Bronchial Washings Research Articles

Dengue Fever with pulmonary alveolar hemorrhage - Common infection with uncommon association - rare case report

Dengue fever (DF) is major health hazard around the world in recent decades especially in India. Flu like illness to polyserositis among common presentation of DF. Dengue fever presenting as pulmonary hemorrhage is rare. Here we present a case of 16 -year young male patient presented with fever and shortness of breath, initially diagnosed as dengue fever by serological examination. CT chest findings mimiking as pneumonia ,however further fall in hemoglobin and progressive dysnoea, bronchoscopy and bronchial wash cytology done which reveal association of pulmonary hemorrhage. This case report alerted clinicians about rare presentation and high index of suspicion of pulmonary hemorrhage in DF with dysnoea for early diagnosis and to avoid its fatal outcome.
 Bangladesh J Medicine Jan 2019; 30(1) : 38-40

Bronchial Washing to Diagnose Smear-Negative Pulmonary Tuberculosis

Introduction: Bronchoscopy with bronchial washing is useful for the diagnosis of pulmonary tuberculosis (TB) when sputum smears are negative. However, its indication has not been standardized. Therefore, we conducted a retrospective study to assess the diagnostic value of bronchial washing in patients suspected with pulmonary TB. Methodology: A retrospective analysis was performed on patients diagnosed with pulmonary TB in Kosin university gospel hospital, a tertiary hospital with 969 beds in South Korea, from March 2017 to December 2018. We obtained three serial sputum samples for acid-fast bacilli (AFB) smear and culture, and all patients underwent bronchoscopy with bronchial washing for AFB smear and culture. Results: Fifty-six patients were enrolled in the study. Smear-negative pulmonary TB (SNPT) was diagnosed in 42/56 (75%) patients. Among the patients with smear-positive sputum, 14/14 (100%) showed culture-positive sputum, while smear- and culture-positive bronchial washing were seen in 7/14 (50%) and 12/14 (85.7%) patients, respectively. Among the patients with SNPT, 17/42 (40.47%) had culture-negative sputum and were diagnosed using the bronchoscopic washing. Conclusions: For patients with smear-negative sputum, it is necessary to perform bronchoscopic washing to increase the diagnostic rate of pulmonary TB. To control the transmission of pulmonary TB, it is necessary to use a fast and accurate examination method.

Role of Bronchial Washing Gene Xpert in Sputum-Scarce Cases of Suspected Pulmonary Tuberculosis.

Objective:To determine the frequency of mycobacterium tuberculosis detection, in bronchial washing in sputum-scarce cases of suspected pulmonary tuberculosis.Methods:A descriptive cross-sectional study was conducted at the Ojha Institute of Chest Diseases, Dow University of Health Sciences, Karachi, during July 2016 to December 2017. Sputum-scarce patients with suspicion of pulmonary tuberculosis were selected and underwent for bronchoscopy, detailed examination of bronchial tree was performed, and bronchial washing collected for testing of mycobacterium tuberculosis with Gene Xpert.Results:A total of 120 patients were included. In this study 55 (45.8%) patients were female and 65 (54.2%) were male with mean±SD of age was 39.9 ±14.7 years. Bronchial washing Gene Xpert for mycobacterium tuberculosis was detected in 83 (69.2%) sputum-scarce cases of suspected pulmonary tuberculosis patients.Conclusion:Bronchial washing Gene Xpert has an excellent diagnostic yield for detection of mycobacterium tuberculosis in sputum-scarce cases of suspected pulmonary tuberculosis.

A comparative cyto-histopathological study of pulmonary neoplasms between bronchial washings and brushings vis-à-vis bronchial biopsy

A comparative cyto-histopathological study of pulmonary neoplasms between bronchial washings and brushings vis-à-vis bronchial biopsy

Cytologic Features of Pulmonary Langerhans Cell Histiocytosis in Bronchial Washing: A Report of Two Cases.

Cytologic Features of Pulmonary Langerhans Cell Histiocytosis in Bronchial Washing: A Report of Two Cases.

SPECIES DIVERSITY OF NON-TUBERCULOUS MYCOBACTERIA IN PATIENTS WITH MYCOBACTERIOSIS IN THE NORTH-WESTERN FEDERAL DISTRICT OF RUSSIA

The objective of the study: to analyze the structure and trends in non-tuberculous mycobacteria (NTBM) population causing diseases in the North-Western Federal District of the Russian Federation. Subjects and methods. 745 clinical NTBM strains were identified. All clinical strains of NTBM were isolated by culture from clinical samples (sputum, bronchial washings, bronchoalveolar lavage fluid, pus, stool, urine, surgical and biopsy specimens, and venous blood in case of sepsis). In 23 cases, NTBM were detected post mortem. Mycobacteria were cultured on solid media or by the automated system of Bactec MGIT 960 BD USA. Species of re-cultured mycobacteria were identified using the test system of GenoType® Mycobacterium CM/AS (Hain Lifescience, Germany). Results. Analysis of the structure of the NTBM population isolated from patients with mycobacteriosis in the North-West of Russia, for the period of 2012-2018 showed overall dominance of M. avium (56.4%). However, certain NTBM species were found to be prevailing in some regions: M. lentiflavum and M. gordonae dominated in the Komi Republic and Arkhangelsk respectively. Unlike other regions of Russia, in the North-Western region, there was a consistently low level of detection of M. кansasii and M. xenopi. For the last 12 years in Saint Petersburg and Leningrad region, the variety NTBM in patients with different immune status has been growing but the portion of M. avium remains to be stably high exceeding 50%.

Disseminated Mycobacterium haemophilum Infection and Pneumocystis jirovecii Pneumonia in a Patient Receiving Immunosuppressive Therapy

Abstract A 53-year-old woman with mixed connective tissue disease and rheumatoid arthritis on successive treatment regimens consisting of rituximab then adalimumab + prednisone then azathioprine + hydroxychloroquine + prednisone developed multiple tender upper and lower extremity skin lesions followed shortly by dry cough and shortness of breath. Skin biopsy and blood cultures eventually revealed Mycobacterium haemophilum, and transbronchial lung biopsy and bronchial washings revealed Pneumocystis jirovecii pneumonia. The patient was treated with endotracheal intubation, clarithromycin/rifampin/ciprofloxacin, and trimethoprim-sulfamethoxazole and survived, gradually returning to baseline state after hospital course during which she was intubated for 17 days. She survived but continues on lower-dose azathioprine and prednisone for her mixed connective tissue disease and rheumatoid arthritis. We conducted a strict review of the literature for all patients with disseminated M. haemophilum infection and looked for concurrent opportunistic infections. There was only one other patient with concurrent disseminated M. haemophilum infection and P. jirovecii pneumonia. Three patients were diagnosed as having P. jirovecii before having a diagnosis of disseminated M. haemophilum infection. Other concurrent opportunistic infections found were herpesvirus-8–associated Kaposi sarcoma and disseminated histoplasmosis. As physicians become more aware of M. haemophilum and as diagnostic techniques improve and become more widely available, we may see more disseminated M. haemophilum infections and associated opportunistic infections.

Pulmonary tuberculosis occurred in patient with Tracheobronchopathia Osteochondroplastica

Tracheobronchopathia osteoplastica (TO) is a rare benign disease in which the anterior inner wall of the tracheobronchus changes because of abnormal chondrogenesis or ossification, while the posterior wall of the trachea is spared. The etiology is not clearly understood, but may relate with chronic infection, inflammation, and trauma. In some case studies, it has also been reported to be accompanied by other chronic diseases such as atrophic rhinitis and amyloidosis. However, Coexistence of TO and tuberculosis has rarely been reported, and has never been reported in Korea. Here, we report a case of a 70-year-old male patient who complained of hemoptysis and whose case was diagnosed as TO and pulmonary tuberculosis through bronchoscopy with bronchial washing and biopsy.

Factors predisposing to non-tuberculous mycobacterial lung disease in the patients with respiratory isolates of non-tuberculous mycobacteria.

An increasing incidence rate of respiratory isolates of non-tuberculous mycobacteria (NTM) has been noted recently in most European countries as well as in the US. Despite many publications, there is no consensus concerning the importance of different factors in promoting NTM lung disease (NTMLD). The aim of the present retrospective study was to analyse patients with positive NTM respiratory isolates in search of factors predisposing to NTMLD. 73 patients, 23 males, 50 females, median age 62.2 years, in whom NTM have been cultured from respiratory specimen (sputum and/or bronchial washings), in the period 2010-2015, entered the study. NTMLD (according to ATS/IDSA) has been recognised in 36 patients, airways colonisation by NTM - in 37 patients. NTMLD was diagnosed more often in the patients infected with M. kansasii, M. abscessus and M. avium/M. intracellulare comparing to those infected with M.xenopi, M. gordonae and M. fortuitum (p < 0.0001). The proportion of females to males was significantly higher in the NTMLD group comparing to the colonisation group (p < 0.007). Previous tuberculosis or mycobacteriosis were noted significantly more frequently in the group of patients with NTMLD comparing to the colonisation group (28% vs 8%, p = 0.038). Univariate regression analysis revealed M. kansasii, female gender, and previous tuberculosis or mycobacteriosis as significant predictors of NTMLD. The risk factors of NTMLD recognition in the presented group of patients were the following: female gender, M. kansasii isolation, as well as past tuberculosis or mycobacteriosis.

356. Bronchoalveolar Lavage Fluid Cytology by GMS Stain for the Diagnosis of Invasive Pulmonary Aspergillosis in Patients With Hematologic Malignancies: Analysis of 67 Episodes

BackgroundThe yield of direct fungal visualization by GMS (Gomori–methenamine–silver) stain in bronchoalveolar lavage (BAL) cytology has rarely been studied in the diagnosis of invasive pulmonary aspergillosis (IPA) in patients with hematological malignancies (HM).MethodsWe analysed a series of patients with proven or probable culture-documented IPA (EORTC/MSG criteria) in HM patients (1999–2015). All patients had BAL cultures that were positive for Aspergillus spp. and had concurrently obtained BAL cytology GMS available for analysis.ResultsWe identified 67 such patients. BAL cytology based on GMS showed hyalohyphomycetes consistent with Aspergillus in 28/67 (41.8%) patients, whereas only in 2/67 (3.6%) direct smear Calcofluor White stain was positive. Based on BAL GMS cytology, co-infections were identified in six patients: two Pneumocystis and five viral infections with cytopathic changes (one had both). The yield of cytology was not different in patients with IPA caused by non-fumigatus Aspergillus, although patients with IPA and >1 Aspergillus in BAL culture had more often positive cytology GMS (100% vs. 0%, p 0.027). Cytology was also more often positive when obtained from a lesion-targeted BAL as compared with non-targeted bronchial washings (60.7% vs. 7.1%, p 0.038). Patients with IPA and cavitary lesions (32.1% vs. 5.1%, P = 0.006), history of SCT (64.3% vs. 33%, P = 0.015) or prior exposure to itraconazole (75% vs. 41%, P = 0.007) had positive cytology GMS results more often than did patients without these characteristics. In the multivariate analysis, only cavitary lesions were significantly associated with positive BAL GMS cytology.ConclusionGMS stain in cytology of BAL in patients with HM and culture-documented IPA had a sensitivity of 41.8% and was more often positive in patients with cavitary lesions. Although there were no differences in the proportion of GMS-positive cytology rates among differing Aspergillus spp. causing IPA, mixed Aspergillus spp. IPA was associated with an increase in positive cytology. BAL cytology was diagnostic for co-infections in more than 10% of patients. BAL cytology should be part of the diagnostic wok up in HM patients with suspected IPA.Disclosures All authors: No reported disclosures.

Lung allograft donors with excessive alcohol use have increased levels of human antimicrobial peptide LL-37.

The relatively low long-term survival rate of lung transplant recipients as compared to other organ recipients serves as an impetus to identify potential lung dysfunction as early as possible. There is an association between donor heavy alcohol use and acute lung injury in the lung allograft after transplant, known as primary graft dysfunction. Excessive alcohol use (EAU) can induce pulmonary immune dysregulation in response to an infection. Antimicrobial peptides (AMPs) are an important component of the innate immune response to pulmonary infections, but the impact of EAU on AMPs in the allograft lung has not been evaluated. Our hypothesis is that specific lung AMPs, LL-37, α-defensin-1,2,3, and β-defensin-2, are dysregulated in the lungs from organ donors who had EAU. In this prospective observational investigation, we measured AMPs via ELISA and inflammatory cytokines via multiplex bead array, in bronchoalveolar lavage (BAL) fluid of lung allograft donors, comparing results based on their alcohol consumption. LL-37 levels in lung donors with EAU were found to be increased compared to nondrinker (ND) donors [median 7.7ng/mL (IQR 4.1-37.0) vs. 2.3ng/mL (IQR 1.1-7.9), p=0.004], whereas α-defensins-1,2,3 were decreased only in the presence of an infection in donors with EAU compared to ND donors [median 2.2ng/mL (IQR 1.6-2.4) vs. 3.2ng/mL (IQR 2.3-3.8), p=0.049]. There was no difference in β-defensin-2 levels. Gene expression levels of these AMPs were not different. Elevated levels of CXCL8 were noted in bronchial washings of donors with EAU compared to ND donors, [median 4372pg/mL (IQR 3352-13180) vs. 867.3pg/mL (IQR 163.6-3675), p=0.04], suggesting a potentially heightened inflammatory response. At 1 month post-transplant, LL-37 and CXCL8 levels are decreased compared to levels at time of transplant. In lung donors with EAU, LL-37 and α-defensins-1,2,3 dysregulated levels in the presence of an infection may be a harbinger of dysfunction of the lungs through the transplant process.

LATE-ONSET CYSTIC FIBROSIS IN AN ELDERLY MALE

Introduction Cystic fibrosis (CF) is described as a disease that manifests primarily in childhood, with only 7 percent diagnosed during adulthood. We describe a man with history of infertility and recurrent bronchitis who was diagnosed with CF at age 69. Case Description A 69-year-old with history of recurrent bronchitis since mid-age (once a year, quickly resolved with short course oral antibiotics) presented with refractory cough with yellowish sputum and sinusitis symptoms after a viral upper respiratory infection 18 months prior. He underwent several rounds of antibiotics and steroid taper but his symptoms quickly relapse after completing each treatment course. CT chest showed cylindrical type bronchiectasis. CT sinuses showed extensive mucosal thickening. Culture from his maxillary sinus and sputum grew pan-sensitive pseudomonas aeruginosa. His bronchial washing grew Methicillin-sensitive Staphylococcus aureus and Mycobacterium abscesses. Physical exam was consistent with chronic sinopulmonary infection, no digit clubbing. His comprehensive immunological deficiency workup was unrevealing. However, his sweat test showed chloride level of 68 to 73 mmol/L. In addition, his genetic test for CFTR showed compound heterozygote for the p.F508del pathogenic variant and [5T; 12TG] allele. The patient was infertile, although no absent vas deferens. There was no family history of CF. Patient was subsequently diagnosed with CF based upon combination of clinical characteristics and laboratory studies. Discussion Patients with CF may present at adult age in a diversity of clinical disciplines. Our case is a reminder that CF should be considered in differential diagnosis of bronchiectasis, even in elderly population.

Symptomatic respiratory Encephalitozoon cuniculi infection in renal transplant recipients

ObjectivesEncephalitozoon spp. and Enterocytozoon bieneusi are intracellular parasitic fungi from the phylum Microsporidia, which initially localize to the intestine. As opportunistic pathogens, Encephalitozoon spp. in particular can disseminate to the respiratory tract, among other locations. Patients on life-long immunosuppression are at higher risk of such infections, mostly symptomatic. MethodsSputum samples and bronchial washings from 72 renal transplant recipients and 105 patients with various respiratory diseases were screened for Encephalitozoon spp. and E. bieneusi by microscopic examination and genus-specific nested PCR followed by genotyping. ResultsA total of 8.3% (6/72) of immunosuppressed renal transplant recipients and 1.9% (2/105) of patients with various respiratory diseases, both immunocompetent and immunosuppressed, were positive for respiratory microsporidial infection. All six transplant recipients were Encephalitozoon cuniculi-positive by PCR/sequencing and five of them suffered from respiratory symptoms. The presence of microsporidial spores was also confirmed microscopically in three of the transplant recipients. Of the two immunocompetent patients with various respiratory diseases, one had an E. cuniculi infection, while the second had an E. bieneusi infection. ConclusionsLife-long immunosuppression in renal transplant recipients increases the risk of respiratory infection by E. cuniculi. Microsporidia should be screened in respiratory samples of these patients, particularly when they have respiratory symptoms.

DIAGNOSTIC IMPACT OF TBC PCR IN BRONCHIAL WASHING FOR THE DETECTION OF ACTIVE PULMONARY TB IN SMEAR NEGATIVE PATIENTS

SESSION TITLE: Chest Infections 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Diagnosis of pulmonary tuberculosis is not easy when the sputum smear for Mycobacterium tuberculosis(M.tbc) is negative or in the patients who can not expectorate effectively.The aim of the study has been that to evaluate the diagnostic impact of a commercially developed Tbc PCR test (Amplicor) in bronchial washings for detecting pulmonary tuberculosis in smear negative patients. METHODS: We recruited 205 patients whose sputum smear for M.Tbc were negative or who could not any sputum from January 2013 to December 2015. We performed bronchoscopy for acid-fast stain, culture of mycobacteria, and PCR test of bronchial washing if there were signs of hemoptysis, patients who could not cough up sputum, lung lesion that exclude pulmonary tuberculosis. RESULTS: Active pulmonary tuberculosis were identified in 136 patients. The number of male patients were65 and that of female patients were71. The mean age is 43.2 (16-86) years old. In underlying cormobidity, diabetes was most common disease in 25cases(18.3%). Active pulmonary tuberculosis combined with endobronchial tuberculosis and pleural effusion were identified in 28 cases (20.6%), 15 cases(11%), respectively. The sensitivity of bronchial washing smear, culture and AmplicorTbc PCR were 41.9%, 76.4%, 72.8%, respectively. The specificity and positive predictive values of bronchial washing for Tbc PCR were 96.2, 98.1%, respectively.In 130 cases, the sputum AFB smear was negative in 98 cases(72%) and the patients who could not any sputum were 38 cases(27.9%). The AFB smearand Tbc PCR of bronchial washing were the only diagnostic test in 31cases(22.8%), 64cases(47%) respectively. Therefore early diagnosis of pulmonary tuberculosis was possible by bronchial washing smear and PCR for M. tbc in 65cases(47.8%). In the 98 cases of sputum AFB smear negative M Tbc, the sensitivity of bronchial washing AFB smear, culture, PCR were 42.8%, 75.5%, 71.4%, respectively. In laboratory findings, CRP was significantly increased in sputum AFB culture positive group than negative group (7.65 vs 3.72mg/ml, P<0.05). CONCLUSIONS: Bronchial washing for AmplicorTbc PCR was effective nearly same as culture and rapid diagnostic method in patients who could not sputums expectorate effectively or smear negative pulmonary tuberculosis. CLINICAL IMPLICATIONS: Bronchoscopy and bronchial washing tbc PCR was effective diagnostic tool for sputum smear negative pulmonary tuberculosis. DISCLOSURES: No relevant relationships by Young Min Lee, source=Web Response

UNUSUAL PRESENTATION OF TB IN AN ENDEMIC COUNTRY

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Endobronchial tuberculosis is the tuberculous infection of tracheobronchial tree with histological and microbiological evidence1. Diagnosis of endobronchial tuberculosis remains a challenge, in cases with normal chest radiograph. Endobronchial tuberculosis is highly contagious and delayed diagnosis leads to sequelae of broncho-stenosis. We report three cases of endobronchial tuberculosis diagnosed by bronchoscopy from a tertiary care hospital in Chennai, India. CASE PRESENTATION: Case-1: 48 year old male, with no known comorbidities, presented with hoarseness of voice, dry cough and breathlessness for 6 months. Chest radiograph was normal. Computed tomography showed nodularity of inner surface of trachea. Bronchoscopy revealed pseudomembranous form, corresponding to actively caseating variety of endobronchial TB( figure-1). Bronchial wash and brush showed many acid fast bacilli and bronchial biopsy showed granulomatous inflammation. Bronchoscopy repeated after a course of anti tuberculous treatment showed normal mucosa.Case-2: 31 year old female, presented with dry cough and fever since 6 weeks. Chest x-ray showed right perihilar opacity. CT chest showed few irregular, fluffy opacities in the right upper lobe and right hilar adenopathy. Bronchoscopy revealed tumorous variety with exophytic growth from RUL bronchus( figure-2). Bronchial wash and brush showed many acid fast bacilli and bronchial biopsy showed granulomatous inflammation.Case-3: 66 year old lady, a case of right renal cell carcinoma, with history of pulmonary tuberculosis 15 years back, presented with persistant fever and dry cough for 1 month and was evaluated to have right upper lobe fibrosis and nodular opacities in right upper lobe and left lower lobe on CT Chest. Bronchoscopy revealed ulcerative lesions in right tracheobronchial angle and right lower lobe apical segment(figure-3). Bronchial wash showed many acid fast bacilli and bronchial biopsy showed granulomatous inflammation. DISCUSSION: Endobronchial TB usually occurs in young patients2. Diagnosis is often challenging due to its wide range of presentations, clinically resembling bronchial asthma, foreign body, recurrent non resolving pneumonia, bronchogenic carcinoma. Seven types of endobronchial presentations based on bronchoscopic appearance include actively caseating, edematous hyperaemic, fibrostenotic, tumorous, granular, ulcerative, nonspecific bronchitis3. We hereby report actively caseating, tumurous and ulcerative varieties. Delayed diagnosis leads to multiple, irreversable complications like bronchial stenosis and strictures, airway obstruction, para cicatrical bronchiectasis, hemoptysis and atelectasis. CONCLUSIONS: Bronchoscopy remains investigation of choice for early diagnosis and followup, in cases of high clinical suspicion for tuberculosis with dry cough or sputum negative. Timely diagnosis prevents various complications and infection control. Reference #1: Hoheisel G, Chan BK, Chan CH, et al. Endobronchial tuberculosis : Diagnostic features and therapeutic outcome. Respir Med 1994; 88 : 593-97. Reference #2: M. S. Ip, W. K. Lam, S. Y. So, and C. K. Mok, “Endobronchial tuberculosis revisited,”Chest,vol.89,no.5,pp.727–730,1986 Reference #3: Winner-Muram HT, Rubin SA. Thoracic complications of tuberculosis. J Thoracic Imag 1990; 5 : 46-63 DISCLOSURES: No relevant relationships by ANILKUMAR GANDHAM, source=Web Response No relevant relationships by A. Gayathri, source=Admin input

COMPARISON OF CYTOLOGIC EXAMINATION OF BRONCHIAL WASHING SAMPLES VS BRONCHIAL BRUSHING IN THE DIAGNOSIS OF LUNG CANCER

SESSION TITLE: Advances in Diagnostic Modalities of Peripheral Lung Nodules SESSION TYPE: Original Investigations PRESENTED ON: 10/07/2018 02:15 PM - 03:15 PM PURPOSE: In routine clinical practice, bronchial washing (BW) and/or bronchoalveolar lavage (BAL) sample is routinely submitted for cytology evaluation during bronchoscopic evaluation of possible lung cancer. However, its diagnostic role when compared to other standard procedures such as bronchial brushing (BB) is not well studied. It is not clear if the routine examination of BW adds much to the final diagnosis. The purpose of this study is to assess the diagnostic performance of cytologic examination of BW and BAL samples for lung cancer diagnosis, when compared to standard BB performed during the same procedure. METHODS: A cross-sectional study was carried out from Jan 2016 to December 2016, and included those lung cancer cases diagnosed through bronchoscopic techniques, including BW and BAL, BB, transbronchial biopsies (TBBX), endobronchial biopsies (EBBX) and transbronchial needle aspiration (TBNA). RESULTS: In total, 55 cases of lung cancer were analyzed. Mean age was 66. A total of 58% were males, 27% cases corresponded to small-cell carcinoma, and 29% of the cases had a visible endoscopic lesion. A nodule or mass was seen in 95% of the cases and 64% had enlarged lymph nodes by thoracic imaging. Out of the 55 cases, BW/BAL was performed in 100% of them and it identified only 22 cases (sensitivity of 40%). All of the cases confirmed by BW/BAL were also confirmed by another technique employed in the same procedure. There were no false positive BW/BAL diagnoses. BB was employed in 39 cases (all 39 had BW/BAL obtained as well) and confirmed the presence of lung cancer in 33 of them (overall sensitivity of 85%). When compared to BB, BW/BAL had a sensitivity of 55% (18/33 cases), a specificity of 100%, and a negative predictive value of only 29%. Between these two techniques, BW/BAL didn't add any additional diagnostic yield for malignancy. CONCLUSIONS: Cytology of BW/BAL samples are routinely collected during bronchoscopic evaluation of lung cancer. The overall diagnostic yield (sensitivity) was only 40%. It didn't identify any additional cases of malignancy compared to other techniques in the same procedure. When compared to BB, which is also routinely obtained during bronchoscopy, the sensitivity was 55%. All of the cases diagnosed by BW/BAL were also diagnosed by BB. Our study suggests that routine BW/BAL doesn't provide additional diagnostic value when other procedures are performed, especially BB. The additive cost of cytologic examination of BW/BAL should be taken into consideration and will be studied in more detail by our group. CLINICAL IMPLICATIONS: Given the limited value of routine collection of BW/BAL during bronchoscopic workup of lung malignancy, we propose that its use be limited to very specific cases at the discretion of the bronchoscopist. Eliminating this procedure of the routine sample collection might have significant positive financial implications. DISCLOSURES: No relevant relationships by Isaac Biney, source=Web Response No relevant relationships by Paul Branca, source=Web Response No relevant relationships by John Callison, source=Web Response No relevant relationships by Michael McCormack, source=Web Response No relevant relationships by Francisco Soto, source=Web Response No relevant relationships by J Turner, source=Web Response

STENOSIS OF THE BRONCHIAL TREE DUE TO GRANULOMATOSIS WITH POLYANGIITIS

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Tracheobronchial tree (TBT) stenosis is a severe complication of Granulomatosis with Polyangiitis (GPA) due to granulomatous lesions along the respiratory tract. There is limited data regarding appropriate therapy for these patients. This is a case of a rare subtype of TBT, bronchial stenosis. CASE PRESENTATION: A 73-year-old woman with a history of rheumatic fever, chronic obstructive pulmonary disease requiring tracheostomy with reversal and residual tracheal stenosis, presented with a productive cough worsening over three months. She had associated chills, fevers, night sweats, dyspnea, and weight loss. Her sputum was brown without hemoptysis. She denied prior tobacco use and had no recent sick contacts or travel. Antibiotic and steroid therapy provided no relief. Chest radiograph showed hyperinflation, bilateral patchy infiltrates, and left lower lobe atelectasis. A computerized-tomography scan showed complete impaction of the left main bronchus with collapse of the left upper and lower lobes, significant bronchiectasis, and mediastinal lymphadenopathy.Bronchoscopy revealed 70% stenosis of the upper trachea, friable respiratory mucosa, and complete occlusion of the left main-stem bronchus. The right main-stem bronchus and the bronchus intermedius were circumferentially narrowed by granulation tissue. Cryoablation of the left main stem occlusion was unsuccessful.Endobronchial biopsy revealed granulation tissue with fibrosis and multi-nucleated giant cells. Her cytoplasmic anti-neutrophil cytoplasmic antibody titer was 1:320. Bronchial washings were negative for bacterial organisms. She was then diagnosed with bilateral bronchial stenosis due to GPA. DISCUSSION: TBT stenosis presents in 12-23% of patients with GPA. The stenosis is due to a non-infectious ulcerative tracheobronchitis caused by an underlying small vessel vasculitis, followed by fibrotic scarring. Symptoms such as cough, hemoptysis, or dyspnea mimic infection or obstructive lung disease.There is no clear consensus on the management of patients with bronchial stenosis. These fibrotic lesions are often refractory to pharmacological management with corticosteroids or immunosuppressive agents alone, and an endoscopic intervention such as cryotherapy, balloon dilation, or stent placement is needed for symptomatic relief. The benefits of endoscopic intervention can be transient due to a high restenosis rate. Comparison of patient outcomes based on the treatment modality of choice would prevent delay in therapy or worsening of disease. CONCLUSIONS: Bronchial stenosis is a complication of GPA that can mimic other common obstructive lung diseases due to the similar pathogenesis of bronchoconstriction. Optimal therapeutic approach for bronchial stenosis is controversial. Literature currently supports a combination of pharmacological and endoscopic therapy. Investigation of patient outcomes based on treatment modality is warranted. Reference #1: Girard et al. Tracheobronchial Stenosis in Granulomatosis With Polyangiitis (Wegner’): A Report on 26 Case. Medicine (Baltimore). 2015 Aug;94(32):e1088. Reference #2: Daum et al. Tracheobronchial Involvement in Wegener’s Granulomatosis. Am J Respir Crit Care Med. 1995 Feb;151(2 Pt 1):522-6. Reference #3: Terrier et al. Granulomatosis with Polyangiitis: Endoscopic Management of Tracheobronchial Stenosis: Results From a Multicenter Experience. Rheumatology (Oxford). 2015 Oct;54(10):1852-7. DISCLOSURES: No relevant relationships by Omar Ibrahim, source=Web Response No relevant relationships by Anil Magge, source=Web Response No relevant relationships by Rahul Mutneja, source=Web Response No relevant relationships by Evan Nadler, source=Web Response No relevant relationships by Aysha Tandon, source=Web Response

CAVITARY LUNG DISEASE: ADENOCARCINOMA IN SITU OF THE LUNG WITH CONCOMITANT MYCOBACTERIUM AVIUM COMPLEX INFECTION

SESSION TITLE: Lung Cancer 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Adenocarcinoma in situ (AIS) of the lung usually presents on computed tomography (CT) of the chest as solid nodules, although part-solid or groundglass nodules are also often seen. In the case of cavitary lesions on CT in combination with nodular opacities, the diagnosis of Mycobacterium avium complex (MAC) infection is more readily considered. Herein is a case in which AIS with concurrent MAC infection presented on CT with multifocal cavitary lesions. CASE PRESENTATION: A 60-year-old Caucasian female with a history of former tobacco use presented with chronic cough productive of white sputum for four months as well as dyspnea on exertion. She was diagnosed on two separate occasions with pneumonia thirteen and three months prior to presentation. Evaluation of her cough included chest CT, which revealed dense consolidation with air bronchograms and widespread interstitial infiltration with groundglass opacities highlighting numerous cysts in the right upper lobe; a 6-cm cavitary lesion in the superior segment of the right lower lobe; and bilateral nodularity with both groundglass and cavitary components in a centrilobular, non-hematogenous distribution in the central lung zone regions. The clinical presentation and the radiologic findings were initially concerning for MAC infection. Bronchoscopy with transbronchial lung cryobiopsy (TBLC) was performed to confirm the diagnosis. However, cytology revealed malignant glandular cells consistent with adenocarcinoma, and surgical pathology revealed moderately-differentiated, non-mucinous neoplastic epithelium with papillary architecture consistent with AIS. Sputum smear initially revealed no acid-fast bacilli, but three weeks later cultures grew Mycobacterium avium-intracellulare. DISCUSSION: The pathology results of this patient are consistent with a diagnosis of lepidic-predominant, non-mucinous adenocarcinoma, which has rarely, if ever, been shown to present with cavitary lesions. In contrast, MAC infections routinely exhibit multiple small nodules and fibrocavitary lesions. In addition to radiologic evidence, the patient’s demographics and clinical presentation gave further reason to suspect a diagnosis of MAC infection, so the initial diagnosis of adenocarcinoma in situ was unexpected. Because diagnostic criteria for MAC infection includes radiologic evidence and bronchial washing, biopsy might not always be considered to rule out malignancy, especially with cavitation evident on CT scan. However, without biopsy, the significant diagnosis of adenocarcinoma could be missed. It is also notable to mention that it is necessary to follow up on sputum culture results that could modify treatment if resulted positive. CONCLUSIONS: When considering MAC infection as a diagnosis for cavitary lesions, it may be appropriate to consider biopsy of lesions to rule out malignancy, especially if suggested by the clinical presentation. Reference #1: Austin J, et al. Radiologic Implications of the 2011 Classification of Adenocarcinoma of the Lung. Radiology. 2013;266(1):62-71. Reference #2: Field S, Fisher D, Cowie R. Mycobacterium Avium Complex Pulmonary Disease in Patients Without HIV Infection. Chest. 2004;126(2):566-581. Reference #3: Travis W, et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma. Journal of Thoracic Oncology. 2011;6(2):244-285. DISCLOSURES: No relevant relationships by Andrew Astin, source=Web Response No relevant relationships by Ezmin George, source=Web Response No relevant relationships by Jeff Hon, source=Web Response No relevant relationships by Vikas Pathak, source=Web Response No relevant relationships by Christine Zhou, source=Web Response

Prevalence of blaKPC and its occurrence with other beta-lactamases in Klebsiella pneumoniae.

BACKGROUND:Klebsiella pneumoniae (K. pneumoniae) is an important nosocomial pathogen, and the emergence of multidrug resistance in these organisms limits the treatment options for serious infections caused by them. K. pneumoniae carbapenemase (KPC) is one of the clinically significant Class A beta-lactamases.AIM AND OBJECTIVE:This study was aimed to detect the KPC and its coexistence with other beta-lactamases in K. pneumoniae.MATERIALS AND METHODS:A total of 370 isolates, collected over a period of 1 year, were included in this study. The source of these isolates were urine (n = 170), exudative specimens (n = 132), respiratory secretions such as bronchial wash, endotracheal aspirate, and pleural fluid (n = 38), and blood (n = 30). For all the isolates, antibiotic susceptibility tests by disc diffusion, modified Hodge test, and KPC screening test were done. Polymerase chain reaction (PCR) was performed for the detection of KPC and the copresence of other beta-lactamases genes.RESULTS:Among the 370 isolates, 41 were resistant to the carbapenem by disc diffusion and minimum inhibitory concentration tests. Screen test using ertapenem and the boronic acid disk was positive in 14 isolates. Only one isolate harbored KPC gene by PCR, and it was co-produced with SHV-12 and CTX-M-15.CONCLUSION:PCR remains the gold standard for detection of KPC compared with any other phenotypic methods. Early detection of these genes helps in initiating proper antibiotic treatment.

EPIDEMIOLOGY OF NONTUBERCULOUS MYCOBACTERIUM FROM AN INNER-CITY PHILADELPHIA HOSPITAL IN PATIENTS WITHOUT HIV

SESSION TITLE: Chest Infections 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Nontuberculous mycobacterium (NTM) are free-living organisms that are ubiquitous in the environment, however the importance of NTM disease in humans is increasingly evident. As NTM is a non-reportable disease and as environmental exposure is dependent on geographical areas, the incidence and risk factors of NTM in our area are ill-defined. This study is to help us determine the incidence of NTM in inner Philadelphia in those without HIV infection, the risk factors which lead to disease and the speciation related to the different diseases. METHODS: We conducted a retrospective study of patients without known HIV infection who had an AFB culture positive from 2016 to 2017. Patients with blood cultures or tissue biopsy positive for NTM were concluded to have disease; respiratory disease was considered if they met ATS guidelines: 1. chest radiograph or, in the absence of cavitations, chest high-resolution computed tomography; 2. Positive cultures from sputum samples or one bronchial wash; and 3. Exclusion of other disorders, such as TB. The data was collected from cultures at Hahnemann University Hospital in Philadelphia. This was an IRB study. RESULTS: From 2016-2017, there were 87 total patients who were identified to have NTM positive cultures, of which 61 were in patients who were not infected with HIV, of those 42 were identified to have an active NTM infection. Demographics include: average age 57, 27 males and 15 females, and 20 White, 14 Black, 5 Asian and 3 Hispanic patients. Out of the 42 infections, there were 36 respiratory infections, 3 positive tissue cultures, 2 positive blood cultures and 1 urinary culture. Species identified included 33 cultures positive for MAC, 4 cultures M. abscessus, 3 cultures M. bolletii, 2 cultures each of M. chelonae and M. kansasii, and 1 culture each for M. xenoxpix and M. szulgai. Coexisting medical illnesses included 24 with underlying lung disease, 6 patients immunocompromised, 4 patients with cancer, 3 transplant patients and 6 with no underlying medical illness. There were 3 patients on immunosuppressants, 2 on steroids, 1 on chemotherapy and 1 on an immunomodulator. There were patients who occasionally had >1 NTM in the AFB culture, more than one source of culture positivity or more than one underlying medical co-illness. CONCLUSIONS: Although MAC was shown to be the most prevalent in the community, 31% of cultures grew disease causing NTM species other than MAC with the next most common being M. abscessus and M. bolletii. It is important to note that in those with underlying lung disease, various species of NTM can be attributed to disease and should be treated. CLINICAL IMPLICATIONS: This small study gives us an insight into the types of infections and the speciation of those with disease that is prevalent in this community. Although MAC being the most common, patients with other infectious NTM species should be considered for treatment also. DISCLOSURES: No relevant relationships by Janpreet Mokha, source=Web Response No relevant relationships by Ekamjeet Randhawa, source=Web Response No relevant relationships by Michael Stephen, source=Web Response