SESSION TITLE: Chest Infections in Immunocompromised Patients Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Aspergillus species exist ubiquitously in the environment, and clinical sequelae generally occur after inhalation of spores. Invasive Pulmonary Aspergillosis (IPA) is characterized by culture-positive Aspergillus species and tissue invasion with hyphae on histopathological exam, and the most relevant risk factor is immunosuppression (particularly neutropenia). IPA can manifest with nonspecific pulmonary symptoms including fever, shortness of breath, pleuritic chest pain, and hemoptysis.CASE PRESENTATION: A 39-year-old man with AIDS, stage IV Hodgkin's lymphoma, and active IV drug use presented with decreased mentation, septic shock and profound pancytopenia and was diagnosed with secondary hemophagocytic lymphohistiocytosis (HLH). His course was complicated by intermittent epistaxis, hemoptysis, and persistent fevers. Computed tomography (CT) chest performed at that time revealed scattered areas of ground glass opacities (Figure 1) in the setting of nosocomial rhinovirus. One month later, a repeat CT chest was performed due to persistent cough (Figure 2). During this interval one month period, peak serum Fungitell level was >500 pg/mL (N <80 pg/mL). A bronchial alveolar lavage (BAL) culture grew Aspergillus flavus, and the patient was started on voriconazole. After several weeks, patient had complete resolution of symptoms, and repeat CT chest showed interval decrease in the size of the mycetomas.DISCUSSION: Diagnosis of IPA requires characteristic mycologic identification, clinical context, and imaging features.3 Characteristic CT chest findings including dense, well-circumscribed lesions, air-crescent sign, cavitary lesions, or mycetomata (Figure 2). Clinical features also include the presence of a persistent pulmonary infection despite broad-spectrum antibiotics. Mycological evidence includes detection of Aspergillus species in sputum, BAL, bronchial brush, or bronchial aspirate; galactomannan antigen detection in plasma, serum, or BAL. In this case, bronchoscopy was performed with unremarkable cell count-BAL fungal cultures identified Aspergillus flavus. In the context of recent neutropenia, recognized hematologic malignancy, cavitary lung nodules, ICU admission, and Aspergillus species detected on BAL culture, the diagnosis of IPA was definitive.CONCLUSIONS: Our patient presented atypically with rapid progression of cavitary pulmonary nodules over one month in the context of active malignancy and secondary HLH. In patients with suspected IPA, bronchoscopy is a useful diagnostic tool and can rule out concurrent infectious processes.Reference #1: Patterson TF, Thompson GR, Denning DW et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63 (4), e1-e60.Reference #2: Kosmidis C and Denning DW. The Clinical Spectrum of Pulmonary Aspergillosis. Thorax 2015; 70: 270-277.Reference #3: Russo A, Tiseo G, Falcone M et al. Pulmonary Aspergillosis: An Evolving Challenge for Diagnosis and Treatment. Infect Dis Ther 2020; 9: 511-524.DISCLOSURES: No relevant relationships by Zein KattihNo relevant relationships by Simon MeredithNo relevant relationships by Jonathan MooreNo relevant relationships by Margarita OksNo relevant relationships by Sean Zajac SESSION TITLE: Chest Infections in Immunocompromised Patients Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Aspergillus species exist ubiquitously in the environment, and clinical sequelae generally occur after inhalation of spores. Invasive Pulmonary Aspergillosis (IPA) is characterized by culture-positive Aspergillus species and tissue invasion with hyphae on histopathological exam, and the most relevant risk factor is immunosuppression (particularly neutropenia). IPA can manifest with nonspecific pulmonary symptoms including fever, shortness of breath, pleuritic chest pain, and hemoptysis. CASE PRESENTATION: A 39-year-old man with AIDS, stage IV Hodgkin's lymphoma, and active IV drug use presented with decreased mentation, septic shock and profound pancytopenia and was diagnosed with secondary hemophagocytic lymphohistiocytosis (HLH). His course was complicated by intermittent epistaxis, hemoptysis, and persistent fevers. Computed tomography (CT) chest performed at that time revealed scattered areas of ground glass opacities (Figure 1) in the setting of nosocomial rhinovirus. One month later, a repeat CT chest was performed due to persistent cough (Figure 2). During this interval one month period, peak serum Fungitell level was >500 pg/mL (N <80 pg/mL). A bronchial alveolar lavage (BAL) culture grew Aspergillus flavus, and the patient was started on voriconazole. After several weeks, patient had complete resolution of symptoms, and repeat CT chest showed interval decrease in the size of the mycetomas. DISCUSSION: Diagnosis of IPA requires characteristic mycologic identification, clinical context, and imaging features.3 Characteristic CT chest findings including dense, well-circumscribed lesions, air-crescent sign, cavitary lesions, or mycetomata (Figure 2). Clinical features also include the presence of a persistent pulmonary infection despite broad-spectrum antibiotics. Mycological evidence includes detection of Aspergillus species in sputum, BAL, bronchial brush, or bronchial aspirate; galactomannan antigen detection in plasma, serum, or BAL. In this case, bronchoscopy was performed with unremarkable cell count-BAL fungal cultures identified Aspergillus flavus. In the context of recent neutropenia, recognized hematologic malignancy, cavitary lung nodules, ICU admission, and Aspergillus species detected on BAL culture, the diagnosis of IPA was definitive. CONCLUSIONS: Our patient presented atypically with rapid progression of cavitary pulmonary nodules over one month in the context of active malignancy and secondary HLH. In patients with suspected IPA, bronchoscopy is a useful diagnostic tool and can rule out concurrent infectious processes. Reference #1: Patterson TF, Thompson GR, Denning DW et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63 (4), e1-e60. Reference #2: Kosmidis C and Denning DW. The Clinical Spectrum of Pulmonary Aspergillosis. Thorax 2015; 70: 270-277. Reference #3: Russo A, Tiseo G, Falcone M et al. Pulmonary Aspergillosis: An Evolving Challenge for Diagnosis and Treatment. Infect Dis Ther 2020; 9: 511-524. DISCLOSURES: No relevant relationships by Zein Kattih No relevant relationships by Simon Meredith No relevant relationships by Jonathan Moore No relevant relationships by Margarita Oks No relevant relationships by Sean Zajac