Bilateral Lung Infiltrates Research Articles

Acute exacerbation of progressive pulmonary fibrosis: incidence and outcomes.

Few data are available on acute exacerbation (AE) in patients with progressive pulmonary fibrosis (PPF) besides idiopathic pulmonary fibrosis (IPF). This study aimed to investigate the AE incidence and outcomes among patients with PPF. Clinical data of patients with PPF (n = 133) were retrospectively collected at a single center. PPF was defined based on the criteria used in the INBUILD trial. AE was defined as a worsening of dyspnea typically within 30 days with new bilateral lung infiltration and no evidence of cardiac failure or fluid overload. Among patients with PPF, the mean age was 60.6 years old, 57.1% were females, and the most common etiology was connective tissue disease-related ILDs (63%). During the follow-up (median: 38.0 months) after PPF diagnosis, 42 patients (31.6%) experienced AE. The 1-, 3-, and 5-year AE incidences were 12.5%, 30.3%, and 38.0%, respectively. Older age, rheumatoid arthritis associated ILD, fibrotic hypersensitivity pneumonitis, and lower lung diffusing capacity for carbon monoxide were AE risk factors. Patients with AE demonstrated worse survival (median survival: 30 months vs. not reached; p < 0.001) after PPF diagnosis than those without. AE was independently associated with mortality in patients with PPF (hazard ratio [HR], 2.194; 95% confidence interval [CI], 1.285-3.747; p = 0.004) in the multivariable Cox analysis, along with older age, lower lung diffusing capacity for carbon monoxide, and the usual interstitial pneumonia-like pattern on high-resolution computed tomography. Our results suggest AE is not uncommon and significantly impacts on survival in patients with PPF.

Proteome Signature for Differential Diagnosis of Patients with Bilateral Lung Infiltrates

BackgroundThe differential diagnosis of bilateral lung infiltrates and prognosis prediction can be challenging for clinicians in the intensive care unit (ICU). We analyzed the proteome from bronchoalveolar lavage fluid (BALF) and determine their usefulness for evaluating the infectious causes and mortality associated with bilateral lung infiltrates.MethodsIn the ICU cohort, 136 patients with bilateral infiltrate on chest radiographs were selected, and bronchoscopy with bronchoalveolar lavage (BAL) was performed. Proteomics profiling of the exosomes in the BALF (n=20) was conducted to identify candidate protein biomarkers potentially associated with infection or mortality. The BAL samples (n=116) were used to measure the candidate biomarker levels.ResultsThe candidate biomarkers, CD20, CLIC4, SCFD1, and TAP1, were selected for the differential diagnosis of infection or mortality. The levels of CD20 were significantly elevated in patients with non-infectious causes compared to those with infectious causes (248.6±154.5versus177.6±150.9 ng·mL−1, p=0.014). The levels of CLIC4, SCFD1, and TAP1 did not differ between the two groups. As per the receiver operating characteristic analysis, CD20 was a significant predictor of non-infectious causes (area under curve, 0.668; 95% CI, 0.567–0.769; p=0.002; cut off value, 167.6 ng·mL−1; sensitivity, 74.1%; specificity, 63.2%). There were no significant differences in the concentrations of the biomarkers between survivors and non-survivors.ConclusionsOur results suggested that CD20 levels in BALF might be a useful biomarker for differentiating non-infectious and infectious diseases in patients with bilateral lung infiltrates.

Patients with influenza admitted to a tertiary-care hospital in Riyadh between 2018 and 2022: characteristics, outcomes and factors associated with ICU admission and mortality

BackgroundInfluenza is a common cause of hospital admissions globally with regional variations in epidemiology and clinical profile. We evaluated the characteristics and outcomes of patients with influenza admitted to a tertiary-care center in Riyadh, Saudi Arabia.MethodsThis was a retrospective cohort of adult patients admitted with polymerase chain reaction-confirmed influenza to King Abdulaziz Medical City-Riyadh between January 1, 2018, and May 31, 2022. We compared patients who required intensive care unit (ICU) admission to those who did not and performed multivariable logistic regression to assess the predictors of ICU admission and hospital mortality.ResultsDuring the study period, 675 adult patients were hospitalized with influenza (median age 68.0 years, females 53.8%, hypertension 59.9%, diabetes 55.1%, and chronic respiratory disease 31.1%). Most admissions (83.0%) were in the colder months (October to March) in Riyadh with inter-seasonal cases even in the summertime (June to August). Influenza A was responsible for 79.0% of cases, with H3N2 and H1N1 subtypes commonly circulating in the study period. Respiratory viral coinfection occurred in 12 patients (1.8%) and bacterial coinfection in 42 patients (17.4%). 151 patients (22.4%) required ICU admission, of which 62.3% received vasopressors and 48.0% mechanical ventilation. Risk factors for ICU admission were younger age, hypertension, bilateral lung infiltrates on chest X-ray, and Pneumonia Severity Index. The overall hospital mortality was 7.4% (22.5% for ICU patients, p < 0.0001). Mortality was 45.0% in patients with bacterial coinfection, 30.9% in those requiring vasopressors, and 29.2% in those who received mechanical ventilation. Female sex (odds ratio [OR], 2.096; 95% confidence interval [CI] 1.070, 4.104), ischemic heart disease (OR, 3.053; 95% CI 1.457, 6.394), immunosuppressed state (OR, 7.102; 95% CI 1.803, 27.975), Pneumonia Severity Index (OR, 1.029; 95% CI, 1.017, 1.041), leukocyte count and serum lactate level (OR, 1.394; 95% CI, 1.163, 1.671) were independently associated with hospital mortality.ConclusionsInfluenza followed a seasonal pattern in Saudi Arabia, with H3N2 and H1N1 being the predominant circulating strains during the study period. ICU admission was required for > 20%. Female sex, high Pneumonia Severity Index, ischemic heart disease, and immunosuppressed state were associated with increased mortality.

Hot Dab Associated Pneumonitis - a case report

BackgroundDabbing is recently getting popular among young adults. It is a new method of using the most active form of marijuana where large amounts of concentrated tetrahydrocannabinol are inhaled. Tetrahydrocannabinol is associated with a feeling of ‘High’ which makes the user feel joyous and relaxed. With increasing use of such techniques, dabbing becomes an important differential for evaluation of acute respiratory failure with pneumonitis especially in the adult population.Case presentationA Fifty-one years old Caucasian man presented to the hospital with chest pressure and shortness of breath. The patient was noted to be hypoxic, desaturating down to 82–83% on nasal cannula oxygen. Imaging revealed bilateral lung infiltrates. Patient was started on high flow oxygen, broad spectrum antibiotics and intravenous corticosteroids. The patient gradually improved and was able to come off oxygen completely. He was discharged home on prednisone taper.ConclusionsDabbing is a newer technique which has been gaining popularity for marijuana usage. With the legalization of marijuana, newer techniques are getting popular. Our case report emphasizes the importance of keeping dabbing as a differential when a patient presents with respiratory failure and has concerns for pneumonitis. Patients might not reveal until specifically asked about their practices.

Atypical Presence of Leuconostoc pseudomesenteroides in a Lower Respiratory Tract Infection

Introduction: Leuconostoc species are gram-positive microorganisms typically isolated from dairy and brewing industries. Infections in humans are extremely rare. They are vaguely associated with patients who have co-morbidities and a history of antibiotic use. The rise of inadvertent microbiota complicates treatment delivery. Case Presentation: We report a rare case of Leuconostoc pseudomesenteroides in a patient with a lower respiratory tract infection. The patient suffered from diffuse axonal injury with bilateral subdural hematoma following a road traffic accident. An emergency tracheostomy was performed, and the patient was managed conservatively. The patient developed symptoms clinically, such as fever, and radiographically exhibited bilateral lung infiltrates. Endotracheal aspirate samples were sent for microbiological evaluation. Conclusions: The bacterial culture was identified as L. pseudomesenteroides. Bacterial identification and antibiotic susceptibility testing were verified. Antibiotics were administered empirically and intravenously until the patient achieved normal clinical status.

Hyperacute Radiation Pneumonitis after Severe irAE.

A 54-year-old woman presented to an outpatient clinic with a recurrence of triple-negative breast cancer and multiple bone metastases. The patient had a large mass lesion of 10 cm on the sternum. She received the immune checkpoint inhibitors pembrolizumab and taxane. Initially, the patient responded excellently to treatment, but stopped pembrolizumab for grade IV skin toxicity with multiple ulcerative wounds over the bilateral leg and trunk. The lesions abated following administration of antibiotics and oral prednisolone for two months. After that, she was referred to the radiation oncology department for further treatment. She received radiotherapy for the sternum mass but stopped radiation at 42Gy/21 fractions for severe dyspnea and fever. Blood sampling found leukocytosis with neutrophil predominance. Chest radiography showed bilateral lung infiltration. Pulmonary CT scan yielded bilateral lung patchy consolidation compatible with radiation isodose-line. Bronchial lavage showed positive Pneumocystis jiroveci PCR. Dyspnea improved after titrating methylprednisolone within two days. The patient recovered well with TMP-SMX and glucocorticoids after the initiation of therapy.

Clinical and prognostic implications of hyaluronic acid in patients with COVID-19 reinfection and first infection.

Previous research has shown that human identical sequences of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) promote coronavirus disease 2019 (COVID-19) progression by upregulating hyaluronic acid (HA). However, the association of HA with mortality and long COVID in SARS-CoV-2 reinfection and first infection is unclear. Patients with COVID-19 at Beijing Ditan Hospital from September 2023 to November 2023 were consecutively enrolled. SARS-CoV-2 reinfections were matched 1:2 with first infections using a nearest neighbor propensity score matching algorithm. We compared the hospital outcomes between patients with COVID-19 reinfection and first infection. The association between HA levels and mortality and long COVID in the matched cohort was analyzed. The reinfection rate among COVID-19 hospitalized patients was 25.4% (62 cases). After propensity score matching, we found that reinfection was associated with a better clinical course and prognosis, including lower levels of C-reactive protein and erythrocyte sedimentation rate, fewer cases of bilateral lung infiltration and respiratory failure, and shorter viral clearance time and duration of symptoms (p < 0.05). HA levels were significantly higher in patients with primary infection [128.0 (90.5, 185.0) vs. 94.5 (62.0, 167.3), p = 0.008], those with prolonged viral clearance time [90.5 (61.5, 130.8) vs. 130.0 (95.0, 188.0), p < 0.001], and deceased patients [105.5 (76.8, 164.5) vs. 188.0 (118.0, 208.0), p = 0.002]. Further analysis showed that HA was an independent predictor of death (AUC: 0.789), and the risk of death increased by 4.435 times (OR = 5.435, 95% CI = 1.205-24.510, p = 0.028) in patients with high HA levels. We found that patients with HA levels above 116 ng/mL had an increased risk of death. However, the incidence of long COVID was similar in the different HA level groups (p > 0.05). Serum HA may serve as a novel biomarker for predicting COVID-19 mortality in patients with SARS-CoV-2 reinfection and first infection. However, HA levels may not be associated with long COVID.

Case Report: Scrub Typhus manifesting as Acute Respiratory Distress Syndrome (ARDS) with corresponding radiological findings

Background Scrub typhus is a life-threatening infectious disease endemic in the Asia-Pacific region. It typically presents with nonspecific symptoms such as fever, headache, and myalgia, making early diagnosis challenging. Acute Respiratory Distress Syndrome (ARDS) is a severe pulmonary condition characterized by acute-onset hypoxemia, bilateral lung infiltrates on radiology, and increased pulmonary capillary permeability. Case Presentation An 18-year-old female student in central India presented with a seven-day history of recurrent fever, chills, dry cough, and severe shortness of breath, escalating to Modified Medical Research Council dyspnea grade III-IV. After unsuccessful local clinic treatment, a chest radiograph revealed bilateral pneumonia. On admission, she displayed tachycardia, tachypnea, hypotension, and hypoxia requiring non-invasive ventilation (NIV). Computed tomography confirmed scrub typhus-associated pneumonia, and serological testing was positive for scrub typhus. She was diagnosed with moderate ARDS and began treatment. Symptomatic improvement was seen in the ICU, and she was discharged on day 10 with radiological and clinical resolution. Management and Outcomes She received intravenous doxycycline and oral azithromycin for scrub typhus and any potential concurrent lung infection. In the ICU, she required continuous NIV and supplemental oxygen, with significant symptomatic improvement, evidenced by reduced tachypnoea and oxygen requirements after 72 hours. She was weaned off NIV and monitored for an additional four days. After satisfactory oxygen saturation on room air, she was discharged on the tenth day. High-resolution CT scan demonstrated resolution of ground glass opacities and consolidation. Sequential chest radiographs exhibited gradual reduction in bilateral alveolar infiltrates over time, in parallel with clinical improvement. Laboratory findings, including reduced CRP and D-dimer values, and a normal hemogram on discharge indicated a resolution of leukopenia. Conclusion This case underscores the importance of early recognition and intervention in scrub typhus-associated ARDS and highlights the utility of timely diagnostic imaging in monitoring the progress of the disease.

SARS-CoV-2 induced urinary tract infection in an infant: a rare case

BackgroundThe incidence of SARS-CoV-2 infection in pediatric population is less than 7% that too when associated with a urinary tract infection, the presentation is very rare. There have been numerous case reports in adults and adolescent population but very few in pediatrics and none in our socioeconomic.Case presentationWe present here the case of a 1-year-old boy with SARS-CoV-2 induced urinary tract infection whose urine biochemistry showed severe urinary tract infection but no hematuria. His COVID-PCR was positive. His chest radiograph showed bilateral lung infiltrates with peri-hilar lymphadenopathy. His computerized tomography scan showed infiltrates with lung fibrosis. He was admitted to the isolation ward, successfully managed, and discharged home after 5 days of in-hospital treatment.ConclusionPediatricians and pediatric emergency physicians should be vigilant and well aware of the atypical presentation of SARS-CoV-2 infection in infants and children, as they can present with both gastrointestinal and renal manifestations. And once missed, the patient may end up with devastating complications.

Risk Factors Predicting in Hospital Mortality Among Intubated Patients with Exacerbation of Chronic Obstructive Pulmonary Disease Associated with Ventilation-Associated Pneumonia

Approximately every fourth patients with acute exacerbation of chronic obstructive pulmonary disease (AE COPD) will require intensive care unit (ICV) admission with further mechanical ventilation (MV) and therefore with high risk of development ventilator- associated pneumonia (VAP). VAP is the commonest ICU infection and results in increased morbidity/ mortality. The study was aimed to learn risk factors predicting in- hospital mortality among patients with AE COPD associated with VAP and to evaluate the modifiable risk factors in term on reduction of mortality. This retrospective study involved patients with AE of COPD who required MV and admitted in respiratory care unit at a University teaching Hospital from January 2017 to December 2022 various baseline demographic and clinical features were compared between patients with VAP and without VAP. Although various baseline demographic and clinical features were compared between survivors and non-survivors with VAP. The study included 164 intubated patients with AE of COPD with age of 60.42+ 8.44 years, 48 patients developed VAP. Multivariable analysis showed that severe sepsis/septic shock, pulmonary complications such as bilateral and multi-lobar lung infiltrates, malnutrition, concomitnant bronchiectasis and history of previous hospitalization were independent predictors in-hospital mortality in intubated COPD patients associated with VAP with odds ratio (95%) confidence interval of 3.74(1.04-7.69; p= 0.004), 4.26 (0.48-9.24: p= 0.002), 2.89(1.01- 5.96: p=0.012), 2.48 (1.14-5.41; p= 0.019), 3.26 ( 1.46-7.52;p= 0.01, respectively). Acinotebacter baumannii was the most common causative organism (n= 21: 43.7%) and was frequent finding among non-survivors with VAP.(p=0.001). All infections releated to Acinotebacter baumannii were multidrug resistant (MDR). Our retrospective study provide to clinicans and especially to ICU department physicians a tool approach to identify the mortality rosk of VAP complicated the intubated COPD patients. We found a high burden of concominant bronchiectasis releated to in hospital mortality and several other predictors associated with fatal outcomes, which could help identife found a high burden of concominant bronchiectasis releated to in hospital mortality and several other predictors associated with fatal outcomes, which could help identify patients who might benefit from adequate, early amprical antibiotic treatment, as well as, determine prognosis. Although prevention of malnutrition and exacerbations leading to hospitalization of COPD patients may associated with decreased fatal outcomes. Our findings should be validated by studies with larger samples of patients.

Abstract #1407860: Rare Cause of Non-PTH Mediated Hypercalcemia Due to Pneumocystis Pneumonia in Renal Transplant Recipient

Hypercalcemia secondary to persistent hyperparathyroidism is common in kidney transplant recipients (KTR). We report a rare cause of non-PTH mediated hypercalcemia in KTR due to pneumocystis jirovecii pneumonia (PJP). The incidence of PJP in KTR is 5-15% in absence of antibiotic prophylaxis. Incidence of hypercalcemia in KTR with PJP is unclear, but scattered case reports are found in literature. The proposed mechanism for hypercalcemia is an infectious granulomatous reaction. PJP induced hypercalcemia needs to be considered in KTR patients with non-PTH mediated hypercalcemia. A 62-year-old male with kidney transplant for renal failure from glomerulosclerosis, three years prior to presentation was admitted for dyspnea and fever. Imaging showed bilateral lung infiltrates, concerning for multifocal infection. Considering his imaging findings and elevated Beta D glucan levels, he was empirically started on PJP treatment with atovaquone on day 4 of admission. Bactrim was not used due to acute renal failure. On day 1, calcium was 10 mg/dL (8.4-10.4), which then progressively increased from 10.7mg/dl on day 4 to a peak calcium level of 14.4 mg/dL on day 12. Further work up showed PTH: 4.7 pg/mL (12-88), PTHrP: 0.6 pMol/L (< /= 4.2), Vitamin D 1, 25: 198 pg/mL (18-72), Vitamin D 25: 79 ng/mL (20-100), SPEP: no M spike, UPEP: no M spike but had a lysozyme band suggestive of granulomatous infection, other fungal studies negative, normal thyroid levels, AFB culture negative. On day 12, he was started on prednisone 60mg presuming hypercalcemia from PJP. On day 13, calcium improved to 11.7 mg/ dL, but his renal function worsened requiring hemodialysis (HD). On day 14, he had respiratory failure requiring intubation and underwent bronchio-alveolar lavage (BAL) which was positive for pneumocystis PCR. He was started on bactrim on day 17 and continued on high dose steroid. By day 19, he was extubated, renal function stabilized without HD and calcium normalized to 8.9 mg/dL. Unfortunately, he had gastrointestinal bleed and refused further procedures eventually opting for hospice on day 23. PJP is a common opportunistic infection in immunosuppressed patients like KTR. The advent of prophylaxis has significantly decreased the incidence of PJP in KTR to 0.3%-2.6%. PJP in KTR is sometimes associated with hypercalcemia. Prevalence of hypercalcemia in KTR with PJP is unclear, but as per a hospital based retrospective study (Hamroun et al., 2019), 37% of PJP patients in KTR (18/49) had hypercalcemia that preceded pneumonia/findings on imaging. The proposed mechanism for hypercalcemia is granulomatous in nature, due to increased extra renal production of 1 alpha hydroxylase enzyme from increased macrophage recruitment in lungs to clear pneumocystis organisms. Hypercalcemia resolved after completion of treatment and resolution of PJP. High dose steroids can be used as hypercalcemia is mediated by a granulomatous reaction. It is crucial for physicians to have a high index of suspicion for PJP as the etiology of pneumonia in immunocompromised organ transplant recipients with non- PTH mediated hypercalcemia, thus ensuring timely diagnosis and treatment.

COVID-19 SECOND WAVE: EXPERIENCE OF CLINIC FOR LUNG DISEASE, UNIVERSITY CLINICAL CENTER TUZLA

The objective of this paper was to present basic clinical characteristics and outcomes of treating Covid 19 patients during the second wave of the pandemic. In the retrospective study for the period from September 2020 to February 2021 it was analyzed disease history data and radiological lung changes, time from the initial start of the disease until hospitalization, parameters of blood gas analysis, comorbidities, and the outcome. The research covered 409 patients, out of which 263 (64.3%) were males. Average age was 67.07± 12.44 years (min. 20; max. 93). A high comorbidities prevalence (82.9%) was noticed out of which arterial hypertension (69.2%), diabetes mellitus (37.7%) and obesity (24.7%). On the radiological lung scan the most noticed changes were consolidation (46.2%), “ground glass” (41.3%) and interstitial changes (13%). Bilateral lung infiltration was noticed in 91.9% of the patients. Average oxygen saturation was 84.29%±10.28% (min. 35; max. 98; med. 87%). In patients with unilateral lung infiltration, average oxygen saturation was 85.09%±8.60% (med. 89%, min.61% max 98%), while in patients with bilateral lung infiltration average was 84.22%±10.42% (med. 87%, min. 35%, max. 98%). From the total all patients’ death was noticed in 35.7% cases. Morbidity of patients with unilateral lung infiltration was 27.3% and in patients with unilateral infiltration 36.4%. Hospital admission in the first week of the disease indicates the severity of the clinical condition and can be a predictor of poor outcome. Bilateral pulmonary infiltration, obesity and diabetes mellitus are risk factors for high mortality.

Long-term clinical course and outcomes of patients with microscopic polyangiitis-associated interstitial lung disease.

Background: Interstitial lung disease (ILD) is a significant complication associated with microscopic polyangiitis (MPA) that has a poor prognosis. However, the long-term clinical course, outcomes, and prognostic factors of MPA-ILD are not well defined. Hence, this study aimed to investigate the long-term clinical course, outcomes, and prognostic factors in patients with MPA-ILD. Methods: Clinical data of 39 patients with MPA-ILD (biopsy proven cases, n = 6) were retrospectively analyzed. High resolution computed tomography (HRCT) patterns were assessed based on the 2018 idiopathic pulmonary fibrosis diagnostic criteria. Acute exacerbation (AE) was defined as the worsening of dyspnea within 30days, with new bilateral lung infiltration that is not fully explained by heart failure or fluid overload and that does not have identified extra-parenchymal causes (pneumothorax, pleural effusion, or pulmonary embolism). Results: The median follow-up period was 72.0months (interquartile range: 44-117months). The mean age of the patients was 62.7years and 59.0% were male. Usual interstitial pneumonia (UIP) and probable usual interstitial pneumonia patterns on high resolution computed tomography were identified in 61.5 and 17.9% of the patients, respectively. During the follow-up, 51.3% of patients died, and the 5- and 10-year overall survival rates were 73.5% and 42.0%, respectively. Acute exacerbation occurred in 17.9% of the patients. The non-survivors had higher neutrophil counts in bronchoalveolar lavage (BAL) fluid and more frequent acute exacerbation than the survivors. In the multivariable Cox analysis, older age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.01-1.14; p = 0.028) and higher BAL counts (HR, 1.09; 95% CI, 1.01-1.17; p = 0.015) were found to be the independent prognostic factors associated with mortality in patients with MPA-ILD. Conclusion: During the 6years-follow-up, about half of patients with MPA-ILD died and approximately one-fifth experienced acute exacerbation. Our results suggest that older age and higher BAL neutrophil counts mean poor prognosis in patients with MPA-ILD.

COVID-19-Associated Erythema Nodosum Detected on FDG PET/CT.

We report the case of a 69-year-old woman who underwent 18F-FDG PET/CT due to prolonged fever. One month before, the patient was diagnosed with COVID-19 infection. The 18F-FDG PET/CT showed several subcutaneous nodules with 18F-FDG uptake on the thorax and upper extremities and bilateral lung infiltrates due to organizing pneumonitis. Clinical examination revealed multiple tender nodules on thorax, arms, and legs, consistent with erythema nodosum (EN) induced by COVID-19 infection. The woman was treated with prednisone with a good effect on EN. To our knowledge, this is the first report on EN secondary to COVID-19 infection diagnosed on 18F-FDG PET/CT.

PS-R04-10: MALIGNANT HYPERTENSION AFTER COVD-19 VACCINE INJECTION

Case; 40 y/o male. Clinical course; The patient was transferred to our university hospital because of DOE and severe headache. He had been well and had no history of hypertension or obesity. He had experienced the COVID-19 vaccine injection two week before this visit. After the injection he had been experienced high fever and general fatigue as well as 7 kg of weight loss. On examnation, it was found that he had severe hypertension (190/110 mmHg) and hypertensive optic fundi. On chest X-ray, cardiomegaly and bilateral lung infiltrations was evident and biochemical data indicated renal dysfunction (serum creatinine 2.35 mg/dl), high levels of plasma renin activity (39.1 ng/ml/hour normal; 0.6–3.9) and aldosterone concentration (176 pg/ml normal; 4.0–82.1), and inflammatory changes (CRP = 23 mg/dl). We also found that increased levels of LDH and decreased levels of hemoglobin which indicated hemolytic anemia and thrombotic microangiopathy. After the control of high blood pressure by intravenous administration of Calcium channel blockades, We performed renal biopsy, which had a finding of diffuse findings of onion skin lesion and global glomerular sclerosis compatible with the diagnosis of malignant hypertension. Any secondary etiologies including renal artery disease or collagen disease had not been identified. Seven days after the admission, we started hemodialysis for this patient because of the renal failure was not resolved. We also had startred ACE inhibitors. We stopped the diuretics and minimized the ultrafiltration. Twenty-five days after the admission the patients was withdrawn from dialysis with the urine volume around 2000 ml/day and the serum creatinine concentration 5.29 mg/dl. He was discharged without any aid of dialysis and with small number of anti-hypertensives. Four months after the discharge, his serum creatinine concentration was 3.36 mg/dl and his blood pressure was 139/85 mmHg with the ACE inhibitor and calcium channel blockades. Conclusions; The case suggested that the malignant hypertension might be triggered by COVID-19 vaccine injection, which is of clinical importance.

Clinical profile and outcome of H1N1 influenza patients in a tertiary care hospital in Kochi, Kerala

Background: After the 2009 pandemic, a re-emergence of hemagglutinin type 1 and neuraminidase type 1 (H1N1) influenza cases has been noted in India recently. The number of swab-positive cases has increased in the year 2017 compared to yesteryears. Since the current circulating strain (A/Michigan/7/2009 [H1N1] pdm09) is different from previous pandemic strains, a look into the clinical profile is imperative. Aims: The aim is to study the clinical, biochemical, and radiological profile of H1N1 patients at initial presentation and its influence on the mode of treatment and outcome. Patients and Methods: A cross-sectional record-based analysis of all confirmed cases of H1N1 influenza admitted at Lourdes Hospital, Kochi, Kerala, between 2015 and 2017. Confirmation of cases was done by reverse transcriptase polymerase chain reaction of respiratory specimens at Manipal Centre for Virus Research. Results: A total of 76 confirmed cases of H1N1 influenza were detected during the study period of which 36 required Intensive Care Unit admission. Most patients were between 51 and 60 years (25%). The predominant presenting symptoms were fever (98.7%), dry cough (61.8%), breathlessness (53.9%), and the most common auscultatory finding being bilateral crepitations (64.47%). Around 32.89% of cases presented with bilateral lung infiltrates on X-ray. Sixty-nine of 76 patients (90.79%) survived the disease. Conclusions: Vaccination, early recognition of the disease, and prompt initiation of treatment seem to be the only way to reduce H1N1 disease progression and associated mortality. Patients with risk factors require additional attention as clinical course can be unpredictable. Pregnancy is associated with higher rate of complications. Early respiratory support helped in preventing progression to respiratory failure in most of our patients.

Correlation of Radiological Findings (High Resolution Computed Tomography Chest) with Anti-SARS-COV-2 Antibodies in Patients Visiting Tertiary Care Hospitals

Background: Coronavirus (COVID 19) pandemic has taken so many lives and has contributed to an increase in morbidity due to its complications. The research is still in infancy and much has yet to be investigated. Objective: To correlate the HRCT findings on chest with antibody testing in patients visiting tertiary care hospitals in Lahore. Methodology: Three hundred and thirty-two patients with mild, moderate and severe symptoms of COVID 19 were recruited. Those with raised CRP levels were sent for HRCT chest and PCR testing as protocol of the hospitals. All patients were tested with Rapid antibody kits for reactivity. Results: Showed that males were affected more than females. Similarly, non-health care workers were more affected. All patients with bilateral involvement of lungs on HRCT chest and positive PCR findings also tested reactive on antibody testing. However, a few people with bilateral lung involvement and negative on PCR testing got reactive results on Rapid antibody testing. Linear regression model shows significant correlation of HRCT chest findings with Ant-SARC- COV 2 antibodies. Conclusion: HRCT findings (Unilateral and bilateral lung infiltrates) correlated significantly with Anti SARC-COV 2 Antibodies.

Co-existence of Carcinoma Tongue with Pulmonary Tuberculosis

We present the case of a 45-year-old male diagnosed to have carcinoma base of tongue, whose chest radiograph showed bilateral lung infiltrates and was referred for evaluation of suspected pulmonary metastases. Diagnostic evaluation confirmed the diagnosis of smear-positive pulmonary tuberculosis.

Fat Embolization Syndrome Secondary to Steroid Treatment for Intractable Migraine

Sickle vaso-occlusive crises secondary to steroid therapy are well reported in the medical literature. Fat embolization syndrome (FES) is an uncommon yet serious complication that occurs due to bone marrow necrosis and is usually associated with increased mortality or damaging neurologic sequelae to the surviving patient. We report a case of FES secondary to steroid therapy administered for an unrelated condition. Our patient was initially admitted for intractable migraine. The initial work up for other intracranial emergencies was negative and she was administered steroids for intractable migraine. Within 24 hours of initiating steroid therapy, she developed pain in her neck and shoulders progressing to her chest and lower extremities. The initial signs of FES following steroid therapy in this patient included altered mental status and hypoxic respiratory failure. Cerebral imaging showed diffuse bilateral cerebral/cerebellar and brainstem micro-hemorrhages. Lung imaging showed bilateral diffuse lung infiltrates confirming acute chest syndrome. The patient was transferred to the intensive care unit for further management of her hypoxic respiratory failure secondary to acute chest syndrome (ACS). In addition to ACS, she had acute kidney and hepatocellular injury in keeping with multi-organ failure. Steroid therapy was discontinued and she was treated with red cell exchange transfusion for multi-organ failure. The patient had an almost complete resolution of multiple organ damage except for hypoesthesia of her lower jaw and lower lip- the "numb chin syndrome". This case report highlights the importance of recognizing potentially fatal multi-organ failure secondary to steroid therapy and for hematologists to consider concurrent red cell transfusions to attenuate the risk of such complications from steroid therapy.

Abstract 13195: A Case of Ebstein Anomaly Diagnosed Following Tricuspid and Pulmonic Valve Infective Endocarditis in an Adult Patient

Background: We present a rare case of infective endocarditis (IE) involving both tricuspid (TV) and pulmonic valves (PV) in the setting of newly diagnosed Ebstein anomaly (EA) with isolated, small membranous VSD. Case: A 48 yo woman with no known medical history presented with two weeks of fever, flu-like symptoms, and dyspnea. Vitals showed fever, tachycardia, and tachypnea. Poor dentition, grade III systolic murmur, and S3 gallop were noted on physical exam. EKG showed sinus tachycardia and right bundle branch block. Laboratory studies showed leukocytosis and elevated CRP. A chest CT revealed bilateral lung infiltrates in a rounded configuration concerning for septic emboli. Blood cultures grew Streptococcus mitis , and IV antibiotics were initiated. TTE revealed 3.2cm apical displacement of the TV resulting in right ventricular atrialization, diagnostic for EA. TTE also found a 26x17mm vegetation on the septal and anterior leaflets of the TV with moderate tricuspid regurgitation and an 11x6mm vegetation on the PV, confirmed by TEE. Cardiac MRI also noted a focal aneurysm of the membranous interventricular septum with a hemodynamically insignificant shunt. Discussion: While interatrial communications are seen in a majority of EA patients (80-94% of cases), this patient presented solely with a small membranous VSD and absence of ASD and PFO. Moreover, this patient had no PDA to depend on for pulmonary flow. Remarkably, she had an asymptomatic course with EA until the development of endocarditis. It is believed the presence of an isolated VSD in this patient’s severe EA likely promoted forward pulmonic flow in an already inadequate right ventricle. Right-sided IE is itself rare (5-10% of cases) with isolated PV involvement being even rarer (2% of cases). This patient’s uncorrected EA with redundant TV and PV leaflet tissue likely contributed as a nidus for simultaneous infection of both valves.