Computed Tomography Angiogram Of Chest Research Articles

Primary pulmonary T-cell lymphoma mimicking asthma and community-acquired pneumonia: a rare case report

Primary pulmonary T-cell lymphoma (PPTL) is a rare disease. Diagnosing PPTL is challenging due to non-specific clinical symptoms and imaging. A 32-year-old female presented with persistent fever, cough, and dyspnoea. The symptoms were initially treated as asthma and community-acquired pneumonia without improvement. Chest computed tomography (CT) revealed bilateral consolidations with a CT angiogram sign, and flexible bronchoscopy showed infiltrative lesions causing bronchial stenosis. Histopathological examination of the tissue biopsy identified T-cell lymphoma through immunohistochemical staining positive for CD3. This case highlights the importance of considering differential diagnoses such as PPTL in patients with atypical presentations of asthma or non-resolving pneumonia. This case also demonstrates the diagnostic utility of flexible bronchoscopy in identifying airway obstruction due to malignant cells, which can mimic asthma.

Asymptomatic bradycardia as a manifestation of intermediate high-risk pulmonary embolism

Progressively worsening dyspnea as an initial manifestation of an intermediate high-risk pulmonary embolism (PE) is a readily reported life-threatening cardiac emergency. Atypical presentation of PE may make the initial diagnosis challenging and is often the reason it is missed by clinicians. A 60-year-old woman with asymptomatic bradycardia presented with shortness of breath and dizziness. On examination, she was noted to have a heart rate of 40 beats per minute (bpm) which slightly improved to 55 bpm after intravenous (IV) fluids were administered. A transthoracic echocardiogram (TTE) showed evidence of severe right ventricular strain. Chest computed tomography angiogram (CTA) confirmed PE. After percutaneous aspiration thrombectomy, she was transitioned to direct oral anticoagulant (DOAC) from a heparin infusion and discharged on oral anticoagulation. Notably, her hospital course was marked by labile cycles between normotension and hypertension, with blood pressures exceeding 200/100 mmHg. The possibility that hypertensive states may prevent hemodynamic deterioration and a resulting high-risk pulmonary embolism is considered in patients presenting with multiple risk factors for thromboembolism.

Pulmonary embolism complicated by tamponade revealing metastatic lung cancer in a woman pregnant with twin: about a case report.

The authors report the case of a 38-year-old patient, with a twin pregnancy of 16 weeks, complicated by proximal and distal peripheral venous thrombosis of the left lower limb under low molecular weight heparin therapy at a curative dose. A week later, the patient presented to the emergency room with respiratory distress associated with chest pain and low-abundance metrorrhagia. The obstetrical ultrasound performed confirmed the vitality of only one of the two foetuses. The transthoracic ultrasound objectified a very abundant pericardial effusion producing a tamponade, which was drained percutaneously and whose cytological study revealed a liquid rich in tumour cells. After the unfortunate death of the second twin and an endouterine evacuation, a chest computed tomography angiogram demonstrated a bilateral proximal pulmonary embolism associated with bilateral moderate pulmonary effusion as well as multiple thrombosis and secondary aspect liver lesions with a suspicious parenchymal lymph node of the upper lung lobe. A liver biopsy concluded to a secondary hepatic localization of a moderately differentiated adenocarcinoma whose immunohistochemical complement revealed a pulmonary origin. A multidisciplinary consultation meeting leaned towards treatment with neoadjuvant chemotherapy. The patient died 7 months later. Venous thromboembolic disease is more common in pregnant women. Delayed diagnosis is common in these cases, resulting in a high rate of locally advanced or metastatic disease. Since the treatment of pregnancy-associated cancer does not rely on a standardized approach, the decision on how to proceed must be made by a multidisciplinary team. The cornerstone of management remains to find the balance between treating the mother as well as possible while preventing the foetus from the possible harm of cytotoxic drugs frequently used to treat lung cancer. Because of the delayed diagnosis, the maternal prognosis often remains poor.

Answer: Acute dyspnoea with an unusual mass in the right ventricle.

What is the most likely diagnosis? ... Chest computed tomography angiogram showed dense, bilateral pulmonary embolism compatible with cyanoacrylate remnants which is used to obliterate varices. Cyanoacrylate is a monomer, which polymerizes fast when in contact with blood to form a strong glue. There are already clues to the aetiology of the mass on transthoracic echocardiography (Figure 1 and see Supplementary material online, Videos S1–S4). A history of drug abuse is a risk factor for endocarditis of the tricuspid valve, but vegetations tend to be irregular shaped with myocardial like grey scale. Furthermore, they are typically attached on the low-pressure side of atrioventricular valves. A papillary fibroelastoma is mostly localized downstream and would display a well-demarcated border with digitations but will rarely exceed a size of 3 cm as seen in this case (Figure 1A and B and see Supplementary material online, Videos S1 and S2), making it less plausible.1 A thrombus is less likely because it is frequently multi-lobulated and hypoechogenic in the acute phase.

Pulmonary Embolism in Critically Ill COVID-19 And Non-COVID-19 Patients: Systematic Analysis of Risk Factors, Diagnostic and Management Strategies, and Prognosis.

Background: Coronavirus disease of 2019 or COVID-19 is characterised by two main features: the first is the respiratory compromise which corresponds to acute respiratory distress syndrome while the second corresponds to the state of hypercoagulability responsible for thromboembolic complications particularly pulmonary embolism which is the subject of this work. Indeed, a high prevalence of pulmonary embolism has been reported throughout the pandemic period with a significant morbidity and mortality. This reflects the severity of this life-threatening emergency chiefly in the elderly, hemodynamically unstable patients, and patients with severe underlying conditions, mainly cardio-pulmonary comorbidities. The aim of our study is to point out the incidence, the risk factors, the clinical and paraclinical features, the management strategies, and the overall prognosis of pulmonary embolism in critically ill COVID-19 and non-COVID-19 patients. Patients and methods: It is a retrospective observational study carried out over a two-year-period from January 2019 (non-COVID-19) to December 2020 (COVID-19). Over the study period, 42 cases of COVID-19 and non-COVID-19 pulmonary embolism were collected from an overall set of 611 patients admitted to the medical intensive care unit of the IBN ROCHD university hospital of Casablanca. Results: The mean age in the COVID-19 group was 64-year-old versus 46-year-old in the non-COVID-19 group. The sex ratio was 1.2 and 0.94 in the non-COVID-19 and COVID-19 group, respectively. Clinical symptomatology was dominated by respiratory failure and chest pain in non-COVID-19 patients while in the COVID-19 group, semiology was dominated by dyspnea, cough, and chest pain. The major sign of severity in both groups was tachypnea. The chest X-ray was performed in all our patients, it displayed radiological abnormalities in all patients mainly hyper clarity in pulmonary fields. D-dimers were performed in all patients within the two study groups. A chest computed tomography angiogram was performed for all patients and showed unilateral pulmonary embolism in 61% of cases in the non-COVID-19 group versus 61.3% in the COVID-19 group. Cardiac ultrasound was performed for all patients. It showed dilatation of right cavities in both groups (81.8% in non-COVID-19 versus 93.5% in COVID-19 patients). Venous ultrasound of the lower limbs was performed in 96.8% of COVID-19 patients and in 72.7% of non-COVID-19 patients. With regards to management, all COVID-19 and non-COVID-19 patients received anticoagulation therapy based on standard heparin and anti-vitamin K. Mortality accounted for 54.5% in non-COVID-19 patients versus 74.2% in COVID-19 patients. Conclusion: COVID-19 pulmonary embolism is often associated with significantly higher morbidity and mortality as compared with non-COVID-19 pulmonary embolism.

Aortic dissection presenting as a stroke: a case report

Aortic dissection is an uncommon yet frequently fatal illness. Patients generally present with tearing chest pain with possible acute hemodynamic instability. Hence, early diagnosis and intervention is critical for survival. This is a case of a 62-year-old male who was transferred to our emergency department for severe chest pain, left side hemiplegia, left hemianopsia, left facial weakness, suggesting a right-sided stroke. A chest computed tomography angiogram showed an extensive circumferential aortic dissection of the intimal layer involving the great vessels. Antiplatelet medications were withheld, nicardipine was started, and the cardiothoracic surgeon was consulted. There was no indication for surgery, and patient was admitted to the intensive care unit. We highlight here the importance of considering an aortic dissection in patients who present with neurological symptoms and an acute history of tearing chest pain.

S2302 Dysphagia Lusoria as a Rare Cause of Dysphagia Due to ARSA and KD With Esophageal Compression

Introduction: Dysphagia lusoria (DL) is a rare cause of dysphagia in which abnormal vasculature, most often an aberrant right subclavian artery (ARSA) with a retroesophageal course, leads to esophageal compression. We report a case of DL caused by an ARSA and Kommerell diverticulum (KD). Case Description/Methods: A 64-year-old male with a history of Celiac disease, Sjogren’s syndrome, gastroesophageal reflux disease, and rheumatoid arthritis presented with weight loss and worsening solid food dysphagia. Current medications included naproxen and omeprazole. Esophagogastroduodenoscopy (EGD) showed no lesions but a slight narrowing of the proximal esophagus, for which mild dilation was performed. Six months later the patient presented for persistent dysphagia. An esophagus barium swallow found a 5 cm long narrowing of the esophagus, the narrowest portion measuring 0.9 cm (Figure 1A). No mucosal abnormalities, gastroesophageal reflux, or hiatal hernia were detected. Chest computed tomography angiogram (CTA) revealed an ARSA which emerged from a fusiform aneurysmal dilation of the left aortic arch and followed a retroesophageal course. This vasculature resulted in compression and displacement of the esophagus (Figure 1B). The left subclavian artery also arose from the dilation, and a common origin of the right and left common carotid arteries was observed. The patient was diagnosed with DL, caused by an ARSA and KD. As EGD with dilation would not alleviate this source of external compression, the patient was referred to vascular surgery for definitive management. Discussion: KD is a remnant of the fourth aortic arch which forms a dilation at the point of which an abnormal subclavian artery arises, and is noted in about 15% of patients with an ARSA. DL diagnosis is complicated by the fact that many vascular abnormalities do not result in dysphagia. While CTA confirms the presence of abnormal vasculature, a thorough workup of esophageal function including assessments like EGD and barium esophagram are necessary to confirm DL diagnosis. Typically for DL patients, diet modifications and endoscopic or medical interventions like PPI use should be utilized before surgery, as targeting abdominal vasculature may not prove beneficial. This case is distinguished by the presence of a KD, which makes surgical intervention the best treatment option to relieve a clear source of external compression and avoid possible KD rupture or dissection.Figure 1.: (A) Barium esophagram showing a narrowing of the cervical and thoracic esophagus. (B) 3-dimensional CT showing aneurysmal Kommerell diverticulum (KD) and emerging aberrant right subclavian artery (ARSA), which followed a retroesophageal course.

Patent Ductus Arteriosus Can Coexist With Pulmonary Sequestration in Adults, Conditioning Pulmonary Hypertension

A woman in her early 40s attended the hospital for dyspnea. Her chest radiograph revealed cardiomegaly, prominence of the cone of the pulmonary artery, and hyperflow (Figure A). The electrocardiogram revealed growth of the atrium and right ventricle. The chest computed tomography angiogram depicted right intralobar pulmonary sequestration (PS) with a patent ductus arteriosus (Figure B); the blood supply of the sequestrum originated from the abdominal aorta with venous drainage toward the pulmonary vein and the left atrium (Figure C and D).

Yield of pelvic CT in emergency department patients undergoing CT torso for generalized or multiple complaints.

To evaluate the utility of pelvic computed tomography (CT) in emergency department (ED) patients undergoing chest CT angiogram (CTA) for chest pain or suspected pulmonary embolism (PE) followed by abdominopelvic CT in the same session for additional multisystem or generalized complaints. This retrospective study included consecutive adult ED patients from January 2017 to December 2019 who underwent CTA for suspected PE followed by portovenous abdominopelvic CT for multisystem or generalized complaints. Patient demographics, vitals, laboratory values, exam indication, malignancy history, and recent surgery/intervention were recorded. CT reports were reviewed for acute chest, abdomen, and/or pelvic pathology. There were 400 patients with 243 (61%) women and mean age of 59.8years. Acute pelvic findings were seen in 11% (45/400). In 53% (24/45) of these, pelvic pathology could be diagnosed based on the abdominal portion of the CT. Five percent (21/400) of patients demonstrated isolated acute pelvic findings with 86% of these (18/21) clinically suspected prior to imaging. Acute pelvic pathology was associated with female gender (p = 0.015) and elevated white blood cell count (WBC) (p = 0.03). Specific pelvic CT indications and female gender were significantly associated with (p = 0.02 each) and independent predictors of isolated acute pelvic pathology. In ED patients undergoing chest CTA for chest pain or suspected PE combined with abdominopelvic CT, the presence of acute pelvic-related pathology not visualized on abdominal CT is low. For this ED patient cohort, pelvic CT may not be necessary in men with normal WBC and a low pre-imaging clinical suspicion for acute pelvic pathology.

Yield of chest computed tomography angiogram in cystic fibrosis patients with suspected pulmonary embolism.

IntroductionIndividuals with cystic fibrosis (CF) may be at increased risk of pulmonary embolism (PE). Symptoms of PE overlap substantially with those of CF respiratory exacerbations. CF patients commonly undergo chest computed tomography (CT) angiograms (CTPA) to evaluate for PE, but little is known about the clinical presentation and diagnosis of PE in this population.ObjectivesThe objectives of this study are to determine the diagnostic yield of CTPA for PE in adult patients with CF and assess the utility of the Revised Geneva Score (RGS) in this population.MethodsRetrospective review of all CTPA results was performed on CF patients with suspected PE at a large CF center from 1 January 2011 through 31 March 2017. Patient demographics, medical history, and presenting signs and symptoms were abstracted by chart review.ResultsA total of 103 unique CTPA studies were performed in 68 patients. Most were hospitalized at the time of CTPA, predominantly for respiratory manifestations of CF. CTPA identified four patients with PE. The small number of positive studies precluded analysis of predictors of PE. Fewer PE were diagnosed than predicted by the Revised Geneva Score, which was intermediate probability in 77/103 (75%) patients.ConclusionThe prevalence of PE in CF patients undergoing CTPA for suspected PE was 4%, which is lower than predicted by the Revised Geneva Score. This may be due to a large overlap in the signs and symptoms of PE and exacerbations of CF lung disease.

All in the Family: A Curious Case of Aortopathy

A 28-year-old African American male with history of intermittent headaches presented to an outside hospital (OSH) with few days history of severe right lower extremity pain, swelling and dyspnea. Lower extremity venous ultrasound revealed a large occlusive deep vein thrombosis (DVT) extending from the right common femoral to the right popliteal vein. Chest Computed tomography angiogram (CT Angiogram) revealed a 5.9 cm mid ascending thoracic aortic aneurysm, a 3.2 cm pulmonary artery dilatation and no evidence of pulmonary embolus. He was started on anticoagulation with intravenous heparin and transferred to our institution for surgical management of the aortic aneurysm and evaluation for large vessel vasculitis.

Pneumonic-type lung adenocarcinoma with different ranges exhibiting different clinical, imaging, and pathological characteristics

BackgroundPneumonic-type lung adenocarcinoma (PLADC) with different ranges might exhibit different imaging and clinicopathological features. This study divided PLADC into localized PLADC (L-PLADC) and diffuse PLADC (D-PLADC) based on imaging and aimed to clarify the differences in clinical, imaging, and pathologic characteristics between the two new subtypes.ResultsThe data of 131 patients with L-PLADC and 117 patients with D-PLADC who were pathologically confirmed and underwent chest computed tomography (CT) at our institute from December 2014 to December 2020 were retrospectively collected. Patients with L-PLADC were predominantly female, non-smokers, and without respiratory symptoms and elevated white blood cell count and C-reactive protein level, whereas those with D-PLADC were predominantly male, smokers, and had respiratory symptoms and elevated white blood cell count and C-reactive protein level (all p < 0.05). Pleural retraction was more common in L-PLADC, whereas interlobular fissure bulging, hypodense sign, air space, CT angiogram sign, coexisting nodules, pleural effusion, and lymphadenopathy were more frequent in D-PLADC (all p < 0.001). Among the 129 patients with surgically resected PLADC, the most common histological subtype of L-PLADC was acinar-predominant growth pattern (76.7%, 79/103), whereas that of D-PLADC was invasive mucinous adenocarcinoma (80.8%, 21/26). Among the 136 patients with EGFR mutation status, L-PLADC had a significantly higher EGFR mutation rate than D-PLADC (p < 0.001).ConclusionsL-PLADC and D-PLADC have different clinical, imaging, and pathological characteristics. This new imaging-based classification may help improve our understanding of PLADC and develop personalized treatment plans, with concomitant implications for patient outcomes.

DO NOT MISS MIS-A: MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT AFTER COVID-19

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Reports indicate a rare but serious complication of coronavirus disease 2019 (COVID-19) in children is a multisystem inflammatory syndrome in children (MIS-C). The cause of this is yet to be found. However, since the summer of 2020, some case reports have documented multisystem inflammatory syndrome in adults (MIS-A). CASE PRESENTATION: A 37-year-old male with a past medical history of diabetes and tobacco use presented to the emergency department (ED) for two days of fever, chest pain, and dyspnea. He had been diagnosed with COVID-19 and quarantined at home without symptom progression 17 days prior to his ED visit. In the ED, the patient was found to have a temperature of 39°C, heart rate of 145 bpm, and blood pressure of 95/41 mmHg. Lab values showed a creatinine of 4.74 mg/dL, lactic acid 4.7 mmol/L, C-reactive protein 640.4 mg/L, sedimentation rate 108 mm/hr, ferritin 2126 mcg/L, D-Dimer 2770 ng/mL and pro-B-type natriuretic peptide 629 ng/L. Chest computed tomography angiogram was negative for pulmonary embolism;however, it did show mediastinal lymphadenopathies (Figure 1). The patient was given intravenous fluids, piperacillin-tazobactam, vancomycin, and started on norepinephrine followed by admission to the medical intensive care unit (MICU). In the MICU, the patient required a second vasopressor (vasopressin) and hydrocortisone. Nephrology was consulted to start continuous renal replacement therapy. An echocardiogram revealed new-onset heart failure with an ejection fraction of 40%. Infectious, hematologic, and autoimmune investigations continued to be unremarkable;however, the patient's COVID-19 antibodies were reactive to spike and nucleocapsid antigens. After three days of treatment, the patient no longer required vasopressor support, and steroids were discontinued. Even so, the next morning he was again febrile and hypotension requiring vasopressors as well as new-onset atrial fibrillation with controlled rate. On exam, he developed a new non-blanching rash of his bilateral feet (Figure 2). Thereafter, infectious disease was consulted and diagnosed the patient with MIS-A. They started steroids along with intravenous immunoglobulin. This regimen saw a rapid resolution in fevers, despite holding antibiotics. DISCUSSION: Common symptoms of MIS-A are fever, chest pain, palpitations, and gastrointestinal distress. Elevated inflammatory markers include C-reactive protein, ferritin, and D-dimer [1]. Both children and adults have been reported to have cardiac dysfunction with MIS [1,2]. Recently the most common therapies provided to patients with MIS-C and -A are IVIG, vasoactive medications, and steroids [3]. CONCLUSIONS: Though MIS-C has been recognized in the pediatric population, MIS-A is beginning to present in adults after a COVID-19 infection. Increased awareness, as well as further study of this syndrome's pathophysiology, may lead to rapid treatment and improved outcomes. REFERENCE #1: Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep 2020;69:1450–1456. DOI: http://dx.doi.org/10.15585/mmwr.mm6940e1 REFERENCE #2: Belhadjer, Z., Meot, M., Bajolle, F., Khraiche, D., Legendre, A., Abakka, S., Auriau, J., Grimaud, M., Oualha, M., Beghetti, M., Wacker, J., Ovaert, C., Hascoet, S., Selegny, M., Malekzadeh-Milani, S., Maltret, A., Bosser, G., Giroux, N., Bonnemains, L., Bordet, J., … Bonnet, D. (2020). Acute Heart Failure in Multisystem Inflammatory Syndrome in Children in the Context of Global SARS-CoV-2 Pandemic. Circulation, 142(5), 429–436. REFERENCE #3: Abrams, J. Y., Godfred-Cato, S. E., Oster, M. E., Chow, E. J., Koumans, E. H., Bryant, B., Leung, J. W., & Belay, E. D. (2020). Multisystem Inflammatory Syndrome in Children Associated with Severe Acute Respiratory Syndrome Coronavirus 2: A Systematic Review. The Journal of pediatrics, 226, 45–54 e1. Advance online publication. https://doi.org/10.1016/j.jpeds.2020.08.003 DISCLOSURES: No relevant relationships by Ojobumijo Agbaji, source=Web Response No relevant relationships by Abdelrahman Elfaham, source=Web Response No relevant relationships by Michael Hubbard, source=Web Response No relevant relationships by Tyler Kemnic, source=Web Response No relevant relationships by Micah Larsen, source=Web Response No relevant relationships by Amy Rechenberg, source=Web Response Site PI for VENT AVOID trial relationship with A-Lung Please note: $1-$1000 Added 12/03/2020 by Maximiliano Tamae Kakazu, source=Web Response, value=No direct payment to me

LATE DISTAL RECURRENCE OF PRIMARY BONE LEIOMYOSARCOMA PRESENTING WITH HEMOTHORAX

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: We describe a case of previously treated bone leiomyosarcoma (LMS) with unique presentation of distal recurrence after a prolonged latency period. CASE PRESENTATION: A 41-year-old woman with LMS of the left tibia treated with neoadjuvant chemotherapy and surgical resection nine years ago presented with shortness of breath and cough. Physical examination revealed dullness to percussion and lack of air entry over the right lung Laboratory work-up was significant for a hemoglobin of 7.6 g/dl (normal range 12.0 – 16.0 g/dl). A chest X-ray showed complete opacification of the right lung. Chest computed tomography angiogram revealed a right-sided mass with a prominent central vessel and a large pleural effusion. A thoracentesis drained 500 milliliters of serosanguinous fluid. Pleural fluid analysis showed a lactate dehydrogenase of 1,364 and protein of 4.0. Cytology was negative for malignancy. Coil embolization of the right eleventh intercostal artery was performed due to concern for active bleeding. A repeat chest X-ray showed poor lung expansion with a large amount of residual clot and fluid. Video-assisted thoracoscopic surgery was performed with biopsy of the mass and removal of two liters of clotted blood. Pathology was consistent with LMS compatible with metastasis from the patient's previously treated sarcoma. A PET scan showed an FDG-avid mass with involvement of the right chest wall, vertebra, and right posterior ribs. Surgical resection of the mass was performed. Final pathology showed high-grade LMS measuring 8.5 centimeters. DISCUSSION: Primary bone LMS is a rare malignancy of smooth muscle differentiation accounting for less than one percent of sarcoma cases. It is considered an aggressive malignancy with high rates of recurrence. Need for adjuvant therapies is generally dependent on size, stage, location, and success of tumor resection.2 Most recurrence occurs within five years of the original diagnosis with grade and size of the primary lesion conferring the greatest risk.4,5 Our patient's time to recurrence was unusual as she developed metastatic malignancy nine years from her original diagnosis of non-metastatic, low-grade LMS.This case was also unique in that the presenting complaints of dyspnea and cough were the result of a large hemothorax. Approximately 75 cases of soft tissue sarcoma with hemothorax have been documented in the literature. Only one case involving LMS was discovered during our search. Without this rare complication, our patient's malignancy may have been more advanced before its discovery. CONCLUSIONS: Primary bone LMS is a rare malignancy with high rates of recurrence. Our patient's case highlights the importance of maintaining long-term follow up and high clinical suspicion of recurrence due to the potential for prolonged latency periods. REFERENCE #1: Serrano, C., & George, S. (2013). Leiomyosarcoma. Hematology/Oncology Clinics Of North America, 27(5), 957-974. REFERENCE #2: Adelani, A., Schultenover, S., Holt, G., & Cates, J. (2009). Primary Leiomyosarcoma of Extragnathic Bone: Clinicopathologic Features and Reevaluation of Prognosis. Arch Pathol Lab Med, 133(9), 1448-1456. REFERENCE #3: Gladdy, R., Qin, L., Moraco, N., Agaram, N., Brennan, M., & Singer, S. (2013). Predictors of Survival and Recurrence in Primary Leiomyosarcoma. Annals Of Surgical Oncology, 20(6), 1851-1857. DISCLOSURES: No relevant relationships by Ian Jackson, source=Web Response No relevant relationships by Bryan Krajicek, source=Web Response No relevant relationships by Ali Nayfeh, source=Web Response No relevant relationships by Bryton Perman, source=Web Response

Metastatic Signet Ring Cell Carcinoma Masquerading as Acute on Chronic Thromboembolic Pulmonary Hypertension Requiring ECMO

<h3>Introduction</h3> Pulmonary thromboembolism can result from underlying hypercoagulability. Malignancy can cause hypercoagulability; however, gastrointestinal malignancy is rare in pediatric patients. We present the case of an adolescent female with severe pulmonary thromboemboli and subsequent right heart failure requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) who was found on autopsy to have widely metastatic signet ring cell carcinoma (SRCC) of gastric origin. <h3>Case Report</h3> An obese 16-year-old female taking combination oral contraceptives for menorrhagia presented to an outside facility with chest pain, dyspnea, and vomiting. She had no recent history of travel, surgery, or trauma. Her father had been diagnosed with protein C/S deficiency, though she had tested negative for this. She had inverted T-waves with elevated troponin. Chest computed tomography angiogram revealed bilateral pulmonary arterial thrombi and evidence of right heart strain. After transfer to our institution, she developed cardiogenic shock from right ventricular failure. She was placed on peripheral VA ECMO. After failing to wean from ECMO, she was evaluated by our lung transplant committee but was declined for listing. She continued to deteriorate despite ECMO support and maximal medical therapy, developing refractory sepsis and coagulopathy. After one month on ECMO, decannulation was performed. She expired two days later due to multi-system organ failure. Autopsy revealed widely metastatic diffuse SRCC of gastric origin that was not seen on multiple rounds of axial imaging and endoscopies (Figure 1). <h3>Summary</h3> This report highlights an unusual cause of pediatric hypercoagulability resulting in pulmonary embolism and right heart failure requiring mechanical circulatory support. It is imperative to maintain a broad differential diagnosis for pediatric patients requiring mechanical circulatory support.

A Case Report of Likely Nosocomial-Acquired COVID-19 in a Trauma Patient

As the pandemic of coronavirus disease 2019 (COVID-19) continues to spread worldwide, there has been an increase in unique clinical presentations leading to delayed diagnoses and nosocomial transmissions. One of the patient populations most at risk includes patients in the critical care units. Early diagnosis and isolation are paramount to avoid nosocomial transmission amongst these closely hospitalized patients. While quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) is the current method for testing, we highlight the importance of utilizing chest computed tomography (CT) and laboratory findings for early diagnosis. We report a 48-year-old trauma patient who suddenly became hypoxemic, nine days postoperative from uncomplicated right lower extremity fracture repair. CT angiogram chest revealed bilateral extensive consolidations, hazy opacities, and pleural effusions. The patient continued to desaturate on noninvasive respiratory support and eventually required intubation. He was empirically treated with azithromycin and hydroxychloroquine due to high clinical suspicion of COVID-19, despite negative qRT-PCR results. The patient progressed clinically and was successfully extubated after 5 days. This unique presentation of acute hypoxemic respiratory failure warrants a discussion on the importance of clinical manifestations, CT findings, and laboratory findings in diagnosis of COVID-19, to prevent further nosocomial spread within a closed critical care unit. J Curr Surg. 2020;10(3):37-40 doi: https://doi.org/10.14740/jcs409

A Stab in the Heart: Scimitar Pulmonary Venous Anomaly Complicating a Case of Cardiogenic Shock

Introduction Scimitar syndrome is described as an abnormal connection between one pulmonary vein and the right atrium or vena cava. Case presentation 40 year old female presented with respiratory failure and septic shock that was unresponsive to pressors and IV fluids. Transthoracic echocardiogram showed severely dilated right ventricle with severe tricuspid regurgitation. Chest computed tomography angiogram (CTA) was negative for pulmonary embolism but showed right upper pulmonary vein connecting to inferior vena cava consistent with Scimitar anomaly. (Figure 1) Invasive hemodynamic evaluation showed mixed venous saturation (SvO2) 14%, cardiac index (CI) 1.89 L/min/m2, systemic vascular resistance (SVR) 754 dynes, severely elevated filling pressures, and pulmonary artery pressure (PAP) 77/44 (57) mmHg. Dialysis, dobutamine and inhaled nitroglycerin (iNO) were added to pressors for RV support. Follow up hemodynamic profile showed SvO2 75%, CI 4.9 L/min/m2, improved filling pressures, SVR 473 dynes, PAP 79/37 (48) mmHg. However, liver/kidney function and lactic acid continued to worsen indicating inadequate organ perfusion. Inaccurate SvO2 and subsequent CI and SVR calculation in the setting of L to R shunt through the anomalous vein was suspected. Subsequently, the decision was made to titrate hemodynamic support using MAP>70 accepting the presence of shunt, after which lactic acid and liver/kidney function started improving. Unfortunately, the patient suffered hypoxemic cardiac arrest. The rate of iNO was decreased as it was thought to increase V/Q mismatch despite its hemodynamic benefit to RV. Initiation of extracorporeal membrane oxygenation was difficult because of severe vasospasm. Vegetative state was noted and care was withdrawn per family request. Discussion The patient's hemodynamic profile was consistent with cardiogenic shock secondary to acute RV failure caused by initial IV fluid administration. RV support in the setting of pulmonary hypertension was achieved with dialysis, dobutamine and iNO. Improving hemodynamic parameters obtained by pulmonary catheter didn't correlate with worsening laboratory perfusion parameters. The availability of chest CTA showing an unexpected pulmonary venous anomaly helped our multidisciplinary team explain the inaccuracy of hemodynamic parameters.

A Case Report of a Spontaneous Breast Pseudoaneurysm

Background Breast pseudoaneurysms are rare and most commonly associated with iatrogenic causes such as core needle or surgical excisional biopsies. Other causes include blunt force trauma, breast implants, or underlying malignancy. This report describes the presentation and management of a spontaneous breast pseudoaneurysm. Case Presentation A 55-year-old female with a past medial history of hypertension and hyperlipidemia presented to the emergency department with sudden onset of a pulsatile left breast mass after a coughing spell. Doppler ultrasound (US) revealed a pulsatile vascular structure with internal arterial waveforms concerning for a breast pseudoaneurysm. The patient underwent a chest computed tomography angiogram (CTA) that confirmed a pseudoaneurysm arising from the left internal mammary artery. Mammography and target ultrasound showed no findings suggestive of underlying malignancy. Conservative management with compression was initiated resulting in partial thrombosis. Repeat doppler US showed persistent internal flow, and therefore, US-guided thrombin injection was performed by vascular surgery with complete thrombosis. Conclusion Breast pseudoaneurysms can occur spontaneously and can be managed with both conservative and local invasive interventions.

A Case Report of a Spontaneous Breast Pseudoaneurysm

Background Breast pseudoaneurysms are rare and most commonly associated with iatrogenic causes such as core needle or surgical excisional biopsies. Other causes include blunt force trauma, breast implants, or underlying malignancy. This report describes the presentation and management of a spontaneous breast pseudoaneurysm. Case Presentation A 55-year-old female with a past medial history of hypertension and hyperlipidemia presented to the emergency department with sudden onset of a pulsatile left breast mass after a coughing spell. Doppler ultrasound (US) revealed a pulsatile vascular structure with internal arterial waveforms concerning for a breast pseudoaneurysm. The patient underwent a chest computed tomography angiogram (CTA) that confirmed a pseudoaneurysm arising from the left internal mammary artery. Mammography and target ultrasound showed no findings suggestive of underlying malignancy. Conservative management with compression was initiated resulting in partial thrombosis. Repeat doppler US showed persistent internal flow, and therefore, US-guided thrombin injection was performed by vascular surgery with complete thrombosis. Conclusion Breast pseudoaneurysms can occur spontaneously and can be managed with both conservative and local invasive interventions.

Venous Thromboembolism After Adult Lung Transplantation: A Frequent Event Associated With Lower Survival.

The incidence of venous thromboembolism (VTE) after lung transplantation (LTX) varies significantly across studies. Two studies have suggested that these thrombotic events are associated with a lower posttransplant survival. Herein, we sought to determine the incidence, predictors, and impact of VTE on survival after LTX at a quaternary referral center. This was a large cohort study of LTX recipients. Key outcome parameters were time to VTE after transplant and survival. Deep vein thrombosis (DVT) diagnosis required a positive ultrasound. Pulmonary embolism diagnosis required either a positive chest computed tomography angiogram or a high-probability ventilation/perfusion scan. The overall incidence of VTE among 701 LTX recipients was 43.8%, of which 97.7% were DVT episodes, of which 71.3% were in the upper extremities. Predictors of VTE were prior history of DVT (hazard ratio [HR], 2.82; 95% confidence interval [CI], 1.49-5.37), days in intensive care (HR, 1.01; 95% CI, 1.01-1.02), and the use of extracorporeal membrane oxygenation (HR, 2.22; 95% CI, 1.43-3.45). Importantly, VTE predicted a lower posttransplant survival (HR, 1.70; 95% CI, 1.28-2.26), when occurring within or after the first 30 days. The location of the DVT, either upper extremity or below the knee, also predicted a poor survival. VTE was frequent in LTX recipients and predicted a poor survival even when located in the upper extremities or below the knee. These data suggest that aggressive VTE screening/treatment protocols be implemented in post-LTX population.