Clin Infect Dis Research Articles

Антикоагулянтное ведение беременных с коронавирусной инфекцией

Введение. Частота распространения новой коронавирусной инфекции COVID-19 (НКИ COVID-19) среди беременных сравнима с общепопуляционными показателями, что требует особого внимания в связи с повышенным риском материнской смертности в результате осложнений инфекционного процесса. Учитывая наличие гиперкоагуляционного статуса во время физиологически протекающей беременности, инфицирование вирусом COVID-19 может способствовать еще большему усилению прокоагулянтных свой ств крови. Патогенетически обоснованным является применение антикоагулянтной терапии во время беременности при условии верифицированной коронавирусной инфекции с целью снижения риска развития тромботических осложнений. Материалы и методы. Представлены 2 клинических случая успешного применения антикоагулянтов (низкомолекулярного гепарина) у беременных с подтвержденным инфицированием COVID-19. Результаты. Ретроспективный анализ лабораторных и клинических данных продемонстрировал эффективность парнапарина натрия в качестве средства профилактики тромботических осложнений у беременных с НКИ COVID-19. Заключение. Применение антикоагулянтной терапии у беременных с НКИ COVID-19 позволяет снизить риск развития тромботических эпизодов и улучшить репродуктивные исходы беременности. Background. The COVID-19 frequency among pregnant women is comparable to general population but it requires specific approach due to increased risk of maternal mortality as a result of infectious complications. The hypercoagulation is during physiological pregnancy, and COVID-19 can enhance further a procoagulant conditions. In such cases the anticoagulant therapy is aimed to reduce the thrombotic risk. Patients / Methods. The article presents 2 clinical cases of successful use of anticoagulants (low molecular weight heparin) in pregnant women with confirmed COVID-19. Results. A retrospective analysis of laboratory and clinical data has demonstrated the effi cacy of parnaparin sodium as a means of preventing thrombotic complications in pregnant women with COVID-19. Conclusions. Anticoagulant therapy in pregnant women with COVID-19 allows to reduce the thrombotic risk and improve the reproductive outcomes of pregnancy.

Definitions for coronavirus disease 2019 reinfection, relapse and PCR re-positivity

Definitions for coronavirus disease 2019 reinfection, relapse and PCR re-positivity

Decreased influenza activity during the COVID-19 pandemic-United States, Australia, Chile, and South Africa, 2020.

Transplant recipients are among the groups for whom the updated recommendations for 2020–2021 influenza vaccination should generally be considered essential, notably in the face of the COVID‐19 pandemic.

A randomized clinical trial to assess the immunogenicity of a single-visit four-dose intradermal booster rabies regimen with topical imiquimod

Background: Two-visit intradermal pre-exposure rabies vaccination schedules (PrEP) are now advised by the WHO. Moreover, a double-dose single-visit intradermal 12ID PrEP schedule showed robust immune responses following four-dose or double-dose single-visit intradermal post-exposure prophylaxis (14ID or 12ID PEP) (Soentjens P et al. Clin Infect Dis Aug 2019). Such accelerated 1-visit schedules for PrEP and PEP at very low cost are very practical. Methods and materials: Aim. To investigate the additional effect of the topical pre-administration of imiquimod (IMIQ) (during 1-visit intradermal PrEP) on the neutralizing antibody responses after a four-dose 1-visit intradermal booster schedule. Methods. Belgian soldiers (N = 268) were vaccinated with a 12ID PrEP schedule and boosted with a 14ID PEP schedule, using the Purified Chicken Embryo Cell Vaccine (PCECV). In this study (EudraCT 2017-002953-12), subjects were randomized (during PrEP) for the topical treatment with IMIQ versus placebo cream, as well as for the use of an intradermal device (VAX-ID™) versus routine intradermal syringe. We investigated the serological responses, by rabies fluorescent focus inhibition test (RFFIT) on day 7, after 14ID PrEP in the four treatment groups for 162 of the 268 subjects. A titer ≥3.0 IU/ml is considered to be a strong and adequate antibody response. Results: Median age was 23.5 (IQR 22.7–24.7). 83% were male. Timing between PrEP and PEP was 1.13 years (IQR 1.13–1.13). The GMT of RFFIT on day 7 after 14ID PEP was 19.42 IU/mL (CI 12.43–30.35). 92.3% of the 52 subjects had a RFFIT ≥0.5 IU/mL at day 7 of which 88,5% a level >3.0 IU/mL and 83% >10.0 IU/mL, following 12ID PrEP. The GMT (2 groups comparison) of RFFIT on day 7 after 14ID by intervention groups was 20.20 (10.58–38.57) and 18.66 (9.63–36.15) for the IMIQ versus placebo group respectively, and 18.09 (8.39–39.00) and 20.84 (12.47–34.85) for the VAX-ID versus needle group respectively. Conclusion: Good anamnestic booster responses following 14ID PEP, one year after 12ID PrEP, were recorded. This powered clinical data, in addition with the data of 12ID PrEP by Soentjens et al., proofs that the concept of single-visit priming and single-visit boosting (PrEP and PEP) is very promising and deserves more promotion.

Hydroxychloroquine in the prevention of COVID-19 mortality.

Hydroxychloroquine in the prevention of COVID-19 mortality.

Coronavirus Disease 2019 and Vaccination of Children and Adolescents: Prospects and Challenges

Coronavirus Disease 2019 and Vaccination of Children and Adolescents: Prospects and Challenges

Steroid Use, Advanced Stage Disease and ≥3 Lines of Prior Chemotherapy Are Associated with a Higher Risk of Infection Following CD19 CAR T-Cell Therapy for B-NHL: Real World Data from a Large UK Center

Steroid Use, Advanced Stage Disease and ≥3 Lines of Prior Chemotherapy Are Associated with a Higher Risk of Infection Following CD19 CAR T-Cell Therapy for B-NHL: Real World Data from a Large UK Center

A very rare case of mycobacterium gordonae infection of the breast.

Mastitis is a common disease in women with both infectious and noninfectious causes. Most cases occur during lactation and are caused by Staphylococcus aureus and Streptococcus species; parasites and Mycobacteria have rarely been reported to cause breast infections (Mandell, Douglas, and Bennett's principles and practice of infectious diseases (9th edn);2019, Am J Respir Crit Care Med. 2007;175:367). Nontuberculous mycobacteria (NTM) which are also referred to as atypical mycobacteria, mycobacteria other than tuberculosis (MOTT), or environmental mycobacteria are a large group of Mycobacteria which are becoming increasingly common cause of infection all over the world (Arch Dermatol. 2006;142:1287). NTM can cause infection diseases especially in immunocompromised patients, such as HIV-positive hosts, most commonly in the lungs, skin and soft tissue, lymph nodes or rarely spread with multiorgan dissemination (Arch Plast Surg. 2014;41:759). Mycobacterium gordonae (M. gordonae) is a slow-growing atypical mycobacterium that is considered the least pathogenic NTM. The organism is ubiquitous, and mostly isolated from soil and water. Despite its nonvirulent nature, clinically significant infections have been reported also in some immunocompetent patients (J Formosan Med Assoc. 2020, Clin Infect Dis. 1992;1229). We report the first documented case of breast infection in a young immunocompetent woman sustained by Mycobacterium Gordonae.

In adults exposed to COVID-19, hydroxychloroquine did not reduce confirmed or probable COVID-19; trial stopped for futility.

Boulware DR, Pullen MF, Bangdiwala AS, et al. A randomized trial of hydroxychloroquine as postexposure prophylaxis for COVID-19. N Engl J Med. 2020;383:517-25. 32492293.

Adolescent Driver Testing During the COVID-19 Pandemic

Adolescent Driver Testing During the COVID-19 Pandemic

Imperfect storm: is interleukin-33 the Achilles heel of COVID-19?

The unique cytokine signature of COVID-19 might provide clues to disease mechanisms and possible future therapies. Here, we propose a pathogenic model in which the alarmin cytokine, interleukin (IL)-33, is a key player in driving all stages of COVID-19 disease (ie, asymptomatic, mild–moderate, severe–critical, and chronic–fibrotic). In susceptible individuals, IL-33 release by damaged lower respiratory cells might induce dysregulated GATA-binding factor 3-expressing regulatory T cells, thereby breaking immune tolerance and eliciting severe acute respiratory syndrome coronavirus 2-induced autoinflammatory lung disease. Such disease might be initially sustained by IL-33-differentiated type-2 innate lymphoid cells and locally expanded γδ T cells. In severe COVID-19 cases, the IL-33–ST2 axis might act to expand the number of pathogenic granulocyte–macrophage colony-stimulating factor-expressing T cells, dampen antiviral interferon responses, elicit hyperinflammation, and favour thromboses. In patients who survive severe COVID-19, IL-33 might drive pulmonary fibrosis by inducing myofibroblasts and epithelial–mesenchymal transition. We discuss the therapeutic implications of these hypothetical pathways, including use of therapies that target IL-33 (eg, anti-ST2), T helper 17-like γδ T cells, immune cell homing, and cytokine balance.

Coronavirus (COVID-19): the potential contamination among dentistry professionals in Brazil

The coronavirus (COVID-19) is considered a global pandemic with several respiratory syndrome caused by coronavirus 2 (SARS-CoV-2). The main symptoms of COVID-19 are fever, cough, and fatigue, while other symptoms include sputum production, diarrhea and alterations on the gastrointestinal system. The COVID-19 was recently identified in the saliva of infected patients and the transmission through of droplets and aerosols generated during clinical dental care is possible among dentists, oral health assistants and/or oral health technicians and others around the social cycle of the friendship of these health professionals, such as families and colleagues. Thus, there is very necessary to improve the several types of prevention to healthcare professionals that realize the liberation of aerosol during oral assistance. It’s important to mention that these precautions are important to prevent human-to-human transmission and protect the global system of health. In addition, this care is essential to decrease the spread of COVID-19 in this moment. Descriptors: Coronavirus Infections; Dentistry; Occupational Diseases.ReferencesLi LY, Wu W, Chen S, Gu JW, Li XL, Song HJ et al. Digestive system involvement of novel coronavirus infection: Prevention and control infection from a gastroenterology perspective. J Dig Dis. 2020;21(4):199-204. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-33.Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J et al. Clinical Characteristics of COVID-19 Patients With Digestive Symptoms in Hubei, China: A Descriptive, Cross-Sectional, Multicenter Study. Am J Gastroenterol. 2020;115(5):766-73.Gabutti G, d'Anchera E, Sandri F, Savio M, Stefanati A. Coronavirus: update related to the current outbreak of COVID-19. Infect Dis Ther. 2020;9(2):1-13.Liu L, Wei Q, Alvarez X, Wang H, Du Y, Zhu H et al. Epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques. J Virol. 2011;85(8):4025-30.To KK, Tsang OT, Yip CC, Chan KH, Wu TC, Chan JMC et al. Consistent Detection of 2019 Novel Coronavirus in Saliva. Clin Infect Dis. 2020;71(15):841-43.Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig. 2020;24(4):1619-21.Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-69.Brazilian Ministry of Health. https://saude.gov.br/Brazilian Institute of Geography and Statistic. https://www.ibge.gov.br/Lauc G, Sinclair D. Biomarkers of biological age as predictors of COVID-19 disease severity. Aging (Albany NY). 2020;12(8):6490-91.Federal Council of Dentistry from Brazil. http://website.cfo.org.br/dados-estatisticos-de-profissionais-e-entidades-ativas-por-ano/Regional Dentistry Council of the State of São Paulo. http://www.crosp.org.br/intranet/estatisticas/estMunicipios.phpThompson RN. Novel Coronavirus Outbreak in Wuhan, China, 2020: Intense Surveillance Is Vital for Preventing Sustained Transmission in New Locations. J Clin Med. 2020;9(2):498.

Coronavirus disease 2019 re-infection: first report from Turkey.

There are concerns about the possibility of SARS-CoV-2 reinfection and recently, a patient with SARS-CoV-2 re-infection (or COVID-19) confirmed by epidemiological, clinical, serological and genomic analyses have been published. We have noticed another patient with SARS-CoV-2 re-infection based on clinical and laboratory studies: A 23-year-old woman presented to her hospital with fever (39°C), chills, fatigue, cough, headache, sore throat, muscle and joint pain on April 9, 2020. On examination, oropharynx was mildly hyperemic, and chest auscultation was normal. SARS-CoV-2 PCR from nasopharyngeal specimen was ordered. She was given isotonic saline and acetaminophen and prescribed azithromycin and acetaminophen and sent home for isolation. SARS-CoV-2 PCR was reported positive and she was given hydroxychloroquine for five days. She improved in 10 days and PCR studies on April 22, and April 27 remained negative. On 4 August 2020, she was re-admitted with fever (38.7°C), chills, fatigue, loss of appetite, taste and smell loss, muscle and joint pain. On examination, oropharynx and chest auscultation were normal. SARS-CoV-2 PCR was reported positive and she was prescribed hydroxychloroquine, acetaminophen and sent home for isolation again. She improved in one week (taste-smell loss improved in 10 days) and on follow-up visit after 14 days, she was doing well. PCR was negative on 17 August 2020. Her anti-SARS-CoV-2 antibodies were negative on 17 August 2020 and slightly positive (2.14 signal-to-cutoff) on 29 August 2020. Previous report from To et al. [Clin Infect Dis. 2020;ciaa1275. doi:10.1093/cid/ciaa1275] showed that viral genomes from first and second episodes belonged to different clades/lineages. They described second episode of asymptomatic infection occurred 142 day after the first symptomatic one. Our patient is the first report, describing two symptomatic episodes 116 days apart. We conclude that as the patients recovered from COVID-19 increases, increased awareness may delineate the characteristics of re-infection.

THE TALE OF A HALO SIGN

SESSION TITLE: Fellows Imaging Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Halo sign on chest imaging is characterized by a circular area of ground-glass attenuation around a central pulmonary nodule or mass. It is most commonly associated with invasive fungal infections; however, can also be seen in a wide range of neoplastic and inflammatory conditions. Here we present a case of angio-invasive neoplasm presenting with characteristic halo sign in an immunocompromised patient. CASE PRESENTATION: A 62-year-old male with alcoholic cirrhosis post orthotopic liver transplant on chronic immunosuppression with recurrent cirrhosis of his graft liver was initially admitted for management of acute hepatic encephalopathy. A CT scan of his chest showed numerous part solid centrilobular nodules bilaterally with central solid component and surrounding ground glass halo. Invasive fungal infection was suspected, and micafungin was initiated. Serum aspergillus antigen and beta D-glucan were negative. He underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB). BAL was negative for bacterial, fungal and acid-fast bacilli cultures. Pathology from the TBB showed atypical epithelioid cells that could be reactive or due to a metastatic disease. A repeat CT scan performed after 10 days of antifungal therapy showed a significant increase in size of the previously noted centrilobular nodules with surrounding ground glass halo. Surgical open lung biopsy was considered but he was deemed to be a poor surgical candidate due to his frailty and comorbidities. Transbronchial cryobiopsy was then performed which showed poorly differentiated epithelioid neoplasm predominantly within the vascular spaces. Based on immunohistochemical staining positive for both cytokeratin and vascular markers, a differential diagnosis of epithelioid angiosarcoma vs. epithelioid sarcoma was made. After detailed discussion with him and his family in regards to his overall prognosis, he wished for no further testing or interventions and chose to go home with hospice. DISCUSSION: Halo sign indicates presence of hemorrhagic nodules. It was first described in immunocompromised patients with invasive pulmonary aspergillosis where the nodule itself is a focus of pulmonary infarction with surrounding alveolar hemorrhage. However, it has now been associated with a variety of pulmonary diseases including both infectious and non-infectious hemorrhagic nodules, tumor cell infiltration and few non-hemorrhagic etiologies. Metastatic lung disease from hyper vascular tumors such as angiosarcoma, chondrosarcoma and melanoma can form a halo of ground glass attenuation as a result of peritumoral hemorrhage or infiltration. Malignancy is a leading cause of death in post liver transplant patients and should always be considered in the evaluation of these patients. CONCLUSIONS: While evaluating halo sign a wide differential should be considered including malignancy in a post liver transplant patient. Reference #1: Georgiadou SP, Sipsas NV, Marom EM, Kontoyiannis DP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. Clin Infect Dis. 2011;52(9):1144-1155. doi:10.1093/cid/cir122 Reference #2: Parrón M, Torres I, Pardo M, Morales C, Navarro M, Martínez-Schmizcraft M. Signo del halo en la tomografía computarizada de tórax: diagnóstico diferencial con correlación anatomopatológica [The halo sign in computed tomography images: differential diagnosis and correlation with pathology findings]. Arch Bronconeumol. 2008;44(7):386-392. DISCLOSURES: No relevant relationships by Sadia Benzaquen, source=Web Response No relevant relationships by Ena Gupta, source=Web Response No relevant relationships by ATUL MATTA, source=Web Response No relevant relationships by Corrado Minimo, source=Web Response No relevant relationships by Carlos Oberto, source=Web Response

CO-INFECTION WITH HISTOPLASMA CAPSULATUM AND PNEUMOCYSTIS JIROVECII IN A PATIENT WITH LIVER CIRRHOSIS: A DIAGNOSTIC DILEMMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Histoplasma capsulatum and Pneumocystis jirovecii pulmonary coinfection are unusual in HIV negative populations. We present the case of a man in respiratory failure with H. capsulatum and P. jirovecii detected in bronchial washings. CASE PRESENTATION: A 64-year-old man with T2DM, moderate COPD, and NASH cirrhosis with pancytopenia presented with 2-month history of progressive hypoxic respiratory failure. CT chest revealed multifocal consolidations with mediastinal lymphadenopathy which progressed despite antimicrobial therapy (Fig. 1). Bronchoalveolar lavage (BAL) was remarkable for 2800 copies/mL of P. jirovecii PCR with beta-D-glucan of 286. BAL specimen also grew H. capsulatum on culture and the FNAC specimen taken from lymph node 7 during the transbronchial biopsy was indicative of fungal elements similar to Histoplasma (Fig. 2A-2C). The patient was started on itraconazole for Histoplasmosis and trimethoprim-sulfamethoxazole with steroids for P. jirovecii pneumonia (PJP). He was tested during the hospitalization and found to be negative for HIV but had CD4 and CD8 counts at 86 and 70 x10E9/L respectively. Due to progression of his disease the patient was transitioned to comfort measures and passed on hospital day 36. DISCUSSION: Histoplasmosis is an endemic mycosis in the Ohio and Mississippi river valleys often resulting in asymptomatic infection [1]. PJP has also been reported as an asymptomatic infection or colonization in immunocompetent hosts [2]. Co-infection with both H. capsulatum and PJP ranges from 0.5-13% in studies on HIV positive patient groups [3,4]. In the sample population studied by Carreto-Binaghi et al, a coinfection rate of 1.5% was noted in the HIV negative group [5]. Irrespective of host immune status, patients with coinfection have a higher mortality rate than with a single infection alone [5], thus warranting treatment for both pathogens. Our patient had a history of chronic lymphopenia which had been attributed to his cirrhosis, with tests showing extremely low CD4 counts. Patients with end stage liver disease are recognized as being relatively immunocompromised when compared to healthy individuals due to coexisting leucopenia, lymphopenia and CD4/CD8 ratio abnormalities [6]. This case raises the question if patients with cirrhosis and lymphopenia should be treated with prophylactic antimicrobial agents based on their CD4 counts. CONCLUSIONS: This case highlights the importance of recognizing and treating co-infection of PJP and Histoplasmosis in non-HIV infected individuals. Additionally, it reminds us that patients with liver disease have important deficiencies in their cellular and humoral immunity which make them more susceptible to unusual opportunistic infections. Reference #1: [1] Goodwin RA, Loyd JE, Des Prez RM. Histoplasmosis in Normal Hosts. Medicine. 1981; 60(4): 231-266. Reference #2: [2] Ponce CA, Gallo M, Bustamante R, et al. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population. Clin Infect Dis. 2010; 50(3):347-353. [3] Baughman RP, Dohn MN, Frame PT. The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients. Am J Med. 1994; 97(6): 515-522. Reference #3: [4] Wheat JL, Slama TG, Zeckel ML. Histoplasmosis in the acquired immune deficiency syndrome. Am J Med. 1985; 78(2): 203-210. [5] Carreto-Binaghi LE, Morales-Villarreal FR, García-de la Torre G, et al. Histoplasma capsulatum and Pneumocystis jirovecii coinfection in hospitalized HIV and non-HIV patients from a tertiary care hospital in Mexico. Int J of Inf Dis. 2019; 86: 65-72. [6] Tuchendler E, Tuchendler PK, Madej G. Immunodeficiency caused by cirrhosis. Clin Exp Hepatol. 2018;4(3):158-164. DISCLOSURES: No relevant relationships by James Dugan, source=Web Response No relevant relationships by Akisha Glasgow, source=Web Response No relevant relationships by Eduarda Grinsztejn, source=Web Response No relevant relationships by Amrita John, source=Web Response

TRAVEL-ASSOCIATED COCCIDIOIDOMYCOSIS WITH ENDOTRACHEAL INVOLVEMENT: A CASE REPORT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coccidioidomycosis is a fungal infection caused by dimorphic fungi which is endemic to the Southwestern parts of America. However, it can be imported to non-endemic areas due to travel for business or pleasure. Involvement of airways including endotracheal and endobronchial lesion is rare and can present with a wide array of symptoms ranging from cough to airway obstruction1. We present a case of non-endemic coccidioidomycosis with rare endotracheal involvement. CASE PRESENTATION: Our patient is a 53-year-old male who presented with complaints of having productive cough, fever, and shortness of breath for past few weeks. Patient was recently treated with azithromycin and oral steroids in outpatient settings with no improvement in symptoms. Chest x-ray (CXR) on presentation was suggestive of consolidation in the right middle lobe. Patient was started on ceftriaxone, azithromycin, and prednisone. As patient continued to spike high-grade fever despite being on antibiotics, computerized tomography (CT) scan of the chest was done which was suggestive consolidation in right middle lobe with central areas of necrosis. Antibiotics were escalated to vancomycin, cefepime, and metronidazole. Blood culture, urinary legionella, and streptococcous antigen were negative. Fungitell-B-D glucan level was elevated to 73 pg/ml and coccidioides antibody and histoplasma galactomannan antigen were negative. Sputum culture was remarkable for coccidioides immitis. Upon a detailed review of history, patient reported that he recently went to vacation in California and was golfing there quite often. Since then he has been having fever with night sweats and cough. Patient was diagnosed with travel-related coccidioidomycosis and was discharged on diflucan. Patient continued to have a persistent cough with hoarseness and low-grade fever. Bronchoscopy was done which was suggestive of tracheal mass above carina in a concentric fashion. Considering disseminated coccidioidomycosis and fluconazole induced transaminitis, patient was started on amphotericin B with improvement in symptoms. DISCUSSION: Coccidioidomycosis is being increasingly reported in non-endemic areas as a result of travel to endemic areas. There is a need to increase awareness to help in early diagnosis and treatment and prevent progression and dissemination. Dissemination to airway can cause mass lesions, nodules, and papillary growths. These can be particularly life-threatening as they can cause airway obstruction, especially in children. CONCLUSIONS: Further research is required to establish a better understanding of disease so that travel medicine guidelines are updated and appropriate changes can be made in pre-travel consultation before travel to endemic areas. The need of the hour is development of vaccine for primary prevention of this disease to prevent morbidity and improve cost effectiveness. Reference #1: Polesky A, Kirsch CM, Snyder LS, et al. Airway coccidioidomycosis--report of cases and review. Clin Infect Dis. 1999;28(6):1273-1280. doi:10.1086/514778 DISCLOSURES: No relevant relationships by michael centore, source=Web Response No relevant relationships by Haris Zia, source=Web Response

E. COLI PNEUMONIA WITH PNEUMATOCELE, EMPYEMA NECESSITANS, AND BRONCHOPLEURAL FISTULA IN A PATIENT WITH SEVERE COVID-19

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tocilizumab, an interleukin-6 inhibitor used in rheumatologic disease and cytokine release syndrome, is one of many investigational drugs used for coronavirus disease-19 pneumonia (COVID). While the safety profile has been well studied, there is little known about its effect on opportunistic infections (OI) risk in patients with COVID. We present a 43-year-old man with COVID who received tocilizumab and subsequently developed cavitating lung lesions suspicious for invasive aspergillosis. CASE PRESENTATION: A 43-year-old man with diabetes mellitus was admitted for hypoxemic respiratory failure (HRF). Nasopharyngeal swab polymerase chain reaction was positive for COVID. He was placed on high-flow nasal cannula (HFNC), and on day 10 he was intubated for worsening HRF. He was treated with ceftriaxone, azithromycin, methylprednisolone, convalescent plasma, and tocilizumab. Antibiotics later included ertapenem due to E. coli with extended-spectrum beta lactamase (ESBL) found in sputum culture. He was extubated on day 15 and oxygen requirements were weaned to HFNC. However, bronchial aspirate cultures from day 14 grew mold and subsequent serologies were positive for Aspergillus. Chest computerized tomography (CT) was notable for the development of multiple new cavitary lesions concerning for invasive pulmonary aspergillosis. The patient was initially treated with voriconazole and later with amphotericin B due to liver enzyme elevation. The patient’s oxygen requirements initially decreased, however on day 30 the patient suffered an aspiration event and was reintubated. Subsequent CT was concerning for worsening of cavitary lung disease. Bronchoalveolar lavage was collected, which tested positive for Aspergillus galactomannan. On hospital day 31, the patient suffered a left-sided tension pneumothorax requiring tube thoracostomy. At the time of submission the patient remains critically ill. DISCUSSION: Influenza-associated pulmonary aspergillosis (IAPA) is a known complication of severe influenza.1,2 Similarly, COVID-associated pulmonary aspergillosis (CAPA) may become an emerging problem given the overwhelming inflammation and use of experimental immunosuppressive therapies in COVID.1,2 While tocilizumab has not been shown to increase risk of Aspergillus infection in rheumatologic disease, it has not been studied in COVID and the risk of OI in an already-susceptible group may outweigh the benefits of using this drug in patients with COVID.3 If CAPA is similar to IAPA, BAL galactomannan is the gold standard for diagnosis.2 CONCLUSIONS: As the medical community searches for COVID treatments, these patients’ potentially inherent vulnerability to OI may be under-appreciated. When using immunosuppressive agents to curtail the inflammatory cascade, the risk of OI must be considered and agents like tocilizumab must be further studied in this context. Reference #1: Koehler P, Cornely OA, Böttiger BW, et al. COVID-19 associated pulmonary aspergillosis. Mycoses. 2020;63(6):528-534. Reference #2: van Arkel ALE, Rijpstra TA, Belderbos HNA, van Wijngaarden P, Verweij PE, Bentvelsen RG. COVID-19 associated pulmonary aspergillosis. Am J Respir Crit Care Med. 2020;online May 2020. Reference #3: Kourbeti IS, Ziakas PD, Mylonakis E. Biologic therapies in rheumatoid arthritis and the risk of opportunistic infections: a meta-analysis. Clin Infect Dis. 2014;58(12):1649-57. DISCLOSURES: No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response No relevant relationships by Richard Watson, source=Web Response

AN OBSTACLE AROUND THE CORNER

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post obstructive pneumonia (POP) is found in 2-5% of patients with community acquired pneumonia (CAP), characterized by infection distal to a mechanical obstruction of the bronchus. Post obstructive pneumonia is in the differential diagnosis in patients with recurrent infections in the same lung segment(s). Bronchoscopic intervention is usually diagnostic and may also be therapeutic in certain cases. We present a case of post obstructive pneumonia which was later found to be secondary to foreign body aspiration. CASE PRESENTATION: A 60-year old woman was admitted to the hospital for recurrent right lower lobe pneumonia. She endorsed cough with dark green sputum, shortness of breath, drenching night sweats and a 30lb unintentional weight loss in the preceding 6 months. She had a history of recurrent pneumonias for the past eighteen months, with chest imaging that revealed similar right lower lobe infiltration. On physical examination she was afebrile with unremarkable vital signs. Auscultation revealed right lower lobe crackles. Procalcitonin was 0.06 ng/mL and WBC was 10.32. A CT chest demonstrated a right lower lobe infiltrate and possible endobronchial lesion. (Figure 1) Due to concern for endobronchial mass, bronchoscopy was performed which revealed a mobile obstructing mass in the right lower lobe that was retrieved with forceps. There was moderate amount of purulent secretion distal to the obstruction. (Figure 2) Pathology revealed “probable vegetable matter” (Figure 3) and bronchoalveolar lavage (BAL) cultures grew Streptococcus Sanguinis. She was discharged with amoxicillin/clavulanic acid. DISCUSSION: In patients with recurrent pneumonia in the same lung segment, the differential is broad and includes post obstructive pneumonia (POP), ”non-resolving pneumonia” (due to infectious and non-infectious causes) and aspiration. In patients with POP, the most common etiology of obstruction is malignancy, including malignant and benign tracheobronchial tumors. [1,3] The microbiology is diverse and spans gram positive, gram negative and anerobic bacteria thus broad coverage is often initially indicated. [2] Features that distinguish POP from CAP include a lower likelihood of leukocytosis, bandemia, elevated procalcitonin, or fever. With POP there is often >5% weight loss and have increased duration of symptoms. [1] Foreign body aspiration in adults occurs with swallowing disorders of varying etiologies and in states of impaired consciousness. Food causes a more prominent inflammatory reaction (acute and chronic bronchus inflammation in our patient) compared with inorganic objects. CONCLUSIONS: In a patient with recurrent pneumonia in the same lung segment with constitutional symptoms consider post obstructive pneumonia. Workup and treatment includes CT imaging, bronchoscopy and antibiotics. Reference #1: Abers, M.S., et al., Postobstructive Pneumonia: An Underdescribed Syndrome. Clin Infect Dis, 2016. 62(8): p. 957-61. Reference #2: Rolston, K.V.I. and L. Nesher, Post-Obstructive Pneumonia in Patients with Cancer: A Review. Infect Dis Ther, 2018. 7(1): p. 29-38. Reference #3: Stevic R, Milenkovic B. Tracheobronchial tumors. J Thorac Dis. 2016;8(11):3401–3413. DISCLOSURES: No relevant relationships by Giuliana Cerro, source=Web Response No relevant relationships by George Chaux, source=Web Response No relevant relationships by Michael Lewis, source=Web Response No relevant relationships by Jason Wong, source=Web Response

TO CAVITATE OR NOT TO CAVITATE: ATYPICAL PRESENTATION OF A COMMON PATHOGEN

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A patient with extensive cavitary lung disease and new diagnosis of Human Immunodeficiency Virus (HIV) infection who described clinical features suggestive of pneumocystis jiroveci (PCP) infection failed to improve with initial management. She was subsequently diagnosed with histoplasmosis after bronchoalveolar lavage (BAL) and transbronchial biopsy with a successful treatment response. CASE PRESENTATION: A 40 year-old woman with a past medical history of asthma and tobacco abuse presented with a two-week history of productive cough and pleuritic chest pain. She also reported a 40 pound unintentional weight loss over the past several months and denied hemoptysis. The patient was newly diagnosed with HIV (CD4 count of 41). Chest radiography showed extensive cavitary disease in the right upper lung lobe (RUL) and increased interstitial markings. Computed tomography showed multiple areas of peripheral soft tissue attenuation with central cavitation, the largest in the RUL measured at 7.4 cm, but no mediastinal or hilar lymphadenopathy. Her T-spot mycobacterium tuberculosis (TB) test was negative as were two expectorated sputum samples tested for TB by polymerase chain reaction. The patient underwent bronchoscopy with BAL. PCP smear from bronchial washings was positive, but the patient failed to improve after initial treatment with trimethoprim-sulfamethoxazole and steroids. Transbronchial lung biopsy (TBLB) of the right upper lobe showed lung parenchyma with fungal organisms in a background of necrosis and acute and chronic inflammation. The Grocott Methenamine Silver (GMS) stain of TBLB showed numerous budding yeast suggestive of Histoplasmosis. Fungal culture from BAL eventually grew Histoplasma capsulatum. The patient was treated with a two-week course of amphotericin B and transitioned to daily oral itraconazole for 12 months. DISCUSSION: Cavitary lesions in an immunocompromised patient should always prompt a search for an infectious cause. Although certain pathogens such as Staphylococcus aureus may cause cavitation during acute illness, cavitation due to infection is usually associated with chronic illnesses. Chronic infections most commonly associated with pulmonary cavitations are TB, Histoplasma, Aspergillus, Blastomyces, and Cryptococcus, among others. Cavitary lesions are a rare manifestation of PCP, and a solitary cavity is more common than multiple cavities. Fungal infections can be difficult to diagnose, given the poor sensitivity of culture, cross-reactivity of antigens and antibodies, and the modest sensitivity in BAL. As illustrated in our case, multiple tests may be needed to confirm the diagnosis. CONCLUSIONS: The presence of a cavitary lesion should lower the threshold for performing transbronchial biopsy in addition to BAL. Furthermore, this case calls to consider the interaction between different infectious processes as a contributing factor of such atypical presentation. Reference #1: Wheat J. Endemic mycoses in AIDS: a clinical review. Clin Microbiol Rev. 1995;8(1):146-59. Reference #2: Holt MR, Chan ED. Chronic Cavitary Infections Other than Tuberculosis: Clinical Aspects. J Thorac Imaging. 2018;33(5):322-333. Reference #3: Gallant JE, Ko AH. Cavitary pulmonary lesions in patients infected with human immunodeficiency virus. Clin Infect Dis. 1996;22(4):671-82. DISCLOSURES: No relevant relationships by JENNIFER CHIURCO, source=Web Response No relevant relationships by Jaime Palomino, source=Web Response No relevant relationships by Osman Perez, source=Web Response No relevant relationships by Hanyuan Shi, source=Web Response

PULMONARY MUCORMYCOSIS: A RARE CAUSE OF HYDROPNEUMOTHORAX

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mucormycosis is a rare but often fatal fungal infection. These fungi are ubiquitous in nature and most commonly cause rhino-orbital-cerebral infections. Patients who are immunocompromised are at higher risk (1). CASE PRESENTATION: A 76 year-old never-smoker with a medical history significant for type 2 diabetes (HbA1c 5.8%) and Coombs negative hemolytic anemia was admitted with 3 months of progressive dyspnea. She had an associated nonproductive cough for 10 days. She denied fevers, night sweats, chest pain or hemoptysis. Two months prior to presentation, she started prednisone 60 mg daily for hemolytic anemia. Prednisone was slowly tapered to 30 mg daily at the time of presentation. She received one dose of Rituximab due to persistent anemia. Evaluation 2 weeks prior to presentation revealed a right upper lobe, 5 cm cavitary lesion on chest CT. On arrival she was tachycardic (heart rate 110) and tachypneic (respiratory rate 32) without hypoxemia. Labs were notable for a hemoglobin of 9.5 g/dl, WBC of 13.6, and creatinine of 1.85 mg/dl. Chest x-ray showed a loculated right hydropneumothorax. Chest CT showed the right hydropneumothorax with progression of the right upper lobe cavitary lesion. A 14 French pigtail catheter was placed at bedside via ultrasound guidance. Pleural studies demonstrated exudative fluid with negative cytology and cultures. She underwent CT-guided biopsy of the cavitary lesion, which revealed inflammation, necrosis, and numerous broad-ribbon-like, pauci-septate hyphae favoring mucormycosis. IV liposomal amphotericin and posaconazole were initiated. Thoracic surgery declined operative intervention due to her age and comorbidities. She developed respiratory and renal failure and passed away 1 month after presentation. DISCUSSION: This patient developed pulmonary mucormycosis in the setting of glucocorticoid and Rituximab therapy. The diagnosis of mucormycosis can be difficult due to nonspecific symptoms (1) and lack of serologic tests. Commonly used fungal antigen tests such as 1,3-beta-D-glucan are traditionally negative (2). Chest CT findings are nonspecific with the classic halo or reversed halo sign present in only a minority of cases (1). A definitive diagnosis is made with histopathology (1). Successful treatment requires early diagnosis, reversal of predisposing factors, surgical debridement, and prompt initiation of antifungal therapy (3). Liposomal amphotericin is first-line pharmacologic therapy (1); however, antifungal therapy without surgical debridement is unlikely to be successful. CONCLUSIONS: Our patient presented with an unusual case of pulmonary mucormycosis; a high suspicion and histopathology are required to make the diagnosis. CT findings are non-specific and common fungal antigen tests can be negative. Early diagnosis and prompt initiation of antifungal therapy with surgical debridement improves the chance for survival. Reference #1: Farmakiotis D, Kontoyiannis DP. Mucormycoses. Infect Dis Clin North Am 2016; 30:143. Reference #2: Ostrosky-Zeichner L, Alexander BD, Kett DH, et al. Multicenter clinical evaluation of the (1-->3) beta-D-glucan assay as an aid to diagnosis of fungal infections in humans. Clin Infect Dis 2005; 41:654. Reference #3: Spellberg B, Walsh TJ, Kontoyiannis DP, et al. Recent advances in the management of mucormycosis: from bench to bedside. Clin Infect Dis 2009; 48:1743. DISCLOSURES: No relevant relationships by Meghan Hill, source=Web Response author/editior relationship with UpToDate Please note: $5001 - $20000 Added 04/01/2020 by David Midthun, source=Web Response, value=Royalty No relevant relationships by Kelly Pennington, source=Web Response