Cavitary Lung Lesions Research Articles

Pulmonary Actinomycosis and Multiple Cavitary Lung Lesions in a Patient Previously Reported with Pulmonary Candidiasis: A Case Report

This paper presents the case of a 43 years old patient admitted three times to the Pneumology Department with productive cough, asthenia,
 important weight loss, and fever. His chest CT showed multiple pulmonary cavities growing over time, ground-glass opacities, and pleural effusion. Clinical symptoms and radiological signs were highly suggestive of tuberculosis, but he tested negative multiple times. Candida spp. was diagnosed through bronchial washing and treated. After a few months, the patient comes back with worsened symptoms and is diagnosed with pulmonary actinomycosis.

A curious case of exploding cannonball

Pulmonary cavitary lesions with pneumothorax are very common in chest imaging and usually pose diagnostic challenge to clinicians Pneumothorax with a cavitary lesion is a rare occurrence in primary and metastatic lung cancer. A 40-year-old male presented with cough with whitish expectoration, right loin pain, loss of weight and appetite for 3 months and difficulty in breathing for 2 days. Chest x-ray was suggestive of right-side pneumothorax with bilateral nodular opacities in all zones. Contrast-enhanced computed tomography (CECT) thorax and abdomen revealed a non-homogenous large mass in the right kidney with hydronephrotic changes with cavitary lesions in bilateral lungs. Urine cytology was suggestive of urothelial carcinoma. Thus, a diagnosis of urothelial cancer with cavitating metastasis leading to secondary spontaneous pneumothorax was made. Herein, we aim to highlight that cavitating metastasis should be considered in a case of pneumothorax with bilateral lung nodules.

Diagnosing and treating Mycobacterium kansasii.

This article describes an 18-year-old immunocompetent patient who developed Mycobacterium kansasii, manifested with shortness of breath and a cavitary lung lesion seen on radiograph. Initial sputum smears were negative; however, after 2 weeks, the cultures grew M. kansasii and the patient was started on an antimycobacterial regimen.

SEVERE COVID-19 ASSOCIATED WITH ADVANCED FORMS OF PULMONARY TB DISEASE IN AN ENDEMIC AREA OF ROMANIA

TYPE: Abstract TOPIC: Lung Pathology PURPOSE: of the study consisted in assessing the prevalence and severity of COVID-19 among patients diagnosed with pulmonary tuberculosis (PTB) in an endemic Romanian TB area. METHODS: A prevalence study, performed in a Pneumology Hospital, during COVID-19 pandemic year, 2020, from March to December, included 128 PTB patients, tested by real-time polymerase chain reaction SARS CoV2. Confirmed COVID-19 patients were evaluated for severity of both diseases. RESULTS: The prevalence of COVID-19 among hospitalized PTB patients was 8.59% (n=11/128). The association was frequent reported in males (n=8/11; 72.72%), smokers (72.72%) and elderly (n=4/11; 36.36%). Moderate to severe forms of COVID-19 were predominantly diagnosed (n=6/11; 54.54%) and death outcome was reported in 2 males (18.18%) with cavitary PTB, but no other comorbidities. Positive smears and/or cultures for Mycobacterium tuberculosis (n=7/11; 63.63%) were mostly associated with cavitary lung lesions. Miliary TB with positive smears was reported in a single case of a 49 year-old alcoholic male. CONCLUSIONS: The risk of interaction between PTB and COVID-19 is high among males, elderly and smokers. Delayed diagnosis of advanced contagious forms of hospitalized PTB could be a possible risk factor of SARS CoV2 infection's increased severity and death. CLINICAL IMPLICATIONS: The immunological and epidemiological interactions between PTB and COVID-19 are still debating. It seems a dual risk of SARS CoV2 infection is capable to reactivate PTB disease and TB is capable to aggravate the evolution of COVID-19. Screening of tuberculosis disease is mandatory among all COVID-19 patients especially in endemic TB areas and vice versa. DISCLOSURE: Nothing to declare. KEYWORD: COVID-19

A RARE CASE OF TRIPLE PNEUMONIA: TB, COCCIDIOIDOMYCOSIS, AND COVID-19

TYPE: Late Breaking Case Report TOPIC: Chest Infections INTRODUCTION: This is a case of concurrent pulmonary infections with mycobacterial tuberculosis, coccidioidomycosis, and SARS-COV-2 in an otherwise immunocompetent host. CASE PRESENTATION: A 62-year-old male with no known medical history presented with three weeks history of worsening non-productive cough, dyspnea and pleuritic chest pain with associated small volume hemoptysis, twelve-pound weight loss, intermittent fevers and night sweats. The patient’s vital signs were normal except for a temperature of 38.2C. Physical exam showed a well-nourished man with no abnormal findings. Initial labs were significant for pancytopenia, a positive COVID PCR nasopharyngeal swab, and negative HIV. Chest x-ray showed bilateral opacities and a subsequent computed tomography angiogram of chest showed bilateral multiple thick-walled cavitating lung lesions in the upper lobes and bilateral scattered ground glass opacities suggestive of COVID pneumonia. Further work-up resulted in induced sputum showing acid fast bacilli which speciated Mycobacterium tuberculosis 3 weeks later. Serology revealed positive IgM antibodies to Coccidioides by quantitative immunodiffusion and negative IgG by complement fixation. Cocci-Direct PCR was negative twice. Fungal culture from induced sputum grew Paecilomyces formosus. DISCUSSION: The patient likely had both these conditions and more recently acquired SARS-COV-2. There is no literature regarding a triple infection but, an excellent case series was done by Cadena et al that looked at 44 cases of PTB/Coccidioidomycosis co-infection. They found a significantly higher mortality rate compared to monoinfection. Such a coinfection in a patient with severe COVID-19 could become potentially devastating. CONCLUSIONS: Treatment was initiated with rifampin, isoniazid, pyrazinamide, ethambutol, and fluconazole. He was discharged in good health. DISCLOSURE: Nothing to declare. KEYWORD: Coccidioidomycosis

Cavitary lung disease in hospitalized patients: Differences between melioidosis and tuberculosis.

To differentiate cavitary lung lesions caused by melioidosis and tuberculosis is challenging, especially in endemic countries. A study with a matched-sampling method (16 cavitary pulmonary melioidosis vs. 16 cavitary pulmonary tuberculosis) showed characteristics of bacterial infection more obvious and severe in the melioidosis patients, which were useful to distinguish two conditions.

Chronic COVID 19 Related Disease Requiring Lung Transplantation with Calcified Cavitary Lesions in Explanted Lungs

IntroductionBilateral cavitary lung lesions with calcification in a patient with chronic COVID requiring transplantation are described.Case Report46-year-old woman presented for lung transplant with respiratory failure due to COVID-19 pneumonia following remdesivir, decadron, tocilizumab and baricitinib therapy. Cavitary upper lobe lung lesions were noted on imaging with negative cultures. She was started on VV ECMO as a bridge to bilateral lung transplant. Explanted lungs were consolidated and fibrotic with bilateral upper lobe calcification surrounding cavitary lesions. Varied microscopic pathology included NSIP pattern of inflammation, and foci of airway centered inflammation with giant cells suggesting chronic hypersensitivity reaction. The calcification was reminiscent of dendriform/metastatic calcification, and involved areas of necrotic/mummified parenchyma.SummaryCavitation as a late stage complication of COVID19 has been described in rare cases and is considered atypical. The constellation of findings in our case, including cavitary lesions with associated dendriform like calcifications are unique and maybe attributable to COVID19 itself +/- exacerbation of underlying chronic lung disease +/- intercurrent infection, or COVID19 related cavitation with superimposed secondary changes due to ECMO treatment. Bilateral lung transplantation has a reasonable short-term prognosis for patients with end stage respiratory failure secondary to COVID19; examination of these native lungs may expand our concept of COVID19 related chronic lung injury patterns.

Pulmonary Amyloidoma: A Rare Entity Complicating a Post-Heart Transplant Course

<h3>Introduction</h3> Heart transplantation (HT) is a viable, life-prolonging therapy for patients with severe cardiac amyloidosis. Unique amyloid-related pathology may complicate their care. We present a case of a rare manifestation of amyloidosis complicating a post-HT course. <h3>Case Report</h3> A 51-year-old female with cardiac AL amyloidosis (treated with daratumumab, cyclophosphamide, bortezomib, and dexamethasone) and chronic kidney disease was transferred for advanced options evaluation. She presented in cardiogenic shock and PEA arrest requiring escalation to venoarterial-ECMO. Admission sputum culture was positive for <i>Enterobacter cloacae</i>. CT scan revealed right lower lobe consolidation with a 5cm cavitary lesion concerning for aspiration pneumonia. Broad spectrum antibiotics were initiated. Given near-complete resolution of her light chains on chemotherapy, Oncology agreed to proceed with transplantation. She was emergently listed as status 1 and underwent heart-kidney transplantation. One-week post-HT, she developed severe leukocytosis and abdominal discomfort but remained afebrile with only mild dyspnea. Abdominal CT incidentally noted an 11cm right lower lobe cavitary lung lesion. Dedicated CT chest raised concern for aspergilloma or other necrotizing pneumonia (Figure 1). Bronchoalveolar lavage had unremarkable fungal and viral studies but did reveal <i>Acinetobacter</i>. Antibiotics were appropriately adjusted. VATS was attempted but required conversion to thoracotomy with right lower lobectomy. Pathology revealed necroinflammatory findings and Congo-red stain-positive material both inside the cavity and extensively deposited within the cavity walls. These findings were consistent with pulmonary amyloidoma. <h3>Summary</h3> Though rare, pulmonary amyloidomas may be incidentally found as large cavitating lesions amongst patients with systemic amyloidosis. In the post-HT patient, they may serve as a nidus for infections and appear similar to necrotizing pneumonias, resulting in delays in diagnosis.

The rising burden of invasive fungal infections in COVID-19, can structured CT thorax change the game

BackgroundThe occurrence of invasive fungal infections in COVID-19 patients is on surge in countries like India. Several reports related to rhino-nasal-sinus mucormycosis in COVID patients have been published in recent times; however, very less has been reported about invasive pulmonary fungal infections caused mainly by mucor, aspergillus or invasive candida species. We aimed to present 6 sputum culture proved cases of invasive pulmonary fungal infection (four mucormycosis and two invasive candidiasis) in COVID patients, the clues for the diagnosis of fungal invasion as well as difficulties in diagnosing it due to superimposed COVID imaging features.Case presentationThe HRCT imaging features of the all 6 patients showed signs of fungal invasion in the form of cavities formation in the pre-existing reverse halo lesions or development of new irregular margined soft tissue attenuating growth within the pre-existing or in newly formed cavities. Five out of six patients were diabetics. Cavities in cases 1, 2, 3 and 4 of mucormycosis were aggressive and relatively larger and showed relatively faster progression into cavities in comparison with cases 5 and 6 of invasive candidiasis.ConclusionIn poorly managed diabetics or with other immunosuppressed conditions, invasive fungal infection (mucormycosis, invasive aspergillosis and invasive candidiasis) should be considered in the differential diagnosis of cavitary lung lesions.

Rhodococcus equi Related Bacteremia and Cavitary Lung Lesion in a Patient Receiving Renal Transplant: A Rare Case Report

Rhodococcus equi Related Bacteremia and Cavitary Lung Lesion in a Patient Receiving Renal Transplant: A Rare Case Report

Rapidly evolving cavitary lung lesion in a patient with severe COVID-19-An atypical pulmonary manifestation with the review of literature

The cavitary lesions in the lungs are rare radiological findings in patients infected with COVID-19. The most common causes for such lesions are secondary infections with either bacterial, fungal, or viral pathogens, preexisting malignancy, or autoimmune diseases. In our patient, none of the above-mentioned obvious reasons could be found. Pulmonary embolism and lung infarction have also been observed to be possible causes in COVID-19 patients. The persistent positivity of nasopharyngeal swab sample for coronavirus disease by reverse transcriptase-polymerase chain reaction test, clinical and laboratory evidence of thromboembolic phenomenon suggested the lesion to be a result of a complication of the COVID-19 infection with a possible microangiopathic mechanism.

1303. A Rare Case of Legionella micdadei Lung Abscess in an Immunocompromised Patient

Abstract Background Legionella micdadei is the most common legionella species causing infection after L. pneumophila. It usually causes infection in immunocompromised hosts and leads to nodules with tendency to cavitate. It is difficult to culture which makes diagnosis challenging. We report a case or L. micdadei in an immunocompromised host with cavitary pneumonia. Methods Case Report. An 82 year-old female presented with upper abdominal pain for one day duration. She has history of hypertension, coronary artery disease, hyperlipidemia, heart failure, and hypothyroidism. She was diagnosed with hypersensitivity pneumonia 5 months prior, treated with prednisone (40 mg daily). The pain was not associated with nausea, vomiting or diarrhea. She was found with hypoxia despite she denied shortness of breath, cough, hemoptysis or chest pain. There was no fever, chills, headache, myalgia or upper respiratory symptoms. She was afebrile, tachycardic 134/min and hypoxic to 88% on room air. White cell count was 22x10(3) /mcL (90% neutrophils), hemoglobin was 10.4 g/dL, creatinine was 1.23 mg/dL and lactic acid was 3.6 mmol/L. Chest CT scan showed left lower lobe cavitary lesion with surrounding infiltrates (image 1). Quantiferon gold, serum galagtomannan, B-D-glucan, and vasculitis work-up were negative. Bronchoscopy showed a patent airway. Bronchial smears and cultures were negative for bacteria, fungi and mycobacteria. The patient was treated with ceftriaxone and metronidazole with de-escalation to amoxicillin/clavulanate. Bronchial culture was positive for legionella micdadei after discharge, azithromycin was added. Image 1. Cavitary lesion on thoracic CT Results Our patient was considered immunocompromised given steroid use, predisposing her for L. micdadei infection. L. micdadei is considered an opportunistic infection and was reported in hematologic malignancy population. It can cause an invasive lung disease with lung cavities. It needs special media for growth making it difficult to diagnose especially it is not detected by legionella urine antigen. Conclusion L. micdadei should be considered in the differential diagnosis for cavitary lung lesions in immunocompromised patients. Disclosures All Authors: No reported disclosures

Hodgkin’s Lymphoma Presenting as Multiple Cavitary Lung Lesions

Hodgkin Lymphoma (HL) typically presents similarly to an infectious etiology, thus awareness of its atypical presentations is essential. We present a case of an adult woman who was found to have HL after presenting with a dry, non-productive cough and showing cavitary lesions on chest computed tomography (CT). We also describe the clinical, laboratory, and radiological workup done leading to the diagnosis and management of HL in a critical care setting.

Hodgkin's Lymphoma Presenting as Multiple Cavitary Lung Lesions.

Hodgkin Lymphoma (HL) typically presents similarly to an infectious etiology, thus awareness of its atypical presentations is essential. We present a case of an adult woman who was found to have HL after presenting with a dry, non-productive cough and showing cavitary lesions on chest computed tomography (CT). We also describe the clinical, laboratory, and radiological workup done leading to the diagnosis and management of HL in a critical care setting.LEARNING POINTSCavitary lung lesions, particularly multiloculated, are often caused by mycobacterium tuberculosis (TB), aspergillosis, granulomatosis with polyangiitis, sarcoidosis, and rheumatic nodules.Pulmonary infiltration is a rare disorder of an extra-nodal site in Hodgkin’s Lymphoma. The mediastinum and head and neck regions remain the most common sites affected by HL.Radiologically, primary pulmonary HL may mimic pneumonia, carcinoma making the diagnosis unclear.

DISSEMINATED NOCARDIOSIS PRESENTING AS ACUTE LIVER FAILURE AND INTRAPARENCHYMAL HEMORRHAGE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Nocardiosis is an opportunistic infection that most commonly manifests as pulmonary disease. Disseminated nocardiosis is rare and is associated with high mortality. We present a case of a woman with disseminated nocardiosis presenting with acute liver failure complicated by intraparenchymal hemorrhage. CASE PRESENTATION: A 30-year-old woman with a history of alcohol abuse presented with jaundice, bloating, and diarrhea for 2 weeks. Laboratory examination revealed hemoglobin of 5.2 g/dL, platelets 60,000/µL, INR 3.4, AST 113 U/L, ALT 38 U/L, and total bilirubin of 30 mg/dL. MRCP revealed a normal biliary tree, nodular liver contour and evidence of portal hypertension. Acetaminophen level and acute viral hepatitis panel were negative. HIV serology and autoimmune hepatitis panel were negative. Chest CT revealed a 5 x 3.5 cm subpleural mass in the left upper lobe with areas of gas density (Fig 1). Her hospital course was complicated by a rapid deterioration in mental status and DIC. Head CT revealed an acute left occipital-parietal intraparenchymal hemorrhage. She was intubated and transferred to the ICU. Bronchoscopy with BAL grew Nocardia otitidiscaviarum. Brain MRI revealed FLAIR signal hyperintensity lining the ventricles, concerning for ventriculitis or abscess (Fig 2). An external ventricular drain was placed for interval development of hydrocephalus. The patient received IV trimethoprim-sulfamethoxazole and intrathecal amikacin. Given her poor prognosis, her family elected to withdraw care. DISCUSSION: Nocardia is a branching, filamentous gram-positive bacilli found ubiquitously in soil. Infection usually occurs by inhalation of aerosolized bacteria resulting in predominant lung involvement with potential hematogenous spread to other organs. Patients with impaired T-cell mediated immunity, such as HIV, chronic steroid use, diabetes, or alcoholism are at risk of developing severe infection. Our patient had a longstanding history of heavy alcohol use, likely predisposing her to disseminated infection. Nocardiosis is considered disseminated when two or more nocardial abscesses are found at two or more locations. Up to 20% of all Nocardia infections involve the brain. Current guidelines recommend imaging of the brain for any patient with confirmed or suspected pulmonary nocardiosis. Prognosis is usually poor, and mortality can be as high as 64%. First-line treatment is trimethoprim-sulfamethoxazole. However some species, such as N. otitidiscaviarum found in our patient, are occasionally resistant. Due to suspected CNS involvement, dual coverage was recommended with the addition of IV amikacin at dosing for CNS penetrance. CONCLUSIONS: In patients presenting with a cavitary lung lesion and associated brain lesion, nocardiosis should be considered in the differential. Early brain imaging may be warranted in patients presenting with severe disease. REFERENCE #1: Pulmonary nocardiosis: risk factors and outcomes. AU Martínez Tomás R, Menéndez Villanueva R, Reyes Calzada S, Santos Durantez M, Vallés Tarazona JM, Modesto Alapont M, Gobernado Serrano M SO Respirology. 2007;12(3):394. REFERENCE #2: Conville PS, Witebsky FG. Nocardia, Rhodococcus, Gordonia, Actinomadura, Streptomyces, and other Aerobic Actinomycetes. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, editors. Manual of Clinical Microbiology. 9th ed. Washington, DC: ASM Press; 2007. p. 515. DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by Abdul Rahman Halawa, source=Web Response No relevant relationships by MAYKEL IRANDOST, source=Web Response no disclosure on file for Sean Marco; No relevant relationships by Andrew Talon, source=Web Response No relevant relationships by Anthony Vaccarello, source=Web Response

DOES THICKNESS REALLY MATTER? DIAGNOSTIC DILEMMAS IN CAVITARY LESIONS

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: A pulmonary cavity is a gas-filled space seen as a lucency within a pulmonary consolidation, a mass, or a nodule. The differential for a solitary cavity of the lung includes anaerobic lung abscess, fungal infections, tuberculosis and malignancy. Wall thickness <4 mm has been shown to be caused by benign processes while thickness >15 mm are usually malignant. We describe the case of a former smoker in whom an infection was masking a cavitary squamous cell carcinoma of the lung. CASE PRESENTATION: A 75 year-old former smoker presented to the ER with hemoptysis for 1 week. He was afebrile with BP 90/50 and HR 124. WBC count was 17.8K/L. CT Chest revealed a 9.7 cm irregular cavitary mass in the right upper lobe of the lung with thick walls measuring 29 mm and evidence of invasion into the right hilum and chest wall causing rib fractures. Exam was significant for foul-smelling breath and poor dentition with gross aspiration while lying flat. Bronchoscopy demonstrated thick purulent secretions in the RUL and advancement into RUL takeoff with the bronchoscope led directly inside the cavity, revealing thick, friable walls. BAL and endobronchial brushings were obtained. Given patient's risk factors for aspiration and imaging findings, there was concern for possible anaerobic lung abscess. BAL cultures were polymicrobial. He received antibiotics and improved. However, BAL cytology and endobronchial brushing demonstrated malignant cells. Pathology from a CT-guided biopsy of the lesion confirmed squamous cell carcinoma of the lung. DISCUSSION: Several features of our patient's clinical presentation were suggestive of anaerobic lung abscess including aspiration, poor dentition, halitosis and leukocytosis. However, primary lung cancer remains the most frequent cause of a solitary cavitary lung lesion. Squamous cell carcinoma is the most common subtype to cavitate due to tumoral necrosis, in up-to 82% of patients. Features that can raise suspicion for malignancy as an etiology of a lung cavity include thickness of cavity wall >15 mm with irregular internal contours, upper lobe location and chest wall invasion, all of which were present in our patient. Our case highlights the importance of maintaining a high index of suspicion for underlying malignancy in smokers with cavitary lesions, despite an overwhelming clinical picture of infection. CONCLUSIONS: Cavitary lung lesions with high-risk radiological features such as wall thickness>15 mm should prompt accelerated work-up for malignancy to minimize high morbidity and mortality. REFERENCE #1: Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, Brown KK, Mehta A, Husta B, Ryu JH, Sarosi GA, Franquet T, Verschakelen J, Johkoh T, Travis W, Raoof S. Cavitary Lung Diseases: A Clinical-Radiologic Algorithmic Approach. Chest. 2018 Jun;153(6):1443-1465. doi: 10.1016/j.chest.2018.02.026. Epub 2018 Mar 6. PMID: 29518379. DISCLOSURES: No relevant relationships by Roxanne GarciaOrr, source=Web Response No relevant relationships by Sumit Patel, source=Web Response No relevant relationships by Nehan Sher, source=Web Response

GET THE MUNKII OFF YOUR BACK! A RARE BLACK MOLD CAPRONIA MUNKII CAUSING INVASIVE FUNGAL INFECTION IN AN IMMUNOCOMPROMISED INDIVIDUAL

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Individuals receiving chemotherapy or undergoing transplantation are increasingly susceptible to invasive fungal infections. They are commonly caused by opportunistic pathogens like Aspergillus and Candida and are associated with high morbidity and mortality. Such individuals are also susceptible to invasive mold infections. We present a rare case of a black mold Capronia munkii causing cavitary lung lesions in a patient with NHL. CASE PRESENTATION: A 65-year-old female with non-Hodgkin's Lymphoma, CNS lymphoma treated with chemotherapy and autologous stem cell transplant five years ago, had progression of disease last year. She began Ibrutinib therapy for her lymphoma. She was admitted to the hospital for altered mental status due to progression of CNS disease. She developed worsening respiratory failure during hospitalization requiring intubation and mechanical ventilation. She was empirically treated with intravenous vancomycin and piperacillin-tazobactam. Her initial infectious workup and lumbar puncture was negative. Computed tomography (CT) of her chest showed new diffuse ground glass opacities.Bronchial wash was notable for black mold Capronia munkii. She was started on Voriconazole and Amphotericin B. Repeat CT chest showed improving opacities with increasing apical cystic lesions. Respiratory failure can be attributed to mold infection in the lung, immunotherapy-induced pneumonitis and organizing pneumonia. After multiple failed spontaneous breathing trials and septic shock necessitating vasopressors, she was transitioned to comfort care and subsequently expired. DISCUSSION: Capronia munkii is a saprotrophic yeast commonly found on decaying plant matter. There is a lack of clinical information on this mold in literature. It is closely related phylogenetically to Exophiala dermatides which is a neurotrophic black mold. It typically causes a non-specific granulomatous inflammatory response. The host responses are highly variable, and include pulmonary cyst formation and tissue necrosis. The patient's immunosuppression and cystic lesions on CT scan make invasive black mold infection likely. Biopsy of the cavitary lesions to determine the presence of mold would have been confirmatory. The lack of response to anti-fungal treatment reiterates the high mortality associated with this rare infection. CONCLUSIONS: Invasive fungal infections have become more prevalent due to increasing number of individuals undergoing transplantation or receiving aggressive immunosuppression and chemotherapy. Early diagnosis and prompt treatment of uncommon pathogens like black mold with appropriate azole and caspofungin antibiotics is essential to prevent poor outcomes. Newer molecular techniques such as 18S ribosomal RNA PCR and genome sequencing have led to improved diagnosis.Treatment algorithms should be adapted to accommodate changing epidemiologies and anti-fungal drug resistance patterns. REFERENCE #1: Bassetti M, Bouza E. Invasive mould infections in the ICU setting: complexities and solutions. J Antimicrob Chemother. 2017 Mar 1;72(suppl_1):i39-i47. doi: 10.1093/jac/dkx032. PMID: 28355466. REFERENCE #2: Enoch DA, Yang H, Aliyu SH, Micallef C. The Changing Epidemiology of Invasive Fungal Infections. Methods Mol Biol. 2017;1508:17-65. doi: 10.1007/978-1-4939-6515-1_2. PMID: 27837497. REFERENCE #3: Badiee P, Hashemizadeh Z. Opportunistic invasive fungal infections: diagnosis & clinical management. Indian J Med Res. 2014 Feb;139(2):195-204. PMID: 24718393; PMCID: PMC4001330. DISCLOSURES: No relevant relationships by Padmastuti Akella, source=Web Response No relevant relationships by Saira Imran, source=Web Response No relevant relationships by Shashank Nuguru, source=Web Response

LATENT MYCOBACTERIUM TB REACTIVATION IN TWO PATIENTS WITH COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Since December 2019, the world has been suffering from the pandemic of the new coronavirus (COVID-19) with a significant mortality rate. It mainly affects the respiratory system with a wide severity range from being asymptomatic to causing severe acute respiratory distress syndrome (ARDS). Few case reports have reported pulmonary tuberculosis co-infection or reactivation in COVID-19 pneumonia patients(1-2). We present two cases of COVID-19 pneumonia who presented, after the resolution of the acute symptoms, with shortness of breath and were found to have pulmonary cavities, suspicious for tuberculosis (TB). CASE PRESENTATION: Case 1: 76-year-old Brazilian male with multiple comorbidities including COPD on home oxygen, who received the monoclonal antibody infusion (Bamlanivimab) a month ago for mild COVID-19 pneumonia, presented with generalized weakness associated with fever and cough. CT chest showed extensive peribronchiolar and centrilobular patchy and nodular opacities with internal cavities (Figure 1 Right). A previous chest x-ray showed left basal lung scarring (Figure 1 left). Case 2: 71-year-old Columbian male with a history of diabetes mellitus and COVID-19 pneumonia treated with dexamethasone and remdesivir for 10 days, presented 3 months later with dyspnea, fever, and productive cough. X-ray and CT chest showed diffuse nodular opacities with dense consolidation in both upper lobes associated with areas of cavitations (Figure 2 Right). A previous chest x-ray did not show any evidence of prior lung pathologies (Figure 2 Left). Bronchial washing PCR was positive for mycobacterium tuberculosis in both cases. DISCUSSION: Cavitary lung lesions are usually caused by mycobacterial, fungal, neoplastic, or autoimmune pathologies. Viral pneumonia, including SARS-CoV and MERS-CoV, is not a common cause of lung cavities even in severe viral infections (3). Although few case reports have reported cavitary lesions as sequelae of COVID-19 pneumonia, common causes should be excluded first. The two most common CT chest findings in COVID-19 patients are ground-glass opacities and bilateral patchy shadowing (4). The presence of lung cavities in such patients should raise the suspicion of TB, especially in high-risk patients. Whether or not the immune system reaction to the COVID-19; including leukopenia, lymphopenia, and an inflammatory cytokine storm can lead to latent TB reactivation is not fully understood yet. However, treatment of COVID-19 with immunosuppressant drugs such as corticosteroids could be a risk factor for TB reactivation. Both of our patients had new lung cavitary lesions with confirmed mycobacterial infection. CONCLUSIONS: Pulmonary cavities in COVID-19 pneumonia patients should raise the suspicion of other pathologies such as tuberculosis, especially in high-risk patients. REFERENCE #1: 1.Tham, S.M., et al., Four Patients with COVID-19 and Tuberculosis, Singapore, April-May 2020.Emerg Infect Dis, 2020. 26(11): p. 2764-2766.10.1056/NEJMoa2002032. REFERENCE #2: 2. Torre, A., et al., Preliminary observations on IGRA testing for TB infection in patients with severe COVID-19 eligible for immunosuppressive therapy. Respir Med, 2020. 175: p. 106204. REFERENCE #3: 3. Zoumot Z, et al. Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease. BMC Pulm Med 21, 24 (2021). https://doi.org/10.1186/s12890-020-01379-14. Guan WJ, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020; 382:1708-1720. DOI: 10.1056/NEJMoa2002032. DISCLOSURES: No relevant relationships by Sherif Elkattawy, source=Web Response No relevant relationships by Muhammad Atif Noori, source=Web Response No relevant relationships by onyeka Nwachukwu, source=Web Response No relevant relationships by John Viechweg, source=Web Response No relevant relationships by Islam Younes, source=Web Response

COVID‐19‐associated subacute invasive pulmonary aspergillosis

BackgroundThough invasive pulmonary aspergillosis is a well known complication of COVID‐19 pneumonia, indolent forms of aspergillosis have been rarely described.MethodsWe prospectively collected the clinico‐radio‐microbiological data of 10 patients of subacute invasive pulmonary aspergillosis (SAIA), who presented to our hospital with recent history of COVID‐19 pneumonia along with cavitary lung disease, positive IgG (against Aspergillus) with or without positive respiratory samples for Aspergillus spp.ResultThe mean age of presentation of SAIA was 50.7 ± 11.8 years. All the patients had recently recovered from severe COVID‐19 illness with a mean duration of 29.2 ± 12 days from COVID‐19 positivity. Cough was the predominant symptom seen in 8/10 (80%) patients followed by haemoptysis. 7/10 (70%) patients were known diabetic. While serum galactomannan was positive in 5/9 patients (55.5%), fungal culture was positive in 2/7 patients (28.5%) and polymerase chain reaction (PCR) for Aspergillus was positive in three patients. Eight (80%) patients presented with a single cavitary lesion; pseudoaneurysm of pulmonary artery was seen in two patients and post‐COVID‐19 changes were seen in all patients. All patients were treated with voriconazole, out of which four (40%) patients died during the follow‐up period.ConclusionSAIA should be considered in the differential diagnosis of cavitating lung lesions in patients with recent history of COVID‐19 in the background of steroid use with or without pre‐existing diabetes.

The role of computed tomography hounsfield unit values in the differentiation of benign and malignant cavitary lung lesions

The role of computed tomography hounsfield unit values in the differentiation of benign and malignant cavitary lung lesions