Course Of Levofloxacin Research Articles

A retrospective study of the efficacy and safety of levofloxacin in children with severe infection.

Levofloxacin is widely used because of its broad-spectrum antimicrobial activity and convenient dosing schedule. However, the relevance of its use in children remains to be investigated. The purpose of this study is to investigate the efficacy and safety of levofloxacin use in children with severe infections. We conducted a retrospective observational study of patients <18 years of age who received levofloxacin intravenously in the Pediatric Intensive Care Unit (PICU) of our hospital during the period between 2021 and 2022. Patient demographics, course characteristics, clinical effectiveness, and adverse event correlations were extracted through a retrospective tabular review. We included 25 patients treated with 28 courses of levofloxacin. The mean age of these children treated with levofloxacin was 4.41 years. Conversion of pathogenic microbiological test results to negative after levofloxacin treatment was detected in 11 courses (39.29%). A decrease in inflammatory markers, white blood cell or C-reactive protein counts, was detected in 18 courses (64.29%). A total of 57 adverse events occurred during the treatment period, of which 21 were possibly related to levofloxacin and no adverse events were probably related to levofloxacin. The effectiveness of levofloxacin use in children with serious infections is promising, especially for the treatment of multidrug-resistant bacteria. Adverse events occurring during the initiation of levofloxacin therapy in children are reported to be relatively common, but in this study, only a small percentage of them were possibly related to levofloxacin, and none of them were highly possibly related to levofloxacin.

Two-day versus seven-day course of levofloxacin in acute COPD exacerbations

Two-day versus seven-day course of levofloxacin in acute COPD exacerbations

Levofloxacin to Prevent Bacterial Infection in Patients with Acute Myeloid Leukemia Treated By Azacitidine and Venetoclax: A Study from the Dataml Registry

Introduction: Antibioprophylaxis in patients with cancer and neutropenia is controversial and is not a broadly recommended intervention in management of patients with hematological malignancies. Previous study showed that prophylactic treatment with levofloxacin (LEVO) is an effective and well-tolerated strategy to prevent febrile episodes and other relevant infection-related outcomes in patients with cancer and neutropenia, including acute leukemia ( Bucaneve et al., NEJM 2005). However, impact on microbial resistance discouraged the widespread use of this strategy., Venetoclax (VEN) and azacitidine (AZA) combination was recently approved in newly diagnosed patients with AML who are ineligible for intensive chemotherapy. VEN-AZA allowed higher rates of complete remission and longer overall survival but twice the incidence of febrile neutropenia compared to AZA alone making primary antibioprophylaxis a relevant question, especially in patients who are treated as outpatients or discharged after the seven days of AZA treatment. Methods: We retrospectively selected AML patients who received VEN-AZA treatment from the Toulouse-Bordeaux DATAML registry. The two centers have similar management protocols, but patients in Toulouse (but not in Bordeaux) receive antibacterial prophylaxis with LEVO 500 mg/day from day 11 during the neutropenia period following the 1 st course of VEN-AZA, until neutrophil recovery (&amp;gt;0.5 G/l). We included ≥ 18-year-old non-APL de novo or secondary AML receiving VEN-AZA treatment between June 2015 and May 2023, excluding patients that deceased before day 11 VEN-AZA or who were receiving antibiotherapy before start of VEN-AZA. The primary endpoint was the incidence of febrile neutropenia during the first course of VEN-AZA. Secondary endpoints included clinically documented infections, microbiologically documented infections, and safety data. Results: The population included 264 patients, 71 received LEVO as primary antibioprophylaxis during 1 st course of VEN-AZA and 193 received no prophylaxis [antibiotherapy in case of febrile neutropenia, i.e. standard of care (SOC)]. The median age was 69 (range 20-87) years, 55.3% of patients were male, 48.5% of patients received VEN-AZA as front-line treatment and others 51.5% ≥ 2 nd line of treatment. Febrile neutropenia occurred in 32.4% of patients who received LEVO prophylaxis leading to a hospitalization of 100% of patient with antibiotherapy for a median of 10 days (range 2-45), as compared with 38.9% of those in SOC group leading to hospitalization of 73.3% of patient with antibiotherapy for a median of 10 days (range 1-31), (23 of 71 vs. 75 of 193; relative risk, 0.90; IC95% 0.74-1.10; P=0.33). Delay from day 1 VEN-AZA to febrile neutropenia was 23 (range 10-38) and 18 (range 7-44) days in LEVO and SOC groups (p=0.008), respectively. The LEVO group had a significantly lower rate of clinically documented infections (26.1% vs 52.0%, relative risk, 0.65; IC95% 0.46-0.91; P=0.03) (Figure 1A), but similar microbiologically documented infections (30.4% vs 32.0%) (Figure 1B). It is noteworthy that among patients receiving LEVO prophylaxis, no urinary tract infections were reported. The rate of lung infections was considerably reduced (5% vs 25%) as well as gram-negative bacterial infections (50% vs 74%), consistent with LEVO's broad spectrum, including non-fermenting micro-organisms. Anaerobia infections could be due to the lack of activity of LEVO on this bacterial spectrum. There was no difference in frequency of intensive care unit (ICU) hospitalization (1.4% vs 5.2%, P=0.29). No selection of extended spectrum beta-lactamase bacteria nor burden of fluoroquinolone resistance has been detected. Clostridium difficile colitis has been detected in 2 patients, both in SOC group. No adverse musculoskeletal events have been observed. Conclusion: A short course of levofloxacin as primary prophylaxis in AML patients treated with VEN-AZA was well tolerated, seemed to have no impact on microbial resistance and was associated with a lower rate of clinically documented infection but not febrile neutropenia.

Can You Establish the Cause of This Patient's Shortness of Breath?

Mr. B is a 56-year-old man diagnosed with metastatic HER2-positive gastroesophageal adenocarcinoma. He received front-line leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX) and trastuzumab for 10 months before restaging imaging revealed progressive disease. He then received second-line trastuzumab deruxtecan. His treatment was complicated by several admissions felt to be unrelated to his cancer therapy. He was discharged after an episode of pneumonia on a steroid taper with prophylactic trimethoprim/sulfamethoxazole. Once he recovered, he was given a fourth dose of chemotherapy. About a week later, wheezes were noticed on physical exam, and he was given a 5-day course of levofloxacin. Around the same time, he also finished his steroid taper. Twelve days after his dose of chemotherapy, he presented to the emergency room with 3 to 4 days of progressive shortness of breath and dry cough following the completion of levofloxacin without symptom improvement. A CT scan showed increasing airspace opacities and multifocal areas of consolidation. Blood, nasal, and sputum cultures were negative. A bronchoscopy was performed that did not reveal findings concerning for capillaritis. He was ultimately diagnosed with drug-induced pneumonitis/interstitial lung disease (ILD). Mr. B continued to experience worsening hypoxic respiratory failure despite continuous IV steroids. He was discharged to an inpatient hospice facility where he passed away 2 weeks later. Drug-induced pneumonitis/ILD should be considered in all patients receiving trastuzumab deruxtecan who develop progressive shortness of breath or other respiratory complaints.

Expression of concern: 'Two-day versus seven-day course of levofloxacin in acute COPD exacerbation: a randomized controlled trial'.

Expression of concern: 'Two-day versus seven-day course of levofloxacin in acute COPD exacerbation: a randomized controlled trial'.

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

S2689 A Rare Case of SpaceOARTM Hydrogel-Induced Rectal Ulcer Leading to Hematochezia

Introduction: SpaceOAR hydrogel is a soft gel-like synthetic material that was FDA approved in 2015 for prostate cancer patients who are planning to undergo radiotherapy (RT). It is intended to position the anterior rectal wall away from the prostate during RT thereby reducing the dose of radiation delivered to the rectum and minimizing complications. We present a case of rectal ulcer after implantation of SpaceOAR prior to the patient receiving RT. Case Description/Methods: A 76-year-old male was diagnosed with prostate cancer- Gleason 3+4 and was planned for RT. He underwent implantation of spaceOAR hydrogel and gold fiducial markers before RT to minimize his risk of rectal toxicity. Approximately 10 days after placement, he started experiencing severe rectal pain and hematochezia. On physical exam his abdomen was benign, but a digital rectal exam showed bright red blood. Labs revealed normal hemoglobin of 16 g/dL. A computerized tomography (CT) scan without contrast was obtained showing the presence of hydrogel between the posterior margin of the prostate and the anterior wall of the low rectum with focal proctitis in that area of the rectum. Due to ongoing hematochezia, he was scheduled for a colonoscopy which confirmed CT findings of focal proctitis but also showed a large ulcer with overlying fibrotic tissue congruent with the site of his recent urological procedure. The tissue was friable and not amenable to biopsy. He was managed with a course of levofloxacin and given polyethylene glycol to avoid constipation. At a follow-up visit, he reported resolution of hematochezia and improvement in his rectal pain. He will proceed with the initiation of RT for prostate cancer. (Figure) Discussion: The SpaceOAR Hydrogel is designed to reduce rectal toxicity during RT for prostate cancer so a higher dose of radiation can be delivered to the prostate. There have been only a few cases of rectal ulcers after placement of the Hydrogel before the patient received RT. In most reported cases, the management was conservative. The mechanisms of injury are thought to be from infection, inflammation, or ischemia due to mechanical injury. We managed our patient with a course of antibiotics and laxatives resulting in improvement of his symptoms and he will proceed with RT as planned. This case is unique in that the patient developed symptoms only 10 days after implantation of SpaceOAR when all other documented cases took at least a few weeks to a few months.Figure 1.: A- Focal proctitis and large rectal ulcer in the anterior wall B- Friable tissue not amenable to biopsy C- CT scan showing hydrogel and focal proctitis.

S2858 Post-ERCP Subcapsular Hepatic Hematoma

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic procedure used for management of biliary pathology. Rates of even the most common complications, including biliary perforation and pancreatitis, are low, however other complications can be life-threatening and must be kept in mind when evaluating a patient post-ERCP. Here, we describe a case of post-ERCP subcapsular hepatic hematoma (SHH). Case Description/Methods: A 39-year-old man with a history of hypertension, type II diabetes mellitus and alcohol use disorder complicated by chronic pancreatitis with multiple episodes of common bile duct (CBD) stricture status post multiple ERCPs presents with epigastric pain and right upper quadrant pain. He was admitted two weeks prior for epigastric pain, where he was found to have CBD stricture, and underwent ERCP with stent placement. Pain did not completely resolve after his last hospitalization and escalated to a 10/10. On arrival, he was afebrile with stable vitals. Physical exam demonstrated epigastric tenderness to palpation with voluntary guarding, but a soft abdomen without rebound tenderness. Labs significant for WBC count of 10.8 x 10^9/L, alkaline phosphatase of 117 U/L, and hemoglobin 11.7 g/dL. Abdominal ultrasound showed a 7.3 x 3.9 cm area of mixed echogenicity in the right liver lobe. Triple phase CT of the abdomen and pelvis showed a 9 x 6.5 x 2.5 cm heterogeneous subcapsular liver collection. He was given Zosyn, and WBCs downtrended. On day 3, liver function tests (LFTs) rose: aspartate aminotransferase was 397 U/L, alanine aminotransferase was 206 U/L, alkaline phosphatase was 571 U/L, and total bilirubin was 5.0 mg/dL. Repeat CT showed expected hematoma resolution with correct biliary stent placement. Antibiotics were re-started. LFTs and symptoms improved. He was discharged on a 14-day course of Levofloxacin and Metronidazole. (Figure) Discussion: SHH is a rare but known complication of ERCP. Hematomas can expand, resulting in significant anemia and LFT elevation, or become infected with resultant sepsis. Patients with SHH must be carefully monitored in the post-ERCP setting. This patient exhibited an elevated WBC count with delayed elevation in LFTs, concerning for potential infection of the hematoma, yet without overt signs of infection, including lack of fever. He was managed with antibiotics without hematoma drainage, demonstrating the efficacy of conservative management for such a potentially deadly complication of ERCP.Figure 1.: Triple phase computed tomography scan of the abdomen and pelvis demonstrating a right-sided subcapsular hematoma in segment 6 of the liver in the coronal (a) and transverse (b) planes (arrow).

37-Year-Old Man With Headache and Nasal Congestion

37-Year-Old Man With Headache and Nasal Congestion

Two-day versus seven-day course of levofloxacin in acute COPD exacerbation: a randomized controlled trial.

Introduction:Duration of antibiotic treatment in acute exacerbation of COPD (AECOPD) is most commonly based on expert opinion. Typical administration periods range from 5 to 7 days. A 2-day course with levofloxacin was not previously assessed. We performed a randomized clinical trial to evaluate the efficacy of 2-day versus 7-day treatment with levofloxacin in patients with AECOPD.Methods and analysis:Patients with AECOPD were randomized to receive levofloxacin for 2 days and 5 days placebo (n = 155) or levofloxacin for 7 days (n = 155). All patients received a common dose of intravenous prednisone daily for 5 days. The primary outcome measure was cure rate, and secondary outcomes included need for additional antibiotics, ICU admission rate, re-exacerbation rate, death rate, and exacerbation-free interval (EFI) within 1-year follow-up. The study protocol has been prepared in accordance with the revised Helsinki Declaration for Biomedical Research Involving Human Subjects and Guidelines for Good Clinical Practice. The study was approved by ethics committees of all participating centers prior to implementation (Monastir and Sousse Universities).Results:310 patients were randomized to receive 2-day course of levofloxacin (n = 155) or 7-day course (n = 155). Cure rate was 79.3% (n = 123) and 74.2% (n = 115), respectively, in 2-day and 7-day groups [OR 1.3; 95% CI 0.78–2.2 (p = 0.28)]. Need for additional antibiotics rate was 3.2% and 1.9% in the 2-day group and 7-day group, respectively; (p = 0.43). ICU admission rate was not significantly different between both groups. One-year re-exacerbation rate was 34.8% (n = 54) in 2-day group versus 29% (n = 45) in 7-day group (p = 0.19); the EFI was 121 days (interquartile range, 99–149) versus 110 days (interquartile range, 89–132) in 2-day and 7-day treatment groups, respectively; (p = 0.73). One-year death rate was not significantly different between the 2 groups, 5.2% versus 7.1% in the 2-day group and 7-day group, respectively; (p = 0.26). No difference in adverse effects was detected.Conclusion:Levofloxacin once daily for 2 days is not inferior to 7 days with respect to cure rate, need for additional antibiotics and hospital readmission in AECOPD. Our findings would improve patient compliance and reduce the incidence of bacterial resistance and adverse effects.

EOSINOPHILIC PNEUMONIA AND EXTENDED-RELEASE INJECTABLE NALTREXONE

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Extended-release injectable naltrexone is an opioid antagonist approved for the treatment of alcohol and opioid dependence. Since the release of the drug in 2006, a literature review reveals five reported cases of drug-induced eosinophilic pneumonia. Our case highlights the clinical presentation of drug-induced eosinophilic pneumonia in the setting of extended-release injectable naltrexone. CASE PRESENTATION: A 35-year-old female with a past medical history lifelong tobacco use and alcohol dependence on extended-release injectable naltrexone presented to the ED with subjective fevers, myalgias, cough, and pleuritic chest pain. She was evaluated at urgent care two days prior and sent home on a course of Levofloxacin for bronchitis. Upon ED arrival, she was noted to be hypoxic and placed on supplemental oxygen. She was afebrile and tachycardic. Exam was pertinent for tachypnea and bilateral crackles. Initial laboratory data revealed WBC 19,500 (neutrophil predominate) and lactic acid 1.4. Chest x-ray and chest CT demonstrated extensive bilateral infiltrates. Empiric antibiotics were initiated while awaiting microbiology data. Due to escalating oxygen requirements and hemodynamic instability over the next 24 hours, the patient was intubated and bedside bronchoscopy was completed. BAL studies revealed lymphocyte predominance (46%) followed by eosinophils (27%) and neutrophils (21%). Given concern for acute eosinophilic pneumonia in the setting of extended-release injectable naltrexone, corticosteroids were started. Antibiotics were discontinued given negative culture data and our patient showed marked clinical improvement with continuation of steroid therapy. DISCUSSION: Extended-release injectable naltrexone is a long-acting opioid antagonist approved for the treatment of alcohol dependence. Clinical trials showed one diagnosed case & one suspected case of naltrexone-induced eosinophilic pneumonia. A current medical literature review reveals a paucity of cases associated with naltrexone and drug-induced AEP. While the etiology & pathogenesis remain largely unknown, it is thought to be related to an acute hypersensitivity reaction to an antigen in a genetically susceptible person. Progression from mild dyspnea to overt respiratory failure is rapid. Initial diagnostics are often nonspecific, however pleural fluid analysis demonstrates striking eosinophilia (10%-50%) and BAL fluid classically shows marked eosinophilia (25%-55%). Treatment includes supportive care, withdrawal of any eliciting medications, and glucocorticoid therapy. Most patients rapidly improve within 12-48 hours of initiation of corticosteroids. The prognosis for acute eosinophilic pneumonia is excellent with the vast majority of patients enjoying complete recovery. CONCLUSIONS: This case highlights the rare but important association between drug-induced eosinophilic pneumonia and extended-release injectable naltrexone. REFERENCE #1: Korpole PR, Al-Bacha S, Hamadeh S. A Case for Biopsy: Injectable Naltrexone-Induced Acute Eosinophilic Pneumonia. Cureus. 2020;12(9):e10221. Published 2020 Sep 3. doi:10.7759/cureus.10221 REFERENCE #2: Eosinophilic pneumonia induced by injectable naltrexone. Kim H, Ali M, Buch K. http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2014.189.1_MeetingAbstracts.A2283 Am J Respir Crit Care Med. 2014;189:2283. REFERENCE #3: Saved by the BAL: a case of acute eosinophilic pneumonia after methyl-naltrexone injection. Esposito A, Lau B. Chest. 2019;156:2210. DISCLOSURES: No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response No relevant relationships by Xian Qiao, source=Web Response

MILIARY PNEUMONITIS AND INTRAVESICULAR BACILLUS CALMETTE-GUERIN TREATMENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bacillus Calmette-Guérin (BCG) is a live attenuated strain of the aerobic bacterium Mycobacterium bovis. Although the mechanism of action by which intravesical BCG elicits anti-tumorigenicity remains elusive, it is a mainstay adjunct treatment of superficial bladder cancer. Non-infectious symptoms including dysuria, hematuria, and fevers are experienced in ~85% of individuals treated. Disseminated mycoplasma infections are reported in less than 5% of patients administered this intravesicular regimen. Most of these infections involve genitourinary structures, but rarely BCG-associated pneumonitis can occur. CASE PRESENTATION: A 59 year-old gentleman presented to urology with gross hematuria. Cystoscopy and biopsy revealed carcinoma in situ with a poorly differentiated transitional cell carcinoma. Transurethral resection of the tumor was performed followed by induction and maintenance therapy with monthly treatments of intravesicular BCG. The patient initially tolerated the BCG treatments quite well, but after two treatment cycles developed an unexplained cough and dyspnea with associated night sweats. A seven-day course of levofloxacin was prescribed for empiric treatment of presumed community acquired pneumonia (CAP). Unfortunately, the patient's symptomatology was recalcitrant to CAP therapy. A high-resolution CT of the chest was performed which demonstrated miliary tuberculosis. Tuberculin skin testing prior to the initiation of BCG was found to be negative. As a guidance counselor, he worked alongside students and fellow faculty at a local high school. He had no recent international travel, prior incarceration, or any other risk factors associated with TB. The decision was made to administer isoniazid and rifampin for treatment of miliary pneumonitis found to be Mycobacterium bovis in origin. The patient's symptomatology resolved following a six-month course the aforementioned regimen. Follow up imaging demonstrated improvement of the previously visualized ground glass opacities in addition to three subcentimeter pulmonary nodules remained. Surveillance imaging after an additional six months showed resolution of the ground glass opacities and pulmonary nodule stability. DISCUSSION: Pulmonary Mycobacterium dissemination is a rare yet grave complication of intravesicular BCG used for the treatment of superficial bladder cancer. The recognition and differentiation of BCG-associated pneumonitis from CAP and Mycobacterium tuberculosis is essential for appropriate pharmacologic intervention, especially since Mycobacterium bovis is resistant to some traditional Mycobacterium drugs. CONCLUSIONS: This case explores the critical features involved in the diagnosis and treatment of BCG-associated miliary pneumonitis. REFERENCE #1: Lamm DL. Complications of bacillus Calmette-Guérin immunotherapy. Urol Clin North Am. 1992 Aug;19(3):565-72. PMID: 1636240. REFERENCE #2: Ghandi NM, Morales A, Lamm DL. Bacillus Clamette-Gurin immunotherapy for genitourinary cancer. BJU int. 2013 Aug;112(3):288-97. doi: 10.1111/j.1464-410X.2012.11754.x. Epub 2013 Mar 20. PMID: 23517232 REFERENCE #3: Sylvester RJ, van der Meijden AP, Witjes JA, Kurth K. BCG versus chemotherapy for the intravescal treatment of patients with carcinoma in situ of the bladder: a meta-analysis of the published results of randomized clinical trials. J Urol. 2005 Jul;174(1):86-91; discussion 91-2. doi: 10.1097/01.ju.0000162059.64886.1c. PMID: 15947584 DISCLOSURES: No relevant relationships by Paul Dugdale, source=Web Response No relevant relationships by Daniel Santone, source=Web Response

A CASE OF MISTAKEN IDENTITY: PULMONARY BLASTOMYCOSIS DIAGNOSED AS PULMONARY CRYPTOCOCCOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Community acquired pneumonia (CAP) has a wide range of differential diagnosis with high potential for misdiagnosis. We report a case of Blastomycosis in an Appalachian hunter who was misdiagnosed with bacterial and Cryptococcal pneumonia. This case highlights the importance of evaluating CAP etiologies based on patients' epidemiological risks. CASE PRESENTATION: A 32-year-old West Virginian man with a history of recurrent sinusitis, body-mass index of 18, current smoker, and avid hunter presented with dyspnea and dry cough. Initially, at an outside facility 3 weeks prior, chest x-ray showed a left upper lobe consolidation. He was prescribed a 10-day course of levofloxacin and steroid taper, but his symptoms did not improve. Further evaluation with computed tomography (CT) chest showed a 1.6-centimeter necrotic lymph node in the subcarinal area and consolidation in the left upper lobe and lingula. He was admitted and received empiric intravenous vancomycin, piperacillin-tazobactam, and azithromycin. Severe acute respiratory syndrome coronavirus 2 and human immunodeficiency virus tests were negative. Initial pathology read of lingula biopsy was stratified squamous epithelia with enmeshed clusters of cysts with double walls and inclusion bodies suggestive of Cryptococcus neoformans. Antibiotics were discontinued and fluconazole was started, but he developed a fever of 103⁰ Fahrenheit. Then, he was transferred to our hospital for further management. Serum Blastomyces and Histoplasma antigens were positive. Silver staining of the original biopsy specimen showed a thick-walled yeast and broad-based budding forms suggestive of Blastomyces. Fluconazole was changed to itraconazole. The patient improved and resumed daily activities. DISCUSSION: It is important to consider individual patients' risk factors to aid in narrowing the broad differential diagnosis for CAP to minimize morbidity. In this case, the patient was empirically treated for bacterial CAP despite having no improvement after taking levofloxacin, a broad-spectrum antibiotic. Differential diagnoses should include fungal etiology due to the patient's hunting history. Identifying the fungus is important, especially in Blastomycosis since it is often missed, which leads to delay in diagnosis, inappropriate treatment, and disease progression. CAP diagnosis is made with visualization of the fungus due to cross-reactivity in serologic tests. Treatment is specific to the organism. Cryptococci spp. are encapsulated, narrow-based budding yeasts, found in immunocompromised patients, and treated with fluconazole. However, Blastomyces are broad-based budding yeasts, found in areas surrounding the Ohio and Mississippi River valleys, and treated with itraconazole. CONCLUSIONS: It is important to consider individual patients' risk factors to aid in narrowing the broad differential diagnosis for CAP to minimize morbidity. REFERENCE #1: Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev. 2011;24(2):247-280. doi:10.1128/CMR.00053-10 REFERENCE #2: Kanjanapradit K, Kosjerina Z, Tanomkiat W, Keeratichananont W, Panthuwong S. Pulmonary Cryptococcosis Presenting With Lung Mass: Report of 7 Cases and Review of Literature. Clin Med Insights Pathol. 2017;10:1179555717722962. Published 2017 Aug 4. doi:10.1177/1179555717722962 REFERENCE #3: Martynowicz MA, Prakash UB. Pulmonary blastomycosis: an appraisal of diagnostic techniques. Chest. 2002;121(3):768-773. doi:10.1378/chest.121.3.768 DISCLOSURES: No relevant relationships by Allison Lastinger, source=Web Response No relevant relationships by Shu Xian Lee, source=Web Response No relevant relationships by Yusra Shah, source=Web Response

Acute Sensorineural Hearing Loss - an Unusual Presentation of Uncontrolled DM

Abstract Background: Diabetes mellitus (DM) is a systemic metabolic disorder that possesses macro- and microangiopathic consequences. Studies have demonstrated that a relationship exists between sensorineural hearing loss (SNHL) and DM, particularly in patients of older age, longer disease duration, and uncontrolled DM. The pathophysiology of DM related hearing loss is poorly understood, however proposed mechanisms include ischemia, fibrosis, demyelination, and atrophy of the eighth cranial nerve. We however, present a case of acute, transient sensorineural hearing loss in the setting of diabetic ketoacidosis that resolved with blood glucose control. Clinical Case: A 34-year-old male with type 2 diabetes mellitus (A1c 6.5% -diagnosed 6 months prior), hypertension, hyperlipidemia, and morbid obesity presented with shortness of breath and acute hearing loss without tinnitus, after being treated for pneumonia and otitis media with a course of levofloxacin for 7 days. On presentation, patient was tachypneic and tachycardic. Physical examination was significant for mild erythema of the right tympanic membrane without bulging, fluid level, mastoid tenderness, or discharge. Laboratory values were significant for hyperglycemia with blood glucose of 628 mg/dL(n 70–99 mg/dL), A1c 15.9% (n 4.8–5.6%), bicarbonate 8 mmol/L (21–31 mmol/L), anion gap 37 mmol/L (9–16 mmol/L), beta-hydroxybutyrate 11.7 mmol/L (0.02–0.27 mmol/L). Venous gas was suggestive of metabolic acidosis, urinalysis was positive for moderate ketones and glucose &amp;gt;500 mg/dL. The patient was diagnosed with diabetic ketoacidosis and was started on an insulin drip. An audiogram revealed profound bilateral sensorineural hearing loss. A Computerized tomography (CT) scan of the bilateral temporal bones was negative for abnormalities, and a magnetic resonance imaging (MRI) of the brain was negative for morphologic abnormalities of 7th and 8th cranial nerves. Infectious and rheumatologic etiologies were excluded with normal syphilis FTA-ABs, Lyme PCR, Rheumatoid factor, ANCA, and ANA. The patient received one dose of empiric prednisone. His hearing improved after 2 days with normalization of blood glucose to a range of 100–200 mg/dL. A repeat audiogram and auditory brainstem response showed significant improvement with normal bilateral hearing. Discussion: SNHL in DM typically presents in a gradual progression with bilateral involvement, affecting higher frequencies. In patients with DM, studies show that chronicity (greater than 10 years) is strongly associated with SNHL. Other variables include older age and HbA1c greater than 8%. This is the first case to demonstrate acute bilateral SNHL, associated with uncontrolled type 2 diabetes mellitus, which resolved after blood glucose control. In the appropriate context, clinicians should consider significant hyperglycemia as a possible etiology of acute hearing loss.

Effect of Antibiotic on Men with Raised Prostatic-Specific Antigen (4-10 ng/ml)

Background: The managing of raised Prostate-Specific Antigen (PSA) in a range of 4 to 10 ng/ml is still controversial among urologists. In addition to prostatic cancer, benign prostatic hyperplasia, and prostatitis is established to increase PSA. PSA reduction after antibiotic therapy might detect those patients in whom biopsy can be avoided or postponed. Objectives: To evaluate the effectiveness of a 6 weeks levofloxacin course on the serum total PSA level and PSA density (PSAD) in patients with PSA 4 -10 ng/ml and ordinary digital rectal examination and ultrasonography results. Materials and Methods: The study conducted at Al-Ramadi Teaching Hospital from February 2016 to December 2019. A total of 177 men with benign prostatic hyperplasia or lower urinary tract symptoms were with a normal digital rectal examination, chronic prostatitis (Expressed prostatic secretion was done before treatment), total PSA 4-10 ng/ml, and ultrasonography findings that did not reveal a hypoechoic lesion in the prostate will be included in this study. Serum PSA and PSAD were measured before, and after treatment with a 6 weeks course of levofloxacin. Results: The age of our 177 men was ranged from 40-80 years with a mean age of 56.52 years ± 7.253. The mean prostatic size was 49.5 ± 28.5 g (range, 23-150 g). In 89 (50.2%) patients of the 177 men, total PSA has normalized to less than 4 ng/ml after antibiotics treatment. In 56 patients of 89 men had a high level of PSAD. PSAD was normalized (less than 0.15 ng/ml/cm3) after treatment in 49 patients of the 56 patients. A significant reduction in total PSA and PSAD after treatment (p <0.05).

KERNEL OF TRUTH: AN INTERESTING CASE OF FOREIGN BODY ASPIRATION

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Foreign body aspiration (FBA) is commonly seen in the pediatric and elderly population. Risk factors include encephalopathy, stroke, alcoholism and neuromuscular disorders affecting swallowing reflex. It is rare in the adult population except in cases of unconscious accidental ingestion. The most common symptom of FBA is chronic cough, which is nonspecific and can often be mistakenly approached as an infectious process. Here we describe a case of a patient who had no significant risk factors, presented with chronic cough and was found to have a lung mass on imaging but ultimately diagnosed with foreign body aspiration. CASE PRESENTATION: A 60-year-old male presented to the pulmonary office for a progressive productive cough of two-year duration. Chest roentgenogram (CXR) showed a dense opacification in the right middle lobe concerning for pneumonia versus obstructive lesion. He completed a 10-day course of levofloxacin but with no improvement of symptoms. He denied history of travel, sick contacts, pet exposure, or incarceration. He had intermittent febrile episodes and a twenty-pound weight loss. He was a non-smoker and didn’t drink alcohol. On physical examination, he had decreased breath sounds on the right lung field. Laboratory workup was significant for leukocytosis. Chest computed tomography showed complete opacification of the right middle lobe (RML) with abrupt cut off of the RML bronchus concerning for an obstructive mass along with subcarinal and right hilar lymphadenopathy (Figure 1). He underwent diagnostic bronchoscopy in which two yellow, spherical foreign body fragments were found to be obstructing the RML bronchus (Figure 2). Both specimens were removed successfully, and further gross examination was consistent with corn kernels. Bronchoalveolar lavage and endobronchial biopsies were negative for malignancy. After foreign body removal, patients' symptoms subsequently improved. DISCUSSION: FBA in the tracheobronchial tree is more common in the pediatric population than adults. Common risk factors in adults include advanced age, stroke, neuromuscular diseases such as myasthenia gravis, and alcohol abuse. Given the lack of such risk factors, prolonged duration of symptoms, and imaging concerning for malignancy, the diagnosis of FBA was not suspected. Undiagnosed FBA can lead to complications such as recurrent pneumonia, atelectasis, or bronchiectasis. Flexible bronchoscopy is the treatment of choice for the diagnosis and removal of FBA. CONCLUSIONS: Due to the predisposition for a delayed diagnosis of FBA in the healthy adult population, a high index of suspicion and thorough history taking is warranted when dealing with cases of chronic cough and recurrent pneumonia to avoid long term sequelae. Reference #1: Kam JC, et al. Foreign Body Aspiration Presenting with Asthma-Like Symptoms. Case Reports in Medicine. 2013;2013:1-4. Reference #2: Cataneo AJM, Reibscheid SM, Ruiz RL, Ferrari GF. Foreign Body in the Tracheobronchial Tree. Clinical Pediatrics. 1997;36(12):701-705. Reference #3: Malinowska E, Dabrowska-Kruszewska J, Doboszynska A, Stangiewicz M, Gugala K, Biernacki M. Foreign Body in the Airway a Female Patient with Myasthenia Gravis. Advances in Experimental Medicine and Biology Pathophysiology of Respiration. 2015:29-36. DISCLOSURES: No relevant relationships by Anthony Cucci, source=Admin input No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Joseph Michael Lim, source=Web Response No relevant relationships by Elizabeth Verghese, source=Web Response

Is It Crohn’s Disease?

Question: An otherwise healthy 22-year-old woman was admitted to a hospital for persistent diarrhea, abdominal cramps, and weight loss over the previous weeks. Laboratory findings showed a C-reactive protein of 5.58 mg/dL (reference value, <0.80 mg/dL), white blood cell count of 7350/μL, hemoglobin of 12.5 g/dL, and calprotectin of 22 μg/g (reference value, <50 μg/g); the remaining values were unremarkable. Stool cultures excluded common bacterial and protozoal pathogens, including Clostridium difficile. Abdominal ultrasound examination showed concentric thickening of the last ileal loop extending 7 cm proximal to the ileocecal valve. A colonoscopy revealed an inflamed mucosa in the distal 15 cm of the ileum with edema and aphthous erosions; colonic examination was normal. Biopsies were taken in all tracts from distal ileum to the rectum and the histopathological examination was suggestive of active ileal Crohn’s disease. During hospitalization, the patient was treated with a single course of oral steroids and received a 5-day course of levofloxacin 500 mg once daily. She had a rapid clinical response and oral steroids were tapered within 8 weeks, after which she maintained clinical remission for 3 more months. In March 2020, the patient was referred to the outpatient clinic of our center, complaining of worsening fatigue and recent onset of diarrhea, with 3–4 nonbloody bowel movements per day. Suspecting a Crohn’s disease exacerbation, a contrast-enhanced intestinal magnetic resonance imaging was performed. Radiologic examination showed regular distention of the intestine, no significant thickening of bowel walls, and no enhancement in the distal ileum (Figure A). Other abdominal findings were normal, thus making a Crohn’s flare improbable. Incidentally, on the cranial scans bilateral consolidations in peripheral pulmonary parenchyma were noticed in T2 sequences (white arrow in Figure B) and T1 sequences after gadolinium infusion (white arrow in Figure C and Figure D). On the basis of the history, the clinical presentation and the radiologic findings, what is your diagnostic suspicion? Look on page 1246 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Finally, a nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The patient did not meet the criteria for hospitalization or treatment. She was therefore discharged at home, with instructions to self-isolate, report to the hospital any change in symptoms or oxygen saturation, and wait 2 weeks before repeating virus testing. At 2 weeks follow-up she repeated 2nasopharyngeal SARS-CoV-2 swabs that were both negative and she was thus declared virus free. Diarrhea resolved spontaneously few days after the first virus test, along with an improvement of fatigue. At a follow-up visit, she reported feeling well and was not experiencing gastrointestinal or respiratory symptoms. Gastrointestinal symptoms are common among patients with coronavirus disease-19 (COVID-19), although their timing in the history of infection is yet to be clarified. In particular, diarrhea has been reported in ≤50.5% of patients alongside nausea and vomiting, which have been found in 1.0%–17.3% of patients.1D’Amico F. Baumgart D.C. Danese S. et al.Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention and management.Clin Gastroenterol Hepatol. 2020; 18: 1663-1672Abstract Full Text Full Text PDF PubMed Scopus (333) Google Scholar Like in the case described, these symptoms can be the main clinical manifestation of COVID-19 and, owing to their nonspecific nature, can mimic several gastrointestinal conditions. In a recent case series from Spain, COVID-19 presented in patients with inflammatory bowel disease (IBD) with pneumonia and fever as most common symptoms, as well as diarrhea in 21%.2Rodríguez-Lago I. Ramírez de la Piscina P. Elorza A. et al.Characteristics and prognosis of patients with inflammatory bowel disease during the SARS-CoV-2 pandemic in the Basque Country (Spain).Gastroenterology. 2020; 159: 781-783Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Hence, in the midst of COVID-19 outbreak, SARS-CoV-2 infection should be ruled out in the assessment of any IBD exacerbation. In conclusion, we recommend considering COVID-19 in the differential diagnosis of any gastrointestinal condition presenting with diarrhea among its main manifestation. Generally, treatment for IBD, including biologics and JAK inhibitors, should not be suspended during COVID-19 pandemic as recently recommended by the International Organization for the Study of IBD (www.ioibd.org/ioibd-update-on-covid19-for-patients-with-crohns-disease-and-ulcerative-colitis/).3Rubin D.T. Feuerstein J.D. Wang A.Y. et al.AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary.Gastroenterology. 2020; 159: 350-357Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar Our described case was reported on SECURE IBD (Surveillance Epidemiology of Coronavirus Under Research Exclusion – IBD, https://covidibd.org/), an international registry aimed at monitor and report outcomes of confirmed COVID-19 occurring in IBD patients. We encourage all physicians caring for patients with IBD to contribute to it.

2388 Peliosis Hepatis Progressing to Acute Liver Failure

INTRODUCTION: Peliosis hepatis is characterized as a vascular condition in which blood-filled cystic cavities are distributed diffusely throughout the liver parenchyma. The condition is rare, with the pathogenesis poorly described in the literature. It is believed that this disease is secondary to an underlying malignancy, immune disorder, infection, or a drug/toxin mediated effect. We present a case of a patient diagnosed with peliosis hepatis complicated by the development of acute liver failure. CASE DESCRIPTION/METHODS: A 71-year-old man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, and prostate cancer treated with radiosurgery was admitted to our hospital with symptoms of fatigue, dysphagia and anorexia. He was in his usual state of health until four weeks prior to admission, when he began experiencing early satiety with poor oral intake, nausea, diarrhea, right upper quadrant abdominal pain, and weight loss. He was evaluated by his primary care provider who prescribed him a five day course of levofloxacin with no resolution of symptoms. Upon admission, labs were notable for leukocytosis and a mild transaminitis. Imaging revealed hepatomegaly with hepatic hemangiomatosis and splenic hemangiomas. A liver MRI was performed which returned consistent with diffuse hepatic peliosis with splenic peliosis. He underwent an intensive hematologic/oncologic, rheumatologic, and infectious workup that was significant for a positive quantiferon TB gold and he was subsequently started on empiric TB therapy. Synthetic liver function continued to worsen consistent with acute liver injury, which progressed to acute liver failure. The patient continued to decline and ultimately passed from multi-organ system failure. DISCUSSION: The majority of patients with peliosis hepatis will present asymptomatically and are found incidentally, while a subset of patients will present with abdominal pain or stigmata of liver disease. A liver biopsy is useful for diagnosis and is used in the context of the clinical picture, laboratory data, and imaging findings. Once the underlying offending etiology is recognized and appropriately treated, symptoms can improve and regression of the hepatic lesions can be seen. Our patient is unique in that his presentation was atypical and rapid, and a true causal etiology was never concretely identified, leading to progression to acute hepatic failure.

2591 Endoscopic Management of Ingested Wooden Splinter Impacted in the Duodenum: A Case Report

INTRODUCTION: Wooden particles, such as splinters off wood spatulas or toothpicks, being ingested is a rare but life-threatening event. In this case report, we will describe a case of duodenitis and focal duodenal perforation by a wooden splinter mimicking superior mesenteric artery vasculitis. CASE DESCRIPTION/METHODS: A 59-year-old female with past medical history significant for celiac disease not adherent to a strict gluten free diet, migraines and osteoporosis, presented to the emergency department (ED) with periumbilical and upper abdominal pain radiating to the back for the past 5 weeks. The pain is described as “sharp and tight” and exacerbated by food, leading to distention and bloating. The patient did endorse having regular bowel movements. On physical exam, she was in no apparent distress after receiving fentanyl in the ED; her abdomen was soft, non-tender, with normoactive bowel sounds. Computed Tomography (CT) angiography of the abdomen showed mild stranding surrounding the superior mesenteric artery (SMA) as it passed over the duodenum, as well as inflammation of the duodenum alongside several surrounding mildly enlarged lymph nodes, consistent with suspicion for duodenitis, ulceration, or SMA vasculitis. She was noted to have elevated C-reactive protein of 5.2 mg/L. Patient had an esophagogastroduodenoscopy (EGD) for further evaluation, which showed a toothpick impacted in the third portion of the duodenum, in the duodenal wall, and causing minimal ulceration around the impacted area, alongside significant duodenitis with erosions in the vicinity. The toothpick was dis-impacted with a snare and brought back to the stomach, then it was grasped with a cold biopsy forceps and removed completely from the patient in one piece. Patient was started on omeprazole daily for 8 weeks. She was started on short course of levofloxacin and metronidazole, as full-thickness perforation of the duodenum could not be ruled out. DISCUSSION: Wooden particle ingestion is a life-threatening event, with a mortality rate estimation of 9.6-18%. Early diagnosis and treatment are critical for reducing morbidity and mortality; however, a correct diagnosis may be challenging as many patients do not recall swallowing a toothpick or wooden splints. The symptoms associated with toothpick or wooden splint ingestion may be non-specific, such as abdominal pain, fever, or nausea caused by localized perforation/impaction. The most common site of toothpick lodgment or perforation is the duodenum (23%).

A PATIENT WITH ACUTE CHRONIC RESPIRATORY FAILURE AND BILATERAL PULMONARY INFILTRATES

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Differential diagnosis of bilateral diffuse pulmonary infiltrate is broad and includes both infectious and noninfectious etiologies, such as vasculitis, allergic bronchopulmonary aspergillosis, interstitial lung disease and autoimmune disease. CASE PRESENTATION: A 45 year old male with a presumptive diagnosis of hypersensitivity pneumonitis presented with worsening shortness of breath and was admitted to the hospital. He received steroids and 5 day course of levofloxacin, but remained hypoxic requiring up to 10 liter oxygen. Due to his worsening respiratory status, he was transferred to the intensive care unit (ICU). On admission to the ICU, chest radiograph showed progressing patchy airspace disease diffusely throughout both lungs. CT chest revealed nonspecific diffuse and patchy ground glass opacity with interlobular septal thickening and superimposed consolidative opacities throughout both lungs, in a crazy paving pattern. He continued treatment with intravenous steroids but had minimal improvement in his respiratory status. He underwent bronchoscopy with bronchoalveolar lavage (BAL) on day 5, which showed scant thick secretions with occasional streak of blood. Based on his imaging results and bronchoscopy appearance, the top differential for his acute on chronic respiratory failure was pulmonary alveolar proteinosis (PAP). He subsequently underwent bilateral total lung lavage during which large amount of debris was cleared from both lungs, and periodic acid-Schiff (PAS) stain showed clumps of granular acellular material suggestive of intra-alveolar proteinosis. Culture from BAL also showed polymicrobial growth with streptococcus anginosus and rothia dentocariosa, and he completed 7 day course of antibiotic therapy, initially with cefepime and then transitioned to ceftriaxone. By the time of discharge, his oxygen requirement was 3L/min via nasal cannula and he was started on GM CSF. DISCUSSION: PAP is a rare disease characterized by accumulation of PAS-positive lipoproteinaceous material in the distal air spaces due to impaired surfactant clearance. Auto-immune PAP is the most common etiology with estimated prevalence of 4 to 40 cases per million. CT scan is the major tool in diagnosis of PAP with patterns of ground-glass opacities, septal reticulations and parenchymal consolidation being highly suggestive of the disease. Diagnosis requires BAL which reveals milky fluid and positive PAS-staining granules. The mainstay of treatment remains symptomatic total lung lavage with GM CSF as an adjunct. CONCLUSIONS: In patients with acute on chronic respiratory failure, the appearance of diffuse ground-glass opacities, septal reticulations and parenchymal consolidation should raise concern for PAP. Proper diagnostic workup includes BAL with PAS staining. Reference #1: Singh I, Kaner R. A Woman with Asthma and Ground-Glass Opacities. Ann Am Thorac Soc. 2017;14(1):140-144. Reference #2: Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med. 1958;258(23):1123-42. Reference #3: Borie R, Danel C, Debray MP, et al. Pulmonary alveolar proteinosis. Eur Respir Rev. 2011;20(120):98-107. DISCLOSURES: No relevant relationships by Alice Gallo De Moraes, source=Web Response No relevant relationships by Melissa Myers, source=Web Response No relevant relationships by Zhenmei Zhang, source=Web Response