Bilateral Ground-glass Opacities Research Articles

FDG PET/CT Findings of Rapidly Progressive Interstitial Lung Disease in a Patient With Anti-MDA5 Dermatomyositis.

Anti-MDA5 dermatomyositis is associated with an increased risk of developing rapidly progressive interstitial lung disease with a high mortality. We describe FDG PET/CT findings in a case of rapidly progressive noninfectious interstitial lung disease associated with anti-MDA5 dermatomyositis. The lung disease showed bilateral diffuse ground-glass opacities with diffuse heterogeneous FDG activity predominantly in middle and lower zones, mimicking infectious pneumonia. Familiarity with the imaging features of this rapidly progressive noninfectious interstitial lung disease can help to suggest the diagnosis and guide appropriate management.

A predictive model to explore risk factors for severe COVID-19

With the rapid spread of the novel coronavirus (COVID-19), a sustained global pandemic has emerged. Globally, the cumulative death toll is in the millions. The rising number of COVID-19 infections and deaths has severely impacted the lives of people worldwide, healthcare systems, and economic development. We conducted a retrospective analysis of the characteristics of COVID-19 patients. This analysis includes clinical features upon initial hospital admission, relevant laboratory test results, and imaging findings. We aimed to identify risk factors for severe illness and to construct a predictive model for assessing the risk of severe COVID-19. We collected and analyzed electronic medical records of confirmed COVID-19 patients admitted to the Affiliated Hospital of Jiangsu University (Zhenjiang, China) between December 18, 2022, and February 28, 2023. According to the WHO diagnostic criteria for the novel coronavirus, we divided the patients into two groups: severe and non-severe, and compared their clinical, laboratory, and imaging data. Logistic regression analysis, the least absolute shrinkage and selection operator (LASSO) regression, and receiver operating characteristic (ROC) curve analysis were used to identify the relevant risk factors for severe COVID-19 patients. Patients were divided into a training cohort and a validation cohort. A nomogram model was constructed using the “rms” package in R software. Among the 346 patients, the severe group exhibited significantly higher respiratory rates, breathlessness, altered consciousness, neutrophil-to-lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) levels compared to the non-severe group. Imaging findings indicated that the severe group had a higher proportion of bilateral pulmonary inflammation and ground-glass opacities compared to the non-severe group. NLR and LDH were identified as independent risk factors for severe patients. The diagnostic performance was maximized when NLR, respiratory rate (RR), and LDH were combined. Based on the statistical analysis results, we developed a COVID-19 severity risk prediction model. The total score is calculated by adding up the scores for each of the twelve independent variables. By mapping the total score to the lowest scale, we can estimate the risk of COVID-19 severity. In addition, the calibration plots and DCA analysis showed that the nomogram had better discrimination power for predicting the severity of COVID-19. Our results showed that the development and validation of the predictive nomogram had good predictive value for severe COVID-19.

Daptomycin eosinophilic pneumonia, a systematic review of the literature and case series.

Daptomycin-induced eosinophilic pneumonia (DIEP) is a rare yet severe adverse event that requires rapid recognition and management. Diagnosing a definite case is challenging and involves meeting the American Thoracic Society (ATS) criteria, although alternative criteria have been suggested. This study aims to conduct a systematic review of literature and includes a case series. Six cases of DIEP identified at Perugia Hospital, Perugia, Italy have been described. A systematic review was carried out adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. a total of 74 cases of DIEP were analysed. Using ATS clinical criteria, 15 were classified as definite (20.3%), 54 as probable (73.0%), and 5 as possible (6.8%). Phillips criteria and the Lyon Algorithm identified 43/74 (58.2%) and 64/67 (95.5%) cases as definite, respectively. Bronchoalveolar lavage (BAL) was performed in 43 cases, revealing an average eosinophil count of 28.6% (SD 24.4). Radiological findings highlighted recurring features like bilateral opacities (68.1%), ground-glass opacities (41.7%), patchy infiltrates (30.6%), and peripheral predominance (19.4%). Upon suspicion, daptomycin was discontinued; 20 cases required no additional treatment, 38 received corticosteroids, and 12 received both corticosteroids and antibiotics. Recovery rates were high across all treatment types (≥ 73.7%). Most reports described rapid improvement post-withdrawal (within 96h). DIEP is a rare, fast-progressing condition where early diagnosis and prompt treatment are vital. Diagnosis relies on clinical, laboratory, and radiological evaluations. Stopping daptomycin is essential, with corticosteroids often necessary. Further research is needed to enhance diagnostic accuracy for this disease.

Chest Computerized Tomography Findings in COVID-19 Patients Presenting to the ER with Gastrointestinal Symptoms

Abstract Background The world continues to face a life-threatening viral pandemic. SARS-CoV-2 has caused over 98 million cases and 2.2 million deaths since January 2020. Chest Computerized tomography is one of the main modalities in the screening and diagnosis of corona virus disease; yet it must correlate with the clinical and laboratory findings. Among available modalities for detecting COVID19, Chest Computerized tomography was done mainly in symptomatic and in high risk patients showing a sensitivity of 94.6% and specificity of 46.0%. Purpose of the Study Detecting COVID19 patients presenting initially or mainly with Gastrointestinal manifestations and to help preventing misdiagnosis and overlooking these patients. In addition to estimating the prevalence of these COVID19 patients presenting with gastrointestinal symptoms only versus those presenting with combined gastrointestinal and respiratory manifestations. Results This study included 95 patients recruited from the Ain-shams and Souad Kafafi University Hospitals from August 2021 till March 2022. These patients presented with gastrointestinal symptoms as their initial or main symptoms with positive PCR test. They were investigated by Chest CT and were interpreted by experienced radiologists in reading CT chest. From such patients, (32%) presented with gastrointestinal manifestations only. The rest of the patients were presenting mainly with gastrointestinal symptoms and associated with chest symptoms. A recurrently observed pattern of bilateral peripheral Ground glass opacities with basal predominance was found in gastrointestinal only group CT scans. Bilateral involvement, consolidation, crazy paving and multi lobar affection were statistically significantly higher in combined group in comparison to GIT only group. Conclusions Commonest Chest CT pattern was bilateral, peripheral GGO with basal predominance among Gastrointestinal only group. These findings indicate high possibility of COVID 19 even in the absence of chest symptoms. Consequently, a rapid diagnosis and earlier quarantine will assist in better treatment and prognosis.

Radioclinical Profile of Eosinophilic Lung: A Case Series.

In this study, we present findings from an analysis of 17 patients diagnosed with eosinophilic lung disease, with a majority (64.70%) being male. The average age of the patients was 54±13.22 years. A history of uncontrolled asthma was noted in nine cases. The clinical picture was characterized by persistent dyspnea and cough. Blood hypereosinophilia was present in all cases, with a median of 1770 cells/ul. Two patients had a pulmonary eosinophilia greater than 25%.Radiological findings were consistent with diffuse bilateral ground-glass opacities or areas of consolidation in the majority of cases. The main etiologies identified were chronic eosinophilic pneumonia (12 cases), followed by eosinophilic granulomatosis with polyangiitis(3 cases), idiopathic hypereosinophilic syndrome (1 case) and drug-induced hypereosinophilia (1 case). All patients were treated with systemic corticosteroids, with the addition of immunosuppressive therapy necessary in three cases. Notably, five relapses were recorded after corticosteroid therapy was stopped.

Towards COVID-19 detection and classification using optimal efficient Densenet model on chest X-ray images

COVID-19 detection is mainly based on molecular testing, especially polymerase chain reaction (PCR) analyses, to find the occurrence of the virus's genetic material in respiratory samples. Computed tomography (CT) scans and X-rays are the two chest imaging techniques, which may provide more details on lungs, aiding in the diagnosis. Radiological findings in COVID-19 cases typically involve special features such as bilateral involvement, ground-glass opacities, and consolidation of the lungs. Deep learning (DL) methods, particularly convolutional neural networks (CNNs) are used for analyzing COVID-19 infection. By training these techniques on large datasets of annotated chest X-rays (CXRs), researches have attained superior outcomes in precisely detecting the possible COVID-19 cases. Leveraging artificial intelligence together with radiological expertise holds great potential for facilitating prompt intervention in the ongoing global efforts and improving the efficiency of early detection. This article focuses on the design of mother optimization algorithm with DL-enabled detection and classification (MOA-DLEDC) technique for COVID-19 diagnosis using CXR images. In the MOA-DLEDC technique, the adaptive median filtering (AMF) approach is used to eliminate the existence of noise. In addition, the complex and intrinsic feature patterns are derived from the Efficient DenseNet model. Besides, the hyperparameter optimization of the Efficient DenseNet model takes place using MOA. For the COVID-19 detection process, the MOA-DLEDC technique applies sparse autoencoder (SAE) model. A detailed set of experiments was conducted on the CXR dataset to highlight the promising results of the MOA-DLEDC technique. The extensive results inferred that the used technique gains superior performance over other models with maximum accuracy of 99.59 %.

Silent pulmonary shadows

An elderly woman with a 1-year history of pulmonary shadows was admitted because of intermittent cough and sputum production for 2 months. Chest computed tomography (CT) scans showed bilateral consolidations and ground-glass opacities, with areas of low attenuation inside consolidative opacities on the mediastinal window. Previous history of radiotherapy for nasopharyngeal carcinoma and long-term use of a compound menthol nasal drops provided were important clues to the diagnosis. CT scan-guided needle lung biopsy and bronchoalveolar lavage were performed, and lipid-laden macrophages were confirmed in both bronchoalveolar lavage and lung tissue. Final diagnosis of exogenous lipoid pneumonia was made on the basis of her risk factors for aspiration, history of oil exposure, and classic radiological and histopathological features. Symptoms improved after discontinuation of causative exposure. It is important for clinicians to raise awareness of exogenous lipoid pneumonia and other aspiration lung diseases.

To assess the impact of covid-19 on maintenance haemodialysis patients: A retrospective study in a tertiary care hospital in south Kerala

COVID-19 was started as a global pandemic in March 2020. It is an infectious disease caused by the SARS COV-2 virus and it has affected the care and outcomes of patient treated with dialysis. Patients with CKD could be more vulnerable to a severe form of COVID-19. Higher risk of mortality caused by COVID-19 in haemodialysis patient is detected with older age, comorbidities and impaired immune response. Clinical presentation of COVID-19 on haemodialysis patient is fluctuating from asymptomatic or mild disease to severe life threatening illness. Initially, common symptoms were presented including fever, dry cough, fatigue, diarrhea and dyspnea. On computerized tomography scan patients had shown bilateral ground-glass opacities revealing that COVID-19 predominantly affected the respiratory system. Maintenance haemodialysis is the most widely used treatment for end stage CKD patients and it has the higher risk of initial mortality from coronavirus 2019. CKD is a severe medical entity with a higher prevalence of comorbid conditions, mostly including diabetes, hypertension, disproportionally affecting older adults. The aim of this study is to assess the impact of COVID-19 on maintenance haemodialysis patient and the objective of the study is to assess the mortality of COVID-19 on maintenance haemodialysis patient and risk factors associated with it and also the severity of COVID19 on maintenance haemodialysis patient. We performed a retrospective cross sectional study using 39 samples. The samples were collected from the case files of the patients who fulfill the inclusion criteria and then the collected data was statistically interpreted using SPSS software version 22.0 and then the severity and mortality of the COVID-19 on maintenance haemodialysis patient was analyzed. The final analysis included 39 patient who met the inclusion criteria .Here the incidence of COVID-19 on maintenance haemodialysis patient is more prone on 41-60 years of age.

Granulomatous Slack Skin With Lung and Esophagus Involvement: A Case Report and Molecular Analysis.

Granulomatous slack skin (GSS) is a rare subtype of mycosis fungoides, and few cases have been known to spread to the blood, lymph nodes, or viscera. We present a case with early dissemination to the lung. A 27-year-old woman, previously healthy, presented with scattered disseminated scaly patches, associated with vulvar and intergluteal firm swelling and groin-skin induration for 1 year. She also reported mild fatigue and breathlessness on moderate exertion. The patient underwent blood tests, skin biopsies, and computed tomography scan. The skin biopsy showed a mildly atypical T-cell lymphoid infiltrate involving the dermis/hypodermis, with focal epidermotropism, associated with a granulomatous infiltrate and elastophagocytosis. The computed tomography scan revealed bilateral ground-glass lung nodular opacities. Positron emission tomography showed an increased signal in the skin and subcutis around the buttocks, inguinal and mediastinal lymph nodes, and lungs. The lung biopsy confirmed a dense T-cell infiltrate with numerous multinucleated giant cells. Subsequently, esophageal involvement was also observed following biopsy. Molecular analyses demonstrated identical T-cell clones in the skin and lung. After 6 cycles of chemotherapy/localized external radiotherapy, the patient had a partial skin response and stable lung disease. A preferred diagnosis of GSS with systemic spread was made based on clinical/histologic/molecular findings, after considering granulomatous mycosis fungoides and peripheral T-cell lymphoma, not otherwise specified. This case highlights the frequent diagnostic difficulty in distinguishing GSS from an inflammatory granulomatous dermatitis. Pulmonary and esophageal involvements are rare in GSS, and the simultaneous presentation of characteristic cutaneous GSS with systemic disease poses an additional classification challenge.

Clinical and Etiological Findings of Viral Pneumonia: A Single Centre Prospective Study

Introduction: Viral pneumonia is a prominent cause of illness that can occur in all age group throughout the year. Worldwide about 200 million cases of viral community acquired pneumonia occur every year of which 50% cases in children and 50% in adults [1]. Bacterial coinfection found only in 3% of cases [2]. The aim of our study is to find out most common viral pathogen causing pneumonia, most common bacterial co-infection, their typical clinical presentation, common abnormal lab parameters, CT findings, duration of ICU and hospital stay. Materials and Methods: All cases with sign and symptoms of respiratory infections with confirmed diagnosis of viral pneumonia (confirmed by BioFire FilmArray Pneumonia Panel from lower respiratory tract sample, confirmed by microscopy) were included in the study after proper consent. Demographic data, clinical history, laboratory investigations, all routine and radiological investigations are noted and evaluated. Results: Of the total 69 cases Influenza A virus (36%) is the predominant etiological agents followed by human rhinovirus (26%) in these cases. Human Rhinovirus predominate in the early part 2023 but towards end of this year Influenza A virus became the predominant cause for pneumonia. Patients of all age groups are affected but there is definitively a seasonal variation with more in the winter months. Most of the patients have typical respiratory findings like cough (83%) and fever (76%). CT scan showed bilateral ground glass opacity (56%) in most cases, and few had consolidation (29%) features. Blood CRP level (91%) was raised in most of these patients. Haemophilus Influenzae (34%) is the most common associated bacterial co-infection followed by Streptococcus Pneumoniae (26%). All patients responded well to conservative management. Conclusions: Viral pneumonia is not uncommon in the community. Though we found Influenza A followed by Human Rhinovirus are the two most common pathogens in these cases but only 59% of them have bacterial co-infection, so not all patients require antibiotics from the beginning. As most are infected with Haemophilus influenzae so aminopenicillin group is the antibiotics of choice for these patients. Hence as a pulmonologist we must be aware of these cases, their typical presentation and not to over treat these cases with high end antibiotics as most require only symptomatic treatment. Even though it is a single centre study, but it definitely throws a light on the pattern of viral pneumonia in our community

Clinical and Temporal Radiological Findings from Critical Patients with COVID-19 Pneumonia: A Descriptive Study.

In late December 2019, Wuhan, the capital of Hubei Province, China, became the center of an outbreak of pneumonia caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). The radiological changes in the lungs of critical people with coronavirus disease 2019 (COVID-19) pneumonia at different times have not been fully characterized. We aim to describe the computed tomography findings of patients with critical COVID-19 pneumonia at different disease stages. Clinical and laboratory features of critical patients were assessed. CT scans were assigned to groups 1, 2, 3, or 4 based on the interval from symptom onset (within 2 weeks; ≥ 2-4 weeks; ≥ 4-6 weeks; or ≥ 6 weeks, respectively). Imaging features were analyzed and compared across the four groups. Total CT scores, corresponding periods of laboratory findings, and glucocorticoid dosages during the imaging intervals were longitudinally observed in five patients with complete data. All 11 critical patients (median age: 60 years [42-69]) underwent a total of 40 CT examinations, and the acquisition times ranged from 1-59 days after symptom onset. Median total CT scores were 18 (9-25.25); 44.5 (42.88-47.62); 43.75 (38.62-49.38); and 42 (32.25-53.25) in groups 1, 2, 3, and 4, respectively. The observed lesions were mainly bilateral (37 [92.5%]). The median values of involved lung segments were 10.5 (4.5-13.5); 17 (16-18.5); 18 (18-19.5); and 18 (18-19) in groups 1-4, respectively. The predominant patterns of observed abnormalities were ground-glass opacities (GGO) (9 [90%]); GGO with reticulation and mixed patterns (3 [37.5%] for both); GGO with consolidation (3 [30%]); and GGO with reticulation (8 [66.7%]) in groups 1-4, respectively. Patients developed fibrotic manifestations at later stages. Critical patients with COVID-19 infection generally presented with temporally changing abnormal CT features from focal unilateral to diffuse bilateral GGO and consolidation that progressed to or coexisted with reticulation in the long term after symptom onset. Low-dose glucocorticoids may be effective in patients with interstitial changes on CT findings.

Pneumocystis jirovecii pneumonia: a case report

Introduction and importancePneumocystis jirovecii (PJP) pneumonia is a serious life-threatening condition in immunocompromised individuals and is often associated with human immunodeficiency virus (HIV) + patients. We describe a case of PJP pneumonia which provided a diagnostic challenge in a patient who presented with no known risk factors leading to a delay in initiation of appropriate antibiotic therapy.Case presentationA 71-year-old previously healthy white/Caucasian male presented with subacute hypoxic respiratory failure due to multifocal pneumonia with diffuse bilateral ground glass opacities with consolidations despite prior treatment with antibiotics and steroids. He was admitted and started on intravenous broad-spectrum antibiotics but continued to deteriorate, eventually requiring intubation and transfer to the ICU. Bronchoscopy revealed PJP and treatment was initiated, but the patient developed refractory shock and multiorgan failure, and ultimately died. It was later discovered that he was HIV-1 positive.Clinical discussionPJP, as a potential cause of his presentation, was not considered given that our patient lacked any overt risk factors for PJP pneumonia. He continued to worsen despite broad spectrum antibiotic therapy and hence bronchoscopy was pursued. His clinical profile, in hindsight, was suspicious for PJP pneumonia and early PJP-directed antibiotic therapy may have prevented a fatal outcome, as in this case. There was an element of cognitive bias across multiple providers which may have contributed to the delay in treatment despite his rapid clinical decline while on conventional pneumonia treatment protocol. His diagnosis was later evident when his BAL-DFA grew PJP in addition to his low levels of CD4 and CD8 cells. He was found to be HIV-1 positive five days after his death; there was a delay in this diagnosis since all positive HIV tests from the hospital are reported as ‘pending’ until the presumptive positive sample goes to the Connecticut Department of Public Health State laboratory for the confirmatory test. PJP-targeted therapies were initiated later in our patient’s hospital course when the infection had progressed to refractory septic shock with multiorgan failure and eventual death.ConclusionPJP pneumonia is a fatal disease if not recognized early in the course of illness, and the patient usually undergoes multiple antibiotic regimens before they are diagnosed and receive appropriate clinical care. The gold standard of diagnostic testing for PJP is by obtaining bronchial washings through a flexible bronchoscopy and the turnaround time for such results may take a few days to result. A significant proportion of patients may not have any overt risk factors of immunosuppression and early empiric treatment for PJP may be clinically appropriate as the delay in diagnosis may be associated with significant morbidity and mortality risk.

Emergency department CT examinations demonstrate no evidence of early viral circulation at the start of the COVID-19 pandemic—a multicentre epidemiological study

BackgroundBiological studies suggested that the COVID-19 outbreak in France occurred before the first official diagnosis on January 24, 2020. We investigated this controversial topic using a large collection of chest CTs performed throughout French emergency departments within 6 months before the 1st lockdown.ResultsOverall, 49,311 consecutive patients (median age: 60 years, 23,636/49,311 [47.9%] women) with available chest CT images and reports from 61 emergency departments between September 1, 2020, and March 16, 2020 (day before the 1st French lockdown), were retrospectively included in this multicentre study. In the macroscopic analysis of reports automatically (labelled for presence of ground glass opacities [GGOs], reticulations, and bilateral and subpleural abnormalities), we found a significant breakpoint on February 17, 2020, for the weekly time series with 1, 2 and ≥ 3 of these 4 radiological features, with 146/49,311 (0.3%) patients showing bilateral abnormalities and ground glass opacities (GGOs) from that day. According to radiologists, 22/146 (15.1%) CT images showed typical characteristics of COVID-19, including 4/146 (2.7%) before February 2020. According to hospital records, one patient remained without microbial diagnosis, two patients had proven influenza A and one patient had concomitant influenza A and mycoplasma infection.ConclusionThese results suggest that SARS-CoV-2 was not circulating in the areas covered by the 61 emergency departments involved in our study before the official beginning of the COVID-19 outbreak in France. In emergency patients, the strong resemblance among mycoplasma, influenza A and SARS-CoV-2 lung infections on chest CT and the nonspecificity of CT patterns in low prevalence periods is stressed.Critical relevance statementWe proposed here an innovative approach to revisit a controversial ‘real’ start of the COVID-19 pandemic in France based on (1) a population-level approach combining text mining, time series analysis and an epidemiological dataset and (2) a patient-level approach with careful retrospective reading of chest CT scans complemented by analysis of samples performed contemporarily to the chest CT. We showed no evidence that SARS-CoV-2 was actively circulating in France before February 2020.Graphical

Pneumomediastinum as a primary manifestation of COVID-19: A case report

Introduction: Pneumomediastinum is a rare complication that occurs in patients with Pneumonia caused by COVID-19 and is more frequent in patients with ARDS that may or may not be related to the use of invasive mechanical ventilation. Pneumomediastinum is an indicator of clinical deterioration with potentially threatening consequences for the patient. Method: We described a case report of a 23-year-old man with Pneumomediastinum, infected with COVID-19 in conditions of respiratory failure due to interstitial pneumonia. Case presentation: A 23-year-old man, who had no pre-existing health conditions presented to the Infectious Diseases service with complaints of difficulty in breathing, dry cough, chest pain, muscle pain, joint pain, loss of taste, sore throat, pronounced body weakness, diarrhea. Symptoms started 11 days ago. On admission the patient refers that he doesn’t suffer from any other disease. The patient was not vaccinated against COVID-19. At the time of admission to the hospital, the objective examination revealed cervical subcutaneous emphysema and harsh respiration in both lungs. The nasopharyngeal swab test (RT-PCR) for Covid-19 was positive from the Institute of Public Health. The CT scan of the chest confirmed the presence of pneumomediastinum major, subcutaneous emphysema and bilateral ground glass opacities. Conclusion: Pneumomediastinum is a rare complication of pneumonia caused by Covid-19 in which the etiopathogenesis consists of severe pulmonary involvement that may or may not be affected using invasive mechanical ventilation. Timely diagnosis of pneumomediastinum in patients with Covid-19 would prevent the occurrence of life-threatening complications. Keywords: Covid-19, pneumomediastinum, ARDS, Macklin effect, vaccine.

Dual bombard by Cytomegalovirus and Mycobacterium tuberculosis in a renal transplantee

Abstract In the first year following an organ transplant, more than 80% of patients encounter a minimum of one occurrence of infection. Here, we report a case of coinfection of the Cytomegalovirus (CMV) and Mycobacterium tuberculosis (MTB) in a kidney transplantee. Computed tomography chest (CT chest) showed bilateral ground-glass opacities. By Cytomegalovirus DNA polymerase chain reaction, 9360 copies were detected in plasma. Cartridge-based nucleic acid amplification test from bronchial washings tested positive for MTB with very low-level resistance to rifampicin. He was started on category-I antitubercular therapy without rifampicin and intravenous valganciclovir. The clinical status of the patient improved after 1 month of treatment.

High resolution chest computed tomography findings in patients with clinically suspected COVID-19 pneumonia in Uganda: a cross-sectional study.

The alarming spread of the COVID-19 pandemic has led to a shortage of RT-PCR kits in Uganda necessitating the use of high-resolution chest Computed Tomography to guide patient management and treatment. To describe the chest HRCT findings in patients with clinically suspected COVID-19 pneumonia and to compare its diagnostic accuracy to RT-PCR. . In this cross-sectional study, chest HRCT findings of 384 patients and available RT-PCR laboratory results were reviewed and recorded in the data collection form. The commonest chest HRCT findings were bilateral ground glass opacities (78.2%). Out of the 31.7% patients that took the PCR test only 26.9% tested positive. 16 out of 17 patients who tested negative, were classified under CORADS 5.The sensitivity of chest HRCT was 90.4%, 95% CI (82.6-95.5), positive predictive value of 84.2%, 95% CI (75.6-90.7), and accuracy of 77.5%, 95% CI (71.5-87.1). HRCT was found superior to RT-PCR in diagnosing COVID-19. A patient with positive HRCT findings should be treated as COVID 19 when RT-PCR is inaccessible or results are negative. A patient with negative HRCT requires complimentary RT-PCR and possibly follow up CT scans if symptoms persist before treating for COVID 19.

A Rare Case Report of Pulmonary Hemorrhage in Electrical Injury

Abstract We report a rare case of bilateral pulmonary hemorrhage with acute respiratory distress syndrome (ARDS), following high-voltage electricity exposure in a 29-year-old electric lineman while cutting an electrical wire for an uncertain duration. He was unconscious after falling from a tree following the exposure. His chest radiograph showed bilateral nonhomogeneous opacities, and high-resolution computed tomography revealed bilateral extensive ground-glass opacities, suggestive of pulmonary hemorrhage with ARDS. The patient was managed conservatively with intravenous fluids and oxygen. He recovered with near-complete resolution of chest X-ray abnormalities by day 5 of admission.

Primary Pulmonary Diffuse Large B-Cell Lymphoma - a Rare Case Report

Background: Diffuse large B cell lymphoma (DLBCL) is an aggressive hematological malignancy, and a common histological form of non-Hodgkin's lymphoma. However, its extra-nodal presentation is seen in 30-40% of cases with involvement of gastrointestinal tract, skin, testes, adrenals and bone. ( Lugogo NL et al., 2006) A pulmonary manifestation is an extremely rare entity. We present an atypical case of DLBCL presenting as pleuritic chest pain with imaging consistent with bilateral pulmonary nodules suggestive of metastasis. Case description: A healthy 87 year old male former smoker with a history of type 2 diabetes mellitus, hypertension presented to the emergency department with pleuritic chest pain. There was no associated cough, shortness of breath, palpitations, nausea, dizziness or diaphoresis. No recent infections or B symptoms. He had a good appetite. He had prostate cancer 20 years ago and had a radical prostatectomy. Upon presentation, work up showed mild anemia (Hb 11.1 g/dL). Cardiac work up for chest pain was unremarkable. Chest X-Ray revealed mass like opacities in each lung with largest in left mid lung measuring up to 6 cm. CT chest with IV contrast revealed multiple lung nodules bilaterally with 2 largest in left upper lobe measuring 5.6 x 3.7 cm and 5.7 x 3.3 cm. Multiple other small nodules are present in both lung fields consistent with diffuse lung metastasis. No lymphadenopathy was noted. (Image 1) PET CT scan was significant for bilateral FDG avid lung lesions. No evidence of other FDG avid disease. CT guided biopsy of the left lung mass surprisingly revealed diffuse large B cell non-Hodgkin's lymphoma, non-germinal center type. (Image 1) Immuno-histochemistry showed atypical lymphocytes positively stained with CD20, BCL6, BCL2, PAX5 and MUM1. C-myc had 50% positivity. Ki67 had 90% proliferative index. FISH analysis was negative for MYC, BCL2 and BCL6; hence there was no double hit lymphoma detected. According to Lunago classification, patient had advanced stage disease with IPI (prognosis index) of 2. His ECOG PS score was 0. He was initiated on R-Pola-CHP. Given his age, Cyclophosphamide and Adriamycin doses were reduced as done with R-mini CHOP. Vincristine was avoided given neurotoxicity. Discussion: Primary pulmonary B-cell lymphomas (PP-BCLs) represent less than 3-4% of all extra-nodal NHL. They primarily affect the lung without evidence of extrapulmonary disease at the time of diagnosis. PP-DLBCL accounts for only 10% cases of PP-BCLs. ( Sanguedolce et al., 2021) Most cases have atypical presentation. Likewise, in our patient, he manifested with atypical chest pain without any B symptoms. Radiographic imaging can show variable findings of consolidation, single/multiple nodules, reticular interstitial infiltrate or bilateral ground glass opacities. In view of the insidious onset and lack of specificity in clinical symptoms, primary pulmonary lymphomas are frequently misdiagnosed as refractory pneumonia, lung abscess, asthma, primary lung cancer, or lung metastasis. ( Liu et al., 2020) Patients with DLBCL are typically treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). However, with this regimen, only 60% of patients are cured and the rest might relapse. In the POLARIX phase 3 trial, polatuzumab vedotin (a monoclonal antibody to CD79b ubiquitously expressed on B cells) combined with R-CHP significantly improved 2 year progression-free survival compared to the routine R-CHOP therapy in previously untreated DLBCL patients. ( Tilly et al., 2022) Given our patient's advanced stage disease, he was initiated on the Pola-R-CHP regimen. Doses of cyclophosphamide and doxorubicin were reduced as per the R-mini CHOP dose-reduced regimen for a physically fit elderly individual. Patient continues on therapy at the time of this abstract. In conclusion, primary pulmonary DLBCL is a rare entity with only a few case reports in literature. It should be considered in patients presenting with large pulmonary masses, mimicking metastatic disease.

Pneumocystis Pneumonia Infection Following the Initiation of Pembrolizumab Therapy for Lung Adenocarcinoma: A Case Report.

Pneumocystis pneumonia (PCP) is an opportunistic infection that presents a ground-glass appearance in the lungs on chest radiography. Interstitial lung disease is a commonly reported adverse effect of immune checkpoint inhibitor (ICI) treatment; however, there are few reports of ICI treatment-associated PCP infection. A 77-year-old man with lung adenocarcinoma was administered pembrolizumab and hospitalized for dyspnea 2 weeks after treatment. Chest computed tomography showed bilateral ground-glass opacities in all lung lobes. PCP was therefore diagnosed, and steroids and sulfamethoxazole-trimethoprim were initiated. Following treatment, the patient's condition improved promptly. This report suggests that ICI treatment can cause PCP infection.

Abstract 12082: Dermatomyositis Associated Pulmonary Fibrosis Masquerading as Severe Aortic Insufficiency

Description of Case: A 56-year-old female with asthma and hypertension presented for two weeks of dyspnea, cough, and fevers. Initial workup revealed bilateral ground glass opacities. TTE revealed severe aortic insufficiency, early mitral valve closure, and a LVEF of 65%. The patient underwent SAVR and was started on diuresis but continued to have significant respiratory distress over the next few months, leading to recurrent hospitalizations and requiring home oxygen therapy. Serial imaging revealed worsening of her pulmonary opacities. Due to persistent musculoskeletal and cutaneous symptoms with an elevated CPK, an alternative diagnosis was considered: dermatomyositis associated pulmonary fibrosis. The patient was started on steroids and immunomodulatory therapy with improvement in her symptoms. Discussion: Dermatomyositis (DM) is an inflammatory myopathy characterized by proximal muscle weakness, rash, and other manifestations including ILD and esophageal dysmotility. Mortality in patients with DM is associated with rapid progression of ILD. Patients may also have myocardial involvement and heart failure. Patients with presumed cardiogenic respiratory failure that does not improve with HF optimization should undergo further workup and consideration of a broader differential diagnosis. Unexplained elevated CPK disproportionate to troponins, and persistent hypoxia in patients with multisystem involvement should trigger an autoimmune work up. If such a process is identified, patients may have a rapid improvement in their symptomatology and excellent prognosis following immunomodulatory therapy. If left undiagnosed, it can cause multi-system failure, including significant myocarditis and heart failure.