Diffuse Bilateral Infiltrates Research Articles

Diffuse Alveolar Hemorrhage as a Life-Threatening Feature of Juvenile Onset Systemic Lupus Erythematosus: A Case-Based Review

Diffuse alveolar hemorrhage is an uncommon but serious complication of systemic lupus erythematosus (SLE). We reported a 17-year-old boy with idiopathic thrombocytopenic purpura, who admitted with pallor and petechiae. He had Coombs positive hemolytic anemia and thrombocytopenia (hemoglobin 6.2g/dL, platelets 10,000/mm3 and lactate dehydrogenase 1024U/L), cough, tachypnea, and desaturation in the room air. Chest radiograph revealed bilateral diffuse alveolar opacities and computed tomography showed bilateral diffuse alveolar infiltrates and ground-glass opacity consistent with pulmonary hemorrhage. Anti-nuclear antibody (ANA) was 1:640 with positive Ro and anti-phospholipid antibodies, low C3 and C4, but negative anti-double-stranded DNA. He was treated with pulse methylprednisolone followed by tapering doses of steroids and with 6 doses of intravenous cyclophosphamide once every two weeks followed by mycophenolate mofetil. He had no relapse in the following 3 years. The case was reported to emphasise this life-threatening complication of juvenile-onset SLE and we reviewed the literature.

Unusual Presentation of Pulmonary Interstitial Glycogenosis: A Case Report Study

Introduction: Pulmonary interstitial glycogenosis (PIG) is a kind of children’s interstitial lung disease (ChILD). This is exclusively limited to neonates and infants. Often, PIG is diagnosed in the lung biopsy in a short time after birth (usually < 6 months). Most cases of PIG in infants are symptomatic within the first days to weeks of life. PIG expresses itself with diverse clinical symptoms such as tachypnea and hypoxia and may lead to acute respiratory failure in neonates. Case Presentation: In this case report study, we presented a 1.5-year-old boy with the chief complaint of stage 4 clubbing in fingers and toes. Mild chest deformity was observed in his physical exam. No evidence of respiratory and cardiac complications was observed. Initial lab tests and further specific studies were normal. His parents did not mention the history of any diseases in this patient. His chest X-ray (CXR) showed hyperinflated lungs, diffuse bilateral interstitial infiltration, and hazy opacities. Ground glass opacities (GGO) and interlobular septal thickening and cystic changes with reversed halo sign in both lungs were observed in his chest computerized tomography (CT). Finally, pulmonary biopsy showed a high level of glycogen-laden mesenchymal cells in the interstitium of alveoli, and vimentin-positive interstitial infiltration in lung parenchyma confirmed the PIG diagnosis. Conclusions: The new manifestation of PIG, which has been reported in this case, can be beneficial for future diagnoses of PIG.

Extensive bilateral diffuse infiltrates and deterioration of lung following infection with severe acute respiratory syndrome coronavirus 2 in a pregnant woman: a case report

IntroductionSevere acute respiratory syndrome coronavirus 2 is the third member of the coronavirus family to cause global concern in the twenty-first century. Pregnant women are particularly at higher risk of developing severe viral pneumonia, possibly because of a partial immune suppression during their pregnancy. Under such critical and rapidly evolving circumstances, these poor findings might be helpful for the treatment of infected pregnant women with the 2019 novel coronavirus.Case presentationIn this study, we report the case of a 33-year-old Asian pregnant woman at 25 gestational weeks with coronavirus disease 2019 who developed severe complications, including hypoxemia, acute respiratory distress syndrome, pulmonary infiltration, and bilateral pleural effusion. She died 1 month after admission to the hospital.ConclusionPregnant populations are especially at higher risk of viral pneumonia development caused by severe acute respiratory syndrome coronavirus 2. Further research on the prevention and treatment of the new coronavirus is necessary.

A CRACK LUNG WITH CRACK COCAINE

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Crack lung is an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings occurring within 48 hours of smoking crack cocaine.1 Patients may present with clinical features of pneumonia. As such, it is important to differentiate the two clinical entities as the management approach differs. Here we present a case of acute pulmonary cocaine toxicity mimicking possible pneumonia. CASE PRESENTATION: A 40 year old man with a history of depression was brought in by paramedics after being found unconscious.He was given naloxone en route with improved consciousness but was tachypneic and hypoxic, requiring oxygen. On arrival to the Emergency Department, he admitted to having smoked crack cocaine which was impure.He reported having hemoptysis and rhinorrhea but denied any chest pain, fever or any gastrointestinal symptoms.There was no personal or family history of lung or autoimmune disease. On presentation he was afebrile, tachycardic, tachypneic and persistently hypoxic requiring high flow nasal cannula (HFNC). Pertinent findings were diminished breath sounds with diffuse rales, with an otherwise unremarkable exam. Laboratory results were notable for cocaine on urine toxicology, leukocytosis with neutrophilia, elevated procalcitonin with normal CRP, BNP, serial troponins, lactic acid, COVID-19 test and HIV. Initial CXR showed bilateral extensive nodular interstitial lung pattern. He was admitted for acute hypoxic respiratory failure (AHRF) secondary to crack lung syndrome with superimposed pneumonia on HFNC and started on empiric antibiotics as well as methylprednisolone. Unfortunately, he remained persistently tachypneic and required non-invasive ventilation (NIV) and transfer to the intensive care unit. On day 2, his respiratory status markedly improved and he was weaned from NIV to room air. Final blood cultures and mycoplasma antibody were negative and the rest of his hospital stay was uneventful. DISCUSSION: In 2018, approximately 5.5 million persons aged ≥ 12 years reported cocaine use within the past year of which 757,000 used crack cocaine.2,3 With likely underreported usage, the deleterious pulmonary complications related to cocaine use including pulmonary edema, alveolar hemorrhage, eosinophilic pneumonia, pneumothorax, thromboembolic disease and AHRF,4 are clinically relevant. However, the diagnosis of cocaine-induced pulmonary diseases remains challenging for clinicians given that the clinical features and chest images are non specific and can mimic several other processes e.g. pneumonia.5 This distinction is important as mortality for pneumonia requiring ICU admission approaches 30%,6 while acute eosinophilic pneumonia portends an excellent prognosis with rapid clinical recovery. CONCLUSIONS: This case highlights that "Crack Lung" should be considered as a differential diagnosis in patients with AHRF and diffuse bilateral pulmonary infiltrates. REFERENCE #1: Forrester, J. M., Steele, A. W., Waldron, J. A., & Parsons, P. E. (1990). Crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. The American review of respiratory disease, 142(2), 462–467. https://doi.org/10.1164/ajrccm/142.2.462 REFERENCE #2: National Institute on Drug Abuse.(2020) What is the scope of cocaine use in the United States? Available from:https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states REFERENCE #3: 3.Center for Disease Control and Prevention. (2019). Annual surveillance report of drug-related risks and outcome. Available from:https://www.cdc.gov/drugoverdose/pdf/pubs/2019-cdc-drug-surveillance-report.pdf DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alicia Thomas, source=Web Response No relevant relationships by Felix Wireko, source=Web Response

COVID-19-ASSOCIATED THROMBOTIC THROMBOCYTOPENIC PURPURA: A FATAL NIGHTMARE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 virus has been reported to be associated with many unusual conditions and coagulopathies including thrombotic microangiopathies, DVTs, and PEs. However, cases of COVID 19 associated TTP are very rare. We discuss a patient with confirmed COVID-19 pneumonia who then developed acquired autoimmune TTP. CASE PRESENTATION: A 68-year-old female with no significant past medical history presented to the hospital with generalized weakness, shortness of breath, and cough. The onset of symptoms was about 7 days. Initial labs were significant for positive COVID-19 on PCR, WBC 10.4 k/ul, Lactic 1.3, D-dimer 3109 ng/ml. Chest x-ray revealed diffuse bilateral pulmonary infiltrates. She was placed on high flow oxygen with saturation between 80 - 89%. Remdesivir, Dexamethasone & one unit of COVID Convalescent Plasma were started for COVID-19 pneumonia. On day 2, she was switched to BIPAP due to worsening respiratory distress. On day 3, she was intubated due to rapidly progressive ARDS. Blood cultures were negative. She developed neutrophil predominant leukocytosis and anemia. On day 5, she developed thrombocytopenia. On day 8, her platelet counts declined to 17,000. Peripheral smears showed minor areas of clumping while platelet still significantly decreased. Redraw with citrate tube showed no major difference in platelet count. Testing showed evidence of hemolysis with undetectable haptoglobin, rising bilirubin level, and markedly elevated LDH with worsening renal functions. Directs Coombs test was IgG positive with abundant schistocytes on smear. PLASMIC SCORE 7 indicating a high risk for ADAMTS 13 deficiency. The patient was started on high dose IV steroids and needed a total of 2 units of packed red blood cell, 7 units of platelets, and 27 units of fresh frozen plasma. Her condition continued to deteriorate, and she was transferred to a tertiary care center that has plasmapheresis capability. Unfortunately, the patient died a few days later despite treatment. DISCUSSION: There have been only few cases in the literature discussing TTP involvement with COVID-19 infection. A case series and a four patient mini-review of this association were published in January 2021. COVID-19 seems to be the primary trigger. Autoimmunity and endothelial damage could be important factors in these manifestations. Plasmapheresis seem to improve this condition. However, due to the low population of patients, more cases are needed to draw a conclusion and better understand the presentation of COVID-associated coagulopathy. CONCLUSIONS: This case highlights the importance of evaluating and recognizing the hematological complication associated with COVID-19. Therapeutic plasma exchange and IV steroids should be started early. Rapid progression if not treated promptly. Further studies are needed to understand pathogenesis, clinical course, and proper management. REFERENCE #1: George JN, Nester CM. Syndromes of thrombotic microangiopathy. N Engl J Med. 2014 Nov 6;371(19):1847-8. doi: 10.1056/NEJMc1410951. PMID: 25372103. REFERENCE #2: I ba, T., Levy, J.H., Connors, J.M. et al. The unique characteristics of COVID-19 coagulopathy. Crit Care 24, 360 (2020). https://doi.org/10.1186/s13054-020-03077-0 REFERENCE #3: Tehrani HA, Darnahal M, Vaezi M, Haghighi S. COVID-19 associated thrombotic thrombocytopenic purpura (TTP) ; A case series and mini-review. Int Immunopharmacol. 2021 Apr;93:107397. doi: 10.1016/j.intimp.2021.107397. Epub 2021 Jan 22. PMID: 33524803; PMCID: PMC7825972. DISCLOSURES: No relevant relationships by Musa Abu-Jubara, source=Web Response No relevant relationships by Dania Abu-Jubara, source=Web Response No relevant relationships by Adebayo Fasanya, source=Web Response

A VERY PROLONGED AND ULTIMATELY FATAL COURSE OF COVID-19 IN A PATIENT WITH LYMPHOMA

TOPIC: Chest Infections TYPE: Global Case Reports INTRODUCTION: Recent data suggest that patients with advanced solid and hematologic malignancies are more likely to have prolonged SARS-CoV-2 viral shedding and poor outcomes with coronavirus disease 2019 (COVID-19) due to disease and therapy-related immunosuppression. We present a patient with lymphoma who had a very prolonged and ultimately fatal course of COVID-19 despite aggressive treatments. CASE PRESENTATION: A 39-year-old male was diagnosed with aggressive follicular lymphoma and received standard chemotherapy. Two years later, his disease recurs with transformation to diffuse large B-cell lymphoma and received Rituximab, Dexamethasone, Cytarabine, and Oxaliplatin and radiotherapy to T8-T10 for chord compression. Autologous hematopoietic stem cell transplant (HSCT) was planned but deferred because he tested positive for SARS-CoV-2 via nasopharyngeal (NP) swab RT-PCR. Over the next 12 months, he required hospitalization 7 times with fever, cough, progressive dyspnea, and diffuse lung opacities on chest radiograph. Chest CT revealed bilateral diffuse ground glass infiltrates. Bronchoscopy with BAL was positive for SARS-CoV-2 RT-PCR;lung biopsy revealed interstitial pneumonitis but negative for other infectious pathogens. Overtime, he tested 6 times positive and 2 times negative for SARS-CoV-2 by RT-PCR. He was treated with antimicrobials, convalescent plasma, Remdesivir, and corticosteroids. Cytoxan was subsequently added as a steroid sparing agent. He had 3 negative and 2 positive SARS-CoV-2 IgG serology tests. On this last admission, he presented with hypoxic respiratory failure requiring ICU admission and mechanical ventilation. IL-6 levels peaked at 244. The cycle threshold (CT) values were in the teens suspicious of active viral replication. In ICU he was treated with proned positioning and received vasopressors, Remdesivir, and another course of IV corticosteroids. A year from the COVID-19 diagnosis, the patient's family decided to focus care on comfort, and he expired. DISCUSSION: Per our knowledge we are describing the longest case that suffered with COVID 19. He had a slowly progressive disease and inconsistent SARS-CoV-2 RT-PCR tests. Our case highlights the challenges in managing lymphoma patients, who due to B-cell dysfunction and treatment depletion of B-cells, may act as persistent shedders and sources of transmission. They harbor dysfunctional CD8+ T cells and have an increased likelihood of virally induced lymphopenia and high mortality. The efficacy of corticosteroids and IL-6 receptor inhibitors to treat COVID-19 in patients with lymphoma is unknown. Although these treatments may be helpful in suppressing the 'cytokine storm', they can impede viral clearance. CONCLUSIONS: Our case suggests that regular viral load testing and prolonged courses of antiviral therapies and use of convalescent plasma may need to be considered in patients with lymphoma and protracted COVID-19. REFERENCE #1: Aries JA, et al. Clinical outcome of coronavirus disease 2019 in haemato-oncology patients. Br J Haematol 2020 REFERENCE #2: Hueso T, et al. Convalescent plasma therapy for B-cell-depleted patients with protracted COVID-19. Blood 2020;136:2290-95 REFERENCE #3: Ji Hoon Baang Prolonged Severe Acute Respiratory Syndrome Coronavirus 2 Replication in an Immunocompromised Patient J Infect Dis. 2020 Oct 22 : jiaa666. Published online 2020 Oct 22 DISCLOSURES: No relevant relationships by Alina Dulu, source=Web Response No relevant relationships by Anna Ford, source=Web Response Advisory Committee Member relationship with Jazz Pharmaceuticals Please note: $1-$1000 by Stephen Pastores, source=Web Response, value=Consulting fee Grant Support for Clinical Trial relationship with Biomerieux Please note: $5001 - $20000 by Stephen Pastores, source=Web Response, value=Grant/Research Support No relevant relationships by Kate Tayban, source=Web Response

Massive retinal infiltrates as the presenting sign of chronic myeloid leukemia: Clinical and imaging features of leukemic retinopathy.

To describe the clinical and optical coherence tomography (OCT) features of two cases with bilateral diffuse retinal infiltrates as the only presenting feature of chronic myeloid leukemia (CML) on initial diagnosis and upon relapse. We reported two patients with CML, one at initial diagnosis and one in remission who presented with bilateral subacute visual impairment. Fundal examination revealed bilateral symmetrical leukostatic appearance with increased vascular tortuosity, diffuse retinal infiltrates with size up to 6 disk diameters, retinal hemorrhages, and Roth's spots. OCT showed multiple intra-retinal hyper-reflective foci corresponding to intra-retinal hemorrhages, and outer retinal hyper-reflective foci in area corresponding to retinal infiltrate. The different retinal layers were relatively preserved and distinguishable. White cell count (WCC) were elevated in both patients ranging from 544 to 810 × 109/L. Bone marrow biopsy confirmed the diagnosis of CML in the patient without prior diagnosis and relapse of CML in another patient. Cytogenetic test detected Abelson murine leukemia (ABL) - breakpoint cluster region (BCR) fusion transcript in both cases. Both patients were started on oral imatinib, subsequently WCC returned to within normal values in both cases. Vision and OCT abnormalities improved and reduction in retinal hemorrhages and infiltrates were observed in follow up. This report highlights the important role of ophthalmologists and detailed fundus examination in making a prompt diagnosis of leukemia in patients with visual complaints. Appropriate systemic investigation and hematologist referrals for prompt treatment of CML may improve survival rate and preserve vision.

VARICELLA PNEUMONIA: ADULT COMPLICATIONS OF A CHILDHOOD DISEASE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Varicella has drastically declined since 1995 when vaccination was introduced in the United States. Children accounted for the majority of cases but adults were more likely to develop complicated disease. Pneumonia has been shown to be disproportionally present in adults and we present two such cases of varicella pneumonia. CASE PRESENTATION: A 25-year-old male who recently immigrated from Guatemala presented with a rash that began on his face and spread down to his trunk. He noted a dry cough, shortness of breath, fevers, sore throat and lethargy. He was febrile and tachycardic with a widespread vesicular rash, and lesions in varying stages of healing. His CT noted nodular opacities in the mid and upper lungs with a prominent 13mm nodule in the right apex. He was found to have a bandemia and a positive varicella IgM. He was treated with a course of IV acyclovir and was discharged with a plan to obtain repeat imaging to follow up the nodules.A 38-year-old man with polysubstance use and asthma presented with shortness of breath and a rash that started on his scalp and descended to his chest and back associated with a burning sensation. He had a cough without sputum production. He was afebrile on exam and had a diffuse rash over the face and trunk consistent with chickenpox. The initial CXR showed bilateral infiltrates and CT chest noted numerous pulmonary nodules throughout both lung fields. Atypical infection was the initial concern but a broad workup was otherwise unrevealing other than a positive zoster IgM. He was treated with valacyclovir and discharged with a plan for repeat imaging. DISCUSSION: With varicella vaccination efforts, incidence, hospitalizations and deaths have all decreased since 19954. Adults are more prone to pneumonia, which has been reported as the leading cause of complicated disease in adults, up to 1/400 patients, but total incidence is likely difficult to assess as many patients with mild symptoms may not have radiographs. Smoking, pregnancy, immunosuppression and male sex are considered risk factors for pneumonia. On xray diffuse bilateral infiltrates and nodularity can be seen, while CTs can show nodular opacities, patchy ground glass opacities, or even a miliary pattern that generally resolve as the rash does, but can persist as calcified nodules. CONCLUSIONS: These cases highlight the need for providers to be able to recognize vaccine preventable diseases, especially in patients not born in the United States. With the current climate of vaccine hesitancy, it is likely health care providers will experience the ill effects of adult varicella in the future as unvaccinated children become adults susceptible to more invasive disease. REFERENCE #1: Alanezi, M. (2007). Varicella pneumonia in adults: 13 Years' experience with review of literature. Annals of Thoracic Medicine, 2(4), 163–165. https://doi.org/10.4103/1817-1737.36551 REFERENCE #2: Franquet, T. (2011). Imaging of pulmonary viral pneumonia. Radiology, 260(1), 18–39. https://doi.org/10.1148/radiol.11092149 REFERENCE #3: Guris, D., Jumaan, A. O., Mascola, L., Watson, B. M., Zhang, J. X., Chaves, S. S., Gargiullo, P., Perella, D., Civen, R., & Seward, J. F. (2008). Changing varicella epidemiology in active surveillance sites - United States, 1995-2005. Journal of Infectious Diseases, 197(SUPPL. 2), 71–75. https://doi.org/10.1086/522156 DISCLOSURES: No relevant relationships by Jacqueline Burnell, source=Web Response No relevant relationships by Rohit Gupta, source=Web Response No relevant relationships by Truong-An Ho, source=Web Response

DIFFUSE ALVEOLAR HEMORRHAGE WITH LATE PRESENTING RIGHT VENTRICULAR THROMBI

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diffuse alveolar hemorrhage is a life threatening emergency that can be caused by multiple etiologies. Pulmonary capillaritis, one common etiology, is particularly associated with autoimmune or inflammatory diseases. We present a challenging case of diffuse alveolar hemorrhage with associated acute hypoxic respiratory failure due to isolated pulmonary capillaritis with multiple late presenting intracardiac thrombi. CASE PRESENTATION: A 20 year-old woman presented with four days of myalgias, fever, and shortness of breath. Testing for pulmonary embolism and SARS-CoV2 was negative. She was diagnosed with pneumonia and treated with ceftriaxone and azithromycin. She then developed blood tinged mucous which was concerning for diffuse alveolar hemorrhage and received three days of pulse dose steroids. Seven days after initial presentation, she required escalation to intensive care. Her oxygen saturation was 96% on 70% FiO2 and 50 liters of pressure and subsequently required intubation for hypoxic respiratory failure. Imaging revealed diffuse bilateral infiltrates and bronchoscopy with lavage yielded mild endobronchial bleeding, but no overt hemorrhage. Pathology demonstrated neutrophilic capillaritis with diffuse alveolar damage. Prior outpatient autoimmune workup was significant only for mildly positive anti-nuclear antibody (speckled pattern 1:80). Transthoracic echocardiogram performed after intubation revealed two right ventricular thrombi that were not present on prior echocardiogram from admission. We initiated a heparin infusion in the setting of her alveolar bleeding and continued treatment with methylprednisolone. She then developed acute hemodynamic changes concerning for pulmonary embolism but stabilized without further intervention. The patient's oxygenation improved and she was successfully extubated. An antiphospholipid syndrome screen returned positive for a Dilute Russell Viper Venom Time (though notably value was 1.25 and upper limit of normal is 1.24) and anticoagulation was transitioned to warfarin prior to discharge home. DISCUSSION: Concurrent hemorrhage and hypercoagulability is a difficult management dilemma that many clinicians will face in the hospital setting. This case highlights the degree of suspicion required to evaluate for thromboembolic phenomena even in a patient with hemorrhage. In this young patient with no significant past medical history, autoimmune etiologies must be considered for her presentation of diffuse alveolar hemorrhage, which can also cause a concurrent hypercoagulable state. Despite mildly positive lupus anticoagulant screen, remainder of autoimmune workup was negative and suspicion low for systemic autoimmune disease. CONCLUSIONS: Bedside clinical judgement must drive decision making in the balance between worsening bleeding with anticoagulation or considering intervention for hemodynamically significant thromboembolic events. REFERENCE #1: Stoots SA, Lief L, Erkan D. Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome. Curr Rheumatol Rep. 2019;21(10):56. Published 2019 Sep 6. doi:10.1007/s11926-019-0852-7 REFERENCE #2: Park MS. Diffuse alveolar hemorrhage. Tuberc Respir Dis (Seoul). 2013;74(4):151-162. doi:10.4046/trd.2013.74.4.151 DISCLOSURES: No relevant relationships by Micah Fisher, source=Web Response No relevant relationships by David Wilhoite, source=Web Response

MILIARY METASTATIC ADENOCARCINOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Miliary opacities are defined as innumerable 1- 4mm pulmonary nodules scattered throughout the lung fields. Differential for miliary pattern is wide including tuberculosis, fungal infection and distinct organ metastasis. We present a case of a 37 year old male with miliary pattern seen on the chest radiograph and CT scan with ostial lesion in his L2 vertebrae, who was initially thought to have miliary TB with Pott's disease later diagnosed with primary adenocarcinoma of the lung with spinal, brain and calvarium metastasis. CASE PRESENTATION: A 37-year-old male with no significant medical history presented to the ED with 2 months of lower back pain. He endorsed shortness of breath and 40 pound unintentional weight loss over 3 months. He was incarcerated 5 years ago at which time his PPD was negative.Chest x-ray showed diffuse bilateral infiltrates with micronodular pattern. Following this, CT scan was obtained to evaluate for lower back pain which showed pathological compression deformity in L2 and innumerable pulmonary nodules consistent with miliary pattern and also showed left upper lobe lung mass.Given his history of incarceration, weight loss, shortness of breath and deformity in his lumbar vertebra, miliary tuberculosis and Potts disease was considered. QuantiFERON gold and AFB sputum were obtained. After AFB x3 negative on sputum studies it was decided to proceed with bronchoscopy with bronchoalveolar lavage (BAL).Lymph node biopsies and BAL pathology reports came back positive for adenocarcinoma. Upon further investigation with MRI of the brain and the spine it was also noted that the patient had Cavalier metastasis, left frontal lobe metastasis and numerous enhancing bone lesions in lumbar and sacral spine with osseous metastasis.Oncology and radiation oncology were consulted and he was started on stereotactic radiation therapy to the left frontal lobe metastasis as well as a right calvarial metastasis and systemic chemotherapy and immunotherapy. DISCUSSION: Miliary opacities are seen in a wide array of conditions including infectious etiologies like miliary TB, histoplasmosis, other fungal infections and noninfectious etiologies including miliary metastasis from thyroid, renal, breast carcinomas, metastatic melanoma. There has also been documentation of miliary patterns seen in Langerhans' cell histiocytosis, hypersensitivity pneumonitis and a few cases of primary pulmonary lung cancers.History is a key component in diagnosis especially for patients coming from areas and populations where TB and other infectious disease are prevalent. Once infectious etiologies have been ruled out approach to rule out malignancies and metastasis should be perused. CONCLUSIONS: It is impossible to distinguish between infectious etiologies and malignancies solely based on CT scan in patient with miliary pattern, hence when definitive diagnosis is uncertain, tissue diagnosis should be perused. REFERENCE #1: Khan D, Danjuma M, Saddique M, U, Murshed K, A, H, Yassin M, A: Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis. Case Rep Oncol 2020;13:139-144. doi: 10.1159/000505685 DISCLOSURES: No relevant relationships by Sarasi Jayaratne, source=Web Response No relevant relationships by Gaurang Prabhu, source=Web Response No relevant relationships by Gaurav Prabhu, source=Web Response

HERPES SIMPLEX VIRUS PNEUMONITIS IN AN IMMUNOCOMPETENT, CRITICALLY ILL HOST

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pneumonitis due to herpes simplex virus is well reported in immunocompromised patients. It is extraordinarily uncommon in immunocompetent patients. CASE PRESENTATION: A 68 year old female with a history of chronic hypoxic respiratory failure on 2 Liters home oxygen presented to our facility with one day of dizziness and profound shortness of breath. At presentation, her oxygen saturation was 75%. A CT of the chest demonstrated significant bilateral diffuse infiltrates of ground glass appearance with consolidation. She was intubated and was transferred to the ICU. She had septic shock requiring vasopressors, and was started on community acquired pneumonia coverage with vancomycin, doxycycline, and ceftriaxone. She was extubated to high flow nasal canula and she was transferred to Step Down. On the floor, she failed to improve and required significant high flow nasal canula and bilevel positive airway pressure (BIPAP) support. A bronchoscopy was performed which showed that the lungs appeared normal. Cytopathology of bronchial washings showed positive staining for HSV-1. Transbronchial biopsy was also performed which demonstrated organizing pneumonia with focal nuclear atypia, findings suggestive of a viral pneumonitis. She was initiated on IV Acyclovir and was evaluated for immunocompromise, however, an extensive workup revealed no cause of compromise. She was noted to have perioral lesions consistent with herpes labialis which she reported started prior to her admission. She improved significantly after initiation of anti-viral therapy. DISCUSSION: Unfortunately, the signs and symptoms of herpes simplex pneumonitis are quite non specific, and in the intensive care setting, diagnosis can be obscured by positive HSV PCR on bronchial specimens in patients without HSV Pneumonitis. . A 2020 retrospective study showed that patients being treated for antibiotic-resistant ventilator associated pneumonia who were also found to have high levels of HSV DNA by PCR experienced a mortality benefit when treated with acyclovir. This finding suggests that HSV may be an underrepresented pathogen in immunocompetent hosts. Despite the vague nature of HSV pneumonitis, there are several features which can be suggestive. It should be considered in patients with disease resistant to antibacterial therapy, difficulty weaning from oxygen, and unexplained leukocytosis. Chest X-ray findings are nonspecific, but CT imaging usually shows ground glass opacities. CONCLUSIONS: Prior case reports have suggested that HSV pneumonitis in immunocompetent hosts occurs late in the course of illness and is associated with ventilator use. This case is significant as it represents HSV as a potential pathogen in immunocompetent patients at the onset of illness prior to initiation of invasive ventilation. REFERENCE #1: 1. Ishihara T, Yanagi H, Ozawa H, Takagi A. Severe herpes simplex virus pneumonia in an elderly, immunocompetent patient. BMJ Case Rep. 2018;2018:bcr2017224022. Published 2018 Jul 18. doi:10.1136/bcr-2017-224022 REFERENCE #2: 2. Schuierer L, Gebhard M, Ruf HG, et al. Impact of acyclovir use on survival of patients with ventilator-associated pneumonia and high load herpes simplex virus replication. Crit Care. 2020;24(1):12. Published 2020 Jan 10. doi:10.1186/s13054-019-2701-5 REFERENCE #3: 3. Pandita A, Dannheim K, Madhuripan N, Ehsan A, Farmakiotis D. Acute Necrotizing Pneumonia from Herpes Simplex Virus. Am J Med. 2021;134(2):e121-e122. doi:10.1016/j.amjmed.2020.06.050 DISCLOSURES: No relevant relationships by Jacob Gelman, source=Web Response No relevant relationships by Lucas Hamrick, source=Web Response No relevant relationships by Allison Lastinger, source=Web Response

ANCHORING BIAS DURING THE COVID-19 PANDEMIC

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Patients presenting in New York City, the epicenter for COVID in the United States, with severe hypoxic respiratory failure in the past year with acute respiratory distress syndrome (ARDS) signs were thought to exclusively have COVID-19 pneumonia. Even if initial tests were negative, physicians often anchored on the diagnosis of COVID as the disease was rapidly spreading and hospitals were at maximum capacity. We present a case of a young male who presented with severe hypoxic respiratory failure in the early stages of the pandemic who was found to be negative for COVID-19 and subsequently found to have pneumocystis jiroveci pneumonia (PJP). CASE PRESENTATION: This is a 42 year-old male with a past medical history of controlled diabetes mellitus type 2, hypertension, and a previous smoker who presented with worsening progressive shortness of breath for three days. On admission, the patient was found to be tachycardic, tachypneic and hypoxic. Chest x-ray showed bilateral diffuse infiltrates most consistent with ARDS. ABG revealed severe hypoxia with PO2 of 39 on room air. He was initially placed on bi-level with minimal improvement and was subsequently intubated. Initial oropharyngeal and nasopharyngeal COVID-19 swabs were negative. His influenza PCR also resulted as negative. Sputum cultures, endotracheal aspirate and blood cultures all returned back negative. On day three of his admission, the patient was tested for HIV and found to be positive with CD4 count <50. He was started on TMP-SMX and methylprednisolone for suspected PJP pneumonia. Due to fears from the ongoing and heightening pandemic, the patient was tested yet again for COVID swab and it resulted negative. He underwent a bronchoscopy with BAL which confirmed the diagnosis of PJP. Patient continued to improve on antibiotics, was eventually extubated, and started on antiretroviral therapy with improvement of CD4 at three month follow-up. DISCUSSION: Physicians have become blinded from the COVID pandemic and often anchor to the diagnosis of severe hypoxic respiratory failure from COVID-19. Other diseases such as PJP can present similarly and prompt treatment is necessary. PJP has a high morbidity and mortality rate amongst immunocompromised patients and remains a leading opportunistic infection in AIDS patients. Our patient was a school teacher who denied any intravenous drug abuse or high-risk sexual encounters. CONCLUSIONS: Although many patients present with severe hypoxic respiratory distress and require mechanical ventilation during the ongoing COVID-19 pandemic, it is important to rule out other infectious causes of ARDS such as PJP which can also lead to morbid outcomes if not treated appropriately. REFERENCE #1: Gaborit BJ, Tessoulin B, Lavergne RA, et al. Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study. Ann Intensive Care. 2019;9(1):131. Published 2019 Nov 27. doi:10.1186/s13613-019-0604-x REFERENCE #2: Harris, J.R., Balajee, S.A. & Park, B.J. Pneumocystis Jirovecii Pneumonia: Current Knowledge and Outstanding Public Health Issues. Curr Fungal Infect Rep 4, 229–237 (2010). https://doi.org/10.1007/s12281-010-0029-3 DISCLOSURES: No relevant relationships by Sahar Ilyas, source=Web Response No relevant relationships by Navim Mobin, source=Web Response No relevant relationships by Nisha Patel, source=Web Response No relevant relationships by Michal Tokarski, source=Web Response

Successful Treatment of Malignant Priapism by Radiotherapy: Report of a Case, Review of the Literature, and Treatment Recommendations

Malignant priapism is a condition of painful induration and erection of the penis secondary to metastatic infiltration by a neoplasm. This condition is associated with a poor prognosis. We report on a case of an 87-year-old man who presented with a painful, partially erected penis subsequent to a diagnosis of metastatic Gleason 4+5 prostate cancer. Magnetic resonance imaging (MRI) showed diffuse bilateral infiltration of his corpora cavernosa. The core biopsy of the penile nodule revealed it to be a poorly differentiated carcinoma consistent with prostatic origin. The patient’s symptoms were completely resolved after treatment with high-dose palliative conformal radiotherapy (40Gy in 16 fractions). We systemically reviewed clinical reports of palliative radiotherapy for malignant priapism with the aim to gain more information on the management of this rare condition.

Adult-onset Still's disease after mRNA COVID-19 vaccine.

Adult-onset Still's disease after mRNA COVID-19 vaccine.

Rat model of smoke inhalation-induced acute lung injury

BackgroundAcute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is a lethal disease with limited therapeutic options and an unacceptably high mortality rate. Understanding the complex pathophysiological processes involved in the...

Pulmonary Involvement in Children With Systemic Lupus Erythematosus.

Background: Symptomatic pulmonary involvement in systemic lupus erythematosus (SLE) seems not uncommon in children. However, there are few data on the characteristics and laboratory parameters of SLE patients with pulmonary involvement.Methods: This was a hospital-based study involving 111 SLE patients from 1 January 2012 to 31 December 2016. The demographic, clinical, and laboratory data of the patients were prospectively collected. They were followed as outpatients until December 2019. Clinical characteristics and laboratory parameters of patients with and without pulmonary involvement were compared.Results: Of the 111 patients with SLE, we identified 18 patients (16.2%) with pulmonary involvement. The most common HRCT findings were ground glass opacity, interlobular septal thickening, bilateral diffuse infiltrates, and pleurisy/pleural effusion (55.6, 50, 50, and 44.4%, respectively). SLE patients with pulmonary involvement tended to have a longer disease duration (14 [12–24.5] vs. 5 [2–9] months, P < 0.01). We also observed a significant association between the presence of anti-Sm antibody, ANCA, Anti-RNP and the presence of pulmonary involvement of SLE (all P < 0.001).Conclusions: Lung involvement was frequent in SLE patients from Southeast China. Patients with a longer duration of symptoms before SLE diagnosis tended to have pulmonary involvement. When children with SLE are found to have anti-RNP antibody and positive ANCA, it should be alert to the occurrence of pulmonary involvement.

Be aware of misdiagnosis tied to COVID-19 focusing: a case report of abciximab-induced alveolar haemorrhage thought to be SARS-CoV-2 in a patient with ST-segment elevation myocardial infarction.

BackgroundEarly diagnosis of diffuse alveolar haemorrhage (DAH) can be extremely difficult, as the common clinical picture is often attributed to more common clinical conditions. High degree of suspicion is key to diagnosis which can be much more difficult during the coronavirus disease 2019 (COVID-19) pandemic.Case summaryA 61-year-old man with inferolateral ST-segment elevation myocardial infarction treated by a stent to the left circumflex artery and intravenous abciximab treatment was started for the high thrombus burden. Two hours later, the patient developed dyspnoea and hypoxaemia. Chest examination revealed diffuse rales over both lung fields. Chest X-ray revealed bilateral diffuse alveolar infiltrates, while the echocardiography was normal. Chest computed tomography (CT) was performed and the ‘crazy paving appearance’, which is the typical radiological finding of COVID-19, was reported. The patient was considered to be suspected of COVID-19 and was transferred to a quarantine unit. Real-time reverse transcriptase–polymerase chain reaction (RT-PCR) test was obtained and azithromycin and hydroxychloroquine were initiated. 48 h later, 2.6 mmol/L reduction was observed in haemoglobin levels and haemoptysis was developed. After the second negative RT-PCR with an interval of 24 h, CT was repeated and the patient was diagnosed to have abciximab-induced DAH. The patient was later followed up conventionally and discharged after two weeks without additional complications.DiscussionDAH and COVID-19 might share common clinical and radiological findings during examination. The physicians must be aware of the high motivation of the COVID-19 pandemic which can lead to misdiagnosis by overlooking other important clinical conditions.

COVID-19 in lung transplant recipients: A multicenter study.

This study describes the clinical presentation, treatment, and outcomes of SARS-CoV-2 infection in lung transplant recipients (LTRs). This is a multicenter, retrospective study of all adult LTRs with confirmed SARS-CoV-2 infection from March 4 until April 28, 2020 in six Spanish reference hospitals for lung transplantation. Clinical and radiological data, treatment characteristics, and outcomes were reviewed. Forty-four cases were identified in that period. The median time from transplantation was 4.2 (interquartile range: 1.11-7.3) years. Chest radiography showed acute parenchymal abnormalities in 32 (73%) cases. Hydroxychloroquine was prescribed in 41 (93%), lopinavir/ritonavir (LPV/r) in 14 (32%), and tocilizumab in 19 (43%) patients. There was a strong interaction between tacrolimus and LPV/r in all cases. Thirty-seven (84%) patients required some degree of respiratory support and/or oxygen therapy, and 13 (30%) were admitted to intermediate or intensive critical care units. Seventeen (39%) patients had died and 20 (45%) had been discharged at the time of the last follow-up. Deceased patients had a worse respiratory status and chest X-ray on admission and presented with higher D-dimer, interleukin-6, and lactate dehydrogenase levels. In this multicenter LTR cohort, SARS-CoV-2 presented with high mortality. Additionally, the severity of disease on presentation predicted subsequent mortality.

A 92 Days Run of Venovenous Extracorporeal Membrane Oxygenation

Abstract Background Venovenous extracorporeal membrane oxygenation (VV-ECMO) is an established life-saving procedure for severe acute respiratory failure due to various causes. In general, the duration of ECMO ranges from 1 to 2 weeks, with withdrawal recommended if no improvement is noted. We report a case of respiratory failure due to acute respiratory distress syndrome (ARDS) following influenza A infection, supported with a long ECMO run and the lessons learned from this experience. Case Report A 40-year-old female weighing 120 kg with pneumonia following H1N1 influenza was transferred to our hospital on mechanical ventilation for worsening respiratory distress. On admission, she presented with bilateral diffuse infiltrates on chest X-ray and severe hypoxemia with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen concentration ratio (PaO2/FiO2) of 85 at FiO2 of 0.8 on endotracheal intubation and mechanical ventilation. Acinetobacter Baumannii was isolated from respiratory secretions; antibiotics were revised as per sensitivity. Her respiratory status further deteriorated over next 96 hours in spite of maximally optimized mechanical ventilation. VV-ECMO was established on 4th day of mechanical ventilation in our hospital. Thereafter, she underwent a prolonged ECMO run with respiratory improvement starting to show some promise only by 86th day of ECMO. Weaning process was initiated gradually. However, on 88th day of ECMO the patient had an episode of seizure followed by low Glasgow Coma Scale (GCS) score (3T/15). The patient did not recover from the cerebral insult and based on clinical neurological examination including apnea test, brain death was determined within next 48 hours and the ECMO was called off. Conclusions Prolonged ECMO therapy poses many challenges and might be considered if the primary cause of respiratory failure necessitating ECMO is expected to resolve or a feasibility of lung transplantation is contemplated. Good team dynamics and appropriate counselling to the family are of utmost importance managing the patients on prolonged ECMO.

Characterizing e-cigarette vaping-associated lung injury in the pediatric intensive care unit.

Adolescent e-cigarette use has risen to epidemic levels in the US, revealing a new phenomenon of e-cigarette vaping-associated lung injury (EVALI). It is important to better characterize EVALI in critically ill adolescents as this is a vulnerable and rapidly growing demographic. This was a retrospective case series of patients ≤21 years old with confirmed or probable EVALI (as defined by the Centers for Disease Control) that resulted in admission to the pediatric intensive care unit (PICU) of a large tertiary academic children's hospital between August 2019 and January 2020. There were six eligible patients, with a median age of 17 years. All patients reported tetrahydrocannabinol as well as nicotine e-cigarette use. Half of the patients had a preexisting diagnosis of asthma and four patients had mental health comorbidities. All patients presented with respiratory alkalosis and chest radiography showing diffuse bilateral infiltrates; two patients had pneumomediastinum, subcutaneous air and/or pneumothorax. The lowest documented ratio of oxygen saturation to inspired oxygen (SpO2:FiO2 or S/F ratio) ranged from 146 to 296. Two patients required an arterial line, with the lowest ratio of arterial oxygen to inspired oxygen (PaO2:FiO2 or P/F ratio) of 197 and 165. Two patients tested positive for rhinovirus and respiratory cultures were negative for all patients. Four patients underwent chest computed tomography imaging, which showed diffuse ground-glass opacities. Every patient required noninvasive positive pressure ventilation, with one progressing to invasive ventilation. All patients received broad-spectrum intravenous antibiotics and steroids, though there was considerable variability in dose, frequency, and duration of steroids. The hospital length of stay ranged from 5 to 16 days (median 8.3 days) with PICU length of stay ranging from 4 to 10 days (median 5.5 days). Four patients had pulmonary function testing before discharge, two of which showed decreased diffusing capacity of the lung for carbon monoxide. There were no patient deaths. This single-center case series describes the presentation, course, and treatment of EVALI in a pediatric intensive care unit setting. Our results show nuanced differences in the presentation and management of the critically ill adolescent, and raise many questions about the long term implications on lung health, morbidity, and mortality. Importantly, these cases illustrate the critical care consequences of a public health phenomenon and should spur further research and policy to address the negative health effects of vaping.