Diffuse Ground-glass Opacities Research Articles

Pneumocystis jiroveci pneumonia in rheumatoid arthritis patient treated with methotrexate but without prednisolone: A case report

Abstract Background/Purpose Methotrexate (MTX) is an anchor drug for rheumatoid arthritis (RA) if there is no contraindication. However, MTX can increase the risk of opportunistic infections including Pneumocystis jiroveci pneumonia (PCP) if combined with other immunosuppressive drugs such as prednisolone. Herein, we report a case of an RA patient who developed PCP during MTX treatment without prednisolone. Methods A 63-year-old woman with RA was admitted with high fever and shortness of breath. She had demonstrated stable RA activity after taking MTX 12.5 mg/week in addition to leflunomide 10mg daily for RA; however, about five months ago, she stopped taking low dose prednisolone. Computerized tomography (CT) of the chest demonstrated diffuse ground glass opacities in bilateral middle and lower lung fields. Laboratory examinations showed β-D-glucagon 140.2 pg/ml. A polymerase chain reaction (PCR) assay of bronchoalveolar lavage (BAL) fluid showed Pneumocystis carinii (PC). MTX and leflunomide were immediately discontinued. High dose trimethoprim/sulfamethoxazole (TMP-SMX) and methylprednisolone pulse therapy were administered. Following treatment, clinical and radiographic improvement were noted. Results The risk factors for RA-PCP have been reported by several studies. However, in this case, the patient had not taken prednisolone for more than five months before the occurrence of PCP and was considered low risk for PCP. In the RA patient, with or without risk factors, PCP should be considered in the differential diagnosis for respiratory infection and interstitial pneumonitis, including MTX-induced pneumonitis. Conclusion In the RA patient, MTX should be considered an important risk factor of PCP.

A Case of Idiopathic Pulmonary Hemosiderosis in a 30-Year-Old Man

Idiopathic pulmonary hemosiderosis is a rare interstitial lung disease that occurs mostly in childhood. Usually, it presents with diffuse alveolar hemorrhage with no identified etiology. This report describes a young male patient who presented a clinical pattern of fatigue, dyspnea, and hemoptysis with iron-deficiency anemia. The iron-deficiency anemia in this patient was resistant to oral elemental iron therapy. This patient had typical findings on chest computed tomography (diffuse ground-glass opacities of the lungs) and bronchoalveolar lavage (detected siderophages). The patient obtained corticosteroid therapy after confirmation of idiopathic pulmonary hemosiderosis diagnosis, which led to improvement of symptoms in one week. This case report shows that early diagnosis and quick initiation of corticosteroid therapy is an effective approach, which reveals the symptoms and prevents complications.

Diagnostic Value of High Resolution CT Imaging for COVID-19 in 24 Confirmed Cases

Background: Covid19 virus causes pandemic worldwide.
 Objective: The purpose of the present study was to investigate the clinical features and imaging characteristics on chest High-Resolution Computer Tomography (HRCT) of COVID-19.
 Methodology: This retrospective study was conducted in the special designated department for covid-19 isolation unit under Ningxia Medical University from 10 January to 15 February 2020. The medical history, clinical symptoms, and imaging characteristics of confirmed COVID-19 patients from a single center were retrospectively analyzed. All cases underwent a chest HRCT examination.
 Results: A total number of 24 patients were recruited for this study of which 18 cases had clinical symptoms of respiratory tract infection; 2 cases had symptoms other than respiratory tract and 4 cases had asymptomatic. There were 15 males and 9 females aged 17 to 74 years. The main chest HRCT manifestation was diffuse ground-glass opacity (GGO) in the peripheral zone of the lungs and under the pleura. Pulmonary interstitial changes, bronchial air signs, bronchial vascular bundle thickening, paving stone signs, and "white lung" changes appeared in some cases. A few cases have enlarged lymph nodes and a small amount of pleural effusion. 
 Conclusion: The COVID-19 has specific characteristics on chest HRCT.
 Bangladesh Journal of Infectious Diseases, April 2020;7(suppl_1):S3-S10

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.

Immunodeficiency diseases with interstitial lung disease as major clinical manifestations: report of six cases

Objective: To summarize the clinical features of immunodeficiency diseases with interstitial lung disease (ILD) as major clinical manifestations and to improve understanding etiology of ILD. Methods: The clinical features and clinical clues for diagnosis of six cases with immunodeficiency presented with ILD in Shenzhen Children's Hospital from January 2014 to December 2016 were retrospectively analyzed. Results: The patients' age ranged from 3 months to 5 years and 9 months, 5 cases were male. All cases had cough and tachypnea, 3 cases had lung infection and respiratory failure, 2 cases had chronic hypoxia and one had clubbing. Three cases had skin rashes; 5 cases had failure to thrive. Chest CT scan showed diffuse ground glass opacity in all the 6 cases, and 2 cases had cystic changes and one had "crazy-paving" pattern. Five patients were suspected to have surfactant dysfunction and genetic testing was performed before diagnosis of immunodeficiency, of which the results were negative. With human immunodeficiency virus antibody test or immunologic laboratory testing and/or immune genetic panel, acquired immune deficiency syndrome was confirmed in one case, hyper-IgM syndrome was confirmed in two cases and hyper-IgE syndrome in one case, Wiskott-Aldrich syndrome in one and STAT3 gain of function genetic mutation in another. All cases had clinical clues indicative of underlying immunocompromise. Conclusions: The clinical features of immunodeficiency diseases with ILD are cough, tachypnea or hypoxia, respiratory failure with infection, diffuse ground glass opacity in Chest CT imaging. With thorough medical history and immunology screening, there would be clinical clues indicative of underlying immunocompromise. Screening for immunodeficiency disease should be emphasized in the differential diagnosis of ILD, otherwise it may lead to misdiagnosis or unnecessary testing.

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.

Clinical Characteristics of Pneumocystis Pneumonia After Parental Renal Transplantation.

PurposeTo analyze the clinical characteristics of Pneumocystis pneumonia (PCP) in renal transplant recipients, identify early sensitivity indicators, and optimize clinical strategies.Patients and MethodsWe retrospectively analyzed clinical data for 24 patients with confirmed PCP who underwent renal transplantation (RT) between 2010 and 2019, encompassing a mean follow-up of 29 (range, 11–49) d.ResultsA 71% incidence was observed for PCP during the first 6 months after RT. Progressive dyspnea (79%) was the most common symptom, followed by fever (75%) and dry cough (67%). In the initial phase of PCP, the most frequent computerized tomography (CT) finding was the presence of symmetric, apically distributed ground-glass opacities. Nine of 11 patients (82%) were diagnosed by induced sputum testing, 14 of 17 (82%) by bronchoalveolar lavage, and 1 of 24 (4%) by sputum smear. The 1,3-β-D-glucan level was elevated (mean, 259.16 ± 392.34 pg/mL) in 80% of patients, while 75% had elevated C-reactive protein levels (median, 37.85 mg/L). Two of 18 patients (11%) were positive for cytomegalovirus. All patients were treated with trimethoprim-sulfamethoxazole (3 doses of 1–6 g/kg) and third-generation cephalosporin or moxifloxacin monotherapy to prevent bacterial infection. The methylprednisolone dose (40–400 mg/d) varied according to illness. Most patients were treated using a nasal cannula or oxygen mask, and 2 by mechanical ventilation. CT showed improved lesions after treatment, and completely absorbed lesions or residual fibrosis at follow-up. The mean hospitalization cost was 14,644.73 ± 11,101.59 RMB.ConclusionPeak PCP incidence occurred during the first 6 months after surgery. Progressive dyspnea, fever, and dry cough are important indicators for PCP. Bilateral and diffuse ground-glass opacities involving both lung apexes are often the first indication for PCP diagnosis. Induced sputum testing may be the method-of-choice for pathogen detection. The cure rate can be improved through early antipathogen, glucocorticoid, and preventive anti-infection therapies, as well as respiratory support.

E-cigarettes: What evidence links vaping to acute lung injury and respiratory failure?

On September 18, 2019, the Middlesex-London Health-Unit (London, Canada) reported that a previously healthy, high-school student who had vaped nicotine daily, required hospitalization for life-support and had recovered. A week later, another single case was reported in Montreal, Quebec. These Canadian cases followed published cases of e-cigarette lung toxicity including a recent cluster of 53 patients in Illinois and Wisconsin and a 5 patient-cluster in North Carolina, both published on September 6, 2019. As of October 2019, there have been 26 deaths and 1,299 cases of lung injury linked to e-cigarettes. These reports have created widespread concern among clinicians and the public, creating a need to understand what we know at this point, with the caveat being that there is no clear understanding of the causes of vaping-related lung-toxicity. Most patients were previously healthy teenagers or young-adults with progressive dyspnea, hypoxemia, nausea and tachypnea with no evidence of bacterial infection while reporting recent e-cigarette use with nicotine and/or tetrahydrocannabinol. Chest computed-tomography findings included hypersensitivity-pneumonitis, diffuse alveolar hemorrhage, consolidation and ground-glass opacities. Most patients were treated with corticosteroids and symptoms resolved so that hospital discharge and community-based care could be undertaken. There have been no reports of long-term follow-up in survivors.

Diffuse alveolar haemorrhage associated with subsequent development of ANCA positivity and emphysema in three young adults

BackgroundDiffuse alveolar haemorrhage (DAH) is characterized by the diffuse accumulation of red blood cells within the alveoli, presence of ground glass opacities and/or consolidation on computed tomography (CT). Aside from identifiable non-immune causes, DAH is classically subdivided into idiopathic (idiopathic pulmonary haemosiderosis, IPH) and autoimmune DAH. Here we describe three cases presenting with recurrent pulmonary haemorrhage, initially classified as IPH, who, several years after first presentation, develop anti myeloperoxidase antibodies (MPO) positivity, emphysema on CT and, in one case, renal involvement.Case presentationPatient 1 was diagnosed with IPH aged 14. Her disease remained poorly controlled despite immunosuppression, although ANCA remained negative over the years. Nineteen years from initial presentation, she developed MPO-ANCA positive antibodies and mild renal impairment. She was treated with Rituximab with good response. From first presentation, the chest CT was consistently characterized by diffuse ground-glass opacities and interlobular septal thickening. Ten years later, cystic opacities consistent with emphysema, with a striking peribronchovascular distribution, developed. Patient 2 was diagnosed with IPH aged 32. He was treated with corticosteroids and methotrexate, with fluctuating response. At 11 years from initial presentation, MPO-ANCA positivity was identified, and emphysema with a peribronchovascular distribution was observed on CT, with subsequent significant increase in extent. Patient 3 was diagnosed with IPH at the age of seven, and had recurrent episodes of haemoptysis of varying degree of severity, treated with intermittent courses of corticosteroids until age 11, when he was intubated due to severe DAH. Eight years after the diagnosis emphysematous changes were noted on CT and MPO-ANCA positivity developed for the first time 11 years after initial diagnosis.ConclusionsWe believe these three cases highlight: 1) the possibility of development of ANCA positivity several years down the line from first DAH presentation 2) the possibility that DAH may lead to cystic/emphysematous changes with peribronchovascular distribution on CT. Moreover, the need for ongoing immunosuppressive treatment and the development of emphysema, emphasize a possible role played by autoimmune phenomena, even when DAH is initially diagnosed as “idiopathic”. Further studies are required to better understand the relationship between DAH, ANCA positivity and development of emphysema.

Usefulness of bronchoalveolar lavage in a French pediatric cohort with hypersensitivity pneumonitis.

Hypersensitivity pneumonitis (HP) is a rare interstitial lung disease in children, and very little data are available on the frequency, diagnosis, and outcomes of HP. In a pediatric cohort with HP, the characteristics of the CD4/CD8 lymphocyte ratio are often described as nonspecific. We used the National French Database (RespiRare) to collect data from the last decade on HP. The diagnosis of HP was defined by the presence of a relevant exposure, clinical symptoms, and compatible lung imaging radiology and was usually defined by positive precipitins antibodies. A total of 16 children with a mean age of 10 years (4-13) presented with HP. All children presented with dyspnea on exertion. Diffuse ground-glass opacity was present in all computed tomography (CT) scans. Research guided by a questionnaire and precipitins antibodies against the corresponding antigens showed that patients were positive for contact with birds with or without fungi. Bronchoalveolar lavage (BAL) was performed in 12 children. The total cell counts were elevated in BAL fluid, with a mean value of 36% lymphocytes. The CD4/CD8 lymphocyte ratio was below one for all children. BAL in our pediatric cohort with HP had the same characteristics as that of adults with HP. An HP diagnosis must be considered when dyspnea on exertion and diffuse ground-glass opacity are observed. Carrying out BAL and serological tests can help diagnose and avoid lung biopsy.

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.

A PATIENT WITH ACUTE CHRONIC RESPIRATORY FAILURE AND BILATERAL PULMONARY INFILTRATES

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

DISCREPANCIES IN BRONCHIAL WASH AND LAVAGE: THE DUBIOUS CASE OF VARICELLA PNEUMONIA

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Varicella pneumonia is a rare but serious infection caused by Varicella Zoster virus (VZV). Diagnosis is attained by clinical presentation, radiologic findings & is aided by detection of VZV in respiratory secretions by polymerase chain reaction (PCR). We present a diagnostic dilemma when two tests have a discrepancy. CASE PRESENTATION: A 41 year old female presented with left upper quadrant (LUQ) abdominal pain, hypotension, melena & somnolence which prompted intubation. She had medical history of end stage liver disease due to alcoholic cirrhosis, esophageal varices, refractory ascites & encephalopathy. Endoscopy showed varices & small bowel ulcer; & paracentesis ruled out bacterial peritonitis. After treatment with octreotide, nexium & prophylactic ceftriaxone; she was was successfully extubated. 3 days later, she developed a new, vesicular, dermatomal rash of shingles on LUQ. This was followed by new extensive multifocal infiltrates, crazy paving pattern & diffuse ground glass opacities on chest imaging (Figure) along with hypoxic respiratory failure which warranted re-intubation. A bronchoscopy was done which showed thick white secretions on bronchial washing (BW) & cloudy fluid on bronchoalveolar lavage (BAL) of right middle lobe & left upper-lingular segment. VZV PCR resulted positive on BW but negative on BAL. Patient was started on Varicella-Zoster immune globulin (VZIG) and acyclovir based on clinical presentation and radiologic features which led to clinical improvement. DISCUSSION: Varicella pneumonia can manifest 1-6 days after onset of the typical rash & is highly infectious with a secondary attack rate of > 90%. In the presence of clinical features of VZV infection, the diagnosis is mediated by chest imaging showing nodular or interstitial pneumonitis with ground glass opacities. Molecular diagnostic assays using PCR are often employed and have sensitivity as high as 96% for detection of VZV (1). However, it can be limited by false positive rate due to contamination and depends on the methodology (2) as well as specimen source although BAL has high sensitivity (3). Our patient developed respiratory failure with radiologic findings shortly after typical zoster rash. Despite adequate sampling, there was a discrepancy in the result obtained from BAL and BW. A comparison of these two hasn’t been studied yet in respect to VZV as well as other common pathogens. We favored to treat the patient due to detection of VZV on BW & the clinical presentation. VZIG administration within 72 hours of exposure is highly efficacious for disease prevention in immunocompromised along with intravenous acyclovir for 7-10 days and has led to overall decline in mortality. CONCLUSIONS: Although VZV DNA detection by PCR is helpful in diagnosing VZV pneumonia, there is no consensus data on its utility on BW in comparison to BAL. The paucity of VZV pneumonia is a hindrance for more extensive studies. Reference #1: Mirouse A et al. Severe varicella-zoster virus pneumonia: a multicenter cohort study. Critical Care. 2017 Dec;21(1):137 Reference #2: Schmutzhard J, Riedel HM, Wirgart BZ, Grillner L. Detection of herpes simplex virus type 1, herpes simplex virus type 2 and varicella-zoster virus in skin lesions. Comparison of real-time PCR, nested PCR and virus isolation. Journal of clinical virology. 2004 Feb 1;29(2):120-6 Reference #3: Stránská R, Schuurman R, de Vos M, van Loon AM. Routine use of a highly automated and internally controlled real-time PCR assay for the diagnosis of herpes simplex and varicella-zoster virus infections. Journal of Clinical Virology. 2004 May 1;30(1):39-44 DISCLOSURES: No relevant relationships by Enambir Josan, source=Web Response No relevant relationships by Supriya Singh, source=Web Response No relevant relationships by Yasir Tarabichi, source=Web Response

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

DURVALUMAB-INDUCED PNEUMONITIS IN A PATIENT WITH RHEUMATOID ARTHRITIS-INTERSTITIAL LUNG DISEASE

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Immune check point inhibitors (CPIs) are now widely used for different malignancies. Patients with autoimmune diseases, have been excluded from the CPIs clinical trials due to concerns of worsening of their autoimmune disease. Thus, the evidence regarding the toxicity of CPIs in this population is limited. Durvalumab, a CPI, is anti-programmed death ligand 1 (PD-L1) monoclonal antibody. We present a case of durvalumab induced pneumonitis in a patient with Rheumatoid arthritis related interstitial lung disease (RA-ILD). CASE PRESENTATION: A 63-year man with active seropositive RA with ILD treated with methotrexate 15 mg/week. He was recently diagnosed with stage IIIB lung adenocarcinoma. He was treated with platinum-based chemo-radiotherapy but developed severe fatigue and was given a treatment-free interval. Decision was made afterwards to administer durvalumab. Four days after infusion, patient had severe dyspnea, dry cough and chest pain requiring hospitalization. His oxygen requirements increased from room air oxygen to 8 L via nasal cannula. Patient was afebrile and labs were significant for normal WBC count, procalcitonin level, negative nasal swab for influenza antigen and respiratory viral panel. Blood and sputum cultures remained negative. A computerized tomography of the chest (CT) , compared to a previous CT, showed new diffuse upper-lobe predominant ground glass opacities with background ILD findings (figure 1). Durvalumab was held and patient was initially treated with empiric antibiotics that was stopped later with negative infectious work up. Patient was diagnosed with grade 4 immune pneumonitis and he was started on intravenous (IV) methylprednisolone (2 mg/kg) tapered down to 60 mg prednisone over 5 weeks with minimal clinical improvement. We decided to treat him again with IV methylprednisolone (250 mg) for 3 days and to add infliximab infusion (500 mg infusion). Over the next 10 days, patient improved clinically with decreasing oxygen requirements and plan was to discharge him to finish a slow steroids taper over 32 weeks with outpatient follow up. DISCUSSION: We describe a case of active RA who was treated with durvalumab for his lung cancer. In our case, patient was steroid-refractory initially but showed clinical improvement after giving another pulse dose steroids with infliximab infusion. Pneumonitis is uncommon immune related toxicity of CPIs but can be fatal. Incidence was reported to be 5% in one report. Our case is important as it describes severe pneumonitis in a patient with underlying RA-ILD who showed a promising response to steroid and infliximab. CONCLUSIONS: Immune mediated toxicities of CPIs, can be life threatening. More studies are needed to clarify whether a pre-existing autoimmune disease pose a higher risk of these adverse events. Clinicians should only start CPIs after having full discussion with their patients about the potential risks and benefits. Reference #1: 1. Review AS. R EVIEW Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease. 2018. https://doi.org/10.7326/M17-2073 Reference #2: 2. Yamaguchi S, Ito S, Akaike K, et al. A case report of using nivolumab for a malignant melanoma patient with rheumatoid arthritis. Int Cancer Conf J. 2016;5(4):192-196. https://doi.org/10.1007/s13691-016-0256-8 Reference #3: 3. Leduc C, Menzies AM, Iyriboz T, et al. Pneumonitis in Patients Treated With Anti–Programmed Death-1/Programmed Death Ligand 1 Therapy. J Clin Oncol. 2016;35(7):709-717. https://doi.org/10.1200/jco.2016.68.2005 DISCLOSURES: No relevant relationships by bashar alzghoul, source=Web Response No relevant relationships by Runi Foster, source=Web Response No relevant relationships by Wissam Hanayneh, source=Web Response No relevant relationships by Saminder Kalra, 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

IT CAN'T BE LUPUS...UNTIL IT IS: A CASE OF DIFFUSE ALVEOLAR HEMORRHAGE IN SYSTEMIC LUPUS ERYTHEMATOSUS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Diffuse Alveolar Hemorrhage (DAH) is a rare, but well-documented phenomenon in systemic lupus erythematosus (SLE). DAH affects only 4% of patients with SLE but has a 50% mortality. CASE PRESENTATION: A 67 year-old female with SLE complicated by lupus nephritis requiring four renal transplants (last in 2015), but currently in remission on maintenance tacrolimus and mycophenolate mofetil with recurrent episodes of hemoptysis and hypoxic respiratory failure. In October 2018 she was admitted with dry cough, scant hemoptysis and developed rapidly progressive respiratory failure requiring intubation. Workup showed normal immunosuppressive levels, elevated white blood count and inflammatory markers. CT revealed diffuse ground glass opacities. Antinuclear antibody (ANA) and anti-double stranded DNA were negative with normal complement levels. Bronchoscopy showed mononuclear predominance with unrevealing microbiology and cytology and no active bleeding despite sequential BAL. She rapidly improved with antibiotics and steroids. In January 2019 she was admitted with similar symptoms of cough, scant hemoptysis, multilobar infiltrates. Again, serologic and bronchoscopic workup were unrevealing, without classical evidence of DAH leading to a broad differential and needing to determine the etiology for the recurrent episodes of hemoptysis. An open lung biopsy was performed and results returned from Mayo Clinic showing acute alveolar hemorrhage, secondary to SLE. Patient was started on high dose steroids. However, 24 hours later she had frank hemoptysis, this time with bronchoalveolar lavage confirming DAH. Unfortunately, despite steroids, dialysis and plasmapheresis, hospital course was complicated by multi-organ dysfunction and she ultimately expired. DISCUSSION: DAH due to SLE is usually in the setting of a flare with thrombocytopenia, hypocomplementemia as well as elevated lupus antibodies. It is often seen within the first 5 years of diagnosis. Our patient had well-controlled disease on immunosuppressive therapy and had consistently negative antibodies and normal complement levels. Her only known risk factor was recurrent lupus nephritis, which is the most associated extrapulmonary manifestation in patients with SLE and DAH. This patient was given high-dose steroids and plasmapheresis; in reviews of DAH in SLE nearly 100% were given steroids, 55% cyclophosphamide and 31% plasmapheresis. Utilizing recombinant factor VII during the massive hemoptysis was considered, but the data to support it was not well-supported. CONCLUSIONS: This may be the first documented patient with well-controlled Lupus, without evidence of a flare, who developed recurrent episodes of DAH from SLE without classical symptoms highlighting need for broad differentials and exact diagnosis. Given the high mortality associated with DAH, it must be recognized that this can occur and recur despite ongoing immunosuppressive therapy. Reference #1: Kusunoki et al. Severe Progressive Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus. Case Reports in Critical Care. 2018 Reference #2: Kazzaz NM, Coit P, Lewis EE, McCune WJ, Sawalha AH, Knight JS. Systemic lupus erythematosus complicated by diffuse alveolar haemorrhage: risk factors, therapy and survival. Lupus Sci Med. 2015;2(1):e000117. Published 2015 Sep 23. https://doi.org/10.1136/lupus-2015-000117 Reference #3: Ednalino, Christina & Yip, Julie & Carsons, Steven. (2015). Systematic Review of Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Focus on Outcome and Therapy. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases. 21. 305-10. 10.1097/RHU.0000000000000291. DISCLOSURES: No relevant relationships by Achal Dhupa, source=Web Response No relevant relationships by Jamie Felzer, source=Web Response No relevant relationships by Shazia Jamil, source=Web Response No relevant relationships by Lakshmi Koripella, source=Web Response

SAVED BY THE BAL: A CASE OF ACUTE EOSINOPHILIC PNEUMONIA AFTER METHYL-NALTREXONE INJECTION

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: Eosinophilic pneumonia (EP) can result as an adverse effect of many drugs. Methyl-naltrexone injection has become increasingly popular this case serves to bring attention to a rare, but potential adverse effects. CASE PRESENTATION: A 44-year-old male with history of alcohol use disorder was brought to the emergency department (ED) by ambulance in acute respiratory failure. He received his monthly naltrexone injection three days prior. The following day, he started having lip swelling, rash, and two days later, had dyspnea. Upon arrival to the ED, he was given two doses of IM epinephrine, as well as methylprednisolone 125 mg IV, and he required BiPAP, after what was thought to be an anaphylactic reaction to naltrexone. Chest x-ray revealed stable bilateral lower lobe opacities, possibly related to aspiration pneumonia, patient was placed on ampicillin-sulbactam. CBC demonstrated increased absolute levels of eosinophils (700k/mm3), anaphylaxis was ruled out with tryptase level of 2.8 (normal <11.5). Patient’s symptoms slightly improved, however patient's eosinophil count continued to trend upwards, as high as 2500k/mm3 four days after presentation. CTA of chest demonstrated no evidence of pulmonary embolism, but did reveal diffuse ground glass opacities consistent with acute infiltrates. Bronchoscopy with bronchoalveolar lavage (BAL) was performed and BAL yielded fluid with eosinophils making up greater than 50% of the WBC's and the fluid was negative for malignant cells. Eosinophilic pneumonia diagnosis was established and steroids were initiated with improvement of symptoms. DISCUSSION: Acute eosinophic pneumonia is characterized by acute onset febrile illness, hypoxemia, diffuse bilateral infiltrates on imaging, and pulmonary eosinophilia with more than 25% eosinophils in BAL. EP is characterized by symptoms lasting less than 1 month and usually less than 1 week. EP will respond rapidly to steroid therapy but early recognition remains important to choose appropriate therapy given mimics such as infection. Several medications have historically been shown to cause EP, in one review of the literature the most commonly cited drugs include antibiotics or anti-inflammatories. Imaging findings typically include bilateral reticular ground-glass opacities that expand as the disease progresses. Methyl-naltrexone is increasingly utilized as an effective treatment for alcohol dependence disorder. Its possible association with EP was initially noted in a large randomized control trial published in JAMA by Garbutt et al. In our review of the literature there have been only four other cases of naltrexone induced eosinophilic pneumonia. CONCLUSIONS: This case demonstrates a likely outcome of eosinophilic pneumonia in a patient receiving methyl-naltrexone injections for alcohol use disorder. It is important to recognize naltrexone as a possible etiology for eosinophilic pneumonia due to its increasing use. Reference #1: Carmi Bartal, MD, MHA, Iftach Sagy, MD, and Leonid Barski, MD. Medicine (Baltimore). 2018 Jan; 97(4): e9688. Published online 2018 Jan 26. Drug-induced eosinophilic pneumonia: A review of 196 case reports Reference #2: Kim H, Ali M, Buch K. Eosinophilic Pneumonia Induced by Injectable Naltrexone. Am J Respir Crit Care Med. 2014;189:A2283 Reference #3: Garbutt JC, Kranzler HR, O'Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, Loewy JW, Ehrich EW; Vivitrex Study Group. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA. 2005 Apr 6;293(13):1617-25 DISCLOSURES: No relevant relationships by Anthony Esposito, source=Web Response No relevant relationships by benison lau, source=Web Response