Left Lower Lobe Consolidation Research Articles

Next-Generation Sequencing of Microbial Cell-Free DNA to Rapidly Detect Fluoribacter Bozemanae Pneumonia in an Immunocompromised Host

Background: Fluoribacter bozemanae is an uncommon pathogen that accounts for just 3-5% of cases of pneumonia caused by the different Legionella species. The mortality rate has been reported to be up to 40%. This organism is difficult to identify, making diagnosis extremely challenging with current diagnostic modalities. Case Report: We present a case of a 75-year-old female with a history of multiple myeloma undergoing active treatment with immunosuppressive agents who presented with confusion, hypoxemic respiratory failure and sepsis. Her initial presentation was consistent with Legionella infection, however, all routine testing including a Legionella urine antigen test came back negative. A CT scan of the chest was completed which showed near complete left lower lobe consolidation concerning for pneumonia. An infectious workup was initiated. Atypical and viral pneumonia polymerase chain reaction panel was negative. Microbial cell-free DNA sequencing returned positive for Fluoribacter bozemanae, a subspecies of the Legionellaceae family that is known to cause severe pneumonia in immunocompromised hosts. This information allowed a therapy adjustment resulting in rapid improvement of our patient’s symptoms. Conclusion: In cases such as this one, the diagnosis of Legionella species is often missed due to the many challenges associated with the different testing modalities. In these circumstances, next-generation genetic sequencing can be extremely useful. Now with the increasing availability of next-generation sequencing as a microbiological diagnostic tool, we can diagnose many more infections that once would have gone undiagnosed and either untreated or delayed in treatment.

Unusual Finding in a Patient of COVID-19 Associated Pulmonary Aspergillosis: A Case Report

Invasive Fungal Infections have posed a difficult challenge in the recovery of people infected with COVID-19. COVID-19-associated pulmonary aspergillosis (CAPA) has been described and found in about 30 % of ICU patients worldwide. Here we present an unusual microscopic finding in a case of CAPA in an ICU patient which was helpful in initiating early definite therapy. A 56-year-old gentleman presented with complaints of fever and shortness of breath and subsequently tested positive for COVID. Post admission, his respiratory distress worsened and his condition deteriorated. A provisional diagnosis of COVID pneumonia with acute respiratory distress syndrome (ARDS) was established based on chest radiographic finding of left lower lobe consolidation, increased pulmonary infiltrates in bilateral lung fields with evidence of pleural effusion. Pleural Aspirate obtained via ultrasound guided thoracocentesis revealed branched hyaline septate hyphae along with structures which were composed of elongated vesicle with one layer of phialides covering two-thirds of the vesicle and bearing globose conidia on KOH direct mount. Aspergillus flavus grew on culture, which was later confirmed by MALDI TOF VITEK MS. Patient was diagnosed with Proven Invasive Pulmonary Aspergillosis with COVID-19 and voriconazole was started. Patient successfully recovered and was discharged. Identifying the Aspergillus species directly on the basis of KOH Mount, helped in decreasing the turnaround time, in early initiation of definite therapy and possibly contributed to the favorable outcome. CAPA is a potentially life-threatening complication in patients with severe COVID-19, thus a timely diagnosis and treatment becomes crucial in the management. Keywords: CAPA, COVID-19, Aspergillus

Extralobar Pulmonary Sequestration.

Male, 71 year-old, asymptomatic, former smoker and previous history of lung tuberculosis. Referred to outpatient clinic due to left lower lobe consolidation diagnosed on non-contrasted CT scan, with increased uptake on PET-CT. Then, a contrast-enhanced CT scan revealed extralobar pulmonary sequestration with venous drainage to the left azygos vein (Blue arrow) and a double branch arterial supply from the thoracic aorta (Red arrow).

SARS-CoV-2 parainfection associated Landry -Guillain- Barre Syndrome (LGBS) in a term pregnant women: A clinical conundrum.

Sir Guillain-Barre Syndrome (GBS) is a rare neurological disease that is characterized by progressive weakness in legs and arms, areflexia, or decreased tendon reflexes in weak limbs.[1] Evidence of GBS cases associated with SARS-CoV-2 infection has recently been reported.[2] Though GBS is considered mostly a post-infectious, immune-mediated disease, it might also occur during the infectious phase in some cases. Herein, we report first case of SARS-CoV-2 parainfection associated GBS in a term pregnant patient. A 22 year primigravida at 36 weeks of gestation, presented with acute onset of quadriparesis since 3 days and cough since 2 days. Patient c/o weakness in all four limbs, sudden onset, started distally in both lower limbs which progressed to involve upper limbs. On examination, she was tachypneic with respiratory rate of 32-34 breaths/min. She maintained saturation of 97% on ventimask at 0.4 fraction of inspired oxygen. On motor examination, in lower limb she had power of 2/5 at both ankle and knee joints. At hip joint, she had power of 1/5. In upper limb, she had power of 3/5 at both the shoulders and 4/5 at both the elbow joints. Deep tendon reflexes were absent. Her blood investigations were normal except for total serum bilirubin which was 3.2 mg/dl. She also tested SARS CoV-2 reverse transcriptase positive. Since she had no prior history of any gastrointestinal infection, she was diagnosed as SARS-CoV-2 parainfection associated Landry -Guillain- Barre Syndrome (LGBS) with respiratory involvement. In view of the worsening motor weakness and decline in respiratory functions, she was planned for urgent caesarean section. After preoxygenation, rapid sequence induction was done using thiopentone sodium and rocuronium and intubated with oral cuffed endotracheal tube with 7.0 mm internal diameter. She was ventilated using controlled mode with peak inspiratory pressure of 22 cm water, positive end expiratory pressure 5 and maintained on sevoflurane + oxygen at minimum alveolar concentration of 0.7-1. After delivery of baby, oxytocine infusion was started at 5 IU/h and injection fentanyl 50 μg was administered. Post-surgery she was shifted unreversed to COVID-19 intensive care unit (ICU). In ICU, she was administered intravenous immunoglobulins gram once a day (OD) for 4 days, low molecular weight heparin 0.6 ml OD, injection dexamethasone 6 mg twice a day, and Tablet Gabapentin 300 mg at night. Her CSF analysis showed total protein of 31.5 mg/dl and glucose levels of 68.9 mg/dL. During her ICU stay, she developed collapse and consolidation of left lung lower lobe with left sided pleural effusion, which resolved over next few days after she was tracheostomized. After 10 days of her ICU stay, she tested SARS-CoV-2 reverse transcriptase negative. Thereafter, she was shifted to non-COVID-19 ICU where she was gradually weaned from ventilatory support. Her nerve conduction study was performed which reported complete absence of compound muscle action potential (CAMP) with normal sensory nerve action potential (SNAP) suggestive of Acute Motor Axonal Polyneuropathy (AMAN) [Table 1]. She was shifted to medical ward for rehabilitative care. She was discharged from the hospital and was mobilized using wheel chair. There was complete return of motor power in upper limbs.Table 1: Nerve conduction study parameters of the patientTo the best of our knowledge, this is the first reported case of SARS-CoV-2 parainfection associated LGBS in term pregnant patient. She presented with short history of acute onset of muscle weakness accompanied by cough which gradually worsened and required assisted ventilation. As patient had already reached term, emergent caesarean section followed by management according to SARS-CoV-2 protocols was done. Guillain barre syndrome (GBS) worsens in postpartum period due to restoration of cellular immunity, with increase in delayed type of hypersensitivity which was adaptively depressed during pregnancy.[3] In an observational multicentre study, thirty GBS cases associated with COVID-19, stated COVID-19-associated GBS as being predominantly demyelinating and more severe than non-COVID-19 GBS.[4] Tekin et al.[5] have reported occurrence of LGBS in pregnant patient who had preceding SARS-CoV-2 infection. The patient developed muscle weakness in postpartum period, which recovered after receiving intravenous immunoglobulins. The prognosis of SARS-CoV-2 parainfection associated LGBS in term pregnant patient is still unclear and requires early recognition of danger signs for timely management and favorable outcome. Thus, clinical course of SARS-CoV-2 parainfection associated LGBS during pregnancy is highly complicated, due to presence of non-specific signs and symptoms and carries high risk of maternal morbidity. Early identification and multidisciplinary involvement are essential for diagnosis and good outcome. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Post-COVID acute pulmonary nocardiosis: Another novel post-COVID infection.

Dear Editor, Treatment of COVID-19 remains challenging, especially in patients with severe disease. Immunosuppressive therapies such as steroids and cytokine blockers are beneficial to control the cytokine storm. However, these drugs increase the risk of opportunistic infections. Nocardiosis is caused by an actinomycete, which primarily affects immunocompromised patients. Here we report a patient with acute localized pulmonary nocardiosis, post severe COVID disease. A 70-year-old male patient with no addictions and comorbidities presented to the emergency room with complaints of high-grade fever, cough with copious brown sputum, left-sided pleuritic chest pain for 2 weeks, and breathlessness for 3 days. He had severe COVID-19 disease with respiratory failure 4 weeks ago for which he was treated with IV remdesivir and IV methylprednisolone 40 mg twice daily for 7 days and discharged. At presentation, he had a respiratory rate of 30 breaths/min and saturation of 60% on room air, which improved to 95% with 5 liters/minute of oxygen support. Arterial blood gases (ABG) showed type 1 respiratory failure. Chest X-ray showed a consolidation in the left lower zone. High-resolution computed tomography (HRCT) chest revealed consolidation in the left lower lobe with internal breakdown and minimal pleural effusion [Figure 1a]. Total leukocyte count and C-reactive protein (CRP) were elevated (21,700 cells/mm3 and 320 mg/L, respectively). Sputum showed gram-positive, acid-fast, branching filamentous structures, morphologically resembling Nocardia species [Figure 1b, c], and hence a diagnosis of acute pulmonary nocardiosis was made. The patient was treated with oral trimethoprim-sulfamethoxazole (TMP-SMX) and IV meropenem for 4 weeks. The patient improved with treatment and was off oxygen support after a week and hence discharged. On follow-up after 3 weeks, antibiotics were changed to oral linezolid and TMP-SMX for 5 months. After completion of therapy, the patient is asymptomatic and the HRCT chest showed near-complete resolution of the left lower lobe consolidation with residual fibrotic bands [Figure 1d].Figure 1: (a) Axial slice of a high-resolution computed tomography scan of the chest showing consolidation of the left lower lobe with internal breakdown. (b) Direct examination of sputum smear after modified acid-fast staining revealing branching filamentous acid-fast organisms (40 × magnification). (c) Positive culture of the same sputum specimen on the blood agar plate. (d) Axial slice of a high resolution computed tomography scan of chest post-treatment, showing near-complete resolution with residual fibroticNocardiosis, an opportunistic infection, has been reported rarely in post-COVID-19 patients. To the best of our knowledge, there are only three case reports to date.[1,2] Nocardia species are ubiquitous saprophytic gram-positive bacteria of the “aerobic actinomycetes” group.Click or tap here to enter text.[3] The primary route of transmission is inhalational, from environmental sources. The majority of patients with pulmonary nocardiosis are immunosuppressed or have chronic lung disease. Radiology usually demonstrates irregular nodular lesions that may have cavitation. “Halo sign,” diffuse consolidations, and pleural effusions have been reported. The definitive diagnosis of nocardiosis requires isolation of the organism. Nocardia appears as a filamentous bacterium with hyphae-like branching and a “beaded” acid-fast appearance on microscopy.[4] Sulfonamides are the treatment of choice for nocardiosis. TMP-SMX is the most widely used drug. Alternative treatment options include amikacin, imipenem, meropenem, ceftriaxone, cefotaxime, minocycline, moxifloxacin, levofloxacin, linezolid, tigecycline, and amoxicillin-clavulanic acid.[3] The duration of treatment is 6–12 months. Our patient, who was otherwise healthy and had received only a short course of corticosteroids developed pulmonary nocardiosis, which suggests that it is vital to investigate for uncommon etiologies in patients presenting with secondary infections post-COVID-19 disease. COVID-19 infection apart from the drugs used in its treatment as a cause of immune suppression needs further research. Abbreviations IV – Intravenous, ABG – Arterial blood gases, HRCT – High resolution computed tomography, CRP- C-reactive protein. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

WHEN FLU LEADS THE WAY: A CASE OF PARVIMONAS MICRA POLYMICROBIAL EMPYEMA IN A PATIENT WITH INFLUENZA A INFECTION

WHEN FLU LEADS THE WAY: A CASE OF PARVIMONAS MICRA POLYMICROBIAL EMPYEMA IN A PATIENT WITH INFLUENZA A INFECTION

LOBAR TORSION FOLLOWING DOUBLE LUNG TRANSPLANTATION: A SURGICAL EMERGENCY

LOBAR TORSION FOLLOWING DOUBLE LUNG TRANSPLANTATION: A SURGICAL EMERGENCY

A 32-Year-Old Dental Surgeon Presented with Massive Hemoptysis, Fever and Hypotension As A Result of Bleeding from Bronchiectasis due to Pulmonary Tuberculosis (New Case) with Concurrent Covid-19 Infection Successfully Treated with Anti-Tubercular Th

A dental surgeon had sudden onset of massive hemoptysis with hypovolemic shock during COVID-19 epidemic; her nasopharyngeal swab for SARS-CoV-2 PCR was positive. She noticed 2 days history of fever and cough; however, she had poor appetite for nearly two weeks. Resuscitation was done successfully with fluids and blood transfusion. Chest radiograph showed opacities in left lower zone; and, NECT chest revealed consolidation in left lower lobe and patchy opacities in right upper lobe with areas of bronchiectasis. Sputum for gene expert for drug resistant tuberculosis, Ziehl Neelsen stain for acid fast bacilli and Lowenstein Jensen media for culture could not be done as microbiological services were limitted in the peak of COVID-19 pandemics. Therefore, anti-tubercular therapy (isoniazid, rifampicin, ethambutol and pyrazinamide) was initiated mainly based on NECT chest without sputum confirmation; the patient made dramatic improvement. Two months later, she gained 10 lbs weight; and radiological improvement.

Tales of the Unexpected: Donor Lung with CTEPH, a Unique Case Report

<h3>Introduction</h3> Whilst chronic thromboembolic pulmonary hypertension (CTEPH) is a recognised indication for lung transplantation, it is an undesirable finding in a lung donor. We present the case of an individual who underwent a single lung transplant with an allograft that was subsequently identified as having CTEPH. <h3>Case Report</h3> This 65 year old, 167cm, blood group A RhD+ female with fibrotic organising pneumonia was listed for a left single lung transplant on the basis of a hypokinetic right hemi-diaphragm. She received an organ from a 55year old, 159cm, blood group A RhD+, non-smoking female DBD donor, who died from a subarachnoid haemorrhage. The donor had possible asthma (not formally diagnosed) and an unenhanced CT chest demonstrated non-specific mosaic attenuation. A donor echocardiogram showed mild tricuspid regurgitation with normal right ventricular (RV) size but impaired radial systolic function. Donor blood gases on FiO₂ 1.0 demonstrated PaO₂ 35kPA in the left upper lobe and 64kPa in the left lower lobe pulmonary veins. The recipient surgery was uneventful, although she developed primary graft dysfunction with RV impairment. She was stabilised and extubated after 24 hours onto 2L/min supplemental oxygen. Day 10 post-transplant she developed increasing oxygen requirements. CT pulmonary angiography demonstrated patent vascular anastomoses, left lower lobe pulmonary artery occlusion and features of CTEPH, but no lung necrosis. A right heart catheter study confirmed mild pulmonary hypertension with a mean pulmonary artery pressure 25mmHg and pulmonary vascular resistance 6 Wood Units. She underwent pulmonary endarterectomy (PEA) with good clearance of the donor vasculature. She weaned easily from cardiopulmonary bypass and her supplemental oxygen was down-titrated. She was discharged home 6 weeks post-transplant to complete 12 weeks of anticoagulation. 5 months post-transplant she developed fever and hypoxia with imaging features of left lower lobe consolidation, but no new thrombus. In the context of poor physiological reserve, the patient and family requested palliation. <h3>Summary</h3> CTEPH is rare in the general population, with a prevalence 3-30 per million. In this case, the diagnosis of CTEPH only came to light after transplantation and this is the first report of PEA performed in a lung recipient. Transplant teams should be alert for CTEPH in potential lung donors.

P6‐41: Rifampicin resistant pulmonary tuberculosis with concomitant bacterial pneumonia. Showing left lower lobe consolidation in the young and immunocompetent physician

P6‐41: Rifampicin resistant pulmonary tuberculosis with concomitant bacterial pneumonia. Showing left lower lobe consolidation in the young and immunocompetent physician

DISSEMINATED ACTINOMYCETOSIS WITH PNEUMONIA, LEFT GLUTEAL, LEFT EYE, AND BRAIN ABSCESSES IN A PATIENT WITH SJÖGREN AND INTERSTITIAL LUNG DISEASE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: A localized or disseminated infection by an aerobic gram-positive beaded filamentous branching actinomycete Nocardia is called Nocardiosis. Its presence is ubiquitous, causing infection in immunosuppressed and healthy individuals. An increased incidence is due to the greater use of immunosuppressants and improved diagnostic processes. On average, 500-1,000 new cases occur in USA [1] CASE PRESENTATION: 86-year-old female with hypertension, diabetes, Sjogren's, and interstitial lung disease (ILD) on 10 mg prednisone came to the eye clinic for left blurry eye pain for three days. A recent ILD flare was treated with a steroid burst. Eye exam showed acute left eye endophthalmitis with bilateral chorioretinal infiltrates (Figure A1-2). A white cell count was normal with neutrophilia and an absolute lymphocyte count of 903 cells/mm3. Human immunodeficiency virus, syphilis, endemic fungal, and Quantiferon testing and blood cultures were negative. Echocardiogram was normal, while prednisone was held. Computed tomography (CT) of the chest, abdomen, and pelvis revealed interstitial pneumonia, new left lower lobe consolidation, left gluteal and right paraspinal muscle abscess, and left gluteal biopsy showed acid-fast filamentous microorganisms with culture positive for Nocardia farcinica resistant to ceftriaxone, clarithromycin, and tobramycin (Figure B1-4). Magnetic resonance imaging (MRI) brain revealed multiple ring-enhancing lesions in the right midbrain, left cingulate gyrus, parietofrontal and temporal lobe (Figure C1-3). On the 14th day, the left eye revealed a small subretinal abscess. An initial regimen of meropenem and bactrim was changed to amikacin and imipenem for six weeks at discharge. A week later, she was back in intensive care in a comatose state with worse MRI brain changes and placed on comfort care DISCUSSION: Disseminated disease is common in males and often presents with brain lesions, with N. farcinica being the frequent subspecies causing it due to its predilection for brain and skin tissue with an increased mortality rate [2-4]. N. farcinica is resistant to multiple antibiotics, including third-generation cephalosporins. A frequent site of the abscess is the parietofrontal lobe [5]. Mortality in multiple abscesses is higher than with a solitary abscess (66% vs. 33%) [6]. Inappropriate empirical therapy has higher mortality at 31% than an appropriate therapy (10%) [7]. Concomitant involvement of lungs, brain, eye, and muscles is rare. Due to a lower incidence, it is not considered at initial diagnosis CONCLUSIONS: In chronic respiratory disease patients on low-dose steroids, the onset of new visual or nervous system symptoms is a concern for disseminated nocardiosis with a recent history of steroid burst, lymphopenia, and neutrophilia REFERENCE #1: Beaman BL, Burnside J, Edwards B, Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. 1976;134(3):286-9 REFERENCE #2: Kramer MR, Uttamchandani RB. The radiographic appearance of pulmonary nocardiosis associated with AIDS. Chest. 1990;98(2):382-5 REFERENCE #3: Sabuncuoğlu H, Cibali Açikgo Z Z, Caydere M, Ustün H, Semih Keskil I. Nocardia farcinica brain abscess: a case report and review of the literature. Neurocirugia (Astur). 2004;15(6):600-3 DISCLOSURES: No relevant relationships by Andres Bran, source=Web Response No relevant relationships by CARLA CARUSO, source=Web Response No relevant relationships by Paragkumar Patel, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by ANTONY RAWINDRARAJ, source=Web Response

ALL THAT PET POSITIVE IS NOT CANCER

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: PET (Positron emission tomography)/CT (Computed tomography) is a common modality used to diagnose and stage various malignancies. Radiotracer FDG (Fluoro18-deoxyglucose) is not cancer-specific and false-positive results may be observed in a wide variety of non-malignant conditions. Here we describe a patient with FDG avid left lower lobe endobronchial mass. CASE PRESENTATION: 75 years old female with a medical history significant for type 2 diabetes mellitus, seizure disorder was referred to pulmonology clinic with shortness of breath, intermittent wheezing, and non-productive cough for 2 months. She denied chest pain, orthopnea, fever, chills, weight or appetite changes, night sweats. The patient is a former smoker with less than 20 pack-year, quit two decades ago. On physical exam, the patient was saturating 92% in room air. BMI was 44.99 kg/m2. Lung examination showed reduced breath sounds at the left lung base. The rest of the exam was unremarkable. The pulmonary function test was normal. Outpatient evaluations were unremarkable. Chest X-ray showed left lower lobe infiltrates. CT chest showed left lower lobe consolidation vs atelectasis of left lung base followed with PET/CT which revealed increased FDG uptake in left lower lobe intraluminal density with SUV 6.5 concerning for malignancy with endobronchial involvement vs inflammatory process. Diagnostic bronchoscopy showed left lower lobe bronchus with significant mucosal hyperemia and edema with yellowish-white foreign body (FB) which was successfully retrieved with endobronchial biopsy forceps and noted to a piece of corn. The patient's symptoms resolved. DISCUSSION: The reported false positive rate of PET/CT was 13% and attributed to FDG uptake by inflammatory cells at the sites of inflammation or infection. Most common FDG avid non-infectious inflammatory etiologies include sarcoidosis, atherosclerosis, pneumoconiosis, and focal foreign body-related inflammation. FB aspiration in the tracheobronchial tree is rare in adults and usually presents with subtle respiratory symptoms with paucity in imaging. Risk factors include loss of consciousness from trauma, drug, seizure disorder or alcohol intoxication, dysphagia related to age-related slowing, stroke, dementia, or Parkinson's disease. In our case, false positives artifacts were related to a focal foreign body (FB) related inflammation with an elevated risk of aspiration related to a seizure disorder, and advanced age. Removal of FB from the tracheobronchial tree may be achieved with flexible bronchoscopy with biopsy forceps or retrieval basket. Rigid bronchoscopy may be needed if flexible bronchoscopy was unsuccessful. CONCLUSIONS: It is essential to understand false positive results while interpreting PET/CT results. FB aspiration in adults is rare and high clinical suspicion is necessary for the diagnosis. Removal of FB can usually be accomplished with bronchoscopy. REFERENCE #1: Common causes of False-positive F18 FDG PET/CT scans in oncology- Kevin R Carter, Eduard Kotlyarov; Vol,50, special number: pp.29-35, September 2007 Brazilian Archives of Biology and Technology- an International Journal. REFERENCE #2: Non-asphyxiating tracheobronchial foreign bodies in adults- Lan RS, Eur Respir J. 1994;7(3): 510 REFERENCE #3: Tracheobronchial foreign bodies in adults- Limper AH, Prakash UB, Ann Intern Med. 1990; 112(8):604 DISCLOSURES: No relevant relationships by Mansur Assaad, source=Web Response No relevant relationships by Rajamurugan Meenakshisundaram, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response

Vasculotoxic snake bite induced multi-organ dysfunction- A case report

Background: A WHO report included snake envenomation in the list of most important Neglected Tropical Diseases (NTD) and 95% of these cases were reported within developing countries. The reason behind this given importance is the high morbidity and mortality rates of snake envenomation as well as the challenges in availability and affordability of anti-snake venom [1]. Vasculotoxic snake bites has a myriad of manifestations ranging from local complications like necrosis and cellulitis to systemic complications such as coagulopathy, acute renal failure, acute respiratory failure, and hemolysis. Case Presentation: We report a case of a young male patient who was bitten by a Russell viper snake and developed cellulitis and blackish discolorations of the local site. The patient developed altered sensorium and subsequent loss of consciousness with a CT scan of the brain showing intra-parenchymal and subarachnoid hemorrhage. The coagulation profile demonstrated disseminated intravascular coagulation. He was treated for the above complications with polyvalent anti-snake venom, fresh frozen plasma, and cryoprecipitate units. Three days later, the patient developed breathlessness and hemoptysis with a drop in haemoglobin level with bilateral parenchymal infiltrates and left lower lobe consolidation indicative of diffuse alveolar hemorrhage with acute respiratory distress syndrome. On the fifth day, the patient reduced urine output with raised serum and creatinine levels. The patient’s clinical status rapidly worsened despite mechanical ventilatory and inotropic support and unfortunately succumbed to death on the 7th day of admission. Conclusion: Although there are case reports of snake bite induced isolated organ involvement, little is known about multi-organ dysfunction due to snake envenomation. The widespread multi-systemic involvement of snake envenomation resulting in fatal intracranial hemorrhage, acute lung, and kidney injury in our patient has been illustrated in this case report.

A case report on sympneumonic effusion

A case of Sympneumonic effusion, a condition in which pleural effusion is associated with pneumonia is reported here. The patient was presented with the shortness of breath, cough. He also had atelectasis changes in right middle lobe and a patchy consolidation in left lower lobe. Generally this is caused due to bacterial infection of streptococcus species .Which can be treated with general pneumonia treatment, includes antibiotics, oxygen supply and other supportive care.

Why My Experience as a Patient Led Me to Join Osler’s Alliance

No abstract available. Article truncated after 150 words. There are a number of books and articles written by doctors that relate their own experience as patients. Count this as another although I promise it will not be nearly as entertaining as “The House of God”. Over a month ago I became short of breath and a chest x-ray revealed left lower lobe consolidation. Despite lack of fever, it seemed that an infectious process was most likely, and when multiple tests for COVID-19 were negative, it was felt by my pulmonary physician to be most likely coccidioidomycosis despite a negative cocci serology. After beginning on empirical therapy with fluconazole for nearly a month, I am feeling better. Most of us know that there is considerable laboratory to laboratory variation in serologic tests for Valley Fever (1). However, when my initial cocci serology was negative, efforts to send it a good reference lab such as Pappagianis’ Lab at UC Davis …

Proteus empyema as a rare complication from an infected renal cyst, a case report

BackgroundThe most commonly isolated organisms in a parapneumonic effusion include S. pneumoniae, H. influenzae, and S. aureus. If unusual organisms are isolated from the pleural space, further investigation is warranted to locate the primary source. We present a patient with an infected chronic renal cyst found to have an empyema secondary to Proteus mirabilis to highlight the importance of further diagnostic workup when encountering unusual organisms in the pleural space.Case presentationA 40-year-old African-American female, with a past medical history of asthma and sickle cell trait, presented with 5 weeks of upper respiratory tract symptoms and chest pain. A computed tomography angiogram (CTA) of the chest was negative for a pulmonary embolism but revealed a loculated left sided pleural effusion with associated left-lower lobe consolidation. She was started on empiric antibiotics, and a chest tube was inserted with drainage of frank pus. Fluid gram stain was positive for gram negative rods.Intrapleural fibrinolytics were administered for 72 h given the presence of loculations. With no improvement following fibrinolytics, she was taken to the operating room for large bore chest tube placement and left visceral pleura decortication. Pleural fluid cultures speciated to Proteus mirabilis, so further cross-sectional imaging of her abdomen/pelvis was pursued to evaluate for a primary source. A complex cystic lesion in the upper pole of the left kidney that communicated with the ipsilateral diaphragm was identified. Subsequent drainage and culture of the renal cyst was positive for Proteus mirabilis. Given clinical improvement following these interventions she was discharged with an extended course of antibiotics with plans for repeat imaging following completion of treatment.ConclusionsWhile cases of Proteus mirabilis empyema have previously been reported as a consequence of conditions such as pyelonephritis, we present, to our knowledge, the first case of a Proteus mirabilis empyema as a consequence of an infected renal cyst communicating with the pleural space. This study highlights that further evaluation with cross-sectional imaging is warranted when unusual organisms are found in the pleural space. Anatomic abnormalities that become apparent on imaging may help elucidate the source of infection.

ACUTE ON CHRONIC DYSPNEA IN A PATIENT WITH METASTATIC BREAST CANCER ON ABEMACICLIB

SESSION TITLE: Medical Student/Resident Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We report a case illustrating the challenging diagnosis of interstitial pneumonitis caused by abemaciclib in an elderly woman with metastatic breast cancer. Lung toxicity is an uncommon but serious adverse effect of cyclin-dependent kinases 4 and 6 (CDK 4/6) inhibitors. Diagnosis is typically based on presentation, and non-contrast CT chest is the imaging modality of choice. Typical findings include ground-glass opacities with or without consolidation. The purpose of this case report is to highlight this uncommon toxicity of CDK4/6 inhibitors which requires high level of clinical suspicion for diagnosis. CASE PRESENTATION: A woman in the 8th decade of life with hormone-receptor positive, HER2 negative breast cancer with metastases to lungs and lumbar vertebrae, on treatment with abemaciclib and fulvestrant, was admitted to the hospital for exertional dyspnea for six weeks, with acute worsening to dyspnea at rest in the past one day. Prior to hospitalization, she had developed a fever three weeks after starting abemaciclib. She was treated for community-acquired pneumonia and COPD exacerbation, but had only partial relief of symptoms. CT chest showed ground glass opacities pronounced in right upper and middle lobes, with post-obstructive consolidation in left lower lobe, and soft tissue fullness around the left lower lobe bronchus and along the bronchovascular bundles suspicious for lymphangitic spread of tumor. Upon hospitalization, she was hypoxic and on 3 liters oxygen by nasal cannula. Repeat CT chest showed interval worsening of ground glass opacities in right upper lobe, new ground glass changes in left upper lobe, and worsening of left lower lobe consolidative change. Sputum cultures, fungal studies, and respiratory viral panel were negative. Symptoms improved with initiation of steroids. DISCUSSION: CDK 4/6 inhibitors are a relatively new class of drugs used in tandem with aromatase inhibitors or fulvestrant in the treatment of advanced hormone-receptor positive breast cancer. Diarrhea, nausea, fatigue, and pancytopenia were among common side effects noted in initial clinical trials. For our patient, a steroid course with taper was initiated, and the offending agent was held. A follow up CT scan three months later showed resolution of the ground glass opacities. This approach to management appears to be in line with the limited literature available. CONCLUSIONS: Our case documents an interesting diagnostic challenge in which a patient with developed pneumonitis in the setting of abemaciclib use. The diagnosis was delayed due to comorbid COPD and pneumonia, and confounded by partial resolution in symptoms with antibiotics. In September 2019, the FDA issued a safety warning that abemaciclib, palbociclib, and ribociclib may cause rare but severe pneumonitis. The temporal correlation between initiation of abemaciclib and development of symptoms remains unclear. Reference #1: Corona SP, Generali D. Abemaciclib: A CDK4/6 inhibitor for the treatment of HR+/HEeR2- advanced breast cancer. Drug Des Devel Ther. 2018;12:321-330. doi:10.2147/DDDT.S137783 Reference #2: Johnston S, Martin M, Di Leo A, et al. MONARCH 3 final PFS: a randomized study of abemaciclib as initial therapy for advanced breast cancer. npj Breast Cancer. 2019;5(1):1-8. doi:10.1038/s41523-018-0097-z Reference #3: FDA warns about rare but severe lung inflammation with Ibrance, Kisqali, and Verzenio for breast cancer | FDA. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-rare-severe-lung-inflammation-ibrance-kisqali-and-verzenio-breast-cancer. DISCLOSURES: No relevant relationships by Sameera Natarajan, source=Web Response No relevant relationships by Arjun Natarajan, source=Web Response

A RARE CASE OF NATIVE TRIPLE-VALVE INFECTIVE ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Infective endocarditis (IE) is a life-threatening infection. Despite medical advances, mortality from IE remains high. Enterococcal IE is becoming more prevalent in elderly patients with degenerative valvular disease and bloodstream infections from gastrointestinal (GI) or genitourinary (GU) tracts. We present a rare case of native triple-valve infective endocarditis. CASE PRESENTATION: A 58-year-old man with a history of squamous cell carcinoma of tongue post hemiglossectomy with chemoradiation therapy and small bowel obstruction post open laparotomy a month earlier presented for altered mental status. Initial vitals showed tachycardia and was otherwise normal. Positive examination findings were cachexia, a healed partial tongue resection, decreased air entry over lung bases and left upper abdominal tenderness without peritonitis. The rest of the physical exam was unremarkable. Initial lab results were significant for leukocytosis, mild anemia, elevated BUN and creatinine. Computed tomography (CT) of chest and abdomen showed a large left lower lobe consolidation, right lower lobe patchy parenchymal disease and gastric wall thickening. He was started empirically on Zosyn, vancomycin and fluconazole. Blood cultures grew Enterococcus faecalis and transthoracic echocardiogram (echo) showed an acute-on-subacute endocarditis with vegetations on the tricuspid, mitral and aortic valves with ejection fraction 65-70%. Bronchoscopy with bronchoalveolar lavage (BAL) culture was positive for Candida Glabrata 3 days after his death. He later developed septic shock with multiorgan failure and was considered ineligible for surgery. Despite optimal medical therapy and no worsening of echo findings, he ultimately died. DISCUSSION: Multivalvular IE increases the likelihood of complications from congestive heart failure, acute renal failure, embolic events, disseminated intravascular anticoagulation and death (1). Enterococcus faecalis is an opportunistic pathogen in oral cavity, the GI and GU tracts. Manipulation of the GI and GU tracts, cancer and previous treatment with antibiotics increase the risk of enterococcal bacteremia. Our patient’s overall immunocompromised state and recent surgical intervention placed him at higher risk of Enterococcus faecalis infection. Enterococcus faecalis bacteremia is a common cause of IE that has had no survival improvement in the past decade (2). Ultimately, his BAL culture was positive for Candida glabrata, which if resulted in fungemia, could be complicated by a rare but aggressive form of IE with a mortality rate of 80% requiring both medical and early surgical intervention (3). CONCLUSIONS: Triple valve endocarditis is rare with few studies in literature to guide the best management. Further research is necessary to identify patients at increased risk of multivalve IE, in regards to optimal screening methods to facilitate early detection and therapy. Reference #1: Kim, N., Lazar, J., Cunha, B., Liao, W., & Minnaganti, V. (2000). Multi-valvular endocarditis. Clinical Microbiology and Infection, 6(4), 207–212. doi: 10.1046/j.1469- 0691.2000.00065.x Reference #2: Dahl, A., Rasmussen, R. V., Bundgaard, H., et al. (2013). Enterococcus faecalis Infective Endocarditis. Circulation, 127(17), 1810–1817. doi: 10.1161/circulationaha.112.001170 Reference #3: Baddley, J. W., Benjamin, D. K., et al. (2008). Candida infective endocarditis. European Journal of Clinical Microbiology & Infectious Diseases, 27(7), 519–529. doi: 10.1007/s10096-008-0466-x DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alem Mehari, source=Web Response No relevant relationships by Lamiaa Rougui, source=Web Response

Tension Pneumocephalus in a Tracheostomized, Chronically Ventilated, Duchenne’s Muscular Dystrophy Patient Without Prior Head Trauma

Tension pneumocephalus is a rare condition that can be a life-threatening neurosurgical emergency. It usually results from head trauma, but there have been case reports of iatrogenic causes including on non-invasive mechanical ventilation. We report a case of pneumocephalus resulting from high mechanical ventilation pressures in a patient without prior head trauma.A 37-year-old male with Duchenne’s muscular dystrophy who had been ventilator-dependent through tracheostomy was admitted for shortness of breath and intermittent fevers. The patient was found to have pneumonia, with left-lower lobe consolidation, and was started on linezolid given known Methicillin-resistant Staphylococcus aureus from previous sputum culture; he was later switched to vancomycin and piperacillin-tazobactam given persistent fevers to cover for hospital-acquired pneumonia. The patient went into septic shock requiring multiple pressors as well as stress steroids for persistent shock, with eventual improvement in hemodynamics. He developed further respiratory acidosis on his usual ventilator settings, and peak inspiratory pressures (PIPs) progressively increased to as high as 45-70 cm H2O during his hospital course. PIPs did not improve with suctioning or after bronchoscopy. On the 17th day of the patient’s stay, he had acutely altered mental status with non-reactive fixed and dilated pupils and disconjugate gaze of the right eye on neurologic examination. CT of the head at that time revealed extensive pneumocephalus along the bifrontal convexities, suprasellar cisterns, and posterior fossa, with a possible fracture of the frontal skull base near the ethmoid roof. Mount Fuji sign was present on CT scan, indicative of “tension pneumocephalus”. Neurosurgical consultation was obtained but the family declined intervention given his overall debilitated stated. Comfort measures were instituted, and the patient expired the following day.Pneumocephalus is the accumulation of air entry into the cranial cavity, generally from head trauma, inflammation, or surgery. Patients may have underlying base skull defects or microfractures that permit air to enter the intracranial cavity. Increased sphenoid sinus pressure from mechanical ventilation may enter the subperiosteal space, allowing air to enter the intracranial cavity. It is important to consider pneumocephalus in a patient with new neurological findings after mechanical ventilation.

SAT-LB309 Amphotericin B Induced Hypocalcemia in a Patient With Severe Hypercalcemia Due to Acute T-Cell Leukemia/Lymphoma

SAT-LB309 Amphotericin B Induced Hypocalcemia in a Patient With Severe Hypercalcemia Due to Acute T-Cell Leukemia/Lymphoma