapid initiation of broad-spectrum antibiotics is vital as overall mortality can be reduced to 44% and increase the opportunity for transplantation.Figure 1.: Initial chest x-ray at presentation to the emergency department demonstrates reticular and alveolar opacities bilaterally (A). Chest x-ray four hours after presentation, status post intubation, demonstrates marked worsening of bilateral airspace opacities consistent with rapid progression of multi-system organ failure later found to be caused by Streptococcus salivarius bacteremia (B).

PRESUMED CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Antiphospholipid antibodies (aPLs) are associated with recurrent early pregnancy loss and arterial as well as venous thrombosis. A small subset of patients develop a life-threatening form of the disease with widespread thrombosis and multiorgan failure, called catastrophic antiphospholipid syndrome (CAPS). CASE PRESENTATION: A 26-year-old female, 10 weeks pregnant, with a history of 2 prior miscarriages presented with hyperemesis gravidarum. She had a pulseless electrical activity cardiac arrest in the ER with return of spontaneous circulation after 15 minutes of advanced cardiovascular life support (ACLS). Left heart catheterization showed no evidence of coronary artery disease. Transthoracic echocardiogram showed preserved ejection fraction and no other abnormality. CT angiogram of the chest ruled out pulmonary emboli but showed diffuse bilateral airspace opacities, concerning for acute respiratory distress syndrome (ARDS). Patient developed acute kidney injury, acute right lower extremity arterial thrombosis and compartment syndrome requiring fasciotomy, upper extremities superficial venous thrombi, fetal loss and spontaneous abortion. Working diagnosis of CAPS was made; aPLs, anti-cardiolipin and anti-beta2 glycoprotien-1 antibodies levels ordered and patient started on IV heparin infusion, IV glucocorticoids and plasmapheresis followed by IV immunoglobulins (IVIG). Anticoagulation was held intermittently due to acutely worsening thrombocytopenia with low fibrinogen levels concerning for disseminated intravascular coagulation (DIC), and bleeding around the fasciotomy site, hematuria and vaginal bleeding (workup for heparin induced thrombocytopenia remained negative). Cryoprecipitate and blood transfusions were required. Acute respiratory failure resolved with low tidal volume ventilation, prone positioning and aggressive diuresis. Tissue biopsies for histopathology were deferred. Patient was discharged to inpatient rehab after prolonged hospital stay. DISCUSSION: Approximately 1% of antiphospholipid syndrome patients develop CAPS. Lungs are the second most common organs involved with ARDS being the most common complication. Mortality was 37% in a cohort of 500 patients. Management of CAPS includes aPL testing including lupus anticoagulant, antibeta-2 glycoprotein-1 and anticardiolipin antibodies without delaying empiric treatment. Combination therapy with glucocorticoid, heparin, and plasmapheresis or IVIG rather than single agents is recommended. CONCLUSIONS: Differential diagnosis of CAPS includes DIC which usually presents with small vessel thrombosis but has been reported to cause arterial thrombosis as well, and for which the patient was treated once the platelet counts dropped later. However, with the patient’s history and clinical presentation and given the high mortality rate, we decided to start aggressive empiric therapy after having sent aPL testing. Reference #1: Cervera R.: Antiphospholipid syndrome. Thromb. Res. 2017; 151: pp. S43-S47 Reference #2: Cervera R., Piette J.-C., Font J., Khamashta M.A., Shoenfeld Y., Camps M.T., et al: Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients. Arthritis Rheum. 2002; 46: pp. 1019-1027 Reference #3: Bucciarelli S., Espinosa G., Cervera R., Erkan D., Gómez-Puerta J.A., Ramos-Casals M., et al: Mortality in the catastrophic antiphospholipid syndrome: causes of death and prognostic factors in a series of 250 patients. Arthritis Rheum. 2006; 54: pp. 2568-2576 DISCLOSURES: No relevant relationships by Priyanka Bhat, source=Web Response no disclosure on file for Shafaq Ejaz; No relevant relationships by Ahmed Qadir, source=Web Response No relevant relationships by karan Singh, source=Web Response No relevant relationships by Rodney Steff, source=Web Response

A CASE OF ACUTE SILICOSIS WITH SEVERE PULMONARY HYPERTENSION

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Silicosis occurs from inhalation of silica dust particles. Acute and accelerated silicosis share nodular formations as seen in chronic silicosis but have granular lipo-proteinaceous collections in the alveolar spaces [1]. These collections impair gas exchange resulting in cyanosis, and ultimately respiratory failure usually exacerbated by respiratory infections. We report a case of a young patient developing acute silicosis from working in a gold mine. CASE PRESENTATION: A 30-year-old African man presented with a 2-week history of worsening shortness of breath associated with productive cough and pleuritic chest pain. The patient was previously diagnosed with progressive massive fibrosis (PMF) and silicosis via lung biopsy at an outside hospital, attributed to a 3-year long silica exposure from gold mining in West Africa. Our patient was initiated on intravenous glucocorticoids, broad spectrum antibiotics, and noninvasive positive pressure ventilation for acute hypoxic and hypercarbic respiratory failure. Chest radiograph revealed extensive bilateral airspace opacities (figure 1). CT-chest showed extensive bilateral perihilar parenchymal opacities with traction bronchiectasis, consistent with PMF (figure 2)(figure 3). Transthoracic echocardiogram showed septal wall abnormalities and a right ventricular systolic pressure of 173 mmHg measured via tricuspid regurgitant jet. The patient’s condition stabilized during hospitalization and the patient was discharged home on prednisone and oxygen supplementation via nasal cannula. Three weeks after discharge, the patient presented again with recurrent acute respiratory failure with a positive viral PCR for RSV requiring intubation and mechanical ventilation. Shortly after intubation, the patient went into cardiac arrest and expired. DISCUSSION: Generally, silicosis presents as a chronic condition but rarely, acute silicosis, most often related to massive exposure, can present within a few years . Lung transplantation is the only definitive treatment of advanced silicosis with studies showing successful lung transplantation with the 6-month, 1-year and 3-year survival rates of 86, 86, and 76 percent respectively [2]. One case report examined initiation of intravenous glucocorticoid therapy followed by oral prednisone which showed transient improvement in chest radiography and pulmonary function tests [3]. Unfortunately, treatment with glucocorticoid therapy was unable to alter the outcome of our patient. Lung transplantation was in the process for the patient but was unable to be obtained. CONCLUSIONS: This case presents a rare case of acute silicosis/PMF with severe pulmonary hypertension, who developed respiratory failure after RSV infection leading to death. Reference #1: Ozkan M, Ayan A, Arik D, Balkan A, Ongürü O, Gümüş S. FDG PET findings in a case with acute pulmonary silicosis. Ann Nucl Med 2009;23:883–886. Reference #2: Singer, J. P., et al. “Survival Following Lung Transplantation for Silicosis and Other Occupational Lung Diseases.” Occup Med (Lond) 62.2 (2012): 134-7. Print. Reference #3: Goodman, George B., et al. “Acute Silicosis Responding to Corticosteroid Therapy.” Chest 101.2 (1992): 366-70. Print. DISCLOSURES: No relevant relationships by Khaled Abu-Ihweij, source=Web Response No relevant relationships by Sung Choi, source=Web Response no disclosure on file for Keith Guevarra; No relevant relationships by John Wisener, source=Web Response

A CASE OF E-CIGARETTE VAPING-ASSOCIATED INTERSTITIAL LUNG DISEASE WITH CRYPTOGENIC ORGANIZING PNEUMONIA

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: E-cigarette/Vaping-associated lung injury (EVALI) is a relatively new term that was described in 2019, since then more than 2000 new cases have been reported in USA.(1) Usual cases present with cough/dyspnea associated with hypoxemia and bilateral air-opacities in the Chest X-Ray. (2) Further research is still needed since the histopathologic pattern is not specific and variable. CASE PRESENTATION: We present a case of a 52-year old female with a history of vaping who presented with dyspnea and cough. Patient was tachypneic and hypoxic at 58% on room air. Chest x-ray (CXR) showed bilateral airspace opacities with perihilar and basilar distribution; Chest CT showed diffuse bilateral ground glass opacities (Figure 1). Patient was intubated due to worsening tachypnea and hemodynamic instability on BiPAP; she was started empirically on broad-spectrum antibiotics, and methylprednisolone. She was successfully extubated after 4 days but required re-intubation for persistent respiratory distress. Bronchoalveolar lavage was attempted but due to insufficient sample Video-assisted thoracoscopic surgery with biopsy was performed. Lung biopsy showed cryptogenic organizing pneumonia, (Figure 1) which in this clinical setting suggested a diagnosis of EVALI (Figure 2). Patient was successfully extubated 10 days after the second intubation. She was discharged home with a 6-week course of methylprednisolone. Patient presented to the Emergency department 3-weeks later with acid reflux, and routine CXR was done showing complete resolution of bilateral opacities and no respiratory distress. DISCUSSION: EVALI is a diagnosis of exclusion that usually presents with cough and dyspnea in a patient with a positive screen for vaping-specific history. Chest Imaging can show nonspecific bilateral ground glass opacities or bilateral infiltrates. As per literature review, only 17 patients amongst the thousands with clinical EVALI have an open lung biopsy confirming the presence of acute lung injury with various histopathologic patterns such as acute eosinophilic pneumonia, cryptogenic organizing pneumonia or lipoid pneumonia. (1) Physicians must be able to recognize EVALI as a probable diagnosis, even in community hospitals, since this condition can response to steroids and could be prevented with patient education. CONCLUSIONS: EVALI is becoming a common pathology. This means that physicians in every setting of patient care must be aware of the possibility of EVALI in patients presenting with cough/dyspnea, typical chest imaging and vaping history. Providers should also be familiar with prevention, structured diagnostic approach and treatment of EVALI. (1) Reference #1: Henry TS, et al. Imaging of vaping-associated lung disease; N Engl J Med 2019;381:1486-1487 Reference #2: Hartnett KP, et al. Syndromic Surveillance for E-Cigarette, or Vaping, Product Use–Associated Lung Injury; N Engl J Med. 2019 Dec 20 DISCLOSURES: No relevant relationships by Jorge Cedano, source=Web Response No relevant relationships by Syed Kazmi, source=Web Response No relevant relationships by Anuraag Sah, source=Web Response

PULMONARY CAPILLARY HEMANGIOMATOSIS: A RARE CASE OF STABLE DISEASE WITHOUT TREATMENT

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary capillary hemangiomatosis (PCH) is a rare cause of primary pulmonary hypertension caused by extensive proliferation of pulmonary capillaries within parenchymal, vascular, and bronchial tissue. Typically, PCH progresses rapidly with a median time to lung transplantation of two years post diagnosis. To our knowledge, we present the longest case of biopsy proven PCH that has been stable without treatment for seven years. CASE PRESENTATION: A healthy 23-year old non-smoking male presented to the emergency department (ED) with a 2-week history of hemoptysis associated with intermittent left-sided pleuritic chest pain, fatigue, and dyspnea. His physical exam, routine lab work, and chest X-ray were unremarkable. He was discharged home and prescribed clarithromycin for suspected bronchitis. He returned to the ED months later with ongoing symptoms and was referred for urgent outpatient consultation to pulmonology. Bronchoscopy was performed with no blood on bronchoalveolar lavage analysis. Further serum rheumatologic and vasculitis panels were negative. A non-contrast computed tomography (CT) scan of his chest revealed subtle bilateral upper lung predominant centrilobular ground-glass opacities. (Figure 1) With worsening hemoptysis, he returned to the ED six months later. A CT Chest angiogram was performed and showed progressive bilateral airspace opacities. (Figure 2) The patient was referred to Thoracic Surgery for lung biopsy. This demonstrated septal proliferation of capillaries consistent with PCH without evidence of vasculitis, venous occlusion or microorganisms. Immunofluorescence staining was also negative. (Figure 3) The patient remains stable with no signs of progression or pulmonary hypertension on echocardiogram. His enhanced CT and pulmonary function tests remain normal seven years from his initial presentation. DISCUSSION: The typical presentation of PCH includes progressive dyspnea, cough with or without hemoptysis, chest pain, and fatigue. (1) Chest X-ray can be normal or progress to demonstrate bilateral opacities in keeping with diffuse alveolar hemorrhage (DAH). CT chest often shows diffuse centrilobular ground-glass opacities. (1) Bronchoscopy may not reveal erythrocytes if the patient is not actively bleeding. Diagnosis of PCH is essential, as vasodilators used in pulmonary hypertension can cause hemodynamic instability in PCH. (2) Interestingly, an autopsy case series found incidental cases of PCH in patients who were asymptomatic during life. (3) This raises the possibility that subclinical cases of PCH may exist which do not require urgent referral for lung transplantation. CONCLUSIONS: This case represents the longest active case of PCH after confirmation with biopsy without treatment. Re-evaluating the expected prognosis for individuals diagnosed with PCH is important, as median survival may be longer than currently reported in the literature. Reference #1: O'keefe MC, and Post MD. Pulmonary Capillary Hemangiomatosis: A Rare Cause of Pulmonary Hypertension. Archives of Pathology & Laboratory Medicine, 2015;139(2):274–277. Reference #2: Almagro P, Julia J, Sanjuame M, Gonalez G, Casalots J, Heredia JL, et al. Pulmonary Capillary Hemangiomatosis Associated with Primary Pulmonary Hypertension. Medicine. 2002;81(6):417–24. Reference #3: Havlik DM, Massey LW, Williams WL, and Crooks LA. Pulmonary Capillary Hemangiomatosis- like foci: an autopsy study of 8 cases. Anatomic Pathology. 2000;113(5):665-662. DISCLOSURES: No relevant relationships by Meredith Chiasson, source=Web Response No relevant relationships by Jasper Johar, source=Web Response No relevant relationships by Daria Manos, source=Web Response No relevant relationships by Matthew Nunn, source=Web Response

DIFFUSE ALVEOLAR HEMORRHAGE AS A CONSEQUENCE OF MICROSCOPIC POLYANGIITIS DUE TO COVID-19

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a small vessel vasculitis of which microscopic polyangiitis (MPA) is a subset. They are known to cause life threatening renal failure and/or pulmonary hemorrhage. Viruses are a known trigger of vasculitis, including MPA. (1) We present a case of MPA caused by COVID-19 presenting as diffuse alveolar hemorrhage (DAH) CASE PRESENTATION: 55 year old female with a past medical history of hemorrhagic stroke, hypertension & asthma who presented with respiratory distress & severe hypoxemia. At the time of intubation, a moderate amount of blood was suctioned from her endotracheal tube. She was profoundly hypoxemic & required 100% FiO2 and PEEP 18 cmH2O. A SARS CoV2 PCR test was positive. Other admission laboratory values were significant for a creatinine of 4.9 mg/dL (baseline: 0.8mg/dL), hemoglobin of 8 g/dL (baseline: 11.8g/dL), ferritin 569 ng/mL, D-dimer 3.18 ug/mL, CRP 62.8 mg/L, ESR 118 mm/hr. Chest X-ray showed dense bilateral airspace opacities. A CT scan showed extensive bilateral consolidations with air bronchograms that were not typical for a COVID-19 pneumonia (Image 1) except in the apices where these dense consolidations had a peripheral pattern. She was admitted to the medical ICU where she continued to have bleeding into her endotracheal tubing. Bronchoscopy showed blood in the airways diffusely with no focality to the bleeding. A bronchoalveolar lavage was performed of two separate lobes, and was notable for progressively bloody aliquots consistent with DAH. Because of concern for a pulmonary-renal syndrome, rheumatologic testing was performed. She was empirically treated with high dose intravenous steroids and plasmapheresis. Unfortunately, profound hypoxia persisted and family elected to withdraw life-sustaining therapies. Two days after her death, serologies revealed a mildly positive ANA and a strongly positive anti-MPO ANCA, suggesting the diagnosis of MPA. DISCUSSION: While the primary signs and symptoms of COVID-19 are fever, cough, and dyspnea, other reported manifesations include kawasaki-like disease in children (2) and cutaneous manifestations such as livedo reticularis (3). We believe that in our case the patient’s infection with COVID-19 & its subsequent increased inflammatory state led to her developing MPA vasculitis with subsequent pulmonary-renal syndrome complicated by diffuse alveolar hemorrhage, rapidly progressive renal failure and ultimately death. Her clinical and serologic picture were consistent with a diagnosis of microscopic polyangiitis. It is unclear whether our patient had a smoldering vasculitis that was triggered by the hyper-inflammatory nature of COVID-19 or whether this virus caused a vasculitis de novo. CONCLUSIONS: With vasculitis potentially being one of COVID-19's presenting symptoms, prompt diagnosis and intervention is essential in improving outcomes. Reference #1: Yates M, Watts R. ANCA-associated vasculitis. Clin Med (Lond). 2017;17(1):60-64. doi:10.7861/clinmedicine.17-1-60 Reference #2: Viner RM, Whittaker E. Kawasaki-like disease: emerging complication during the COVID-19 pandemic [published online ahead of print, 2020 May 13]. Lancet. 2020;10.1016/S0140-6736(20)31129-6. doi:10.1016/S0140-6736(20)31129-6 Reference #3: Sachdeva M, Gianotti R, Shah M, et al. Cutaneous manifestations of COVID-19: Report of three cases and a review of literature [published online ahead of print, 2020 Apr 29]. J Dermatol Sci. 2020;S0923-1811(20)30149-3. doi:10.1016/j.jdermsci.2020.04.011 DISCLOSURES: no disclosure on file for Christopher Damiano; No relevant relationships by Elie Fares, source=Web Response no disclosure on file for Catherine Kuntz; No relevant relationships by Kriti Pathak, source=Web Response

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

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

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.

Disseminated varicella zoster virus encephalitis

A 33-year-old homeless woman presented to the emergency room in September, 2012, with 2 days of dry cough, dyspnoea, and fever, and 1 week of pruritic rash. On examination she had a temperature of 41·0°C, blood pressure of 98/65 mm Hg, heart rate of 85 bpm, respiratory rate of 16 bpm, and O2 saturation of 47% on room air. She had a diff use papular rash with vesicles of diff erent ages with haemorrhagic crust aff ecting the trunk, extremities, face, and scalp, but sparing the palms and soles (fi gure). She had normal mental status, cranial nerves, motor, and sensory examination. Chest radiograph showed diff use bilateral airspace opacities. Within a few hours of presentation she suddenly became confused, with fl accid paralysis necessitating intubation and admission to the medical intensive care unit. Electroencephalogram showed non-convulsive status epilepticus. MRI brain showed multiple foci of punctate microhaemorrhages throughout the corpus callosum, both temporal lobes, and left posterior cingulate gyrus, consistent with infectious haemorrhagic encephalitis (fi gure). HIV testing was positive, with CD4 count 4 cells/μL (normal 348–1456 cells/μL), and viral load was 66 000 copies/mL (normal < 50 copies/mL). A skin biopsy sample stained positive for varicella zoster virus (VZV), but negative for herpes simplex virus (HSV). Zoster-associated encephalitis from disseminated VZV can develop within days of the disseminated rash, and should be strongly suspected in immunosuppressed patients. Characteristic signs of zoster-associated encephalitis include acute delirium, typical signs of stroke such as headache with acute hemiplegia, aphasia, ataxia, hemisensory loss, or visual changes, dependent on the predominant location of the VZV vasculitis. Intravenous aciclovir 10 mg/kg every 8 h for 7–10 days should be started early if there is clinical suspicion of encephalitis. Our patient was given intravenous aciclovir and multiple antiepileptic drugs to control her seizures. We treated her for VZV pneumonia, aspergillus pneumonia, propofolinduced pancreatitis, Escherichia coli urinary tract infection, and critical illness myopathy. After stabilisation in hospital she was started on antiretrovirals and pneumocystis pneumonia prophylaxis. After 2 months of rehabilitation she could walk independently and communicate without diffi culty. At last follow-up in March, 2014, she had made a near full recovery in terms of her cognitive and motor function. Lancet 2014; 384: 1698

Lymphangitic Pulmonary Metastases in Castrate-Resistant Prostate Adenocarcinoma

A 63-year-old man with castrate-resistant metastatic prostate adenocarcinoma with known osseous and pelvic nodal involvement presented with progressive dyspnea for one week. Complete cardiopulmonary evaluation revealed a restrictive lung defect that could not be attributed to any of his previous therapies. On presentation, physical examination revealed coarse breath sounds diffusely with hypoxemia. Computed tomography of the chest showed severe bilateral airspace opacities and ground-glass appearance most consistent with interstitial pneumonitis. The patient was intubated due to progressive hypoxemia and worsening respiratory status despite empiric antibiotics and high dose steroids. Subsequent emergent bronchoscopy with transbronchial biopsies revealed atypical intralymphatic cells that stained positively for prostate-specific antigen and prostatic-specific acid phosphatase, confirming the diagnosis of intralymphatic pulmonary metastasis from prostate adenocarcinoma. Lymphangitic pulmonary metastasis from prostate adenocarcinoma is exceedingly rare, with few reported cases that are biopsy-proven. Herein, we describe a rare case of biopsy-proven lymphangitic pulmonary metastasis in the setting of castrate-resistant prostate adenocarcinoma and provide a comprehensive literature review.

Left Atrial Undifferentiated Pleomorphic Sarcoma Causing Mitral Valve Obstruction

A 61-year-old Latino woman with no past medical history presented to the emergency department with 2 weeks of gradual onset of dyspnea on exertion, cough, and palpitations. She denied any recent illnesses, fevers, or unintentional weight loss. She was not taking any medications or using tobacco, alcohol, or illicit drugs. On physical examination, she had a temperature of 100.6°F, a heart rate of 122 bpm, respiratory rate of 25 breaths per minute, blood pressure of 155/92 mm Hg, and oxygen saturation of 92% on bilevel positive airway pressure. Her physical examination was notable for jugular venous distension, a loud S1 and normal S2, a grade 2/6 middiastolic murmur heard loudest at the apex, crackles throughout her posterior lung fields, and trace bilateral lower-extremity edema. Her ECG showed sinus rhythm with no significant ST-T abnormalities (Figure 1). A portable chest radiograph showed mild enlargement of the cardiac silhouette, bilateral air space opacities, and small bilateral pleural effusions (Figure 2). Computed tomography of the chest with intravenous contrast was done to evaluate for pulmonary embolism; it revealed a mass with lobulated margins within the left atrium (Figure 3) protruding into the left ventricular cavity and infiltrating the left atrial wall. Figure 1. Twelve-lead ECG demonstrating normal sinus rhythm with no significant ST-T segment abnormalities. Figure 2. Portable chest radiograph showing mild enlargement of the cardiac silhouette, bilateral air space opacities, and small bilateral pleural effusions. Figure 3. A …

Education at the margins

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.

Rapidly Progressive Pulmonary Opacities on Thoracic Imaging Studies

In Brief Thoracic imaging studies showing the rapid development of multifocal, bilateral pulmonary opacities are common in clinical practice. From an imaging standpoint, such patients may be broadly classified into those with hydrostatic pulmonary edema versus those with increased permeability edema patterns; combinations of these two patterns may also be encountered. Classification of patients into one or the other pattern provides an approach to the thoracic imaging findings in these patients and may even allow tailoring of additional diagnostic studies and presumptive therapy. In addition to a number of commonly encountered etiologies for an increased permeability pattern on chest radiography, several conditions primarily characterized by interstitial and/or alveolar inflammation or pulmonary hemorrhage should be considered, among them acute eosinophilic pneumonia. Acute eosinophilic pneumonia often presents in previously healthy patients without a prior history of asthma, usually without peripheral blood eosinophilia, and produces respiratory failure. Thoracic imaging studies show rapidly progressing multifocal bilateral air-space consolidation without features of hydrostatic pulmonary edema. Bronchoscopy is the diagnostic procedure of choice and will show significant pulmonary eosinophilia on bronchoalveolar lavage. Corticosteroid therapy causes clearing of the pulmonary findings and rapid resolution of respiratory failure. Relapse is not a feature of acute eosinophilic pneumonia. Acute eosinophilic pneumonia is a rare cause of respiratory failure in previously healthy patients that typically presents on thoracic imaging studies as rapidly progressive bilateral air-space opacities.