Bronchial Washings Research Articles

TB OR NOT TB?

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Testing for active pulmonary TB is often triggered by symptoms such as fever, cough, night sweats. We present an atypical case of pulmonary TB. CASE PRESENTATION: A 69-year-old Filipino man presented to ED for psychiatric clearance due to report of domestic violence. Initial work-up was only remarkable for chest XR finding of bilateral upper lobe infiltrates. Quantiferon was negative. Patient denies any cough, fever, night sweat, or weight loss. He had moved from the Philippines over 40 years ago, but had no recent foreign travels or known TB exposures. However, given chest XR finding, airborne isolation and TB rule-out testing with MTB-PCR and sputum cultures were pursued. CT chest showed bilateral upper lobe cavitary nodules. As patient could not produce sputum samples, he underwent bronchoscopy. Result of MTB-PCR was positive. Bronchial washing culture later was also positive for MTB, which confirmed the diagnosis of active pulmonary TB. DISCUSSION: Current diagnostic approach to pulmonary TB involves an initial clinical suspicion followed by chest imaging and if indicated, testing with MTB-PCR or sputum culture. However, in our case, the patient presented with a completely different chief complaint, and did not have any history or physical exam findings suggestive of TB. Had a chest X-ray not been done, the incidental finding of bilateral upper lobes infiltrates would not have been found, work-up for TB would not have been pursued, and his active pulmonary TB would not have been discovered. Also interestingly, his Quantiferon was negative, although final confirmatory TB testing was positive. Upon literature search, case report of subclinical active pulmonary TB in immunocompetent adults is rare. One population-based study in China in 2015 did find a high percentage of asymptomatic pulmonary TB patients, and called into question the conventional criteria for initiating TB testing. However, there was no follow-up study performed according to the best of our knowledge. Our patient similarly reminds us that subclinical pulmonary TB may not be uncommon as presumed. In addition, based on a study done in Europe in 2011, Quantiferon, which tests for interferon-gamma response to TB antigens, has a sensitivity of only 80% for active TB. Therefore, Quantiferon should not be used as a rule out test for active TB. Also of note, old age is a recognized risk factor for false negative Quantiferon, as the interferon-gamma response to TB antigenic targets decreases with age. CONCLUSIONS: Active pulmonary TB can present subclinically. Delay in treatment in these patients, due to our current symptoms-based trigger for TB testing, can have widespread effect on patient outcome and epidemiological consequences. Further re-examination of our diagnostic approach to active TB testing should be pursued. It is also important to remember that a negative Quantiferon test does not rule out active pulmonary TB Reference #1: M. Sester, et al. Interferon-γ release assays for the diagnosis of active tuberculosis: a systematic review and meta-analysis. European Respiratory Journal Jan 2011 Reference #2: Cheng J, Wang L, Zhang H, Xia Y. Diagnostic value of symptom screening for pulmonary tuberculosis in China. Reference #3: Veerle de Visser, et al. False-negative interferon-γ release assay results in active tuberculosis: a TBNET study. European Respiratory Journal Jan 2015 DISCLOSURES: No relevant relationships by Chia-Dan Kang, source=Web Response No relevant relationships by Arhama Malik, source=Web Response

EP1.05-05 The Optimal Sequence of Bronchial Washing and Brushing for Diagnosis of Non-Visible Lung Cancer During Non-Guided Bronchoscopy

EP1.05-05 The Optimal Sequence of Bronchial Washing and Brushing for Diagnosis of Non-Visible Lung Cancer During Non-Guided Bronchoscopy

HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS TRIGGERED BY ADENOVIRUS PNEUMONIA: A RARE COMPLICATION OF A COMMON DISEASE

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Adenovirus (ADV) pneumonia is a common disease with many extrapulmonary complications. We report a case of a 71-year old lady with history of follicular lymphoma who developed ADV pneumonia triggering hemophagocytic lymphohistiocytosis (HLH) CASE PRESENTATION: A 71-year-old female presented to our hospital with fever and cough. Chest X-ray revealed pneumonia. Additional labs upon admission showed pancytopenia. Six months prior to presentation, she was diagnosed with follicular lymphoma and she completed six cycles of R-CHOP (last cycle being four weeks prior to presentation). A PET-CT scan performed five days prior to admission revealed complete metabolic response, and a complete blood count was normal. Empiric antibiotics did not result in improvement prompting a CT scan of the chest that showed dense consolidation in the left lower lobe, ground glass opacities in upper lobes and trace pleural effusions. Bronchoscopy was performed. Bronchial wash cultures grew ADV. Other bacterial, fungal and viral serology/cultures were all negative. ADV was also isolated from serum. Patient remained febrile and had progressive pancytopenia with counts reaching a nadir of 0.0K/uL neutrophils, 5.8 g/dL hemoglobin and 34K/uL platelets. Further labs showed elevated ferritin at >40,000ng/ml , elevated soluble IL-2 receptor alpha and transaminitis. HLH was suspected and steroids were started empirically. Bone Marrow biopsy confirmed HLH without evidence of lymphoma or metastatic carcinoma. Patient continued to decline, she developed rectus sheath hematoma, hypotension, acute kidney injury and delirium. Family decided to withdraw all active treatments and take the route of comfort care which eventually lead to her unfortunate demise on day nine of admission. DISCUSSION: ADV pneumonia can occur in both immunocompetent and immunocompromised hosts(1). Both outbreaks and sporadic cases have been described. ADV-pneumonia can be fatal with poor prognostic factors including: viremia, multilobar infiltrates and parapneumonic effusions(2, 3). CT commonly shows dens consolidation with surrounding ground glass opacities. ADV infection induced HLH has been well described in children. This phenomenon is rare in adults with only a few reported cases, mostly described in hematopoietic stem cell transplant recipients. Older age, markedly elevated ferritin and underlying lymphoma are considered poor prognostic factors in HLH. Our patient’s history of follicular lymphoma had probably put her at higher risk for developing this immunological catastrophe. She had all of the aforementioned poor prognostic of both ADV-pneumonia and HLH. CONCLUSIONS: Our case signifies that HLH should be suspected in the setting of ADV infection and pancytopenia. Early diagnosis and treatment might be associated with better outcomes in this rare-life threatening- hematological complication. Reference #1: Shen CF, Wang SM, Ho TS, Liu CC. Clinical features of community acquired adenovirus pneumonia during the 2011 community outbreak in Southern Taiwan: role of host immune response. BMC infectious diseases. 2017;17(1):196. Reference #2: Gu L, Qu J, Sun B, Yu X, Li H, Cao B. Sustained Viremia and High Viral Load in Respiratory Tract Secretions Are Predictors for Death in Immunocompetent Adults with Adenovirus Pneumonia. PloS one. 2016;11(8):e0160777. Reference #3: Yoon H, Jhun BW, Kim SJ, Kim K. Clinical characteristics and factors predicting respiratory failure in adenovirus pneumonia. Respirology (Carlton, Vic). 2016;21(7):1243-50. DISCLOSURES: No relevant relationships by Muhammad Hamza, source=Web Response No relevant relationships by Khalid Mohamed Ahmed, source=Web Response No relevant relationships by Mahum Shahid, source=Web Response No relevant relationships by Qazi Ahmed Waqas, source=Web Response

Surfactant Protein A in particles in exhaled air (PExA), bronchial lavage and bronchial wash - a methodological comparison

IntroductionAt present, there are few methods available for monitoring respiratory diseases affecting distal airways. Bronchoscopy is the golden standard for sampling the lower airways. The recently developed method for collecting non-volatile material from exhaled air – PExA (Particles in Exhaled air) is a promising new tool, but no direct comparison between the two methods has yet been performed. The aim of the present study was to compare sampling using PExA with bronchial wash (BW) representing the larger more proximal airways and broncho-alveolar lavage (BAL) representing the distal airways.Methods15 healthy non-smoking subjects (7 female/8 male), age 28 ± 4 years, with normal lung function were included in the study. PExA-sampling (2 × 250 ng particles) and bronchoscopy with BW (2 × 20 ml) and BAL (3 × 60 ml sterile saline) was performed. Albumin and Surfactant Protein A (SP-A) were analyzed with ELISA, and analyses of correlation were performed.ResultsA significant association was found between BAL-fluid albumin and PExA-albumin (rs:0.65 p = 0.01). There was also an association between SP-A in PExA and BAL, when corrected for albumin concentration (rs:0.61, p = 0.015). When correlating concentrations of albumin and SP-A in bronchial wash and PExA respectively, no associations were found.ConclusionsThis is the first direct comparison between the bronchoscopy-based BW/BAL-fluids and material collected using the PExA methodology. Both albumin and albumin-corrected SP-A concentrations were significantly associated between BAL and PExA, however, no such association was found in either marker between BW and PExA. These results indicate that the PExA method samples the distal airways. PExA is thus considered a new promising non-invasive assessment for monitoring of the distal airways.

The case of a 72-Year-Old Male with Hematemesis and Pneumomediastinum due to Acute Bacterial Esophageal Necrosis

Acute esophageal necrosis (AEN) is a relatively uncommon presentation of esophagitis. AEN is characterized by black necrotic esophageal tissue and is associated with high mortality rates. We discuss the case of a 72-year-old Caucasian male who was admitted to the medical intensive-care unit (MICU) for evaluation of pneumomediastinum. CT of the chest revealed a right lower lobe consolidation, pneumomediastinum, and marked thickening of the distal esophagus. Vital signs on arrival revealed a temperature of 38.3° Celsius, heart rate of 92 beats per minute, respiratory rate of 30 breaths per minute, blood pressure of 144/65, and oxygen saturation of 97% on 15 liters of supplemental oxygen via non-rebreather. Laboratory studies on arrival were remarkable for a white blood cell (WBC) count of 19.75 x109/L, procalcitonin of 3.53 ng/mL, and C-reactive protein (CRP) level 43.95 mg/dL. The patient was intubated for acute hypoxemic respiratory failure and started on intravenous (IV) pantoprazole as well as broad-spectrum antibiotics for possible pneumonia. Bedside bronchoscopy showed no obvious airway deformities or perforations on inspection but did reveal thick copious secretions that were sent for culture. Thoracic surgery was consulted, and an esophagogastroduodenoscopy (EGD) was performed, which demonstrated no obvious tear or perforation. However, it did show swollen and black mucosa primarily involving the distal esophagus. Tissue cultures from the EGD grew Klebsiella pneumoniae, which was also grown from the bronchial wash and bronchoalveolar lavage. EGD findings were consistent with AEN. Despite extensive supportive care, the patient ultimately expired. We propose that people with AEN who present with pneumomediastinum and those in whom AEN is found to be secondary to a bacterial cause require not only supportive measures but also prompt surgical consultation.

Hemorrhagic Necrotizing Pneumonia Caused by Trichosporon asahii Suspected by Distinctive Histology in Tissue

Abstract Trichosporon spp. are yeast-like organisms most often responsible for superficial skin infections (white piedra) and may transiently colonize the respiratory tract. Trichosporon asahii can be an opportunistic pathogen, causing invasive disease and sometimes disseminated infections, usually in immunocompromised patients. They are the third most commonly isolated yeast species in clinical settings. They cause hemorrhagic and necrotizing bronchopneumonia due to vascular invasion; mycotic emboli are identified within hemorrhagic infarcts. Distinctive pleomorphic budding yeasts, true hyphae, and arthroconidia stain weakly with silver stain in tissue. A 53-year-old HIV-negative male with PMH of schizophrenia and intravenous drug abuse presented with shortness of breath and chest pain. Patient was admitted to the MICU for acute respiratory distress likely secondary to pneumonia. Chest CT scan revealed multiple ill-defined opacities in the lung periphery. The patient had neutrophilic leukocytosis and positive blood culture for methicillin-resistant Staphylococcus aureus and Candida glabrata. Broad-spectrum antibiotics and antifungal drugs (fluconazole, voriconazole, amphotericin B, micafungin) were started. Two weeks later, wedge lung biopsy revealed necrotizing pneumonia with abscess formation and pleomorphic budding yeast-like cells, measuring 3 to 6 microns in diameter; septated hyphae; and arthroconidia. Culture of a bronchial washing was confirmed to be T asahii by matrix-assisted laser desorption/ionization time of flight (MALDI-TOF). Unfortunately, the patient died and partial autopsy of his lungs showed the same pathogen. Invasive respiratory infections caused by T asahii have increased in frequency over the last two decades. Distinctive histology in tissue (pleomorphic yeasts, septated hyphae, and arthroconidia) can suggest the diagnosis, confirmed with MALDI-TOF. Risk factors for invasion include prior antibiotic therapy, central catheterization, malignancy (often hematologic), and intensive care unit admission. Thirty-day all-cause mortality has been reported to be 42% and has been linked to resistance to amphotericin B and echinocandins.

Community-acquired Achromobacter xylosoxidans infection presenting as a cavitary lung disease in an immunocompetent patient.

Achromobacter xylosoxidans is a gram-negative bacterium that can oxidize xylose. It is commonly found in contaminated soil and water but does not normally infect immunocompetent humans. We report a case of a cavitary lung lesion associated with community-acquired A. xylosoxidans infection, which mimicked pulmonary tuberculosis or lung cancer in an immunocompetent man. The patient was hospitalized due to hemoptysis, and chest computed tomography (CT) revealed a cavitary lesion in the superior segment of the left lower lobe. We performed bronchoscopy and bronchial washing, and subsequent bacterial cultures excluded pulmonary tuberculosis and identified A. xylosoxidans. We performed antibiotic sensitivity testing and treated the patient with a 6-week course of amoxicillin/clavulanate. After 2 months, follow-up chest CT revealed complete resolution of the cavitary lesion.

Fungal Diagnostic Stewardship in Bronchoscopy Specimens for Immunocompetent Patients in the Intensive Care Unit

ObjectiveTo evaluate the diagnostic yield of fungal smears and cultures from bronchial lavage and wash specimens obtained from immunocompetent patients in the intensive care unit (ICU) because respiratory tract samples from patients in the ICU often undergo extensive microbiological testing. Patients and MethodsIn total, we enrolled 112 immunocompetent adult patients treated in the medical and surgical ICU between July 1, 2016, and June 30, 2017. We evaluated whether the results of fungal smears and cultures of specimens obtained from bronchoscopy and bronchoalveolar lavage changed patient care. ResultsIn total, 131 bronchoscopic specimens and 31 bronchoalveolar lavage specimens were tested for fungi. Cultures were held for an estimated 4680 culture-days. Two results changed patient therapy. In both cases, other routine tests provided the same information as fungal culture before these results were returned. ConclusionIn immunocompetent, critically ill patients, fungal culture of respiratory tract specimens does not add diagnostic value. Routine fungal culture of respiratory tract specimens should be discouraged in this population.

A comparison of airway microbiota in donors and recipients of lung transplants

This study was aimed at investigation of relationships between bronchial washing culture in post-transplant recipient and bronchial flora of the lung donor. Methods. A comparative analysis of bronchial washing cultures from 30 post-transplant lung recipients was performed. All lung donors were stratified to ideal, suboptimal and marginal donors according to the lung transplant suitability. Results. As a result, development of post-transplant pulmonary complications was directly related to bacterial flora of the donor lung. The incidence of pneumonia in post-transplant patients was 3.3% after transplantation of ideal donor lungs, 20% after transplantation of suboptimal donors lungs and 100% after transplantation of marginal donor lungs. Conclusion. The rate of pneumonia in transplanted lungs was directly related to bronchial flora in the donor lungs. This should be taken into account when planning antibacterial therapy after lung transplantation.

Study of diagnostic procedures and histopathology in primary malignancies in a tertiary care centre

Background: Primary lung cancer is a leading cause of cancer related death all over the world. In Indian scenario lung cancer is increasingly diagnosed because of beedi and cigarette smoking and majority of times diagnosed in an inoperable stage resulting in poor prognosis. Materials and Methods: In this study we have analysed the diagnostic modalities and histo-pathological analysis of the specimen obtained and correlated with the smoking status and age of the patients. A total of 113 patients having clinical and radiological profile suggestive of primary lung cancer are taken in to the study. Among them only 100 patients were diagnosed as malignancy by histopathological examination. For the confirmation of the diagnosis transthoracic needle aspiration biopsy with the help of ultrasonography and CT scan, bronchoscopic biopsy and bronchial washings, lymph node biopsy and pleural fluid analysis were undertaken. Results: Positive specimens were obtained by TTNA in 54%, Bronchoscopic biopsy and washings in 30%, pleural fluid analysis in 12% and lymph node biopsy in 4% of patients. 82% are males and 18% are females. 82% are smokers and 18% are nonsmokers. 68 patients presented with mass lesions and 73% of them presented with a mass of >5cm in diameter. 27% presented as mass lesions less than 5cm in diameter. Smokers have more mass lesions and more N3 disease and the values are statistically significant. (p

Association between Occupational and Radiological Factors and Nontuberculous Mycobacteria Lung Infection in Workers with Prior Dust Exposure.

This retrospective cross-sectional study was conducted to identify the factors that promote the risk of nontuberculous mycobacteria (NTM) lung infection in subjects with prior occupational dust exposure. All consecutive patients with a history of occupational dust exposure whose expectorated sputum, bronchial wash, or bronchial lavage was subjected to acid-fast Bacilli culture in a tertiary hospital between 2011 and 2016 were identified. The patients who were infected with NTM were identified according to the bacteriological criteria of the American Thoracic Society (ATS) and The Infectious Diseases Society of America (IDSA) statement. Pneumoconiosis-associated radiological findings were graded according to the International Labor Organization guidelines. Of the 1392 patients with prior dust exposure, NTM was isolated from 82. Logistic regression analysis showed that risk factors for NTM lung infection were a history of pulmonary tuberculosis (adjusted odds ratio [aOR] = 1.82, 95% confidence intervals [CI] = 1.03–3.16). Moreover, the unadjusted odds ratios (ORs) were higher when both small-opacity profusion and the large-opacity grades increased. Even after adjustment, the ORs for the A, B, and C large-opacity grades were 2.32 (95% CI = 1.01–4.99), 2.68 (95% CI = 1.35–5.24), and 7.58 (95% CI = 3.02–17.95). Previous tuberculosis, bronchiectasis, and especially extensive small-opacity profusion, and high large-opacity grade associated significantly with NTM lung infection in dust-exposed workers.

Nontuberculous mycobacterial pulmonary disease diagnosed by two methods: a prospective cohort study

BackgroundMicrobiological criteria for diagnosing nontuberculous mycobacterial pulmonary disease (NTM-PD) include positive culture results from at least two separately expectorated sputum specimens or one bronchial washing or lavage. However, the clinical similarities and differences between patients diagnosed by these two methods remain unclear. We compared clinical features and prognoses of patients with NTM-PD diagnosed from both specimen types.MethodsWe analysed data from patients who participated in the Seoul National University Hospital NTM-PD cohort (ClinicalTrials.gov identifier: NCT01616745). Baseline demographics, symptoms, radiographic findings, disease progression, and treatment responses were summarized and compared between patients diagnosed from sputum specimens and patients diagnosed from bronchoscopic specimens.ResultsThree hundred forty-seven patients were included in the analyses. Of these, 279 (80.4%) were diagnosed from two separately expectorated sputum specimens, and 68 (19.6%) were diagnosed from bronchoscopic specimens. Patients diagnosed from sputum specimens had more frequent and severe cough, sputum, postnasal drip, and high St. George’s Respiratory Questionnaire scores. However, the extent and severity of the radiographic lesions, disease progression, and treatment responses were similar for both groups. Further analysis based on the following three groups (sputum culture positive, sputum culture negative/bronchoscopy, and scanty sputum/bronchoscopy groups) suggested that the scanty sputum/bronchoscopy group appeared to have the worst prognosis in terms of both time to progression and time to culture conversion.ConclusionsAlthough some symptoms and quality of life were worse in patients with NTM-PD diagnosed from sputum specimens, their prognoses were similar to those of patients diagnosed by bronchoscopic specimen. We recommend bronchoscopic sampling for patients in whom NTM-PD is suspected clinically or radiographically, especially those who have no or scanty sputum.

Identifying actionable somatic mutations in lung cancer using cell-free DNA from bronchial washing fluid.

8528 Background: Bronchial washing is the most common technique for sampling the components of the alveolar space. Here, we evaluated the potential use of bronchial washing fluid (BWF) in liquid biopsy in lung cancer. Methods: This study enrolled 65 lung cancer patients. BWF (separated supernatant and precipitate) samples, peripheral blood lymphocytes (PBL) and formalin-fixed paraffin-embedded tissues were obtained and subjected to next-generation sequencing using a 1021-gene panel. Results: Mutations were identified in 58 (89.2%) of BWF precipitate (BWFp) samples and 64 (98.5%) of BWF supernatant (BWFs) samples, comparing with 61 (93.8%) of tumor tissues. In total, 461 somatic mutations were identified in tissues, of which 331 (71.8%) and 381 (82.6%) were detected in the matched BWFp and BWFs samples. In addition, there were 44.6% of patients carrying actionable variants identified in tissue DNA, including EGFR, ALK, ROS1, RET, etc. (Table). Similarly, there were 40.0% of BWFp samples and 44.6% of BWFs samples identified actionable variants. Moreover, tumor mutation burden (TMB) was also calculated. Nearly 9% of BWFp samples and 23% of BWFs samples were TMB-H (more than 9 mutations per megabase), comparing with 20% of tissues. Significantly, the combined results of three types of samples showed that, 49.2% of patients carrying actionable variants and 24.6% of patients with TMB-H, which suggested more patients benefit from targeted therapy or immunotherapy. Conclusions: In summary, liquid biopsy using BWF showed high potential to identify actionable mutations and to calculate TMB grade of patients with lung cancer, which might be implemented and standardized into clinical use. [Table: see text]

Isolation and molecular characterization of Mycoplasma spp. in sheep and goats in Egypt.

Background and Aim:Different species of Mycoplasma are associated with many pathological problems in small ruminants including respiratory manifestation, this problem results in significant losses, especially in African countries. This study aimed to (I) study some epidemiological aspects of Mycoplasma species infections in Egyptian sheep and goats at Giza Governorate, (II) diagnosis of Mycoplasma species affections using bacterial isolation and identification, (III) apply the polymerase chain reaction (PCR) for typing of different Mycoplasma species, and (IV) illustrate the phylogenetic tree for the isolated Mycoplasma species and other species from GenBank using the purified PCR product.Materials and Methods:A total of 335 samples were collected from sheep and goats from Giza Governorate in Egypt as 142 nasal swabs from clinically affected animals, 167 pneumonic lungs, 18 samples from tracheal bifurcation, and 8 samples by bronchial wash were cultured on pleuropneumonia-like organisms (PPLOs) media for cultivation of Mycoplasma species. PCR and sequencing and phylogenetic analysis were adopted to identify and classify the isolated Mycoplasma species.Results:A total of 24 Mycoplasma isolates were isolated on PPLO media, identified by biochemical tests, and confirmed and typed by PCR using specific primers. 10 isolates were confirmed as Mycoplasma arginini, four isolates as Mycoplasma ovipneumoniae by PCR, and 10 isolates as undifferentiated Mycoplasma species. A purified isolate of M. arginini and M. ovipneumoniae was sequenced and phylogenetic analysis was illustrated.Conclusion:M. arginini and M. ovipneumoniae are prevalent in Egyptian sheep and goats. Further studies on M. arginini are required due to its high frequency of isolation from pneumonic sheep and goats and also from animals suffer from different respiratory manifestations.

Feasibility of Bronchial Washing Fluid-Based Approach to Early-Stage Lung Cancer Diagnosis.

A blood-based approach such as circulating tumor DNA remains challenging in diagnosis for early-stage disease. Bronchial washing (BW) is a minimally invasive procedure that yields fluids that may contain tumor DNA. Therefore, we prospectively enrolled 12 patients with early-stage non-small cell lung cancer without endoscopically visible tumors. Somatic mutations were analyzed using ultra-deep next-generation sequencing in 48 paired specimens (primary tumor tissue, normal tissue, BW supernatant, and BW precipitate). In primary tumors, 130 missense mutations/indels (5-16 per patient) and 20 driver mutations (0-3 per patient) were found. Concordance of driver mutations between BW fluids and primary tumors was 95.0%. The allele frequencies for missense mutations/indels in BW supernatants significantly correlated with those in primary tumors and were higher than those in BW precipitates. These findings suggest that BW supernatants are reflective of tumor-associated mutations and could be used for early-stage lung cancer diagnosis.

SUN-375 A Diagnostic and Therapeutic Challenging Case of Ectopic Cushing Syndrome

Introduction: Ectopic ACTH secretion is a rare cause of ACTH dependent Cushing syndrome and accounts for approximately 10% of the cases. Identification of ectopic source involves a complex evaluation. We present a case of ectopic Cushing syndrome from small cell cancer posing diagnostic and therapeutic challenges. Clinical case: A 50-year-old woman with HTN, newly diagnosed DM, 45 pack year smoking admitted to hospital for pneumonia, uncontrolled HTN, and hypokalemia. The patient’s CT chest and abdomen showed a new 2cm cavitary lesion in the right lung and incidental left adrenal nodule. Biopsy of the cavitary lesion was negative for malignancy. Endocrinology was consulted for left adrenal incidentaloma. The patient reported 40lb weight gain in 6 months, hirsutism, proximal muscle weakness, and easy bruising. On physical exam, facial plethora, thinning scalp hair, supraclavicular fullness, diffuse bruising, truncal obesity, and bilateral pedal edema were noted. Bilateral lower extremities strength was markedly decreased. No abdominal purple striae were present. Work up for Cushing's showed, serum cortisol after 1mg overnight Dexamethasone suppression test- 49.3mcg/dl (N<1.8), 24 hour urine free cortisol-5767mcg/dl (N<45), midnight salivary cortisol 3.47mcg/dl (N<0.01-0.09) and ACTH-183pg/ml (6-58). 8mg Dexamethasone suppression test did not suppress cortisol more than 50%. Work up for Pheochromocytoma and Aldosteronism were negative. Labs confirmed ACTH dependent Cushing's. The pituitary MRI was unremarkable. Octreotide scan was negative. Ga- DOTATATE scan was unavailable. Meanwhile, the patient deteriorated within a few days, developed right lung empyema, shingles, and could not ambulate without support. The patient was started on Ketoconazole and later switched to Metyrapone because of insurance. The patient had bronchoscopy for her unresolved empyema, which revealed small cell lung cancer in the brushings. Post-discharge, the patient responded fairly well to chemo and radiation. But her cortisol was not fully controlled with ketoconazole, then Metyrapone. And she required high doses of potassium. The complications of her ectopic Cushing's became more life threating necessitating referral for bilateral adrenalectomy for definitive management of her ectopic Cushing's. Conclusion: Localization of ectopic source of ACTH secretion poses a diagnostic challenge. In our case, the initial biopsy of cavitary lung lesion was negative, and later ectopic source was identified on bronchial washings. Early diagnosis of the ectopic source is crucial to avoid complications from Cushing's. Even if initial localization fails, it is prudent to start medical management as early as possible for hypercortisolemia as in our case and to refer for bilateral adrenalectomy if uncontrolled, to decrease the morbidity and mortality from Cushing's.

THE SURGICAL STAGE OF PULMONARY TUBERCULOSIS TREATMENT USING MOLECULAR-GENETIC METHODS TO TEST SUSCEPTIBILITY TO RIFAMPICIN

The objective of the study: to analyze the frequency and patterns of drug resistance of Mycobacterium tuberculosis (MTB) according to the results of microbiological tests of surgical specimens of the patients who underwent surgery due to tuberculosis, and to compare them with the results of sputum tests done in the pre-operative period. Subjects and methods. The data of surgical specimens from 170 patients operated due to tuberculosis were analyzed. The surgical specimens were sent for histological and microbiological tests (detection of MTB DNA and rifampicin resistance by GeneXpert, culture on solid media with drug sensitivity testing). Results. The molecular genetic testing of surgical specimens by GeneXpert was highly effective for detection of rifampicin resistance; in 97.8% of cases, there was a match with the results of sputum culture with consecutive DST performed before the surgery. Molecular genetic tests of surgical specimens allowed detecting MTB DNA in 66.1% of patients in whom no MTB or MTB DNA was detected in sputum and bronchial washings prior to the surgery, and of them in 28.2% of cases, rifampicin resistance was detected, which was unknown before the surgery. These data allowed prescribing adequate chemotherapy immediately after surgery.

Polonium in bronchial washing specimens of smoker, ex-smoker and non-smoker patients with lung cancer

Polonium in bronchial washing specimens of smoker, ex-smoker and non-smoker patients with lung cancer

Typical Carcinoid: Cytological Diagnosis of a Case and Mimickers in Cytological Sampling Techniques with Brief Review of Literature

Typical carcinoids are the most well differentiated and least aggressive of pulmonary neuroendocrine tumors. Cytologic diagnosis on trans bronchial needle aspirate (TBNA) smears is quite diagnostic; however, may be challenging on other cytologic specimens like bronchial brushings and bronchial washings. We discuss such a case of typical carcinoid in a 30 years old female.

Longer Duration of Donor Ventilation Does Not Impact Long-Term Lung Function after Lung Transplantation

Purpose Prolonged mechanical ventilation increases the risk of developing ventilator-induced lung injury, but the relationship between duration of donor mechanical ventilation and post-lung transplant lung function is not known. We sought to test this relationship, and hypothesized that increased duration of ventilation would be associated with lower post-transplant lung function. Methods We conducted a retrospective analysis of patients undergoing lung transplantation in our program between January 2007 and December 2016. The risk factor of interest was duration of donor ventilation (DDV) in days prior to organ retrieval. The primary outcome was FEV1 % predicted at 1 year post-transplant (1yrFEV1%). We used multiple linear regression to test the association between DDV and 1yrFEV1%, adjusting for donor age, donor sex, donor smoking history, total ischemic time, presence of respiratory culture positive for clinically relevant organisms and donor oxygenation at procurement. Secondary outcomes included FVC % predicted at 1 year post-transplant (1yrFVC%), FEV1 and FVC % predicted at 3 months post-transplant (3moFEV1% and 3moFVC%), incidence of grade 3 primary graft dysfunction (PGD3) at 48-72 hours, ICU length of stay (LOS) and hospital LOS and 3-month and 1-year mortality. Results 396 patients were eligible for study, 193 of whom had available DDV data. Median DDV was 3 days (range 0-12 days). 131 donors (68%) had bronchial wash cultures positive for clinically relevant organisms. In the multivariate analysis, longer DDV was not associated with a lower 1yrFEV1% (p=0.396). In terms of secondary outcomes, 1yrFVC%, incidence of Grade 3 PGD, ICU and hospital LOS, 3-month and 1-year mortality were not associated with DDV. A significant reduction in 3moFEV1% (-1.5% per day of ventilation, (95% CI -0.01, -2.91, p=0.05)), and 3moFVC% (-1.9% per day of ventilation (95% CI -0.49, -3.23, p=0.008)) were noted with longer DDV. DDV was not significantly associated with culture positivity (odds ratio [OR] 1.18 per day of ventilation, 95% CI 0.98 − 1.41, p=0.07). Conclusion Duration of donor ventilation prior to procurement was not associated with FEV1 % predicted at 1 year post-transplant. Duration was inversely associated with 3 month FEV1 and FVC % predicted, which may reflect a distinct, transient ventilator-induced lung injury state.