Bilateral Diffuse Ground-glass Opacities Research Articles

P1059ACOULD INFERIOR VENA CAVA DIAMETER REFLECT THE VOLUME STATUS OF THE PATIENT WITH INTERMITTENT HEMODIALYSIS ?

Abstract Background and Aims In 1960, Clyde shields (1st chronic hemodialysis patient) developed severe hypertension under treatment.His physician “Dr.scribner” decided to treat this complication using ultrafiltration to deplete the extracellular volume which was thought to be responsible for the increased blood pressure.It was successful, blood pressure decreased to normal and Clyde remained alive for 11 years.from these coming the rationale of dry body weight and its value in improving dialysis patient and improving his survival and decreasing his suffering. Several different techniques have been used to derive more standard methods of assessment dry weight, however optimal methods for adjusting fluid volume status and ideal dry weight remain uncertain. AIM To assess value of using IVC diameter and collapsibility index in modification of dry body weight in hemodialysis patient. Method A single center study included 98 patients hemodialysis patient unit in our center. all patients were subjected to assessment of IVC diameter before and after one hour of the first hemodialysis session of the week using ultrasound. We choose muscle cramps as an indicator for hypovolemia . Patients were allocated in two groups. Group 1 : patients with muscle cramps (hypotension) at last hour of session& Group 2 :without muscle cramps (normotensive or hypotensive) at last hour of session. Patients with other causes of muscle cramps rather than hypovolumia were excluded (e.g. hypocalcaemia, l-carnitine deficiency ,etc) . Results Patients with muscle cramps in last hour of session were 8 patients with average ivc diameter 0.7 cm & collapsibility more than 80%.Patients without muscle cramps in last hour of session were 84 patient with average ivc diameter 1.3 cm & collapsibility more than 50%. On interpretation of the eight patient :one patient had bilateral lower limb edema 2ry to local cause (varicose vein) not as a part of overload, three patient had uncontrolled blood pressure cannot tolerate more UF and was hypovolemic but on need to increase antihypertensive medication, two Patients had improved nutritional status with increased lean body mass, one patient had prepare for transplantation and during coarse of preparation NCCT chest showed bilateral diffuse ground glass opacities (overload versus interstitial lung disease). There was marked improvement, however NCCT still revealed ground glass opacities, in spite of patient become hypovolemic (clinically and confirmed by IVC diameter ), so patient investigated for the cause of interstitial lung disease and unfortunately diagnosed by further investigation as latent TB. Conclusions Using of ultrasound in assessment of IVC diameter is a promising method for estimating dry body weight in hemodialysis patient because it is simple, quick ,non-invasive and helpful especially in debatable cases. Conclusion Using of ultrasound in assessment of IVC diameter is a promising method for estimating dry body weight in hemodialysis patient because it is simple, quick ,non-invasive and helpful especially in debatable cases.

Computed tomography and point-of-care ultrasound findings in 2 COVID-19 patients.

We present a comparison of computed tomography of the chest and lung ultrasound in the cases of 2 patients who tested positive for COVID-19. Case #1 is a 60-year-old man with past medical history of asthma. Vital signs upon emergency department (ED) presentation were: blood pressure 126/82 mmHg, pulse 75 bpm, temperature 36.4˚C (97.5˚F), respirations 24/min, and SpO2 95%. Review of systems was positive for cough, shortness of breath, chills, fatigue, and fever. Physical examination was otherwise unremarkable. Point-of-care ultrasound (POCUS) completed before Computed Tomography (CT) showed scattered comet tail artifacts and pleural line irregularities (Figures 1 and 2). Chest CT without contrast was significant for extensive bilateral ground-glass opacities (Figure 3). Case #2 is a 59-year-old man with past medical history of asthma and hypertension. Vital signs upon ED presentation were: blood pressure 137/89 mmHg, pulse 84 bpm, temperature 39.7°C (103.5°F), respirations 23/min, and SpO2 98%. Review of systems was positive for cough, shortness of breath, chills, fatigue, and fever. Physical examination was remarkable for acute respiratory distress. POCUS completed before CT showed confluent comet tail artifacts with pleural thickening (Figures 4 and 5). Chest CT demonstrated diffuse peripheral, bilateral ground-glass opacities consistent with multifocal pneumonia (Figures 6 and 7). The World Health Organization declared COVID-19 an international public health emergency on January 30, 2020,1 and the clinical manifestations in the USA are still rapidly unfolding. Chest CT of both presented cases showed bilateral diffuse ground-glass opacities and pleural-based infiltrates, in line with recent COVID-19 imaging findings.2, 3 Lung ultrasound imaging of our patients revealed that the comet tail artifacts seen in COVID-19 are patchy with areas of normal lung in between; the artifacts are associated with an irregular, thickened pleural line with punctate defects akin to “little dents.” Both of these patients ended up decompensating within 48 hours and being intubated. There are few published case series and reports to date on utilization of ultrasound in COVID-19 patients,4, 5 but there are likely more to come. The benefits of POCUS in COVID-19 patients are substantial given its portability, efficiency, and the ability to reduce exposure of additional health care workers when compared to CT. In preparation for an increase in COVID-19-positive patients in the setting of saturated health care resources, POCUS shows promise as an efficacious tool in the diagnosis and management of COVID-19. The authors would like to acknowledge the open access funding support provided by the Dorothy Rider Pool Trust Foundation.

Case report: Mycobacterium monacense isolated from the blood culture of a patient with pulmonary infection

BackgroundThe poorly known mycobacterial species Mycobacterium monacense is a rapidly growing non-tuberculous mycobacterium that was first described in 2006 (Reischl et al., Int J Syst Evol Microbiol 56:2575-8, 2006); it has been reported that its isolation is usually associated with skin and lung infections, especially in immunosuppressed patients (Hogardt et al., Jpn J Infect Dis 61:77-8, 2008; Taieb et al., J Hand Surg Am 33:94-6, 2008; Therese et al., Lung India 28:124-6, 2011; Shojaei et al., Ann Lab Med 32:87-90, 2012; Romero et al., New Microbes New Infect 10:112-5, 2016 ). The clinical significance of Mycobacterium monacense is not yet fully understood. Here, we report the first isolation of Mycobacterium monacense from the blood culture of a patient in China with severe pneumonia.Case presentationOn June 26, 2018, a 38-year-old man was admitted to the intensive care unit with breathing difficulty. One day prior, he was discovered with his face immersed in a small pond (non-chlorinated water) and with limb convulsions. He had undergone craniocerebral surgery after trauma 5 years earlier, which left him with epilepsy as a sequela. Bilateral diffuse ground-glass opacity was found in the lungs on chest X ray and chest CT image at admission. The result of the HIV serology test of the patient was negative. The patient was diagnosed with severe pneumonia. Drug-susceptible Klebsiella pneumoniae and Candida glabrata were isolated in the BALF, and yellow-pigmented colonies were isolated from blood cultures of the patient. The strain isolated from blood was identified by 16S rDNA sequencing as Mycobacteria monacense, which is a rapidly growing mycobacterium (RGM). The patient was treated with a combination of cefoperazone sulbactam, linezolid and voriconazole for 10 days, and the symptoms improved. During the one-year follow-up time, the patient did not relapse.ConclusionsWe report the first case of M. monacense isolated from blood cultures in a patient with severe pneumonia, which provided evidence that the environmental microorganism possessed pathogenic characteristics.

Vaping, lung damage, and cytopathology: A new twist in the medical mystery: Accumulating evidence has clarified the role of cytopathology in the diagnosis of vaping-associated lung injuries and implicated vitamin E acetate as a likely culprit.

Vaping, lung damage, and cytopathology: A new twist in the medical mystery: Accumulating evidence has clarified the role of cytopathology in the diagnosis of vaping-associated lung injuries and implicated vitamin E acetate as a likely culprit.

Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study

SummaryBackgroundA cluster of patients with coronavirus disease 2019 (COVID-19) pneumonia caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were successively reported in Wuhan, China. We aimed to describe the CT findings across different timepoints throughout the disease course.MethodsPatients with COVID-19 pneumonia (confirmed by next-generation sequencing or RT-PCR) who were admitted to one of two hospitals in Wuhan and who underwent serial chest CT scans were retrospectively enrolled. Patients were grouped on the basis of the interval between symptom onset and the first CT scan: group 1 (subclinical patients; scans done before symptom onset), group 2 (scans done ≤1 week after symptom onset), group 3 (>1 week to 2 weeks), and group 4 (>2 weeks to 3 weeks). Imaging features and their distribution were analysed and compared across the four groups.Findings81 patients admitted to hospital between Dec 20, 2019, and Jan 23, 2020, were retrospectively enrolled. The cohort included 42 (52%) men and 39 (48%) women, and the mean age was 49·5 years (SD 11·0). The mean number of involved lung segments was 10·5 (SD 6·4) overall, 2·8 (3·3) in group 1, 11·1 (5·4) in group 2, 13·0 (5·7) in group 3, and 12·1 (5·9) in group 4. The predominant pattern of abnormality observed was bilateral (64 [79%] patients), peripheral (44 [54%]), ill-defined (66 [81%]), and ground-glass opacification (53 [65%]), mainly involving the right lower lobes (225 [27%] of 849 affected segments). In group 1 (n=15), the predominant pattern was unilateral (nine [60%]) and multifocal (eight [53%]) ground-glass opacities (14 [93%]). Lesions quickly evolved to bilateral (19 [90%]), diffuse (11 [52%]) ground-glass opacity predominance (17 [81%]) in group 2 (n=21). Thereafter, the prevalence of ground-glass opacities continued to decrease (17 [57%] of 30 patients in group 3, and five [33%] of 15 in group 4), and consolidation and mixed patterns became more frequent (12 [40%] in group 3, eight [53%] in group 4).InterpretationCOVID-19 pneumonia manifests with chest CT imaging abnormalities, even in asymptomatic patients, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities that progressed to or co-existed with consolidations within 1–3 weeks. Combining assessment of imaging features with clinical and laboratory findings could facilitate early diagnosis of COVID-19 pneumonia.FundingNone.

Lung Biopsy Findings in Severe Pulmonary Illness Associated With E-Cigarette Use (Vaping).

The aim of this report is to describe the lung biopsy findings in vaping-associated pulmonary illness. Lung biopsies from eight patients with vaping-associated pulmonary illness were reviewed. The biopsies were from eight men (aged 19-61 years) with respiratory symptoms following e-cigarette use (vaping). Workup for infection was negative in all cases, and there was no evidence for other etiologies. Imaging showed diffuse bilateral ground-glass opacities in all patients. Most recovered with corticosteroid therapy, while one died. Lung biopsies (seven transbronchial, one surgical) showed acute lung injury, including organizing pneumonia and/or diffuse alveolar damage. Common features were fibroblast plugs, hyaline membranes, fibrinous exudates, type 2 pneumocyte hyperplasia, and interstitial organization. Some cases featured a sparse interstitial chronic inflammatory infiltrate. Although macrophages were present within the airspaces in all cases, this feature was not prominent, and findings typical of exogenous lipoid pneumonia were absent. The histopathology of acute pulmonary illness related to e-cigarette use (vaping) is characterized by acute lung injury patterns, supporting the contention that vaping can cause severe lung damage.

PULMONARY AND SYSTEMIC EOSINOPHILIA-ASSOCIATED WITH METASTATIC COLORECTAL CANCER: A CASE REPORT

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Eosinophilia is common in medical practice and can present with variable clinical manifestations. Pulmonary involvement can mimic the clinical presentation of asthma(1-3). Common conditions associated with eosinophilia include allergies, collagen vascular diseases, drugs, parasitic infections, and, rarely, neoplasms(4). Paraneoplastic eosinophilia is a rare presentation in solid cancers(5). Herein, we report a case of a patient with pulmonary eosinophilia as a primary manifestation of metastatic colorectal cancer. CASE PRESENTATION: A 37-year-old female patient presented with a 2-week history of nonproductive cough, wheezing, and progressive dyspnea. She was previously healthy and denied any allergies or significant exposures. Asthma was suspected and treated without improvement. Physical examinations other than hypoxemia and occasional bilateral expiratory wheezing were unremarkable. Chest imaging revealed diffuse bilateral reticulonodular and ground glass opacities with middle and lower lung predominance, Kerley B lines at both lower lungs, bilateral pleural effusion, and enlargement of bilateral hila and paratracheal area. Blood counts reported hypereosinophilia with absolute eosinophil counts of 10,831 cells/μL. Additional tests including stool for parasites and AFB, ANA and anti-dsDNA, and p- and c-ANCA were all negative except for ANA. Bronchoalveolar lavage fluid (BAL) revealed marked eosinophilia of 76%. Tissue pathology from right lower lung and cytology from subcarinal lymph node aspiration revealed poorly differentiated adenocarcinoma with marked eosinophilic infiltration. Pulmonary lymphangitic carcinomatosis was therefore considered. Immunohistochemical staining results reported positive for CK20 and CDX2, but negative for CK7 and TTF-1; this pattern is highly specific for colorectal cancer(6). Due to clinical deterioration, the patient succumbed after two months of her presentation. DISCUSSION: According to our case, initial presentations with dyspnea, wheezing, and cough along with associated hypereosinophilia seemed to be attributed to asthma. However, a worsening course and pulmonary infiltrates prompted an alternative diagnosis, so additional blood tests and tissue pathology were necessary obtained. Pulmonary metastasis and paraneoplastic eosinophilia can rarely be primary manifestations of solid cancers, such as colorectal cancer in this patient. Since pulmonary manifestations of paraneoplastic eosinophilia are nonspecific, a high degree of suspicion and appropriate evaluations can never be overemphasized. CONCLUSIONS: Pulmonary metastasis with paraneoplastic eosinophilia from colorectal cancer may rarely present with asthma-like symptoms but with a more progressive course and presence of pulmonary infiltrates. Tissue diagnosis is required for definitive diagnosis and should be obtained without delay. Reference #1: 1. Rothenburg ME. Eosinophilia. New Engl J Med. 1998;338(22):1592–600. Reference #2: 2. Huss-marp J, Kahn JE, M K, Nutman TB, Pfab F, Ring J, et al. Analysis of Clinical Characteristics and Response To Therapy. J Allergy. 2010;124(6):1–17. Reference #3: 3. Dulohery MM, Patel RR, Schneider F, Ryu JH. Lung involvement in hypereosinophilic syndromes. Respir Med [Internet]. 2011;105(1):114–21. Available from: https://doi.org/10.1016/j.rmed.2010.09.011 DISCLOSURES: No relevant relationships by Santi Silairatana, source=Web Response No relevant relationships by Pitchaya Worapongsatitaya, source=Web Response

RECURRENT ARDS IN THE SETTING OF POLYSUBSTANCE ABUSE

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Drug abuse remains a significant social problem in many countries. Adverse pulmonary complications of substance abuse are well documented, including diffuse alveolar haemorrhage, aspiration pneumonitis, and opportunistic infections related to HIV and hepatitis. Acute lung injury and acute respiratory distress syndrome are well known complications of narcotic overdose, but ARDS from drug use without overdose is a much rarer entity. [1] CASE PRESENTATION: We report a case of a 39 year old female, current 10 pack-year smoker, with a history of polysubstance abuse including heroin, cocaine and alcohol, who was admitted 5 times in 8 months with recurrent episodes of dyspnea, fever, myalgias and fatigue. Each time she presented with hypoxic respiratory failure and bilateral infiltrates on chest imaging, and required high flow oxygen and BIPAP. She was treated with IV antibiotics, steroids and diuresis with good response. An extensive workup was performed including negative cultures, negative connective tissue disease serologies, and negative HIV testing. Echocardiogram showed a normal ejection fraction and negative bubble study. CT scan during the first hospitalization showed diffuse bilateral ground-glass opacities with bilateral lower lobe predominance and subpleural sparing without bronchiectasis or subpleural honeycombing. Outpatient PFTs showed only a moderately decreased diffusing capacity; methacholine challenge test showed mild bronchial hyperresponsiveness. Patient underwent bronchoscopy during one hospitalization that showed grossly normal airways, neutrophil predominant BAL and no eosinophilia; endobronchial biopsy showed atypical bronchial epithelium favoring reactive process. Surgical lung biopsy revealed rare intracapillary granulomas with exogenous polarizable material – microcrystalline cellulose consistent with IV drug injection. DISCUSSION: Pulmonary foreign body granulomatosis is described in patients who inject oral drugs intravenously. [2-3]. This would not account for the fulminant respiratory failure with ARDS in this patient. A case series of 6 patients using narcotics, gabapentin, and other psychoactive drugs, with presentation similar to our patient, with recurrent ARDS and diffuse alveolar damage on lung biopsy, has been reported [4]. DAD was not identified on this patient’s surgical lung biopsy, perhaps because the patient was biopsied in between recurrences. Management of this condition is unclear with some reports indicating a potential benefit from systemic glucocorticoids [5]. Some patients with recurrent ARDS progress to worsening fibrosis and may eventually need lung transplant. Our patient has been managed with recurrent prolonged prednisone taper, but further treatment is complicated by her social issues and medication noncompliance. CONCLUSIONS: DAD is pathologic manifestation of severe acute lung injury, recurrence can be attributed to polysubstance abuse. Reference #1: [1] Benson MK, Bentley AM. Lung disease induced by drug addiction. Thorax. 1995; 50(11): 1125–1127. Reference #2: [2]Bishay A, Amchentsev A, Saleh A, Patel N, Travis W, Raoof S. A hitherto unreported pulmonary complication in an IV heroin user. Chest 2008;133(2)549-51. Reference #3: [3] Radow SK, Nachamkin I, Morrow C, et al. Foreign body granulomatosis. Clinical and immunologic findings. Am Rev Respir Dis 1983;127:575. [4] Savici D, Katzenstein A-LA. Diffuse alveolar damage and recurrent respiratory failure: report of 6 cases. Human Pathology 2001;32(12):1398-402. [5] Chau CH, Yew WW, Lee J. Inhaled budesonide in the treatment of talc-induced pulmonary granulomatosis. Respiration. 2003;70(4):439. DISCLOSURES: No relevant relationships by Moayad Al Sona, source=Web Response No relevant relationships by Sandrine Hanna, source=Web Response No relevant relationships by Margaret Zambon, source=Web Response

PNEUMONITIS SECONDARY TO EBV-SPECIFIC CYTOTOXIC T-LYMPHOCYTES

SESSION TITLE: Diffuse Lung Disease 1 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 03:30 pm - 04:30 pm INTRODUCTION: Novel immune based therapies are now being used for a wide range of malignancies including post-transplantation lymphoproliferative disorders (PTLD), however, the short and long term risk of these therapies remains unclear. Here, we present a case of a patient who developed hypoxemia one day after receiving an infusion of EBV-specific cytotoxic T-lymphocytes. CASE PRESENTATION: A 66-year-old male presented to the hospital with 4 days of progressive dyspnea, cough, and hypoxemia. He had a history of end stage renal disease and EBV-positive cadaveric renal transplantation which was complicated by EBV viremia and PTLD. Two months prior, the patient began therapy with HLA-matched EBV-specific T-lymphocytes after failing several immunosuppressive and chemotherapeutic regimens. His most recent infusion was 1 day prior to symptom onset. On admission, oxygen saturation was 91% on room air and 96% on 2 liters of oxygen by nasal cannula. Physical exam at that time was notable for faint crackles throughout all lung fields. Chest radiograph was negative for infiltrates or effusions although computed tomography imaging of the chest revealed diffuse bilateral ground glass opacities and patchy airspace disease with an upper lobe predominance (see Figure 1). Bronchoscopy with transbronchial biopsy revealed interstitial inflammation and fibrosis, hyperplasia of type II pneumocytes, and scattered foci of organizing pneumonia consistent with active pneumonitis. Bronchoalveolar lavage demonstrated a lymphocyte predominant cell distribution with 56% lymphocytes, 41% macrophages, and 3% neutrophils. BAL and biopsy were negative for viral, fungal, and bacterial elements. With supportive care alone, the patient improved over the course of 5 days and was discharged to a short term rehabilitation facility. DISCUSSION: PTLD is a serious complication for patients undergoing organ transplantation. EBV-specific cytotoxic T-cells have shown promising results in the treatment of some of these patients, however, emerging evidence suggests that pulmonary complications are a consequence of this therapy. Indeed, in a series of 39 patients there was 1 reported death due to pneumonitis. Moreover, outcomes in another study of 114 patients found that 1 patient developed severe pulmonary infiltrates within one week of receiving EBV-specific T-cells. This patient did not suffer long-term sequelae from this complication. Our case suggests that pneumonitis from EBV-specific T-lymphocytes is characterized by a histopathological pattern of organizing pneumonia and a lymphocyte predominant cellular distribution. CONCLUSIONS: EBV-specific cytotoxic T-cell therapy causes acute pneumonitis in some patients. Additional studies will be important to understand the true incidence of pneumonitis after EBV-specific therapies, and for determining the factors that predispose or prevent the development of this therapeutic complication. Reference #1: Heslop, H. E., Slobod, K. S., Pule, M. A., et al. Long-term outcome of EBV-specific T-cell infusions to prevent or treat EBV-related lymphoproliferative disease in transplant recipients. Blood. 2010; 115(5):925-935. Reference #2: Rooney, C. M., Smith, C. A., Ng, C. Y., et al. Infusion of Cytotoxic T Cells for the Prevention and Treatment of Epstein-Barr Virus–Induced Lymphoma in Allogeneic Transplant Recipients. Blood. 1998; 92(5):1549-1555. Reference #3: Dierickx, D., and Habermann, T.M. Post-Transplantation Lymphoproliferative Disorders in Adults. N Engl J Med. 2018; 378:549-562. DISCLOSURES: No relevant relationships by Robert Hilton, source=Web Response No relevant relationships by Carl Nieweld, source=Web Response No relevant relationships by ross summer, source=Web Response

SHOE SHINING: HAZARDOUS TO THE HEALTH

SESSION TITLE: Occupational and Environmental Lung Diseases SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Hydrocarbons are ubiquitous in society and are found in many common household products, including gasoline, cleaning agents, mineral oil, and industrial solvents. In 2016, the American Association of Poison Control Centers reported 29,796 cases of hydrocarbon exposure, with approximately 20 deaths attributed to this exposure. There are three main types of hydrocarbon exposure: children with unintentional ingestion of household hydrocarbons, workers with dermal or inhalational occupational exposures, and adolescents and young adults with intentional inhalational abuse. CASE PRESENTATION: Our patient is a 40-year-old male sailor who presented to the emergency department with productive cough and dyspnea. Approximately two hours prior to arrival, the patient was waterproofing his boots in an enclosed space. On initial evaluation, his heart rate was in the 100s, respiratory rate in the 30s, and oxygen saturation in the 70s%. His exam was notable for diffusely diminished breath sounds. He was placed on 10 liters via nonrebreather. The Poison Control Center was contacted, and the inhaled toxin was identified as a petroleum-based hydrocarbon. A chest x-ray showed diffuse bilateral hazy opacities. He was admitted to the intensive care unit and placed on high-flow nasal cannula with flow and FiO2 titrated to maintain oxygen saturation greater than 92%. A high resolution CT scan of the chest showed diffuse bilateral upper and central lobe predominant groundglass opacities with subpleural sparing consistent with diffuse alveolar damage. Treatment with high dose steroids and bronchodilators was initiated, and over the next 48 hours the patient had significant improvement. He was discharged on a tapering dose of prednisone and supplemental oxygen at 4 liters per minute for exertion. After discharge, his spirometry showed a mild restrictive pattern with a mild reduction in DLCO; he no longer required supplemental oxygen. Follow up chest imaging is currently pending. DISCUSSION: The mechanisms by which hydrocarbons cause pulmonary toxicity are dose-dependent, and include alveolar and interstitial edema, desquamation of pneumocytes, and disruption of surfactant. Hypoxia results from a combination of ventilation-perfusion mismatch, shunt formation, and bronchospasm. Initial imaging may be normal, with delay of radiographic changes for several hours after the development of pneumonitis. Radiographic findings typically demonstrate bilateral interstitial infiltrates, though may also reveal pneumatocele, pneumothorax, pleural effusions, and lung necrosis; additionally, intra-alveolar oils can coalesce into nodules surrounded by fibrosis called parafinomas. While symptoms usually resolve within a few days, radiographic abnormalities may last months. Most cases of hydrocarbon lung toxicity resolve with supportive care of oxygen and ventilatory support, but there have been case reports of benefit from corticosteroids, whole or segmental lung lavage, and intratracheal surfactant in severe cases, though there is no firm evidence for these treatments. CONCLUSIONS: Hydrocarbons are found in several household products, making exposure to these items not uncommon. While the acute effects of hydrocarbon toxicity are well recognized, the long-term effects of acute and chronic exposure require further research. Reference #1: Connellan SJ. Lung diseases associated with hydrocarbon exposure. Resp Med 2017; 126:46-51. Reference #2: Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report, Clin Toxicol 2017;55:(10)1072-1254. Reference #3: Tormoehlen LM, Tekulve KJ, Nanagas KA. Hydrocarbon toxicity: A review. Clin Toxicol 2014; 52:479-489. DISCLOSURES: No relevant relationships by Jeannette Collins, source=Web Response No relevant relationships by Angeline Lazarus, source=Web Response

AN EVANESCENT RIGHT ATRIAL MASS FROM CATHETER-RELATED THROMBOSIS

SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: A diagnosis of catheter-related upper extremity deep vein thrombosis (CRUE-DVT) should be considered in the differential for right atrial mass in a patient with history of malignancy and presence of peripherally inserted central catheter (PICC) because the pulmonary embolism (PE) can be fatal even with anticoagulation.[1] CASE PRESENTATION: A 34 year old male with a history of diabetes mellitus, chronic kidney disease, testicular cancer status post orchiectomy with mediastinal metastatic seminoma resection, and intravenous drug use, presented with acute encephalopathy. He was admitted for diabetic ketoacidosis secondary to sepsis from osteomyelitis of his right foot and found to have MRSA bacteremia and candida glabrata fungemia. The patient continued to improve clinically until he developed acute hypoxic respiratory failure requiring ventilator support several days after admission. Physical exam was notable for tense right upper extremity at site of PICC without erythema or tenderness. Laboratory studies were notable for WBC of 21.5 with neutrophilia, and MRSA from right foot abscess culture and blood cultures. CT of thorax revealed extensive diffuse bilateral groundglass opacities with intralobular thickening and areas of consolidation, concerning for aggressive acute interstitial pneumonia. Bronchoalveolar lavage showed mildly elevated eosinophilia suggestive of eosinophilic pneumonia, for which the patient was treated with corticosteroids. A critical care transesophageal echocardiogram (TEE) was performed to evaluate for endocarditis and revealed a small gelatinous appearing mass contiguous with right atrial wall at the entrance of superior vena cava and interatrial shunt with suspected patent foramen ovale (Figure 1-3). Right upper extremity venous duplex ultrasonography showed completely thrombosed right basilic, brachial, axillary, and subclavian veins likely catheter-related with thrombus extension to right atrium.PICC was removed for concern of right atrial thrombus infection and anticoagulation was started. The repeat TEE performed 10 days later did not reveal a right atrial mass. The patient left the hospital against medical advice, with a therapeutic international normalized ratio but returned within 24 hours following a cardiac arrest. CT thorax angiography revealed PE with right ventricular strain, and the patient expired 48 hours later, with anoxic brain injury noted following resuscitation. DISCUSSION: CRUE-DVT should be considered with an evanescent right atrial mass, and a duplex ultrasonography should be considered because incidence of PE can be as high as 36 percent in patients with malignancy.[2,3] Optimal therapy is unknown although anticoagulation and infection-driven catheter removal appear to be the first line therapy. CONCLUSIONS: CRUE-DVT patients with ASD can develop PE and paradoxical arterial embolism, which can prove fatal, even with anticoagulation. Reference #1: Monreal M et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines--a prospective study. Thromb Haemost. 1994;72(4):548. Reference #2: Muñoz FJ et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest. 2008;133(1):143. Reference #3: Prandoni P et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157(1):57. DISCLOSURES: No relevant relationships by Michel Boivin, source=Web Response No relevant relationships by Chih-Wei Chang, source=Web Response No relevant relationships by Nicholas Villalobos, source=Web Response

Radiologic evaluation of pulmonary injury following carmustine- and cyclophosphamide-based preparative regimen for autologous peripheral blood stem cell transplantation in children.

Toxicity of carmustine and cyclophosphamide can cause pulmonary injury after hematopoietic stem cell transplantation. To evaluate the radiologic findings of pulmonary injuries following carmustine- and cyclophosphamide-based preparative regimens in children. From 2010 to 2014, 35 children received carmustine- and cyclophosphamide-based preparative regimens. Fourteen of 35 children presented with symptoms and radiologic abnormalities. Eight of 14 children had no evidence of infection, cardiogenic edema, or other explainable causes. We retrospectively analyzed their chest radiographs and CT scans for ground-glass opacity, consolidation, septal thickening and pleural effusion. Major chest radiographic findings were bilateral diffuse ground-glass opacity (n=8) and septal thickening (n=7). CT findings were multifocal patchy (n=4) or inhomogeneously diffuse (n=4) ground-glass opacity, multifocal consolidations (n=7) and septal thickening (n=7). All of these lesions at CT were bilateral, but showed lower lobe predominance in 88, 100, and 63%, respectively. There was no central/peripheral or anterior/posterior predilection. Six children had small pleural effusions, which were bilateral in five children. Bilateral ground-glass opacity with or without consolidation, septal thickening and pleural effusion were common radiologic findings in pulmonary injury following carmustine- and cyclophosphamide-based preparative regimens.

Pulmonary alveolar microlithiasis: A case report with a novel mutation in the SLC34A2 gene and review of the literature

Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive genetic disease characterized by intraalveolar psammomatous calcium phosphate deposition. Patients with PAM are often asymptomatic until the third or fourth decade, when they most frequently develop symptoms including dyspnea, and dry cough. Only one-third of the reported patients are under twenty years of age and manifestation during infancy is extremely rare. We present a case of an infant with chronic respiratory symptoms including tachypnea, retractions, crackles, and hypoxia since 2 months of age. Chest computed topography at age 8 months showed bilateral diffuse ground glass opacities and septal thickening suggestive of interstitial lung disease. Lung biopsy showed numerous intraalveolar calcified laminated structures consistent with PAM. Genetic testing confirmed the diagnosis, demonstrating a previously unreported mutation c.524-18_559del in the SLC34A2 gene.

ミノサイクリンによる薬剤性肺障害とダニ媒介性感染症の鑑別にダニの同定と媒介能評価が有効であった1例(A difficult distinction: a case of drug–induced pneumonitis or a tick–borne infection with lung involvement?)

要旨今回，ダニ媒介性感染症による肺病変と薬剤性肺障害の鑑別に難渋し，刺咬したダニの形態学的評価と媒介能を検討し診断の一助とした症例を経験した。症例は50歳の男性。マダニ刺咬後にミノサイクリンの経口投与を開始された。2週間後に発熱，呼吸困難感を認め当院受診。紅斑はなく，好酸球の軽度増多を伴う白血球数の上昇とCRPの上昇，両側肺に非区域性のすりガラス陰影を認め，ミノサイクリンによる薬剤性肺障害とダニ媒介性感染症による肺病変が考えられた。画像上，両者の鑑別は困難であったため，ダニの同定とその媒介能の評価を各種検査と並行して行い，診断することとした。患者が持参したダニはタカサゴキララマダニであり，その媒介能から重症熱性血小板減少症候群（severe fever with thrombocytopenia syndrome，以下SFTS）と日本紅斑熱による急性呼吸窮迫症候群の可能性は否定できないため，精査を行った。SFTSウイルス，Rickettsia japonicaはいずれも陰性であり，薬剤性障害と判断し薬剤を中止したところ，症状と肺病変の消失を認めた。臨床医と研究者との緊密な連携による，ダニの同定とその媒介能の評価がダニ媒介性感染症の鑑別に有用であった。今後は両者による知見の集積を行い，より正確な媒介能の評価を行うことが重要である。

Clinical Features of Patients with Diffuse Alveolar Hemorrhage due to Negative-Pressure Pulmonary Edema.

Diffuse alveolar hemorrhage (DAH) with negative-pressure pulmonary edema (NPPE) is an uncommon yet life-threatening condition. We aimed at describing the circumstances, clinical, radiological, and bronchoscopic features, as well as the outcome of patients with NPPE-related DAH. We performed a retrospective, observational cohort study, using data prospectively collected over 35years in an intensive care unit (ICU). Of the 149 patients admitted for DAH, we identified 18 NPPE episodes in 15 patients, one admitted four times for recurrent NPPE-related DAH. The patients were primarily young, male, and athletic. The NPPE setting was postoperative (n=12/18, 67%) or following generalized tonic-clonic seizures (n=6/18, 33%). Hemoptysis was almost constant (n=17/18, 94%), yet rarely massive (>200cc, n=1/18, 6%), with anemia observed in 10 (56%) episodes. The DAH triad (hemoptysis, anemia, and pulmonary infiltrates) was observed in 50% of episodes (n=9/18), and acute respiratory failure in 94% (n=17/18). Chest computed tomography revealed diffuse bilateral ground glass opacities (n=10/10, 100%), while bronchoscopy detected bilateral hemorrhage (n=12/12, 100%) and macroscopically bloody bronchoalveolar lavage, with siderophage absence in most (n=7/8, 88%), indicating acute DAH. While one episode proved fatal, the other 17 recovered rapidly, with a mean ICU stay lasting 4.6 (2-15)days. Typically, the evolution was rapidly favorable under supportive care. NPPE-related DAH is a rare life-threatening condition occurring primarily after tonic-clonic generalized seizure or generalized anesthesia. Clinical circumstances are a key to its diagnosis. Early diagnosis and recognition likely allow for successful management of this potentially serious complication, whereas ictal-DAH appears ominous in epileptic patients.

Relationship between Radiological Stages and Prognoses of Pneumocystis Pneumonia in Non-AIDS Immunocompromised Patients.

Background:Although radiological features of pneumocystis pneumonia (PCP) in non-Acquired Immune Deficiency Syndrome (AIDS) immunocompromised patients have been reported by other authors, there were no studies on the radiological stages of PCP previously. This study aimed to elucidate the radiological stages and prognoses of PCP in non-AIDS immunocompromised patients.Methods:Retrospective analysis of radiological manifestations and prognoses of 105 non-AIDS PCP immunocompromised patients from August 2009 to April 2016 was conducted. Chest radiograph was divided into three stages: early stage (normal or nearly normal chest radiograph), mid stage (bilateral pulmonary infiltrates), and late stage (bilateral pulmonary consolidations); chest high-resolution computed tomography (HRCT) was also divided into three stages: early stage (bilateral diffuse ground-glass opacity [GGO]), mid stage (bilateral diffuse GGO and patchy consolidations), and late stage (bilateral diffuse consolidations).Results:The case fatality rate (CFR) of all patients was 34.3% (36/105), all of them took routine chest X-ray (CXR), and 84 underwent chest CT examinations. According to the CXR most near the beginning of anti-PCP therapy, 18 cases were at early stage and CFR was 0 (0/18, P < 0.01), 50 cases were at mid stage and CFR was 28.0% (14/50, P > 0.05), and 37 cases were at late stage and CFR was 59.5% (22/37, P < 0.01). According to the chest HRCT most near the beginning of anti-PCP therapy, 40 cases were at early stage and CFR was 20.0% (8/40, P > 0.05), 34 cases were at mid stage and CFR was 47.1% (16/34, P > 0.05), and 10 cases were at late stage and CFR was 80.0% (8/10, P < 0.05); barotrauma, including pneumothorax, pneumomediastinum, and pneumohypoderma, was found in 18 cases and the CFR was 77.8% (14/18, P < 0.01).Conclusions:Based on the radiological manifestations, the course of PCP in non-AIDS immunocompromised patients can be divided into three stages: early stage, mid stage, and late stage. The prognoses of patients treated at early stage are good, and those at late stage are poor. Furthermore, the CFR of patients with barotrauma is high.

Diffuse Alveolar Hemorrhage Associated with Edoxaban Therapy.

Introduction. The main adverse effect of anticoagulant therapy is bleeding, and major bleeding, including intracranial, gastrointestinal, and retroperitoneal bleeding, has been reported as an adverse effect of edoxaban, a direct oral anticoagulant (DOAC). Bleeding during systemic anticoagulation with edoxaban presents a therapeutic conundrum, because there is currently no safe or efficacious reversal agent to stop major bleeding. Case Report. A 51-year-old woman had multiple traumatic injuries, including lower limb fractures. On day 8, she developed deep venous thrombosis, and edoxaban was administered orally. On day 38, she developed fungemia, which was treated with an antifungal drug. On day 43, she presented with dyspnea. Chest computed tomography scan showed bilateral diffuse ground-glass opacities in the whole lung fields. The results of the subsequent workup (i.e., serum levels of the antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane antibody) and microbiological study were unremarkable. Based on these findings, her condition was diagnosed as diffuse alveolar hemorrhage (DAH) associated with edoxaban therapy. The lung opacities disappeared spontaneously after edoxaban therapy was discontinued. Conclusion. DAH is a dangerous complication associated with edoxaban therapy. DOACs, including edoxaban, should be prescribed with caution, especially for patients in a critical condition.

Methaemoglobinaemia associated with trimethoprim/sulfamethoxazole treatment on a background of leflunomide‐induced pneumonitis

AbstractBackgroundImmunomodulating drugs such as leflunomide are known to be associated with immunosuppression and infection. Off‐label use of such agents may place patients at increased risk of potentially unforeseen adverse effects not commonly observed in clinical trials.AimTo describe a case of leflunomide‐induced pneumonitis, which may have contributed to the development of Pneumocystis jirovecii pneumonia (PJP). Treatment of the infection with trimethoprim/sulfamethoxazole (TMP‐SMX) in this case was associated with the development of methaemoglobinaemia, a relatively rare adverse effect associated with this agent.Clinical detailsA 72‐year‐old female presented with a 2‐week history of progressive dyspnoea and orthopnoea with a background of newly diagnosed, biopsy proven, membranous glomerulonephropathy. She had recently started leflunomide and prednisolone for resistant proteinuria. Soon after admission, her respiratory status deteriorated with tachypnoea (30–40/min) and hypoxia requiring large amounts of supplemental oxygen (oxygen saturation (SaO2) 95%, partial pressure of oxygen (PO2) 68 mmHg with 10 L/min of oxygen). A chest X‐ray and computed tomography revealed diffuse bilateral ground glass opacities with multimodal consolidation. Sputum polymerase chain reaction testing was positive for P. jirovecii, and a diagnosis of PJP was made. Subsequent treatment with primaquine and TMP‐SMX was linked to the development of drug‐induced methaemoglobinaemia (MeHb).OutcomeThe antimicrobial regime was changed to intravenous (IV) pentamidine as an alternative treatment for P. jirovecii pneumonia. Despite this, there was further deterioration associated with a suspected secondary bacterial pneumonia. Additional IV antibiotics were added, including piperacillin/tazobactam and vancomycin. Following failure to respond to this treatment, active interventions were withdrawn after family discussions. Palliative care measures were implemented and she died 4 days later.ConclusionPharmacists should be aware of the potential for serious, rare adverse effects associated with immunomodulating drugs. Patients must be informed of the risks associated with treatment and the evidence for benefit when these drugs are prescribed for off‐label use. PJP pneumonia prophylaxis should be considered for patients commencing high dose, chronic corticosteroid therapy. Methaemoglobin should be measured for patients who become significantly hypoxic after treatment with trimethoprim/sulfamethoxazole.

A young man with hemoptysis: Rare association of idiopathic pulmonary hemosiderosis, celiac disease and dilated cardiomyopathy.

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of recurrent diffuse alveolar hemorrhage (DAH) with no specific treatment. Herein, we discuss a case of hemoptysis, who had IPH and other rare associations. A 19-year-old man presented with recurrent hemoptysis, generalized weakness and progressive dyspnea for 3 years. Earlier, he was diagnosed with anemia and was treated with blood transfusions and hematinics. On examination he had pallor, tachycardia and was underweight. Investigations revealed low level of hemoglobin (7.8 g/dl) and iron deficiency. An electrocardiography (ECG) showed sinus tachycardia, interventricular conduction delay and T-wave inversion. Echocardiography revealed dilated cardiomyopathy with left ventricular dysfunction. Computed tomography of the chest demonstrated bilateral diffuse ground glass opacity suggestive of pulmonary hemorrhage. Pulmonary function tests showed restrictive pattern with increased carbon monoxide diffusion. Bronchoalveolar lavage and transbronchial lung biopsy showed hemosiderin-laden macrophages. Patient could recall recurrent episodes of diarrhea in childhood. Serum antitissue transglutamase antibodies were raised (291.66 IU/ml, normal <30 IU/ml). Duodenal biopsy showed subtotal villous atrophy consistent with celiac disease. He was started on gluten-free diet, beta blockers and diuretics. After two years of treatment, he has been showing consistent improvement. Screening for CD is important in patients with IPH. Cardiomyopathy forms rare third association. All three show improvement with gluten-free diet.

Post-mortem computed tomography findings of the lungs: Retrospective review and comparison with autopsy results of 30 infant cases

ObjectivesInfant cases frequently show a diffuse increase in the concentration of lung fields on post-mortem computed tomography (PMCT). However, the lungs often show simply atelectasis at autopsy in the absence of any other abnormal changes. Thus, we retrospectively reviewed the PMCT findings of lungs following sudden infant death and correlated them with the autopsy results. Materials and methodsWe retrospectively reviewed infant cases (0 year) who had undergone PMCT and a forensic autopsy at our institution between May 2009 and June 2013. Lung opacities were classified according to their type; consolidation, ground-glass opacity and mixed, as well as distribution; bilateral diffuse and areas of sparing. Statistical analysis was performed to assess the relationships among lung opacities, causes of death and resuscitation attempt. ResultsThirty infant cases were selected, which included 22 sudden and unexplained deaths and 8 other causes of death. Resuscitation was attempted in 22 of 30 cases. Bilateral diffuse opacities were observed in 21 of the 30 cases. Of the 21 cases, 18 were sudden and unexplained deaths. Areas of sparing were observed in 4 sudden and unexplained deaths and 5 other causes of death. Distribution of opacities was not significantly associated with causes of death or resuscitation attempt. The 21 cases with bilateral diffuse opacities included 6 consolidations (4 sudden and unexplained deaths, 2 other causes of death), 4 ground-glass opacities (3 sudden and unexplained deaths and 1 other) and 11 mixed (11 sudden and unexplained deaths). Types of opacities were not significantly associated with causes of death or resuscitation attempt. ConclusionAtelectasis is very common in sudden and unexplained death of infants. Bilateral diffuse mixed opacity was observed only in sudden and unexplained deaths. Bilateral diffuse pure consolidation or ground-glass opacity was also observed in other causes of death.