Loculated Fluid Research Articles

Fibrinous central serous chorioretinopathy (CSCR) with posterior choroidal fluid loculation: a unique pachychoroid phenotype in a 41-year-old male.

Fibrinous central serous chorioretinopathy (CSCR) with posterior choroidal fluid loculation: a unique pachychoroid phenotype in a 41-year-old male.

S2820 A Case of Encapsulating Peritoneal Sclerosis Complicated by a Large Loculated Fluid Collection

S2820 A Case of Encapsulating Peritoneal Sclerosis Complicated by a Large Loculated Fluid Collection

Transcecal endoscopic appendectomy for management of complex appendiceal polyps extending into the appendiceal orifice.

Background and study aims Endoscopic resection of appendiceal orifice (AO) polyps extending inside the appendiceal lumen is challenging given the inability to determine polyp lateral margins and risk of appendicitis. Transcecal endoscopic appendectomy (TEA) ensures en bloc resection of these complex polyps. Patients and methods This case series includes patients who underwent TEA by a single endoscopist in the United States. Technical success was defined as achieving complete removal of the appendix along with AO polyp in an en bloc fashion. Results In total, nine patients were included (mean age 69.7 ± 9.6 years). The average appendix size was 4.07 ± 2.02 cm. Technical success was achieved in 100% of the patients. The average procedure length was 118.1 ± 44.21 minutes. The en bloc resection rate, R0 resection rate, and curative resection rates were 100%. Patients were observed for an average of 3.1 ± 1.6 days. One patient developed loculated fluid collection 9 days post procedure, which resolved on its own with oral antibiotic therapy. No other adverse events were recorded. Conclusions This was an early study of the feasibility of TEA in the United States. This novel technique, in early-stage development, is potentially safe and associated with a minimal risk profile in expert hands. Further prospective studies are needed to standardize the technique.

Ultrasound role in diagnosis and as an assisting tool in prognostication of surgery in neonates with necrotizing enterocolitis

ObjectiveAbdominal ultrasonography (AUS) assessment of the neonatal abdomen is emerging as a potential useful addition to traditional abdominal radiographs (AXR) to confirm the diagnosis of necrotizing enterocolitis (NEC). The goal of this study was to assess the abdominal sonographic findings of premature infants with NEC, in order to determine whether AUS is more effective than AXR in the diagnosis of NEC. MethodsThis cross-sectional study was performed on consecutive neonates with clinical suspicion of NEC admitted in our hospital’s NICU (Ali-Asghar Children’s Hospital, Tehran, Iran). We prospectively evaluated the hospitalized subjects using AXR and AUS from May 2018 to May 2020. ResultsA total of 53 neonates were included in the study. These patients were divided into two groups: suspected NEC patients (stage I) including 31 subjects and definite NEC patients (stage II and III) including 22 neonates. We found a substantial agreement between the two modalities regarding the detection of pneumoperitoneum and pneumatosis intestinalis (κ: 0·658 for both). The concordance concerning portal venous gas detection was considered slight (κ: 0·315). Thirty-eight patients did not show any signs of portal venous gas in either of AUS or AXR. On the contrary, four patients demonstrated evidences of portal venous gas in both AUS and AXR. AUS detected ten more portal venous gas than AXR. AXR found no cases with positive portal venous gas that were undetected by AUS. The most predictive indicator for surgical intervention in neonates was the presence of free echogenic ascites and loculated fluid. ConclusionOur findings demonstrated that AUS is superior to AXR in demonstrating portal venous gas and pneumatosis intestinalis. Hence, it seems that AUS is a useful adjunct to AXR in the management of NEC.

Empyema Secondary to Pneumonia: Whom Should We Operate?

Introduction: Empyema secondary to pneumonia is a common condition. A significant number of patients will require surgical intervention for drainage and decortication. The aim of this study was to identify predictive factors for surgical intervention. Materials and Methods: The medical records of patients who were diagnosed with empyema secondary to pneumonia between the years 2010 and 2019 in a university hospital were included in the study. Patients who underwent surgical intervention were defined as group A and nonoperative treatment as group B. Clinical and laboratory data were collected from medical records and patients' chest computerized tomography (CT) scans were reviewed. Results: A total of 194 patients were included in the study-86 patients were included in group A and 108 patients in group B. Several parameters on admission were found to have a statistically significant correlation with surgical intervention: younger age, higher systolic blood pressure, and elevated white blood count. Multivariant analysis showed that younger age was found to have a statistically significant correlation with operative intervention (adjusted odds ratio = 0.971, P = .023). A statistically significant correlation between surgical intervention and survival (adjusted hazard ratio [HR] = 1.762, P = .046) and an inverse correlation between age and survival (adjusted HR = 0.050, P < .001) were found. Surgical intervention was associated with increased survival irrespective of age. A total of 42 CT scans were available for review. The mean density of the empyema fluid in group A was higher by 4.3 hounsfield units compared to group B (P < .067). Conclusions: Younger age was found to be associated with surgical intervention among patients suffering from empyema secondary to pneumonia. Surgical intervention was associated with increased long-term survival, irrespective of patients' age. Several radiologic characteristics were associated with the need for surgery in this study: empyema fluid density, pleural thickening, and fluid loculations. Additional prospective studies are required to ascertain these results.

Outcomes for Malignant Pleural Effusions Because of Melanoma Treated With Indwelling Pleural Catheters.

Indwelling pleural catheters (IPCs) reduce dyspnea and improve quality of life in patients with malignant pleural effusions (MPEs). Data on outcomes of MPEs secondary to metastatic melanoma managed with IPCs are scarce. We aimed to evaluate outcomes of patients receiving IPCs for MPEs secondary to melanoma compared with other malignancies. We identified patients from our prospectively collected database of all patients who had an IPC insertion for MPEs at our tertiary care center for melanoma between May 2006 and November 2018 and for nonmelanoma between May 2006 and June 2013. Chart reviews were conducted to obtain patient demographics, catheter complications, time of IPC removal or death, x-ray imaging, and pleural fluid characteristics. We identified 27 MPEs because of melanoma and 1114 because of nonmelanoma malignancies treated with IPC. The most frequent complication was pleural fluid loculation requiring fibrinolytics which was significantly higher in the melanoma (14.8%) compared with the nonmelanoma group (3.8%; P=0.02). Cumulative incidence functions for catheter removal (P=0.8) or death with catheter in situ (P=0.3) were not significant between melanoma and nonmelanoma groups in competing risk analysis. Baseline radiographic pleural effusion scores were similar, but became significantly higher (increased pleural opacity) in the melanoma group at time points following IPC insertion (P<0.05). MPEs because of melanoma had a higher rate of loculations requiring fibrinolytics and less radiographic improvement after IPC insertion suggesting this patient subgroup has a more complicated pleural space which may be less responsive to drainage.

(549) Case Report of an IPP Reservoir Salvage Following Infection

Abstract Introduction Inflatable penile prosthesis (IPP) infections are rare and devastating. IPP infections are treated with either explant or salvage, the latter with either a malleable or inflatable device. Isolated component infections are very rare in the literature. This is the first description of successful treatment of an isolated IPP reservoir infection, with preservation and eventual reuse of the patient’s uninfected pump and cylinders. Objective To report a case of successful IPP salvage after an isolated reservoir infection. Methods This is a case study of IPP reservoir explant and eventual reimplant in a 51-year-old male, with preservation of the implant pump and cylinders. Past medical history is notable for HIV, hypertension, and hyperlipidemia. The patient had a Coloplast Titan IPP placed penoscrotally in November 2020 for treatment of post-prostatectomy erectile dysfunction. The reservoir was placed ectopically in the patient’s right high submuscular space. Results In January 2021 the patient underwent emergent exploratory laparoscopic washout and drain placement at a different hospital for perforated appendicitis. The IPP reservoir was not encountered during this procedure. In March 2021 he presented to that same hospital with recurrent fevers and right lower quadrant pain. CT showed increased peritoneal stranding and thickening surrounding the IPP reservoir as well as multiple small, complex loculated fluid collections suspicious for abscesses external to the reservoir. There was no evidence of infection of the pump or cylinders on imaging or physical exam. He was transferred to Dartmouth-Hitchcock Medical Center for further care. Conservative treatment with intravenous vancomycin, Zosyn, and fluconazole yielded no change after 48 hours. Three days after initial presentation, the reservoir was explanted during a collaborative procedure with general surgery, during which the appendix remnant was also removed. Intraoperatively the penile prosthesis reservoir was encased in a dense rind that was incised and drained. Copious purulent material was sent for culture, which showed multi-organism aerobic and anerobic bacteria. The reservoir was removed and the remnant tubing to the pump was clamped. The abdomen was irrigated repeatedly with saline, dilute betadine, vancomycin, gentamicin, Zosyn, and amphotericin. The prothesis tubing was cut as low as possible, capped, and wrapped with a paste of vancomycin mixed with Zosyn and amphotericin. There were no intraoperative complications. The patient was discharged two days later. At his one-week postoperative visit, he was readmitted for interventional radiology drain placement due to abdominal abscess recurrence. Once the recurrent abscess had resolved, he underwent successful radiation treatment for recurrent prostate cancer. In March 2022, the reservoir was successfully replaced into the left high submuscular space via counter incision and the dormant cylinders and pump were reconnected. The patient continues to do well, with no signs of recurrent infection and with excellent device function. He is satisfied with the result of surgery. Conclusions To our knowledge this is the only case of isolated IPP reservoir infection successfully treated with reservoir explant and eventual replacement. The original IPP pump and cylinders were preserved without issue and eventually reused. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.

Lemierre's syndrome: an evolving disease

Lemierre’s syndrome is characterized by thrombophlebitis of the internal jugular vein with resulting systemic septic emboli. Most cases occur following an oropharyngeal infection and have been historically caused by the bacterial pathogen Fusobacterium necrophorum. However, infection from other pathogens is becoming more common in recent years. Our case is special in the sense that Lemierre’s syndrome was caused by staphylococcus aureus after influenza infection. A 23-month-old male presented with complaints of left neck swelling and recurrent fever for one week, following influenza A infection. The child was ill-appearing with fever, tachycardia, tachypnea, and erythematous swelling on the left cheek. Laboratory results revealed elevated inflammatory markers. Computed tomography (CT) scan of the neck showed loculated fluid collection suggesting an intra parotid abscess with poor visualization of the internal jugular vein (IJV). Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Due to high clinical suspicion of Lemierre’s syndrome, a doppler ultrasound was obtained which showed a left IJV thrombus. CT scan of the chest after the clinical suspicion showed multiple bilateral pulmonary nodules suggesting septic emboli. He was treated with antibiotics and a six-week course of the anticoagulant with a resolution of his thrombus. Though historically, Lemierre’s disease is caused by Fusobacterium necrophorum, other causative organisms such as methicillin-sensitive Staphylococcus aureus are increasingly being recognized. Lemierre’s disease can present as a complication of influenza. A high index of clinical suspicion based on the location of the abscess helped us delineate diagnostic tests and treatment.

Vaginoscopic Resection of Oblique Vaginal Septum in OHVIRA Syndrome Before Menarche

To demonstrate vaginoscopic resection of the oblique vaginal septum in a girl with Obstructed Hemi Vagina and Ipsilateral Renal Agenesis (OHVIRA) syndrome, before menarche. Stepwise demonstration of surgical technique with narrated video footage. OHVIRA syndrome is a rare urogenital anomaly in which the patients present after menarche, with progressive dysmenorrhea and a palpable pelvic mass due to hematocolpos and hematometra on the obstructed side. Delay in diagnosis may cause endometriosis, pelvic adhesions, and infertility (1)(2). A 12-year-old, premenarchal girl with complaints of pelvic pain and an ultrasound report of right renal agenesis was referred to the urology department of our hospital. She was also found to have uterus didelphys and a loculated fluid collection behind the urinary bladder on ultrasonography and on MRI (Figure 1 & 2). A probable diagnosis of OHVIRA syndrome with mucocolpos was made (3). Vaginoscopy showed an obstructing bulging vaginal septum on the right side. The left uterine horn was inspected by hysteroscopy. The vaginal septum was incised vaginoscopically with monopolar cautery using Collins knife(4)(5)(6). The collected mucus was drained. Right cervix and the right uterine horn were visualized by hysteroscopy. Edges of the septum were resected with a resectoscope loop. The hymen was not injured during the surgery. Relook vaginoscopy done after two months showed a normal and healed vagina. Vaginoscopic resection of the obstructing oblique vaginal septum in OHVIRA syndrome is a very simple, minimally invasive and a virginity conserving surgery. Early diagnosis and treatment can prevent future complications due to cryptomenorrhea.

Giant porta hepatis cystic lymphangioma mimicking intra-abdominal abscess

Background: Intra-abdominal lymphangiomas are very rare benign tumors in adults. Here we demonstrate a 22-year-old male who presented with abdominal pain and fevers. He underwent a CT of the abdomen and pelvis which showed multiple, large loculated fluid density lesions extending from the porta hepatis into the entire right hemi-abdomen and into the left upper quadrant. The largest cyst measured 10.4 cm by 1.9 by 26.4 cm. Due to ongoing fevers and concern for infection, the patient underwent percutaneous aspiration of the fluid for concern of intra-abdominal abscess. From the sampled fluid, cultures were negative for growth, cytology was negative for malignant cells, and cell count was within normal limits. The triglyceride level of the fluid was 2739 mg/dL. The patient had moderate relief, but the following day again developed abdominal distension, discomfort, and anorexia. Due to the symptomatic nature of the mass, the patient underwent an exploratory laparotomy with resection of the mass. 4.6 liters of chylous ascites were removed from within the cystic mass. The mass was noted to extend from the porta hepatis into the right retroperitoneum and extend to the left upper quadrant, abutting the pancreas and spleen. The pathology report was consistent with lymphangioma with marked acute fibrinopurulent inflammation and no evidence of malignancy. The patient had immediate relief postoperatively and recovered well from surgery.

A Five-Year Study of Intrapleural Fibrinolytic Therapy in Loculated Pleural Collections

Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural ibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage. To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies. A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution. There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases. Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

An unusual case of loculated malignant pleural effusion mimicking an infected pericardial cyst

Malignant pleural effusion (MPE) is one of the frequent and distressing conditions identified at the advanced stage of different malignant conditions. This problem seems to affect patients with lung and breast malignancies which contribute to the lower life quality. Less commonly MPE presents as a loculated fluid collection. We present an unusual case of cystic fluid collection in contact with the heart appearing similar to a pericardial cyst, but on cytological examination turned out to be loculated MPE. Furthermore, there was the presence of malignant fissural effusion. This text highlights the unusual location of this loculated MPE along with a few characteristic features to differentiate it from the benign pericardial cyst.

Compatibility and stability of non-ionic iodinated contrast media in peritoneal dialysis solution and safe practice considerations for CT peritoneography.

Computerised tomographic (CT) peritoneography is performed on peritoneal dialysis (PD) patients to identify peritoneal boundary defects, dialysate maldistributions and loculated fluid collections. Iodinated contrast media are added to dialysate and infused through the dialysis catheter, and CT images are obtained. Chemical compatibility of contrast media with dialysis solutions has not been studied. In some institutions, pharmacists charged with oversight of compounded sterile preparations have placed a moratorium on the use of contrast media-dialysate mixtures until compatibility data become available. This study was undertaken to examine the compatibility of non-ionic iodinated contrast agents added to PD solution for the performance of CT peritoneography. 100 mL of three non-ionic iodinated contrast agents, iopamidol 370 mgI/mL, iohexol 300 mgI/mL and iodixanol 320 mgI/mL, were mixed with 2 L 1.5% dextrose PD solution and stored at 2-8°C, 25°C and 40°C. Observations at predefined intervals were made over 5 days for visual appearance, turbidity, pH, drug concentration and chemical degradation. Iopamidol, iohexol and iodixanol were stable for 5 days under study conditions. The contrast-dialysate mixture remained clear and colourless, no turbidity changes observed, pH and drug concentrations were stable and no increase in existing impurities or new impurities were detected. The addition of commonly used non-ionic iodinated contrast agents to 1.5% dextrose dialysis solution is chemically stable, meeting the criteria set forth in the standards and guidelines of the US Pharmacopeia and the Institute of Safe Medication Practices. A protocol for performing CT peritoneography is recommended herein to facilitate patient safety and diagnostic reliability of the imaging study.

A Rare Case of Secondary Streptococcus pyogenes Peritonitis in a Patient With Cirrhosis

CASE REPORT A 42-year-old woman with autoimmune hepatitis with decompensated cirrhosis and ascites presented with 8 days of worsening abdominal pain. She was afebrile with diffuse abdominal tenderness without rebound or guarding and a large umbilical hernia with overlying skin breakdown. Diagnostic paracentesis produced a protein 5.2 g/dL, glucose < 5 mg/dL, lactate dehydrogenase 14,252 U/L, and a white blood cell count of 59,200/μL with 83% polymorphonuclear cells. Cultures grew Streptococcus pyogenes. Imaging showed large ascites communicating with a loculated fluid collection in the umbilical hernia (Figure 1). The loculated collection drained purulent fluid positive for moderate Gram-positive cocci in chains and clusters. Despite 2 weeks of ceftriaxone (2 g) and metronidazole (500 mg), clinical peritonitis with fevers persisted. Repeat paracentesis showed an increase in white blood cells to 82,760/μL. Laparoscopy with peritoneal washout was performed with removal of 6 L of purulent fluid and lysis of dense adhesions and fibrinous exudate (Figure 2). Pathology demonstrated acute fibrinous inflammatory exudate with dense fibrous tissue. Antibiotics were broadened to piperacillin-tazobactam (3.375 g) with improvement, and she was discharged on cefpodoxime (200 mg).Figure 1.: Abdominal and pelvic computed tomography with large volume ascites and loculated fluid collection in the umbilical hernia.Figure 2.: Dense adhesions and fibrinous exudate is seen throughout the peritoneum on laparoscopy.Secondary peritonitis in patients with cirrhosis is uncommon and has a high mortality (53.8%) with appropriate surgical management, so rapid differentiation from primary spontaneous bacterial peritonitis is paramount.1 Runyon's criteria can be used and require 2 of 3 criteria: ascitic fluid protein >1 g/dL, glucose <50 mg/dL, and lactate dehydrogenase greater than normal serum's upper limit. Ascitic fluid growing multiple organisms and clinical failure to respond to appropriate antibiotics are other clues in establishing the diagnosis.2 S. pyogenes peritonitis is rare, limited to case series and reports of individuals without previous underlying liver disease, peritoneal dialysis, or pelvic inflammatory disease. A case series of available evidence until March 2018 identified 30 published cases of S. pyogenes peritonitis in previously healthy individuals. Given female predominance (75%), a hypothesized portal of entry was translocation from the vaginal tract.3 There are 240 cases of culture-positive peritonitis in patients with cirrhosis contained only 2 cases of S. pyogenes, although without case details.4 One case report documented S. pyogenes peritonitis in a patient with cirrhosis with umbilical hernia rupture.5 Given the similarity in the examination, this was considered the likely portal of entry in our patient. This case highlights the challenges in managing secondary peritonitis in patients with cirrhosis, including the importance of early differentiation between primary and secondary peritonitis and successful stepwise management. DISCLOSURES Author contributions: A. Philippou and C. Bowman-Zamora wrote the manuscript. G. Ezaz edited the manuscript and is the article guarantor. Financial disclosure: None to report. Previous presentation: This case was presented at the New York ACP poster presentation; April 8, 2021; Virtual. Informed consent was obtained for this case report.

Myelitis: A Common Complication of Tuberculous Meningitis Predicting Poor Outcome.

BackgroundMyelitis is an important complication in patients with tuberculous meningitis (TBM). However, a paucity of publications exists on the spectrum of neurological and MRI findings of TBM-related myelitis. The risk factors and prognosis of myelitis in patients with TBM are not fully understood. Therefore, this study aims to identify the risk factors, clinicoradiological features, and prognostic impact of myelitis for patients with TBM.MethodsWe conducted a retrospective study in our institution. Patients with TBM who were consecutively admitted during the period of August 2015 to December 2019 were included. We reviewed the demographic characteristics, clinical, laboratory and MRI findings, and clinical outcomes of all of the included patients. The diagnosis of myelitis was identified by a hyperintensity on T2-weighted images that were associated with cord edema, enlargement, and marginal or no enhancement on contrast-enhanced images.ResultsA total of 114 patients were included. Myelitis occurred in 19 (16.7%) patients, five of whom paradoxically developed myelitis. The common clinical signs of myelitis were paraparesis (738.9%), quadriparesis (844.4%), urinary retention or constipation (1,477.8%), and paresthesias in the lower limbs (1,052.6%). In the MRI findings, the hyperintensities on T2-weighted images involved more than 3 spinal cord segments. Myelitis was often combined with other forms of spinal cord injury, including 10 patients (52.6%) with spinal meningeal enhancement, 7 patients (36.8%) with enlargement of the central canal of the spinal cord, 6 patients (31.6%) with tuberculoma, and 4 patients (21.1%) with arachnoiditis and 1 patient (5.3%) with cerebrospinal fluid (CSF) loculations. None of the 5 patients with paradoxical myelitis were complicated with spinal meningeal enhancement and arachnoiditis, while 4 patients were complicated with enlargements of the central canal of the spinal cord. In multivariable analysis, a grade III disease severity on admission [p = 0.003, odds ratio (OR) = 8.131, 95% CI: 2.080–31.779] and high CSF protein (p = 0.033, OR = 1.698, 95% CI: 1.043–2.763) were independent risk factors for myelitis. After the 6 months follow-up, myelitis (p = 0.030, OR = 13.297, 95% CI: 1.283–137.812) and disturbance of consciousness (p = 0.042, OR = 12.625, 95% CI: 1.092–145.903) were independent risk factors for poor outcomes.ConclusionMyelitis was a common complication of TBM and independently predicted a poor outcome. A grade III disease severity and high CSF protein on admission were independent risk factors for myelitis. Paradoxical myelitis was rarely complicated with spinal meningeal enhancements and arachnoiditis, indicating that the immune reaction may play a dominant role.

Spectrum of MRI Features of Mucin-producing Neoplasms in the Abdomen and Pelvis.

Mucin-producing neoplasms in the abdomen and pelvis are a distinct entity, separate from simple fluid-containing neoplasms and loculated fluid collections. Mucin is a thick gelatinous substance and-owing to its high water content-has imaging features that can be mistaken for those of simple fluid-containing neoplasms with multiple imaging modalities. However, mucin-producing neoplasms arise from specific organs in the abdomen and pelvis, with unique imaging appearances, knowledge of which is important to guide accurate diagnosis and management. With its large field of view and high soft-tissue resolution, MRI has advantages over other imaging modalities in characterizing these neoplasms. The authors focus on the spectrum of MRI features of such mucin-producing neoplasms and illustrate how-despite a varied organ origin-some of these neoplasms share similar MRI and histopathologic features, thereby helping narrow the differential diagnosis. One common finding in these tumors is that the presence of internal complexity and solid enhancing components increases as the degree of malignant transformation increases. Lack of internal complexity generally indicates benignity. These tumors have a varied range of prognosis; for example, a low-grade appendiceal mucinous neoplasm is indicative of a good prognosis, while a mucinous tumor of the rectum is known to manifest at an early age with aggressive behavior and poorer prognosis compared with its nonmucinous counterpart. Online supplemental material is available for this article. ©RSNA, 2022.

Role of intrapleural instillation of MESNA in the management of pleural adhesions

Context Intrapleural adhesions and pleural fluid loculation is a common clinical problem. Several options are available to manage the intrapleural adhesions. MESNA has recently been used as a fibrinolytic agent and due to its efficacy and safety it is an option in treating intrapleural adhesions instead of other intrapleural fibrinolytics. Aims To assess the efficacy and safety of MESNA as a fibrinolytic agent in the management of loculated pleural effusions. Settings and design A prospective case series study at the Chest Department, Assiut University Hospital from October 2017 to March 2020. Patients and methods A prospective case series study has been conducted on 25 patients, who were admitted at the Chest Department, Assiut University Hospital. Patients presented with complex septated pleural effusion and their symptoms were anticipated to improve by pleural fluid drainage . MESNA was given daily for 3 consecutive days at a dose of 1800 mg diluted with 20 ml of normal saline and injected into the pleural cavity through the chest tube. The amount of drained fluid, chest ultrasound, and chest radiograph were used to evaluate the improvement of patients, assess the safety of MESNA, and detect any adverse effects. Results After installation of MESNA there is an increase in the amount of the fluid drained through the intercostal tube with significant difference before and after installation of MESNA (P&lt;0.001) with a success rate of 64% in the studied patients. Conclusions Intrapleural installation of MESNA is a safe and effective therapy in the treatment of loculated plural effusions.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum.

S3558 Esophageal Candidiasis Leading to Spontaneous Esophageal Rupture

Introduction: Spontaneous esophageal perforation (SEP) is a rare and potentially life-threatening condition usually caused by esophageal trauma due to instrumentation or prolonged vomiting and retching. SEP due to esophageal candidiasis (EC) is extremely rare. We present a case of SEP in a patient with EC despite treatment with systemic antifungals. Case Description/Methods: A 53-year-old woman with a history of stage IV lung adenocarcinoma treated with chemoradiotherapy and immunotherapy presented with fever, abdominal pain, diarrhea and hematochezia. Her symptoms were consistent with immune-checkpoint inhibitor colitis, similar to a recent episode that improved with corticosteroids. She has a history of radiation esophagitis in the form of superficial ulceration and stenosis affecting the proximal esophagus. High-dose intravenous corticosteroids were initiated. Due to minimal response, infliximab was administered. Colonoscopy was unremarkable and random biopsies were negative for cytomegalovirus (CMV). Upper endoscopy (EGD) revealed resolution of the initially seen ulceration and no evidence of stricture or stenosis. However, a new distal superficial esophageal CMV ulcer was found. CMV viral load was 6,810 IU/mL and was successfully treated with intravenous ganciclovir leading to viral clearance. EGD for ongoing hematochezia revealed severe esophageal candidiasis (EC) confirmed with histopathology (Figure 1). Despite completing a 14-day course of intravenous fluconazole was, she developed septic shock due to SEP leading to a hydropneumothorax (Figure 2 and 3). Pleural fluid culture was positive for C. albicans. At that stage, family decided to enroll her in home hospice where she died a few days later. Discussion: Although, EC is not uncommon in immunocompromised patients, it is usually treated successfully with antifungal agents in 80-90% of cases. Transmural invasive Candida infection, however, is exceptionally rare with only 4 confirmed cases in the literature. It may lead to esophageal perforation and esophageal-pleural fistula formation. A second-look EGD with culture and sensitivity is recommend in symptomatic patients with EC who fail to improve with treatment. However, there are no guidelines recommending a repeat EGD in immunocompromised patients who initially had minimal symptoms. Our case suggests that for those patients a repeat EGD should be done to ensure resolution of EC and discontinuation of immunosuppressive therapy should be considered.Figure 1.: Endoscopic picture showing mucosal yellow-white plaques throughout entire esophagus, consistent with candidiasis.Figure 2.: Non-enhanced CT (axial view) demonstrating right hydropneumothorax with loculated fluid components.Figure 3.: Esophagram with extravasation of contrast from superior upper esophagus extending into right upper chest.

S1669 A Rare Presentation of Acute Pancreatitis in Mild Coronavirus Disease 2019 Infection

Introduction: Viral-induced pancreatitis has previously been well-defined, however there is limited data regarding the association between Coronavirus Disease 2019 (COVID-19) and pancreatitis. A handful of cases have been described, but most commonly are in conjunction with severe COVID-19 infections as well as pancreatic enzyme elevation. It has been demonstrated that patients with acute pancreatitis and coexistent COVID-19 infections have a significantly higher morbidity and mortality than those without acute pancreatitis. We describe a unique case of mild COVID-19 infection resulting in acute pancreatitis in the absence of lipase elevation. Case Description/Methods: A 39-year-old patient with no significant past medical history, including no history of chronic pancreatitis or alcohol use disorder, presented with epigastric pain, loss of taste and smell, fever and dry cough. Vital signs were within normal limits. Laboratory findings were significant for positive COVID-19 testing. Liver function panel, calcium, triglyceride, and lipase levels were all unremarkable. Computed tomography of the abdomen was consistent with acute pancreatitis without evidence of gallstones and without pancreatic, intra or extrahepatic biliary dilatation. The patient underwent conservative management with bowel rest and intravenous fluids and was discharged without complications. Discussion: This case introduces a rare presentation of acute pancreatitis without lipase elevation in setting of mild COVID-19 infection. It has been unclear whether lipase elevation in COVID-19 is due to direct pancreatic injury or viral-induced systemic inflammatory response causing multiorgan dysfunction. Our case may indicate that there is a direct impact on the pancreas by the SARS-CoV-2 virus, which has been postulated given the presence of ACE-2 receptors in the pancreas. This case also highlights the importance of suspecting pancreatitis in patients with mild COVID-19 infections that present with atypical symptoms such as epigastric pain, even without lipase elevation. Early identification in these cases may help to reduce progression and prevent worse outcomes.Figure 1.: Computed Tomography (CT) of the abdomen demonstrated mild peripancreatic inflammation at the level of the tail, with no clear pancreatic lesion and no loculated fluid collection. There was no calcified gallstone and no pancreatic ductal, intra or extrahepatic biliary dilatation.