Diminished Breath Sounds Research Articles

SUN-129 Hipoinsulinemic Hipoglycemia Caused by Solitary Fibrous Tumor IGF-2 Producer: Case Report

BACKGROUND: Solitary Fibrous Tumor is a mesenchymal neoplasm composed of CD34+ fibroblastic cells that can produce spontaneous hypoglycemia by the overproduction of IGF-2. It closely resembles the hypoglycemia characteristic of functioning islet cell tumors. CLINICAL CASE A 77-year-old male was found unconscious and taken to an emergency department with evidence of hypoglycemia and clinical improvement following intravenous glucose administration. He did not have a history of diabetes mellitus and was not taking any glucose lowering medications. He was discharged with nutritional orientation and for control of capillary glycaemia to prevent hypoglycemia. He had 3 episodes of capillary hypoglycemia (50, 45 and 38) at home, that was predominant in the fasting morning and during its occurrence he presented mild sweating, speech difficulty, staring and diplopia, with complete improvement of symptoms after oral glucose replacement. Months earlier, he sought an otolaryngologist for intermittent mild dyspnea; denied cough, hemoptysis, chest pain and unintentional weight loss. He performed chest X-ray with evidence of large right hemithorax mass. Physical examination revealed diminished breath sounds in the right middle and lower lung fields and dullness to percussion. Despite marked hypoglycemia (31 mg/dl), the serum insulin level was less than 0.6 μIU/mL (less than 3 μIU/mL), the C-peptide level was 0.24 nmol/L (less than 0,6 nmol/L), had negative ketonemia and a positive response after glucagon administration (glycaemia increased in 50 mg/dl). Anti-insulin antibodies were negative. Serum cortisol secretion and adrenocorticotropic hormone were normal. The serum level of growth hormone (GH) was 0,03 (less than 0,97ng/ml). The serum IGF-2 level was 227 ng/ml (267 - 616 ng/ml), the IGF-I level was 72 ng/ml (37,1 - 172 ng/ml) and the IGF2/ IGF1 was 3,15 (equal or greater than 3). Computed tomographic (CT) scan revealed a large heterogeneous mass with dimensions of 17,4 × 15× 12.2 cm. It determines almost total atelectasis of the lower lobe on this side and maintains broad medial contact with the mediastinum, compressing the right atrium and the inferior pulmonary vein on this side. Preoperatively, was administered 40 mg oral prednisone with capillary glucose normalization. The tumor was completely resected and was a grayish-white solid, with dimensions of 17 x 16 x 12 cm. Immunohistochemical stains demonstrated positivity for CD34 and IGF2 expression. Postoperatively, serum glucose and insulin levels returned to normal, and episodes of hypoglycemia are resolved. CONCLUSION This case reinforce the importance of investigate IGF-2 tumor production as a cause of hypoinsulinemic hypoglycemia and reports the complete resolution of hypoglycemia after corticoid administration and/or tumor resection.

Enterococcus faecalis-associated lung abscess in a male adolescent- a case report

BackgroundEnterococci are rarely considered pulmonary pathogens; they are usually regarded as colonizers of the airway. The authors present the case of a previously healthy male adolescent, with complaints of fatigue and chest pain, who was diagnosed with Enterococcus faecalis-associated acute primary lung abscess.Case presentationA previously healthy 17-year old boy was admitted to the pediatric ward due to a one-week history of fatigue, inspiratory left side chest pain, dry cough and nasal obstruction. On admission at the emergency department, he was afebrile, with no signs of respiratory distress, but with diminished breath sounds on the left side. A chest x-ray showed a round opacity on the posterior basal segment of the left lower lobe; he was discharged with oral amoxicillin 1000 mg three times a day with the diagnosis of community-acquired pneumonia. Due to the worsening of the productive cough with purulent stinking sputum he was re-evaluated after 4 days. Laboratory studies showed a leukocyte count of 15200/uL and a c-reactive protein of 172 mg/l. The chest computed tomography scan was suggestive of a consolidation of the left lower lobe base and a central abscess. An intravenous course of ceftriaxone and clindamycin was initiated, with a favourable clinical evolution. The bronchofibroscopy performed on day four after his admission revealed the presence of a tracheal bronchus and numerous purulent secretions. Culture examination of bronchoalveolar lavage fluid samples was positive (> 10^5) for Enterococcus faecalis. No complications were registered during his stay in the pediatric ward. He was discharged after a 14-day course of intravenous ceftriaxone and clindamycin, with the recommendation to complete a four-week course of oral amoxicillin/clavulanic acid. On his reevaluation 4 weeks after his discharge, he was asymptomatic.ConclusionThis case report highlights the importance of considering Enterococcus faecalis as an etiologic agent in cases of non-resolving or complicated cases of pneumonia, such as lung abscesses, even in young patients with no comorbidities or risk factors.

Chronic obstructive pulmonary disease: diagnosis and management

The diagnosis of chronic obstructive pulmonary disease (COPD) should be suspected in patients with risk factors (primarily a history of smoking) who report dyspnea at rest or with exertion, chronic cough with or without sputum production, or a history of wheezing. COPD may be suspected based on findings from the history and physical examination, but must be confirmed by spirometry to detect airflow obstruction. Findings that are most helpful to rule in COPD include a smoking history of more than 40 pack-years, a self-reported history of COPD, maximal laryngeal height, and age older than 45 years. The combination of three clinical variables-peak flow rate less than 350 L per minute, diminished breath sounds, and a smoking history of 30 pack-years or more-is another good clinical predictor, whereas the absence of all three of these signs essentially rules out airflow obstruction. Pharmacotherapy and smoking cessation are the mainstays of treatment, and pulmonary rehabilitation, long-term oxygen therapy, and surgery may be considered in select patients. Current guidelines recommend starting monotherapy with an inhaled bronchodilator, stepping up to combination therapy as needed, and/or adding inhaled corticosteroids as symptom severity and airflow obstruction progress.

MASSIVE CARINAL TUMOR REQUIRING VV ECMO FOR RIGID BRONCHOSCOPIC RESECTION

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: Refractory wheezing and pneumonia in patients with chronic obstructive pulmonary disease (COPD) should prompt further evaluation for alternative etiologies. Endobronchial obstruction may mimic classic signs and symptoms of COPD exacerbation. CASE PRESENTATION: A 66-year-old male former smoker with COPD presented to the emergency department (ED) with progressive dyspnea, fatigue, and productive cough after failing outpatient treatment with antibiotics for pneumonia. He was hypoxic to 85% on room air. Chest x-ray demonstrated right middle lobe pneumonia. An infectious evaluation including urinary antigens, viral studies, and respiratory cultures was negative. He quickly improved with intravenous antibiotics and steroids and was discharged the following day on oral antibiotics and a steroid taper. Four days later, he presented to the ED with progressive dyspnea and new orthopnea necessitating non-invasive positive pressure ventilation. Physical examination revealed accessory muscle use, diffuse expiratory wheezing, and diminished breath sounds. Laboratory evaluation was significant only for leukocytosis to 30.0 x 103 μL. Computed tomography scanning of the chest demonstrated a 2 cm endobronchial mass at the carina causing almost complete obstruction of the mainstem bronchi. His condition rapidly deteriorated, and awake femoral cannulation for venovenous extracorporeal membrane oxygenation (VV ECMO) was performed. Rigid bronchoscopic tumor resection was then performed under general anesthesia. Purulent secretions were aspirated from throughout the endobronchial tree. Airway patency was completely restored to the left mainstem bronchus and partially restored to the right mainstem bronchus. ECMO was weaned off immediately after resection of the mass. Pathology returned as invasive squamous cell carcinoma, and treatment with concurrent chemotherapy and radiation was initiated. DISCUSSION: Central airway obstruction (CAO), especially when it involves the trachea or carina, poses a significant management challenge. VV ECMO may be required to preserve ventilatory function in these patients during periods of complete airway occlusion as the obstruction is resected. ECMO support permits additional time for the operator to plan and implement the resection strategy for a life-saving airway procedure. A multidisciplinary team is required for management of these complex cases. Preemptive or nonemergent ECMO cannulation should be considered in patients with significant central airway obstruction. Data on the utility and safety of VV ECMO for rigid bronchoscopic resection of CAO is limited to case series. Future research is needed to assess the impact of VV ECMO on outcomes in these cases. CONCLUSIONS: Large carinal or distal tracheal tumors pose significant management challenges. ECMO may be required to ensure adequate oxygenation and ventilation until airway patency can be restored. Reference #1: J Crit Care. 2013 Oct;28(5):669-74 Reference #2: J Thorac Dis. 2016 Nov; 8(11): 3401–3413 DISCLOSURES: No relevant relationships by Rasika Chepuri, source=Web Response course relationship with Pinnacle Biologic Please note: $1001 - $5000 Added 03/13/2019 by Jonathan Kurman, source=Web Response, value=Travel Speaker/Speaker's Bureau relationship with Biodesix Please note: $5001 - $20000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Honoraria Consultant relationship with Medtronic Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Consulting fee Consultant relationship with Level EX Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Consulting fee educational course relationship with Pinnacle Biologics Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Travel<br Speaker/Speaker's Bureau relationship with American Medical Forum Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Honoraria

UNNATURAL HISTORY OF A RARE VASCULAR DISEASE

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: The reported incidence of this rare genetic vascular disease is 1-2 cases per 100,000 people in North America and 1:5000 to 1:8000 around the world each year. This disease causes vascular dysplasia throughout the body, which in turn cause telangiectasias and arteriovenous malformations (AVMs). This increases the tendency for bleeding, especially in the lungs. CASE PRESENTATION: A 69-year-old female with past medical history of breast cancer status post mastectomy and iron deficiency anemia presented to the Emergency Department (ED) brought in by EMS for massive hemoptysis. The history was limited because the patient was non-arousable. The patient was intubated in the ED due to hypoxia of 50% on room air upon EMS arrival at her home. Physical exam showed tachycardia, oxygen saturation of 84% on 15L non-rebreather, 2/6 systolic murmur at left lower sternal border, and diminished breath sounds at the bases with crackles at the right base. Chest X-ray showed multiple coils in bilateral lung bases. CT chest re-demonstrated coils, areas of ground glass, residual AVMs, and fluid collection concerning for pulmonary hemorrhage. Emergent bronchoscopy was performed to identify source of blood and cause of respiratory failure. It showed active bleeding in the right middle lobe, thought to be due to ruptured AVMs. Patient was taken to Interventional Radiology (IR) for embolization of 2 intercostal/bronchial arteries that were supplying the right middle lobe. They found multiple AVMs in left base and right middle lobe with previous coils in bilateral lung bases. IR was able to coil a remaining middle lobe AVM. Medical records obtained from the Naval hospital noted a history of Osler-Weber-Rendu syndrome with multiple coils and complications, with disease also in the son and grandson. She also developed demand ischemia from pulmonary hemorrhage secondary to AVM rupture causing acute hypoxic respiratory failure secondary to Right-to-Left shunting. She was given home oxygen to maintain oxygenation greater than 86% to prevent more cardiac ischemia and altered mentation. DISCUSSION: Osler-Weber-Rendu syndrome (Hereditary Hemorrhagic Telangiectasia) is an underreported Autosomal Dominant disease. The most common presenting symptom (90%) is epistaxis. They can develop AVMs in the lungs and brain, mucocutaneous and gastrointestinal telangiectasias, and other areas as they increase in age. Pulmonary AVMs cause right-to-left shunt leading to paradoxical embolic strokes and migraines. Pulmonary hemorrhages can be life threatening if treatment is delayed or the vessels causing hemorrhage can’t be found/embolized with mortality at 10%. Life expectancy is in 50s or 60-80s. CONCLUSIONS: All AVMs in this patient’s lungs should be coiled but it was difficult due to the number of AVMs with previous coils. This patient likely had oxygen saturations in 80s but needed a higher oxygen saturation to prevent cardiac ischemia. Reference #1: Lessnau, Klaus-Deter, et al. “Osler-Weber-Rendu Disease (Hereditary Hemorrhagic Telangiectasia).” Background, Pathophysiology, Etiology, 5 July 2018, emedicine.medscape.com/article/2048472-overview. Reference #2: Shovlin, C. “Clinical manifestations and diagnosis of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome).” 2018 March 30, www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-hereditary-hemorrhagic-telangiectasia-osler-weber-rendu-syndrome Reference #3: Shovlin, C. “Management of hereditary hemorrhagic telangiectasia.” 2018 April 03, www.uptodate.com/contents/management-of-hereditary-hemorrhagic-telangiectasia DISCLOSURES: No relevant relationships by Tracy Lee, source=Web Response

GIANT PRIMARY COLLOID CARCINOMA OF THE LUNG

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Colloid carcinomas of the lung are a very rare subset of lung adenocarcinomas. Historically, these neoplasms have been called mucinous cystic tumors and cystic mucinous adenocarcinomas. These tumors can grow very large and appear gelatinous and mucoid. We report a case of an extremely rare giant colloid carcinoma in a relatively asymptomatic patient. CASE PRESENTATION: The patient was a 55-year-old male with chronic kidney disease who was referred to our thoracic surgery service after a huge right lung mass was incidentally found during evaluation for renal transplantation. On MRI, it measured 11.8 x 9.4 x 13.1 cm and occupied most of the right chest cavity. The physical exam surprisingly demonstrated no abnormalities other than diminished breath sounds in the right lower lung base. Prior to surgery, bronchoscopy demonstrated endobronchial tumor extending from the right lower lobe into the intermedius bronchus. It was felt that the patient would require lower and middle lobectomy to obtain adequate tumor clearance. A hilar and lymph node dissection was started using the da Vinci robotic-assisted surgery system to see if adequate vascular control can be obtained in the hilum. After limited success a right thoracotomy was performed in order to complete the dissection and removal of the massive tumor. He made a satisfactory post-operative recovery and was discharged 10 days post-operatively doing well. Five month follow-up visit indicates that he is continuing to improve and currently waiting oncology clearance for consideration for kidney transplantation. The tumor was evaluated to have clear margins and measured 15.5 x 12.2 x 6.5 cm. Final pathologic diagnosis was a 15.5 cm colloid carcinoma of the lung with no evidence of lymph node metastasis. IHC staining revealed CK7 and CDX2 positive-staining tumor cells. DISCUSSION: Colloid carcinoma of the lung is a very rare diagnosis. These tumors are normally evident in breast tissue or the gastrointestinal tract. Because of the higher prevalence in tissues other than the lung, it is important to make sure the lung tumor is not a distant metastasis. In our case, it was important to rule out distant metastasis because of the patient’s potential renal transplantation status. The tumor’s IHC staining was consistent with colloid carcinomas of the lung. To our knowledge, our case represents one of the largest colloid carcinomas of the lung ever documented. The largest tumor we were able to find in the literature measured 15 cm at its largest. Our patient’s tumor measures 15.5 cm at the largest diameter. Complete resection tumor resection with mediastinal lymph node staging is the recommended treatment. CONCLUSIONS: The patient presented with an incidental and rare gigantic lung tumor. Despite the size of the tumor, it was completely resected with a possible cure. Reference #1: Moran CA, Hochholzer L, Fishback N, Travis WD, Koss MN. Mucinous (so-called colloid) carcinomas of lung. Modern pathology: an official journal of the United States and Canadian Academy of Pathology, Inc. 1992 Nov;5(6):634-8. Reference #2: Gao ZH, Urbanski SJ. The spectrum of pulmonary mucinous cystic neoplasia: a clinicopathologic and immunohistochemical study of ten cases and review of the literature. American journal of clinical pathology. 2005 Jul 1;124(1):62-70. Reference #3: Masai K, Sakurai H, Suzuki S, Asakura K, Nakagawa K, Watanabe SI. Clinicopathological features of colloid adenocarcinoma of the lung: A report of six cases. Journal of surgical oncology. 2016 Aug;114(2):211-5. DISCLOSURES: No relevant relationships by John Hallsten, source=Web Response No relevant relationships by Wickii Vigneswaran, source=Web Response

A CLAW TO THE LUNG: A PULMONARY MANIFESTATION OF DISSEMINATED BARTONELLA HENSELAE

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: Infection from Bartonella henselae typically produces a localized cutaneous lymphadenitis. However, disseminated disease may occur and can be life-threatening. Pulmonary manifestations of Bartonella range from solitary nodules to pneumonia and ARDS. CASE PRESENTATION: A 44-year-old man with type 2 diabetes presented with 3 weeks of fever, weight loss, and nonproductive cough. He was otherwise healthy, used no illicit substances, had not traveled recently, but he owned several cats. On arrival, he was afebrile, hypotensive, and mildly hypoxic on room air. His lung exam revealed diffuse fine inspiratory crackles and diminished breath sounds at the bases. His spleen was enlarged and there were no skin lesions. Notable labs included white blood count 2,700/mm3, hemoglobin 9 g/dl, platelets 50,000 /mm3. Chest X-ray showed diffuse bilateral opacities and effusions and testing for HIV was negative. CT chest/abdomen further demonstrated marked splenomegaly, 2.7 cm splenic lesion, a 1.9 cm left upper lobe pulmonary nodule, and prominent mesenteric, mediastinal, and hilar lymph nodes. Bone marrow biopsy revealed normocellular marrow with erythroid hyperplasia, no abnormal B-cell clones or blasts. Subsequently, wedge resection of the pulmonary nodule and sampling of the mediastinal lymph nodes was performed via video assisted thoracoscopic surgery. Post-operatively, despite Vancomycin, Meropenem, Doxycycline, and Rifampin, fevers persisted, and he developed ARDS, ultimately necessitating veno-venous ECMO. Despite these measures, he died one week after admission. All cultures remained negative, however serologies returned positive for Bartonella henselae IgG at a titer >1:1024 and IgM of 1:128. The mediastinal lymph node biopsy demonstrated microorganisms on Warthin-Starry stain consistent with Bartonella. DISCUSSION: Bartonella henselae is a fastidious and fragile organism, thus very difficult to isolate in cultures. Patients are typically diagnosed with disseminated bartonellosis based on serologies or special stains in the context of typical clinical features such as our patient’s lymphadenopathy, splenic lesions, pancytopenia, and cat exposure. Most reports of disseminated bartonellosis occur in those immunocompromised after solid organ transplant or with advanced HIV, in whom mortality rates are 10-40% even with appropriate anti-microbials. Disseminated disease in immunocompetent hosts occurs rarely and does not commonly involve the lungs. Of 16 cases of Bartonella infections with pulmonary manifestations, 80% occurred in immunocompromised adults in whom nodules were more common manifestations than pneumonia or effusions, and only one individual developed ARDS (1). CONCLUSIONS: Because of its rarity, there are no previous reports describing ECMO to treat Bartonella-associated ARDS, emphasizing the importance of further studies. Reference #1: 1. Bandyopadhyay, Anuja, et al. “Pulmonary Nodules in an Immunocompetent Child with Cat Scratch Disease.” The Pediatric Infectious Disease Journal, U.S. National Library of Medicine, Dec. 2013, www.ncbi.nlm.nih.gov/pubmed/24030347. DISCLOSURES: No relevant relationships by Thomas Baudendistel, source=Web Response No relevant relationships by Tess Knudson-Fitzpatrick, source=Web Response

Evaluation of foreign body aspiration cases in our pediatric intensive care unit: Single-center experience.

Aim:Foreign body aspiration is one of the common home accidents that requires urgent diagnosis and treatment, especially in children aged between 1 and 3 years. The type, location, and obstruction level of the aspirated material, age of the patient, and time of diagnosis influence the severity of the clinical picture. In our study, we aimed to evaluate patients who underwent bronchoscopy in our clinic with a diagnosis of foreign body aspiration in light of literature data.Material and Methods:The medical records of 87 patients who underwent rigid bronchoscopy with a prediagnosis of foreign body aspiration in Çukurova University, Faculty of Medicine, between January 2016 and August 2018, and were followed up in the pediatric intensive care unit after the procedure were examined retrospectively. The subjects were evaluated in terms of age, sex, primary referal center, time of presentation, symptoms at presentation, physical examination findings, radiologic investigations, type and location of foreign body, and duration of stay in the intensive care unit.Results:A total of 87 patients were included in the study. Thirty-seven patients (42.5%) were female. The mean age was found as 33.73±39.44 (range, 5–202) months. The most common (74.7%) symptom at presentation was sudden onset of coughing. The foreign body aspirated was organic in 62.1% of patients. The most common foreign bodies aspirated were peanuts, with a rate of 19.5%. Four adolescent female patients underwent broncoscopy because they aspirated needles they held in their mouths while tying their headscarves. Interestingly, one patient aspirated a stone and one patient aspirated a parasite. The most frequent location of foreign body was the right main bronchus (n=27, 31%).Conclusion:In the diagnosis of foreign body aspiration, the most important step is maintaining a high index of suspicion. Foreign body aspiration should be considered in patients who present with cough, respiratory distress or cyanosis, unilaterally diminished breath sounds, ronchi or stridor on physical examination, and air trapping on chest X-ray. Bronchoscopy is life-saving in the presence of any suspicious history suggestive foreign body aspiration or refractory pneumonia, even if a physical examination and radiologic findings are normal, especially in high-risk children between 1–3 years old.

Advanced Biventricular Heart Failure Leading to the Formation of a Gastric Bezoar: The Implications of Heart Failure on the Gastrointestinal Tract

While dyspnea or increasing peripheral edema come to mind when thinking of worsening heart failure (HF), seemingly unrelated symptoms such as nausea or bloating can indicate exacerbation. We highlight the significant gastrointestinal (GI) symptoms that result from HF, with emphasis on impaired gastric and intestinal motility. A 43 year-old man with cardiomyopathy (CM) presented with worsening abdominal pain, distention and nausea for 4 months. Physical exam showed jugular venous distention, peripheral edema, diminished breath sounds and a murmur. The abdomen was soft, mildly distended and tender. Labs showed B-type natriuretic peptide of 1374pg/ml. Blood gas showed a lactic acid of 3.2mmol/L. Platelet count was 66K/UL and international normalized ratio was 2.3. Total bilirubin was 4.0mg/dl with direct of 1.9mg/dl; aspartate aminotransferase of 98IU/L, alanine aminotransferase of 121IU/L and an alkaline phosphatase of 87IU/L. Computerized tomography showed wall thickening of the stomach, ascites, diffuse anasarca and thickening in the sigmoid colon. Echocardiogram showed an ejection fraction of 21-25% and global CM. Upper endoscopy revealed a gastric bezoar. The patient was given a can of Pepsi Cola and kept nil per os for repeat endoscopy, which showed resolution of the bezoar. Cardiac catheterization showed normal coronaries and reduced cardiac output (CO). Gastric emptying study confirmed gastroparesis. We look at the pathophysiology of HF and its effect on the structure and function of the GI tract. The small and large intestine display bowel wall edema with increased wall thickness leading to impaired nutrition of the enterocytes resulting in decreased absorptive function of the bowel. In the sigmoid colon, increased thickness correlates with increased concentrations of C-reactive protein and leukocytes. The intestine is one of the most perfused organs at rest, receiving 25% of the CO. At maximal exercise, gut perfusion drops to 4% of the CO. Increased sympathetic stimulation causes vessel constriction and decreased bowel perfusion. Small changes in CO lead to significant ischemia causing decreased motility and absorption and increased bowel wall permeability. Hepatic congestion from blood backup into the liver results in delayed gastric emptying, slowed gut motility, increased bowel permeability and bacterial translocation. Presented case demonstrates pathophysiology of frequently seen but often underappreciated GI manifestations of heart failure.2631_A Figure 1. CT scan of the abdomen showing wall thickening of the cardia of the stomach2631_B Figure 2. Gastric Bezoar2631_C Figure 3. Body or the stomach, on second EGD, 24 hours after can of Pepsi Cola

LOW TESTOSTERONE IN THE OBESE: HAVE YOU CONSIDERED OSA?

SESSION TITLE: Medical Student/Resident Sleep Disorders SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Obstructive sleep apnea (OSA) has been found to be an increasingly common disorder in the middle-aged men with reports suggesting about 15%-50% prevalence. The widely accepted definition of OSA is apnea hypopnea index (AHI) >5 events/hour as measured by a polysomnogram (PSG) with relevant symptomatology like snoring, fatigue and daytime somnolence. In this report, the relationship between OSA and pituitary-gonadal function manifesting as sexual dysfunction is discussed. CASE PRESENTATION: The patient is a 53-year-old non-smoking Caucasian male with history of asthma, type II diabetes mellitus, and testosterone deficiency, who presented to the with the chief complaint of shortness of breath. He was relatively asymptomatic until two months when he developed fatigue, insomnia, worsened snoring, gasping, and daytime sleepiness. Home medications included albuterol, fluticasone, salmeterol, tiotropium, montelukast, testosterone, ibesartan, glipizide, and pioglitazone. On physical examination, the patient had morbid obesity, a 19.5 cm neck circumference with Mallampati score of IV, and diminished breath sounds. Laboratory studies showed hemoglobin (Hb) of 19.1g/dL and hematocrit (Hct) of 61.3%. Secondary polycythemia was due to eight months of testosterone supplementation, which was subsequently stopped and required a total of six therapeutic phlebotomies. Repeat Hb was 14.7g/dL and Hct was 47.3%. His STOP-BANG score was 7 and diagnostic PSG showed mild obstructive sleep apnea with AHI of 48.9/hour during REM sleep and 14.5/hour overall. He was started on CPAP therapy at night and has continued to show symptomatic improvement. DISCUSSION: Our patient is characteristic of the demographic population being affected by these morbidities. He initially presented with sexual dysfunction due to low testosterone levels, but despite six months of bimonthly testosterone supplementation, his serum testosterone levels did not improve. It is well established that patients with low serum testosterone levels undergoing exogenous supplementation worsen or even precipitate OSA [1]. Interestingly, another school of thought implicates OSA as a potential cause of low serum testosterone levels [2] and that continuous positive airway pressure (CPAP) increases testosterone and sex hormone binding globulin levels. Recent studies have confirmed direct association between serum testosterone levels and sleep deprivation [3]. CONCLUSIONS: We propose that any patient who is found to have low testosterone should be evaluated for OSA before being considered for testosterone supplementation. CPAP should be considered as a first line therapy in patients with both OSA and testosterone deficiency. Albeit, given the complexity (Fig. 1), a causal relationship would be difficult to prove. To further explore this hypothesis, systematic investigations with randomized controlled trials should be performed. Reference #1: Matsumoto AM, Sandblom RE, Schoene RB, et al. Testosterone replacement in hypogonadal men: effects on obstructive sleep apnoea, respiratory drives, and sleep. Clin Endocrinol (Oxf) 1985; 22(6):713–21. Reference #2: Luboshitzky R, Lavie L, Shen-Orr Z, et al. Altered luteinizing hormone and testosterone secretion in middle-aged obese men with obstructive sleep apnea. Obes Res 2005;13(4):780–6. Reference #3: Abu-Samak MS, Mohammad BA, Abu-Taha MI, Hasoun LZ, Awwad SH. Am J Mens Health. 2018 Mar;12(2):411-419. https://doi.org/10.1177/1557988317735412. Epub2017 Oct 13.Associations Between Sleep Deprivation and Salivary Testosterone Levels in Male University Students: A Prospective Cohort Study. PMID: 29025356 DISCLOSURES: No relevant relationships by Ritha Kartan, source=Web Response No relevant relationships by Rohan Parikh, source=Web Response No relevant relationships by Krupa Solanki, source=Web Response

Chylous Ascites and Pleural Effusion Treated with Intravenous Octreotide

Chylous ascites is uncommon. A few case reports have been described in cirrhotic patients. It usually presents as refractory ascites and treatment options are limited. Use of octreotide in management of chylous ascites is limited to case reports and series.(2) We describe the case of a 59 year-old-female who presented with chylous ascites and was managed with octreotide with significant reduction in ascitic volume. A 59-year-old female with past medical history of alcoholic cirrhosis was admitted to the intensive care unit (ICU) with hypoxic respiratory failure. On examination, she had diminished breath sounds, abdominal ascites with shifting dullness. Her hypoxia was attributed to compressive atelectasis from hepatic hydrothorax and from hepato-pulmonary syndrome. She underwent diagnostic and therapeutic thoracentesis and paracentesis. Analysis of both ascitic and pleural fluid revealed presence of triglyceride containing fluid. Microbiological work up was negative. No malignant cells were identified. She was started on optimal diuretic therapy for portal hypertension. She received repeated paracentesis with removal of about 2-3 liters of fluid every 3-4 days. Because of rapid re-accumulation of ascitic fluid, a peritoneal drainage catheter was placed. She was started on treatment with octreotide at 100 micrograms three times a day for five days. Remarkable improvement in ascitic fluid production was seen. Over the five days of treatment, her ascitic fluid drainage reduced from 600 mL per day to 25 mL per day as shown in the figure (Figure 1). With this, her hypoxia improved significantly, patient was discharged. She underwent TIPSS (trans jugular intrahepatic portosystemic shunt) as outpatient and had improvement in her overall functional status. She is being evaluated for liver transplantation.2445 Figure 1. showing ascitic fluid volume by daySpontaneous chylothorax after liver cirrhosis is uncommon. Chylous ascites can occur as an initial presentation or during later stages of cirrhosis with complications from hepatocellular carcinoma, TIPSS or during procedures related to complications from cirrhosis [sclerotherapy related thoracic duct injury]. It has been attributed to portal hypertension leading to increased pressure in the small intestinal lacteals that can cause minute lymphatic rupture. Octreotide helps in improving portal hypertension and decreasing triglyceride level in ascitic fluid.

An Unusual Case of GI Metastasis From Adenocarcinoma of the Lung

Malignancies of the lung most commonly metastasize to the lymph nodes, liver, bones, brain and adrenal glands. Lung cancer metastasizing to the gastrointestinal (GI) tract is rare, and even rarer when there is simultaneous involvement of small and large intestines.?Here we present a rare case of secondary GI metastasis from lung origin. 53-year-old male former smoker of 1 pack-a-day for 20 years and no other medical history was seen in the GI clinic with complaints of unexplained 11 pound weight loss and productive cough with greenishred sputum. He denied a history of recent or recurrent infections, and environmental or occupational exposures. Physical exam was remarkable for diminished breath sounds in the left lower lobe. Chest x-ray revealed a mass on the left lower lobe of the lung which was confirmed on high-resolution chest CT. Biopsy was performed showing adenocarcinoma of the lung. The patient received chemotherapy and underwent left lower lobe lobectomy. Six months later the patient returned to the clinic complaining of fatigue and abdominal bloating, and was found to have iron deficiency anemia. He subsequently had endoscopy and colonoscopy showing an ulcerated lesion of the third portion of the duodenum and a mass in the cecum. Histology confirmed adenocarcinoma of lung origin from both biopsy sites. The diagnosis was validated by histology and immunohistochemical staining. Cells were positive for TTF-1 and CK7, consistent with pulmonary origin. Gastrointestinal origin was excluded with the negative results of CK20 and CDX2 staining. The patient was able to resume chemotherapy.? In our case, the GI tract malignancy happened only months after initial presentation, making secondary GI metastasis a more likely diagnosis. Malignant lung and GI lesions may occur at the same time, however when this happens the primary site is often difficult to establish, particularly if both display the same histologic cell type. In such conditions it is important to perform the immunohistochemically staining for TTF-1, to differentiate the primary origin. Clinicians should be aware of this uncommon presentation.

NEPHRO-PLEURAL ABSCESS SECONDARY TO MRSA

SESSION TITLE: Chest Infections 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: It is not uncommon to have pleural effusions secondary to subdiaphragmatic pathology due to an intrabdominal process. However, pleural suppurative infections caused by direct communication between intraabdominal abscesses and the thoracic cavity is extremely rare. We present a unique case of a female diagnosed with a perinephric abscess extending into the pleural space causing an empyema. CASE PRESENTATION: A 45-year-old female with known history of Moya Moya and intravenous drug use presented with left flank pain and shortness of breath of three weeks duration. On presentation she was notable for fever, tachycardia, tachypnea, and hypoxia requiring supplemental oxygenation. Her physical examination revealed diminished breath sounds on the left and left flank tenderness. Her laboratory tests were significant for a leukocytosis with a neutrophil predominance and were otherwise within normal limits. Her urinalysis was negative for white blood cells, nitrites, and bacteria. Blood and urine cultures were also negative. Chest x-ray revealed a left sided effusion, and a subsequent computed tomography of the abdomen and pelvis revealed a left 5x4x3 suprarenal abscess that extended superiorly into the intrathoracic space. She was empirically treated with vancomycin and piperacillin-tazobactam. A thoracentesis was performed and pleural fluid studies demonstrated an exudative effusion with a pH of 7.13. A chest tube was inserted for management of the empyema and was further treated with consecutive doses of tPA and Dornase. Antibiotics were tailored to linezolid once pleural fluid cultures were positive for MRSA. The patient continued to clinically improve, and the chest tube was removed as the effusion diminished and drainage decreased. The patient was discharged home with a six week course of linezolid and close follow up. Repeat abdominal imaging noted improvement of the pleural effusion and decrease in abscess size. DISCUSSION: The majority of nephro-pleural fistulas are formed in patients with nephrolithiasis. An empyema formed secondary to an intrabdominal abscess, such as this case, is extremely rare and is likely secondary to a fistula formation. Due to our patient's delayed presentation and history of drug abuse she suffered from a MRSA abscess complicated by a potential fistulous track leading to a concomitant empyema. CONCLUSIONS: The significance of this case is to increase awareness that chronic untreated intrabdominal abscesses may develop into an intrathoracic infection. Management typically consists of evacuation and a prolonged course of antibiotics. Reference #1: Jones GH, Kalaher HR, Misra N, Curtis J, Parker RJ. Empyema and Respiratory Failure Secondary to Nephropleural fistula Caused by Urinary Tract Infection: A Case Report. Case Reports in Pulmonology. 2012; 1-5. https://doi.org/10.1155/2012/595402. DISCLOSURES: No relevant relationships by Said Chaaban, source=Web Response No relevant relationships by Rachel Goodwin, source=Web Response No relevant relationships by Melissa Jordan, source=Web Response

SHOE SHINING: HAZARDOUS TO THE HEALTH

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

Traumatic Diaphragmatic Hernia in a 40-Year-Old Lady after 34 Years of Trauma

The diaphragm is a sheath made of muscle and tendon that separates the thoracic cavity from the ab- dominal cavity. A diaphragmatic hernia is the protrusion of intra-abdominal contents through an abnormal opening in the diaphragm. Acquired diaphragmatic tears are rare and occur mainly due to direct penetrating injury to the diaphragm or, less commonly, secondary to blunt abdominal trauma, causing her- niation of the abdominal contents into the thorax resulting in a condition known as post-traumatic diaphragmatic hernia. Signs and symptoms include orthopnea, dyspnea, diminished breath sounds on the side of the rupture and audible gut sounds in the chest. We report a case of a 40-year-old woman with a 34-year-old history of an unmanaged road traffic accident who presented with a complain of gradual in onset shortness of breath, which when approached surgically, revealed to be due to an absent left sided diaphragm. Upon diagnosis, successful primary hernia mesh repair was performed.

Visual Diagnosis: A 7-year-old Boy with Dyspnea and an Unusual Chest Radiograph

1. Katherine B. Salciccioli, MD* 2. Athar M. Qureshi, MD*,† 3. Hugh D. Allen, MD*,† 1. *Department of Cardiology, Texas Children’s Hospital, Houston, TX 2. †Baylor College of Medicine, Houston, TX A 7-year-old boy presents to his pediatrician with gradually worsening shortness of breath and exercise intolerance over months to years. He was admitted for right-sided pneumonia twice during childhood with seemingly complete recovery each time, but otherwise he has been generally healthy and developmentally appropriate. Current medications include albuterol inhalers taken as needed since early childhood for wheezing during viral illnesses. With the recent worsening of his symptoms, albuterol is again tried without any improvement in his symptoms. He does not have fever, cough, nasal congestion, chest pain, palpitations, vomiting, diarrhea, or weight changes. On physical examination, the patient has normal vital signs. He is small for his age but is following his growth curve appropriately with height in the 15th percentile and weight in the 11th percentile. He has normal findings on head and neck examination. His cardiac examination is notable for a fixed split S2 with no murmurs, rubs, or gallops. He has diminished breath sounds on the right with a soft, intermittent expiratory wheeze and a clear left lung. He has no abdominal organomegaly. Pulses are 2+ and symmetric in all extremities. In addition to his physical examination findings, a chest radiograph (Fig 1) is interpreted as showing dextrocardia, so the patient is referred to the cardiology clinic where echocardiography reveals the diagnosis. Figure 1. Chest radiograph interpreted as dextrocardia, prominent right-sided pulmonary vasculature, and hyperinflation of the left lung. In the cardiology clinic, echocardiography shows the heart located in the right chest, with the cardiac apex pointing leftward, partial anomalous venous return to the inferior vena cava (IVC) (Video 1), and mild right heart dilation (Video 2 …

Infrared Video Thermometry Guidance for Surgical Correction of Chylothorax in Dogs

Background: Macroscopic identification of the extravasation site of chyle in patients with chylothorax is a major challenge. Current forms of identification are invasive and/or expose patients to radiation, as in computerized tomography and radiography. A prototype device that uses infrared video thermometry images to detect temperature increments of 0.1ºC has been developed. This device can process and show real-time images or video on a monitor during surgeries. Therefore, the aim of this work was to report the first successful case in which this innovative device was tested in the transoperative period to identify the thoracic duct and its tributaries in a chylothorax surgery performed in a dog.Case: A 2-year-old male dog of the Shiba Inu breed was presented to the veterinary hospital with exercise intolerance, cough, emaciation, and no history of trauma. Clinical examination was performed along with complete blood count, biochemical analysis, and thoracic radiography. The patient exhibited dyspnea and had diminished breath sounds on chest auscultation. Radiographic images revealed moderate pleural effusion. The dog was anesthetized and submitted to thoracotomy, which enabled visualization of a chylous effusion. A sample of the effusion was collected for cytological and biochemical analyses. Subsequently, pericardiectomy was carried out, and identification of the thoracic duct and its tributaries was guided by an innovative device that generates infrared video thermometry images in real time. The extravasation site of the chylewas visualized on the images shown on a monitor. Consequently, after ligation of the tributary vessel, interruption of chyle overflow could be noticed on the monitor. Thoracotomy was routinely closed, and a drain was placed through an intercostal space after incision. Thirty days after the surgery, the dog exhibited no signs of recurrence. Cytological and biochemical analyses of the effusion revealed an abnormal transudate that had a density of 1,030 g/cm3, alkaline pH, predominance of neutrophils and lymphocytes, and high levels of proteins, triglycerides and cholesterol. These results indicated that the effusion analyzed was chyle.Discussion: Macroscopic aspects of an effusion alone should not be used to make a definitive diagnosis; cytological, physical, and biochemical evaluations are indispensable. The specimen analyzed had a higher concentration of triglycerides than blood, and its cholesterol concentration was lower than that found in blood. Findings like these have already been reported as indicative of chylous effusion. Thoracic duct ligation is the most used technique for correction of chylothorax, and is the technique with better outcomes. Thermometry has already been used for clinical examination in several diseases. However, the innovative device used in this study has the advantage of being noninvasive, and was able to guide the surgeon during the surgery to locate the thoracic duct and precisely identify the tributary lymphatic vessel responsible for the chylous effusion. The physical space occupied by the device did not disturb the surgical team since a small infrared image generator was placed one meter above the patient to take high definition images of the entire animal in the evaluation field. The thermometry device was very useful, non-invasive, and precise to differentiate thoracic structures and to identify the siteof extravasation of chyle. It also allowed a more interactive and precise surgical approach by the surgical team, which was essential to the success of the surgery.Keywords: chyle extravasation, infrared diagnosis, surgery, thorax.

Clinical Management of Pneumonitis in Patients Receiving Anti–PD-1/PD-L1 Therapy

CASE STUDY A 48-year-old gentleman with metastatic melanoma currently receiving the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitor, ipilimumab (Yervoy), and the programmed cell death protein 1 (PD-1) inhibitor, nivolumab (Opdivo), returned for evaluation prior to receiving cycle 2. The patient presented with new onset dyspnea and a non-productive cough over the past week, with a temperature of 100.6°F at home on one occasion. He was placed on observation for fever, cough, and shortness of breath. The patient had no previous history of lung disease and was a nonsmoker. Diminished breath sounds were noted on auscultation. However, the patient was without fever or chills, with a heart rate of 101 beats per minute and a blood pressure of 110/75 mm Hg. We obtained a computed tomography (CT) of his chest. The CT demonstrated diffuse ground-glass opacities in his bilateral lower lobes and some minor interstitial thickening of his right middle lobe, possibly suggestive of inflammation or cryptogenic organizing pneumonia. Based on his presentation and CT findings, the patient was initially treated empirically with antibiotics for suspected pneumonia vs. pneumonitis. During the first 12 hours in observation, the patient experienced increasing dyspnea and cough and was admitted to the hospital. Nebulizer treatments were administered with no improvement, so the patient was started on high-dose corticosteroids at 1 mg/kg, and pulmonary and infectious disease consults were ordered. After the administration of steroids, the patient's cough and breathing improved and he remained afebrile, eliciting a high suspicion for immune-related pneumonitis. The patient then underwent bronchoscopy to rule out other etiologies. Bronchoalveolar lavage was performed, which yielded no pathogenic organisms. The patient was placed on a 3-week course of a high-dose steroid taper, following which immunotherapy was reinstated. Within 4 days he again presented with similar symptoms, was restarted on high-dose steroids, and immunotherapy was permanently discontinued.

Simultaneous bilateral spontaneous pneumothorax

Introduction. Simultaneous bilateral spontaneous pneumothorax (SBSP) is a potentially life-threatening state that may imitate many lung diseases. The aim of this report was to describe the presentation and highlights the potential difficulties in diagnosis and management of patients with SBSP. Case outline. A 23-year-old female was urgently assessed because of a progressive dyspnoea of 2-day's duration with associated bilateral chest pain. Lung auscultation revealed equally diminished breath sounds on both sides. During initial examination, there was the evidence of symptomatic deterioration with bilateral pleuritic chest pain, increased dyspnoea and agitation. She was found to have type II respiratory failure with the following biochemical parameters: pH=7.34, PaCO2=6.3 kPa and PaO2=7.9 kPa. The chest radiograph confirmed bilateral partial pneumothoraces of approximately 30%. Both left and right-sided thoracostomies with large-bore chest drain insertions were performed emergently, followed by partial resolutions of pneumothoraces. CT of the chest demonstrated residual pneumothoraces bilaterally with multiple apical bullae. In the further course, she subsequently underwent video-assisted thoracoscopic surgery with bilateral apicoectomies, bullectomies and pleural abrasion. Her chest drains were removed 3 days after surgery and a chest radiograph post-treatment demonstrated resolution of the pneumothoraces. She was discharged home without complications. Conclusion. Using clinical presentation, diagnostic algorithm and therapeutic management applied in the case of our patient, we emphasized a few mandatory steps in establishing the diagnosis of SBSP and further treatment.

A Rare Case of Calcific Rheumatoid Constrictive Pericarditis Complicated by Diffuse Alveolar Hemorrhage and MPO-ANCA-Associated Systemic Vasculitis With Pauci-Immune Glomerulonephritis

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 4 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Diffuse alveolar hemorrhage(DAH) is a rare complication in patients with Rheumatoid arthritis(RA). The added calcific constrictive pericarditis, systemic vasculitis and pauci-immune glomerulonephritis(PIGN) in the same patient poses a unique diagnostic and therapeutic dilemma CASE PRESENTATION: A 60-year-old male with a history of RA, calcific constrictive pericarditis was admitted with fever, chills, dry cough and worsening exertional dyspena. He had diminished breath sounds in bilateral lower lung fields on exam. Computed tomography of the chest revealed patchy nodular infiltrate in the left lung and confluent ground glass infiltrate in the right lung with persistent pericardial calcifications. He developed worsening hemoglobin drop and severe hypoxemic respiratory failure worsening and was intubated. Bronchoscopy with sequential bronchoalveolar lavage was progressively more hemorrhagic and hemosiderin laden macrophages confirmed the diagnosis of DAH. He was started on intravenous methylprednisolone. A workup revealed high titers of antibodies (Table1). Due to severity of his illness he had serial plasmapheresis followed by treatment with intravenous cyclophosphamide. Renal biopsy showed PIGN. By hospital day 20 his respiratory and renal function improved and was successfully extubated DISCUSSION: We report for the first time to the best of our knowledge a rare case with chronic rheumatoid constrictive pericarditis complicated by DAH in the setting of MPO-ANCA associated vasculitis and PIGN. One of the rare cardiac complications of RA is constrictive pericarditis confirmed here by cardiac catheterization with equalization of diastolic pressures and discordant right and left ventricular pressures and pericardial calcifications on imaging. DAH complicates 40% of cases of MPO-ANCA vasculitis however, limited data is available in adults with concurrent RA and is associated with higher mortality. The incidence of ANCA in RA is around 40% and both p- and c-ANCA staining patterns are expressed. one study described three RA patients with renal manifestations who improved with a combination of plasmapheresis and cyclophosphamide with or without methylprednisolone such as in our patient. CONCLUSIONS: A high index of suspicion, careful analysis and early detection is essential to improve chances of recovery in these patients Reference #1: Gauhar UA et al. Pulmonary manifestations of rheumatoid arthritis.Semin RespirCrit Care Med 2007;28:430-40. Reference #2: Kurita N et al. MPO-ANCA glomerulonephritis with RA.ClinExpNephrol.2010Aug;14(4):325-32. DISCLOSURE: The following authors have nothing to disclose: Kavitha Gopalratnam, Despina Michailidou, Ashley Rosario-Durchhalter, Paul Cohen, Armand Wolff No Product/Research Disclosure Information