Multiple Mediastinal Lymph Nodes Research Articles

7200 A Unique Case Of Hypercalcemia From Primary Hyperparathyroidism With Thymoma And Concurrent Pulmonary Tuberculosis

Abstract Disclosure: S. Jing Hang Randy: None. L. Huiling: None. Background: Several case reports have reported the rare association of thymoma with primary hyperparathyroidism. We describe a unique case of hypercalcemia with such association but was also found to have concurrent pulmonary tuberculosis. Clinical Case: A 50-year-old Indian female with a significant history of anterior mediastinal mass underwent median sternotomy with mass resection and was found to have peri-operative hypercalcemia. Her only complaint was chronic cough. Initial investigations showed high adjusted calcium 2.78 mmol/L (2.15– 2.50 mmol/L), normal phosphate 1.1 mmol/L (0.8– 1.4 mmol/L) and high PTH 24.7 pmol/L (1.6– 6.9 pmol/L). Apart from the mediastinal mass, a whole-body CT scan showed multiple prominent mediastinal lymph nodes with non-specific subcentimetre lung nodules. The post-operative finding was a Type AB thymoma with necrotizing granulomatous inflammation in adjacent station I lymph node. Differentials for patient’s hypercalcemia included primary hyperparathyroidism, malignancies such as lymphomas and infectious causes in particular tuberculosis. Her 25-OH Vitamin D was low at 9 ug/L (30 - 100 ug/L), 1,25-dihydroxyvitamin D was elevated at 205 pg/mL (18-64 pg/mL) while creatinine, ALP, serum ACE and PTHrP were unremarkable. She was subsequently admitted for worsening hypercalcemia, fever and left pleural effusion with generalized lymphadenopathy where she underwent an Endobronchial Ultrasound-guided Transbronchial Needle Aspirate of station IV lymph nodes before being started on tuberculosis treatment. The AFB culture showed Mycobacterium Tuberculosis Complex thereafter. Parathyroid sonography revealed a 2.2cm x 0.9cm x 0.8cm lobulated hypoechoic lesion posterior to the inferior pole of left thyroid lobe. However, a confirmatory sestamibi scan could only be done 6 weeks post-thymectomy given the raw surgical bed, with a possibility of false-negative result for cervical parathyroid adenoma given a recent thymectomy. It subsequently showed a hyperfunctioning left inferior parathyroid nodule with no other suspicious focal uptake in the neck or mediastinum. Patient underwent a focused left parathyroidectomy. Histology showed features consistent with parathyroid adenoma. A stepwise trajectory of her calcium normalization was observed with hydration, intravenous zoledronic acid for her osteoporosis, tuberculosis treatment, adjuvant radiation therapy for her thymoma with margins involvement, and parathyroidectomy. Conclusion: This case illustrates the challenges faced while considering localizing scans for primary hyperparathyroidism with recent thymectomy given the common embryological origin of inferior parathyroid and thymus. It also demonstrates the possible co-existence of separate pathologies in hypercalcemia and the need to exercise prudent clinical judgement to further evaluate for these various etiologies. Presentation: 6/2/2024

July 2024 Medical Image of the Month: Vocal Cord Paralysis on PET-CT

No abstract available. Article truncated after 150 words. A 60-year-old woman with a past medical history of hypertension, rheumatoid arthritis, and a significant smoking history (40+ pack-years) presented with a 3-month history of hoarseness of voice as well as a 10 lb weight loss over a 5-month period. Chest CT revealed a spiculated left upper lobe nodule (Figure 1A). Additionally, there was evidence of bulky mediastinal and left hilar lymphadenopathy (Figure 1B). A subsequent 17-FDG PET-CT (Figure 2) demonstrated marked metabolic activity in the left upper lobe nodule with an SUV maximum of 9.1. Metabolically active mediastinal and left hilar lymphadenopathy was also noted with an SUV maximum of 5.9. Interestingly, increased metabolic activity of the right vocal cord compared to the left was noted on the PET scan (Figure 2B). Direct laryngoscopy, performed during intubation for a diagnostic bronchoscopy and endobronchial ultrasound, confirmed left vocal cord paralysis. EBUS sampling of multiple mediastinal hilar lymph node stations, including …

FDG-Avid Granulomatous Lymphocytic Interstitial Lung Disease With Common Variable Immunodeficiency.

A 26-year-old woman with known common variable immunodeficiency was referred for FDG PET/CT because of interstitial pulmonary abnormalities and enlarged mediastinal and hilar lymph nodes. FDG PET showed a combination of ground-glass abnormalities and pulmonary nodules, both displaying increased FDG uptake. In addition, multiple FDG-avid axillary, mediastinal, hilar, and inguinal lymph nodes were found. The abnormalities were diagnosed as granulomatous-lymphocytic interstitial lung disease. Cytology of mediastinal lymph nodes yielded only benign disease, without further specification, whereas histology of an excised axillary lymph node showed reactive changes, but no malignancy.

Abstract 4651: Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing

Abstract Background/Purpose: Previous studies have analyzed the tumor and local immune microenvironments in lung cancers and suggest immune modulation is associated with worse clinical outcome. However, the tumor-immune microenvironment in early stage lung tumors and lymph nodes (LNs) have not been fully described. We aim to compare cell states in the immune microenvironments between lung tumors and LNs through multi-modal profiling of the transcriptome and surface proteins. Methods: Needle biopsy samples were taken from 10 treatment-naive early stage lung cancer patients undergoing lung cancer resections. Tissues were obtained from normal lung, lung tumor, and multiple mediastinal LNs, and processed for scRNA-seq including labeling with Total-Seq C CITE-seq panel to quantify the levels of 130 cell surface proteins. In total, 76,721 cells (4,462 normal lung; 39,019 tumor; 33,240 LN) were identified with a median of 1,673 genes and 92 protein features detected per cell. Protein expression was decontaminated through the decontX algorithm. Weighted-Nearest Neighbor analysis from the Seurat R package was applied to integrate the CITE-seq and RNA-seq level data for clustering cells into subpopulations. Results: Six broad cell populations were identified including T/NK, myeloid (CD14+), B (CD19+), mast (TPSAB1+), pDC (IRF8+), and epithelial (EPCAM+) cells. Among 8 CD4+ T lymphocyte subpopulations and 11 CD8+ T lymphocyte subpopulations observed through clustering, a naïve CD4+ and a CD8+ T subpopulation (LEF1+, TCF7+) was observed respectively. These naïve T lymphocyte populations displayed increased proportions in LNs in comparison to tumors. In addition, 5 of the 8 observed CD4+ T lymphocyte populations were enriched in LNs. Immune populations enriched in LNs were largely shared and uniform across different patients. In contrast, a single CD4+ and CD8+ T lymphocyte subpopulation displayed expression of T lymphocyte exhaustion markers (TIGIT+, LAG3+, PD-1+) and were enriched in tumors. 6 of the 11 observed CD8+ T lymphocyte populations were enriched in tumor samples in comparison to LNs. Two alveolar macrophage populations (MARCO+) were enriched in normal lung tissue, in which one showed a heightened stress response. Conclusion: Single-cell profiling reveals diversity in immune cell populations between LNs, tumor, and adjacent normal tissue in early-stage LUAD. The results suggest the composition of immune cell type is fairly consistent across LNs but more heterogeneous in the tumor and adjacent normal tissue in early-stage patients. In the future, we aim to determine if these immune subpopulations are associated with survival, recurrence, aggressiveness, and predict responses for neoadjuvant treatments, which could improve prognosis and patient quality of life. Citation Format: Zhanhao Xi, Yusuke Koga, Shannon McDermott, Jennifer Beane, Sarah A. Mazzilli, Kei Suzuki, Joshua D. Campbell. Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4651.

Abstract P075: Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing

Abstract Background/Purpose: Previous studies have analyzed the tumor and local immune microenvironments in lung cancers and suggest immune modulation is associated with worse clinical outcome. However, the tumor-immune microenvironment in early-stage lung tumors and lymph nodes (LNs) have not been fully described. We aim to compare cell states in the immune microenvironments between lung tumors and LNs through multi-modal profiling of the transcriptome and surface proteins. Methods: Needle biopsy samples were taken from 10 treatment-naive early-stage lung cancer patients undergoing lung cancer resections. Tissues were obtained from normal lung, lung tumor, and multiple mediastinal LNs, and processed with scRNA-seq along with the Total-Seq C panel to quantify the levels of 130 cell surface proteins. In total, 98,337 cells (4,661 normal lung; 52,119 tumor; 42,117 LN) were identified with a median of 1,401 genes and 23 protein features detected per cell. Weighted-Nearest Neighbor analysis from the Seurat R package was applied to integrate the CITE-seq and RNA-seq level data for clustering cells into subpopulations. Results: Six broad cell populations were identified including T/NK, myeloid (CD14+), B (CD19+), mast (TPSAB1+), pDC (IRF8+), and epithelial (EPCAM+) cells. Protein expression measured with CITE-seq revealed additional T cell populations not captured by scRNA-seq. Preliminary results have identified cell populations enriched in LNs, which include naive CD4+ (CD4, FHIT, LEF1, CCR7) and CD8+ T cells (CD8A, TCF7, LEF1, CD27, CCR7). Additionally, we have identified numerous other CD8+ T-cell subpopulations enriched in tumors, including resident memory CD8+ T cells (KLRC1, ITGAE, ITGA1, VIM, JUN). Furthermore, immune populations enriched in LNs were similarly shared across different patients, while those enriched in tumors displayed patient-level specificity. Conclusion: Single-cell profiling reveals diversity in immune cell populations between LNs, tumor, and adjacent normal tissue in early-stage LUAD. The results suggest the composition of immune cell type is consistent across LNs but more heterogeneous in the tumor and adjacent normal tissue. In the future, we aim to determine if these markers for various immune subpopulations are associated with survival, recurrence, aggressiveness, and predict responses for neoadjuvant treatments, which could improve prognosis and patient quality of life. Citation Format: Zhan Xi, Yusuke Koga, Shannon McDermott, Jennifer E. Beane, Sarah A. Mazzilli, Kei Suzuki, Joshua D. Campbell. Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P075.

Lofgren syndrome: Not an uncommon entity

Lofgren syndrome is a rare acute phenotypic variant of sarcoidosis characterized by short febrile illness associated with symptoms triad of polyarthritis, hilar adenopathy, and erythema nodosum (EN). We describe a patient who presented with migratory polyarthritis, bilateral acute anterior granulomatous uveitis, and EN on both legs. Chest imaging showed bilateral enlarged multiple mediastinal lymph nodes and paratracheal lymph nodes. Transbronchial lung biopsy revealed noncaseating granulomas. He was successfully treated with prednisolone and methotrexate. Prompt recognition of such classical clinical presentation of sarcoidosis leads to early diagnosis and treatment.

741 ACUTE PURULENT MYOPERICARDITIS SECONDARY TO ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION CYTOLOGY

Abstract Introduction Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic method to sample peritracheal and peribronchial le- sions under real-time ultrasound guidance. The most important use of TBNA is the diagnosis and staging of lung cancer and the evaluation of sarcoidosis. Although TBNA is considered generally safe, serious or even fatal complication may develop after the procedure. Here we present a case report of acute purulent myopericarditis complicated by cardiac tamponade occurred after EBUS-TBNA procedure. Case Report A 62-year-old man with preexisting hypertension and previous myocardial infarction and coronary angioplasty was admitted to our hospital for persistent, oppressive and worsening chest pain, which started a few days before admission. Of note, the patient underwent EBUS-TBNA 10 days before admission because he was found to have a tumor in the upper lobe of the left lung and enlargement of multiple mediastinal, right hilar, subcarinal and para-aortic lymph nodes. Two days after the procedure, one week before admission, he was treated with amoxicillin clavulanate and levofloxacin because of fever onset. At the ER, his vital signs showed a blood pressure of 80/60 mmHg and a heart rate of 115 bpm; O2 saturation on room-temperature air was 97%. The ECG at presentation showed concave ST segment elevation in anterolateral and inferior leads. The echocardiography revealed moderate circumferential pericardial effusion without clear tamponade signs. Emergency coronary angiography showed patent coronary arteries. The next morning, the patient developed persistent hypotension (BP 75/50 mmHg). A transthoracic echo showed moderate to large circumferential pericardial effusion with tamponade physiology. He therefore underwent subxiphoid pericardiotomy with drainage of 400 ml of frank pus. Cultures from pericardial fluid were negative for common germs. Cytology was negative for malignancy and acid-fast bacilli. Histological examination of the pericardial tissue was diagnostic for acute fibrinous-purulent pericarditis. The patient was started on broad spectrum antibiotics (piperacillin/tazobactam and ciprofloxacin) with subsequent decrease of inflammation markers and clinical improvement. Control contrast enhanced chest CT scan revealed persistency of a mediastinal pluri-concamerate fluid collection. After a collective discussion with cardiac surgeons, infectious disease specialists and oncologists, given the progressive clinical and instrumental improvement, we decided to discharge the patient with long term oral antibiotics plus colchicine and ibuprofen for pericarditis. Infectious disease and oncological follow up was planned before discharge. Conclusion Complications following TBNA are relatively low, typically around 1.2%-1.4%. To date, only few cases of purulent pericarditis secondary to EBUS-TBNA have been reported in literature. Our case report adds to the existing scant literature regarding cardiac infective bronchoscopic complications and emphasizes concern of weather antibiotic prophylaxis may be needed before respiratory tract invasive procedures. Further research is necessary to better understand the existence of risk factors that could increase the probability to develop such rare but potentially lethal complications.

CARDIAC SARCOIDOSIS: WHEN THE RIGHT VENTRICLE ISN’T RIGHT

CARDIAC SARCOIDOSIS: WHEN THE RIGHT VENTRICLE ISN’T RIGHT

P486 Disseminated Cryptococcosis diagnosed on fine needle aspiration cytology

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PMObjectives (Case)A 48-year-old male with no prior comorbidities presented to our infectious disease clinic with intermittent low-grade fever and gradual progressive swelling in his left axilla for 3 months. On further probing, the patient also gives a history of weight loss of around 7 kg. The patient belonged to a northern state of the Indian subcontinent and owned a grocery shop, where he worked. There was no recent or remote travel history, no history of exposure to animals or birds, no high-risk behavior, and no past or known contact history of tuberculosis. Still, in an endemic country like India and in this given clinical scenario, we kept tubercular lymphadenitis as the first differential and investigated the case further.Methods (Investigation)A contrast-enhanced computed tomography (CECT) of the chest and abdomen was done, showing multiple enlarged mediastinal and axillary lymph nodes with bilateral adrenal mass (Fig. 1). To further evaluate the etiology, a fine needle aspiration of the left axillary swelling was done. A hematoxylin and eosin (H and E) stain of the same showed the presence of numerous organisms of varying sizes present both intracellularly and extracellularly along with chronic inflammatory cells (Fig. 2a). Based on this picture, differentials of Histoplasma, Cryptococcus, or Toxoplasma were kept. But considering the empty spaces (halos) which probably represent the capsule and variability in the size, a strong possibility of Cryptococcus was kept. Serum cryptococcal antigen (latex agglutination) was negative but eventually, the fungal culture of the aspirated sample grew cream-colored, shiny dome-shaped, mucoid colonies on Sabouraud Dextrose Agar suggestive of Cryptococcus (Fig. 2b). The same was confirmed on Bird Seed Agar and Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS). Gene Xpert of the aspirated sample was negative and serum cortisol with serum adrenocorticotropic hormone (ACTH) were under normal limits.Results (Diagnosis)A diagnosis of disseminated cryptococcosis was made based on the involvement of more than two non-contiguous sites (mediastinal with axillary lymph nodes and adrenal gland). The patient was initially started on liposomal Amphotericin B (5 mg/kg intravenous daily) with which he improved clinically. Same was continued for 2 weeks and later he was shifted to fluconazole 400 mg daily. As of now, the patient is on his 3rd month of fluconazole and doing well on follow-up.ConclusionCryptococcus (Cryptococcus neoformans and Cryptococcus gattii) is an encapsulated yeast causing invasive fungal infection, with vast majority occurring in immunocompromised host1. It has a global distribution, predominantly involving the central nervous system (CNS) and lung. Management of non-CNS and non-pulmonary cryptococcosis is tricky as looking for dissemination is key (as the initial choice of agent varies)2. Adrenal involvement in Cryptococcosis is uncommon (as seen in our case). Examination of FNAC samples for Cryptococcus is also challenging as other microbes can also closely mimic the same. Finally, in a tuberculosis endemic country like India, clinical symptoms of Cryptococcal lymphadenitis can closely resemble tubercular lymphadenitis, so empirical therapy may be risky.Figure 1 Axial CT Chest images showing multiple enlarged mediastinal lymph nodes (red arrow).Figure 2a Fine needle aspiration cytology (FNAC) from the left axillary swelling stained with hematoxylin and eosin showing numerous organisms of varying size present both intracellularly (black arrow) and extracellularly with surrounding halos in a background chronic inflammatory cells.Figure 2b Fine needle aspirate sample incubated at 37 0C on Sabouraud Dextrose Agar with gentamicin showing cream-colored, dome-shaped, shiny, mucoid colonies with smooth edge (characteristic of Cryptococcus).Sources:Iyer KR, Revie NM, Fu C, Robbins N, Cowen LE. Treatment strategies for cryptococcal infection: challenges, advances and future outlook. Nat Rev Microbiol. 2021 Jul;19(7):454–66.Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update by the Infectious Diseases Society of America | Clinical Infectious Diseases | Oxford Academic [Internet]. [cited 2022 Jul 28]. Available from: https://academic.oup.com/cid/article/50/3/291/392360

The great masquerader of pancreatic tuberculosis

BackgroundPancreatic tuberculosis is a rare clinical entity. It represents a diagnostic challenge as the clinical presentation may mimic pancreatic malignancy.Case presentationA 66-year-old gentleman presented with an incidental finding of a pancreatic tail mass on routine ultrasonography of the abdomen whilst working up on chronic kidney disease. He denied abdominal pain, fever, night sweats, constitutional symptoms or tuberculosis contact. On examination, there was no palpable mass per abdomen. The tumour marker of Ca 19-9 was normal. Ultrasonography revealed a lobulated heterogeneous hypovascular and hypoechoic mass at the tail of the pancreas. Contrast-enhanced computed tomography (CT) of the thorax and abdomen revealed a thickened right pleura, right pleural effusion with right lung collapsed consolidation and multiple mediastinal lymph nodes. There is an ill-defined hypodense mass seen in the tail and body of the pancreas measuring 3 × 7 × 3 cm with the presences of calcification within. The constellation of CT findings suggests a pancreatic malignancy with metastasis to the lungs. Endoscopic ultrasonography (EUS) assessment showed an irregular hypoechoic mass measuring 3.0 × 2.7 cm at the tail of the pancreas. Multiple rounded hypoechoic lesions were also seen scattered within the body of the pancreas with multiple enlarged para-aortic lymph nodes. A fine-needle aspiration biopsy of the lesion was consistent with granulomatous inflammation. The diagnosis of disseminated tuberculosis was made. The patient was subsequently started on antitubercular medication and recovered well.ConclusionA high index of suspicion is needed to diagnose pancreatic tuberculosis, especially in patients whose radiological imaging shows a pancreatic mass with necrotic peripancreatic lymphadenopathy in endemic countries. EUS-guided fine-needle aspiration is the diagnostic modality of choice, and vigorous attempts should be made at obtaining a preoperative histological or bacteriological diagnosis to avoid unnecessary surgery.

Metastatic Renal Cell Carcinoma With Sarcomatoid Features.

A previously healthy woman, aged 38 years, presented with a 3-month history of fatigue, dyspnea on exertion, significant weight loss, and severe left flank pain; her symptoms restricted any work activities. Laboratory test results were notable for hypercalcemia (corrected serum calcium, 12.8 mg/dL), anemia (9.3 g/dL), and lactate dehydrogenase elevation (>1.5 times the upper limit of normal). A CT scan revealed a 14-cm left renal mass and multiple lung and mediastinal lymph node metastases. A surgical open biopsy was performed; histopathological analysis concluded clear cell renal carcinoma (RCC) with 30% sarcomatoid features. The patient was diagnosed with International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) poor-risk metastatic RCC with sarcomatoid features. She started first-line systemic treatment.

Hemophagocytic Lymphohistiocytosis and Severe Hypoxemia in a Preterm Infant.

Hemophagocytic Lymphohistiocytosis and Severe Hypoxemia in a Preterm Infant.

Multi-systemic melioidosis mimics malignancy

Melioidosis is often referred to as “the great imitator,” and it is more likely to be misdiagnosed when multiple systems are involved. This report describes a patient with an 11-year history of diabetes with poor blood glucose control, a history of heavy smoking, and multi-systemic diseases including lung nodules, multiple enlarged mediastinal lymph nodes, bone destruction and soft-tissue swelling in the proximal right tibia, and intracerebral lesions. Computed tomography (CT) of the lung and tibia and head magnetic resonance imaging with enhanced magnetic resonance spectroscopy led to a misdiagnosis of lung cancer with metastasis to the brain and proximal tibia. The patient was admitted to the hospital on January 17, 2012 and hospitalized for 51 days. He was in stable condition but was not cured and requested to be discharged voluntarily. Head and lung CT was repeated on July 28, 2016. Although the patient's family members reported that he had not received regular treatment in the hospital, his intracerebral lesions, chest lesions, and right calf lesions had all improved. This case indicates that even when medical imaging is consistent with multi-systemic malignancy, imaging must be combined with clinical and laboratory tests to exclude the possibility of melioidosis.

The Survival Efficiency of Initial Surgical Treatment in Stage IIIa-N2 Positive Non-Small Cell Lung Cancer

​ Objective: The role of surgical treatment in the multimodal treatment of stage IIIA-N2 positive non-small cell lung cancer (NSCLC) patients is a matter of debate. We aim to investigate initial surgical treatment's survival efficiency in patients with IIIA N2 positive NSCLC.Methods: The patients treated for stage IIIA N2 positive NSCLC in a single center between January 2009 and December 2014 were retrospectively analyzed. A total of 134 patients with 5 cm tumors in diameter or less and without involvements of the chest wall, mediastinal pleura, phrenic nerve, recurrent laryngeal nerve, pericardium, heart, diaphragm, vertebra, esophagus, large vessel invasion, and satellite nodule were detected. Of these patients, initial surgical treatment before chemoradiotherapy was performed in 72 (Group 1), while definitive concurrent chemoradiotherapy was performed in 62 patients (Group 2). Each patient's gender, age, physical performance status, tumors size, pathological diagnosis, lung resection types, and long-term survival data were evaluated.Results: No statistically significant difference was found in patients' gender, physical performance, tumor size, and tumor histology. Survival rates were higher among patients aged ≤65 years and higher in Group 1 than Group 2. While one-, three, five-, and seven-year survival rates were detected as 86.1%, 62.5%, 41.6%, and 31% in Group 1, respectively, the rates were observed to be as 77.4%, 30.6%, 10.8%, and 6.7% in Group 2, respectively. However, no difference was seen between patients' survival rates with single and multiple ipsilateral mediastinal lymph node metastases.Conclusion: Despite those advocating surgical treatment after neoadjuvant chemotherapy in treating stage IIIA N2 positive patients, others supporting surgical treatment should initially be performed. When conducted as the first step, surgical treatment achieves significant increases in survival.

An Unusual Presentaton of Tuberculosis with Septic Shock and Immune Reconstitution Inflammatory Syndrome in an Immunocompetent Patient

Tuberculosis presenting as septic shock is a rare entity especially in an immunocompetent patient. It has been reported in only 1% of patients with septic shock. Tuberculosis associated immune reconstitution inflammatory syndrome (IRIS) is the paradoxical worsening of the current condition or the development of new lesions in patients who are on anti-tuberculosis treatment. In non-HIV patients with tuberculosis, the incidence of IRIS is only about 2.4%. We report a 29 year old immunocompetant female who presented with septic shock and on continued evaluation she tested positive for mycobacterium tuberculosis by Genexpert (sensitive to rifampicin) done in BAL fluid. All possible causes for immunodeficiency were ruled out. She was started on Anti-Tuberculosis therapy (ATT) and a month later, patient deteriorated clinically with high spiking temperatures and troublesome constitutional symptoms. Contrast-enhanced computed tomography (CECT) abdomen and chest revealed new onset multiple enlarged necrotic mediastinal, para aortic and hilar lymph nodes. After extensive evaluation including autoimmune profile, fungal culture, viral serology, Positron emission tomography (PET) scan, bone marrow analysis and ruling out all other possible causes for fever, IRIS was suspected and patient was started on steroids along with ATT. There was a drastic improvement in her symptoms within a week. She completed her course of ATT and steroids were gradually tapered. At 2 years of follow up, the patient is doing well.

Iliac Extension Trimming, Resheathing, and Deployment for Emergent Repair of Abdominal Aortic Pseudoaneurysm

An 18-year-old woman presented with a 3-week history of severe abdominal pain radiating to the back and left thigh, without trauma or fever. Clinical examination revealed pulsatile swelling in the umbilical region. Computed tomography angiography showed a large pseudoaneurysm (measuring 8.4 × 4.1 × 6.8 cm) arising from the left lateral aspect of the infrarenal abdominal aorta, with a narrow neck (8 mm) (Fig 1a–c). Circumferential mural thickening involving the descending thoracic aorta causing diffuse luminal narrowing was noted (Fig 1c), with multiple enlarged cervical and mediastinal necrotic lymph nodes.

INTRAPULMONARY TERATOMA: A RARE PRESENTATION OF BRONCHIECTASIS

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Intrapulmonary teratomas (IPT) are a rare extra-gonadal manifestation of teratomas and are a challenging diagnosis to make. We present a patient with IPT presenting with hemoptysis. CASE PRESENTATION: A 49-year-old man presented with intermittent non-massive hemoptysis throughout the previous year. Labs were normal with the exception of normocytic anemia with hemoglobin of 12.1 g/dL. CT chest with contrast revealed a necrotic mass in the central left upper lobe invading the left upper lobe bronchus and obliterating the left pulmonary artery with severe bronchiectatic changes. Multiple mediastinal lymph nodes were enlarged. Flexible bronchoscopy was performed and demonstrated occlusion of the left upper lobe with a dense, white mass, and hair-like material within the bronchus. Attempts at biopsy with the cryoprobe demonstrated friable mucosa that easily bled. No intervention was necessary as spontaneous hemostasis occurred. Attempts at forceps biopsy were unsuccessful because of dense, calcified material. As a result, the cryoprobe was used. Cryoprobe biopsies revealed inflammatory cells without evidence of malignancy. Cultures including bacterial, fungal, and AFB were negative. Lack of diagnosis, severe bronchiectasis, and recurrent hemoptysis prompted the recommendation for resection, and he underwent left thoracotomy with interpleural pneumolysis. Due to involvement of the left pulmonary artery, lung sparing surgery could not be safely achieved and ultimately required a left pneumonectomy. Final pathology was consistent with a lung teratoma. DISCUSSION: Teratomas are germ cell tumors commonly located in the sacrococcygeal region, anterior mediastinum, retroperitoneum, cranium, ovary, or gonads. Rarely they are intrapulmonary in location (1). Less than 100 IPT cases have been reported to date, and usually reported in the left upper lobe. (2,7). Patients present with chest pain, cough, fever, dyspnea, bronchiectasis, or recurrent pneumonia (5). Patients may expectorate hair (trichoptysis), which is considered pathognomonic (3). Untreated, patients are at risk of malignant transformation, tumor rupture, hemoptysis, and airway obstruction from compression. (5). CT chest shows well-defined round or lobulated masses that are smooth in contour with areas of peripheral translucency and may contain fat, calcium, or fluid (5,6). Irregular or ill-defined margins can suggest malignant transformation (4).The only definitive treatment is complete surgical resection and diagnosis is often made concomitantly from the gross pathology. Early resection is crucial in order to prevent complications (6). CONCLUSIONS: IPT is a rare cause of endobronchial obstruction and highlights the need for early bronchoscopic evaluation of hemoptysis. Early diagnosis and resection of IPT is critical to prevent complications and provide definitive treatment. REFERENCE #1: Khan J, Aslam F, Fatimi S, Ahmed R. Cough, fever and a cavitary lung lesion-an intrapulmonary teratoma. J Postgrad Med. 2005;51(4):330-1. REFERENCE #2: Faria RA, Bizon JA, Junior RS, Neto VD, Botter M, Saieg MA. Intrapulmonary teratoma. J Bras Pneumol 2007; 33: 612– 615. REFERENCE #3: Siddiqui, F.A., Jain, A., Maheshwari, V. and Beg, M.H. (2010), FNA diagnosis of teratoma lung: A case report. Diagn. Cytopathol., 38: 758-760. https://doi.org/10.1002/dc.21318Webb, W., Brant, W. E., & Helms, C. A. (1991). Fundamentals of Body CT (1st ed.). Philadelphia, PA: W. B. Saunders Company.Sasaka, K., Kurihara, Y., Nakajima, Y., Seto, Y., Endo, I., Ishikawa, T., & Takagi, M. (1998). Spontaneous rupture: A complication of benign mature teratomas of the mediastinum. American Journal of Roentgenology, 170(2), 323-328. doi:10.2214/ajr.170.2.9456938 Mardani P, Naseri R, Amirian A, et al. Intrapulmonary mature cystic teratoma of the lung: Case report of a rare entity. BMC Surgery. 2020;20:1-6. Ditah C, Templin T, Mandal R, Pinchot JW, Macke RA. Isolated intrapulmonary teratoma. J Thorac Cardiovasc Surg. 2016 Dec;152(6):e129-e131. doi: 10.1016/j.jtcvs.2016.07.056. Epub 2016 Aug 5. PMID: 27576374. DISCLOSURES: No relevant relationships by Beren Chandler, source=Web Response No relevant relationships by Garret Duron, source=Web Response No relevant relationships by Lindsey Goldberg, source=Web Response No relevant relationships by Joanna Kosko, source=Web Response No relevant relationships by Jason McClune, source=Web Response No relevant relationships by Lourens Willekes, source=Web Response

S2171 Esophageal Dysphagia: A Rare Manifestation of Sarcoidosis

Introduction: Sarcoidosis is a multi-systemic inflammatory disease with noncaseating granulomas as the main pathological finding in the affected organs. Extrapulmonary involvement of sarcoidosis has been reported in a variety of organs. However, Extrahepatic GI involvement is uncommon. We present an unusual case of sarcoidosis presenting with dysphagia. Case Description/Methods: A 32 years old male with recent history of COVID-19 infection presented with esophageal dysphagia for 1 week, initially to liquids then progressed to solids. On review of systems, patient admitted to subacute dry cough associated with shortness of breath (for?) but denied constitutional symptoms. Physical examination was unremarkable with no palpable lymphadenopathy. Basic laboratory studies were unremarkable. HIV screening test and COVID-19 PCR were negative. CT-chest with contrast showed prominent mediastinal and bilateral hilar adenopathy and multiple pulmonary nodules. Angiotensin converting enzyme level was elevated. Esophagram findings were compatible with extrinsic mass effect involving the middle esophagus. On third day of admission, Patient underwent Endobronchial Ultrasound Bronchoscopy with transbronchial needle aspiration. Flow cytometry was negative. Pathology report showed abundant non-necrotizing granulomas. GMS and AFB stains, Fungus and AFB cultures were negative. Patient was started on oral prednisone therapy resulting in improvement of respiratory symptoms but dysphagia persisted. He underwent EGD with dilation showing normal esophageal mucosa and normal pathology. Manometry studies were unremarkable. Patient reported partial improvement after dilation. Discussion: Digestive tract sarcoidosis is rare. It mainly affects esophagus either by infiltration or extrinsic compression, resulting in dysphagia which is the main presenting symptom in most reported cases. Inflammatory Infiltration can involve mucosa, muscular layer or myenteric plexus. Extrinsic compression is mainly related to mediastinal lymphadenopathy which can lead to direct compression, as in our case, or it can lead to traction esophageal diverticulum or even perforation. Diagnostic approach for dysphagia includes performing EGD or Esophagram depending on whether oropharyngeal involvement is present or not. In our case, patient’s description for dysphagia was esophageal. However, CT chest findings sparked the clinical suspicion for compressive adenopathy affecting mid esophagus level, making esophagogram our initial test of choice.Figure 1.: Esophagram showing narrowing at middle esophagus due to extrinsic mass effect. Figure 2: CT chest ( Sagittal plane ) showing esophageal narrowing. Figure 3: CT chest ( Axial plane ) showing multiple arch mediastinal and bilateral hilar lymph nodes conglomerate measuring 7.9 x 3.6 cm.

A case report of right upper lung adenosquamous carcinoma resection following neoadjuvant targeted therapy

The patient was a middle-aged male smoker who had space-occupying lesions in the right upper lung, Positron emission tomography-computed tomography (PET-CT) suggested right upper lung cancer with multiple mediastinal lymph node metastases. Endobronchial ultrasound-guided transbronchial lung biopsy (EBUS-GS-TBLB) performed in the bronchus of the right apical segment confirmed the lesion as squamous cell carcinoma. Neoadjuvant therapy was planned. Because genetic testing revealed the epidermal growth factor receptor (EGFR) L858R mutation, the possibility of adenosquamous carcinoma was considered. The patient was clinically diagnosed with right upper lung squamous cell carcinoma c-T3N2M0, stage IIIB, and PS 1 point. Dacomitinib was selected for the targeted therapy. Eight weeks after the initiation of treatment, efficacy was assessed as a partial response (PR), suggesting a possibility of R0 resection. After sufficient communication with the patient and his family members, on July 1, 2020, thoracoscopic radical resection of the right upper lung cancer was performed under general anesthesia. Postoperative pathology confirmed adenosquamous carcinoma, of which 80% were adenocarcinoma and 20% were squamous cell carcinoma; no tumor thrombus was seen in the interstitial vessels; and the tumor did not invade the visceral pleura. There was no cancerous infiltration in the bronchial stump of the right upper lung. The following were the results for lymph nodes submitted for examination: L2 (0/1), L4 (0/4), L7 (0/3), L8 (0/7), L10 (0/1), L11 (0/2) and L11 (frozen 0/1) showed no cancer metastasis. The postoperative diagnosis was as follows: adenosquamous carcinoma of the right upper lung p-T2N0M0, stage Ib. After surgery, 4 cycles of the GC (gemcitabine + carboplatin) chemotherapy regimen were given, with continued targeted therapy recommended for 2 years. The patient has been followed-up and is in good condition.

EP33 Sjögren’s and lymphoproliferative disorders

Case report - IntroductionSjögren’s syndrome (SS) is a chronic autoimmune inflammatory condition characterised by lymphocytic infiltration of predominantly exocrine glands as well as other organs involving more commonly in skin, lungs, and neurological system. It is associated with increased risk of both benign and malignant lymphoproliferative disorders.Case report - Case descriptionA 29-year-old woman with 5-year history of Primary SS (ANA, Ro/La positive) was reviewed in a routine follow up. She has mild dry eyes, intermittent vasculitic rash around the ankles, occasional pleuritic chest pain but no cough or dyspnoea initially. She used artificial tears but took no regular mediations. Oxygen saturation at rest was 99% and BP 127/70. Heart sounds were normal, and chest was clear.Blood results showed alanine transaminase (ALT) had risen from 50 (normal 5-45) to 145 over 6 months. Viral screen (hepatitis, HIV, CMV, EBV) and liver ANA panel were negative. C4 was low 0.09 (n 0.15-0.55), C3 normal and DsDNA antibodies 1 (n 0-15.1). Ig G was high, fluctuating between 27 - 33 (n 7.67-15.9). ESR had been mildly elevated at 26 (n 0-19). CRP had always been within normal limits. Ultrasound abdomen showed enlarged spleen (15 cm). CT chest abdomen and pelvis showed multifocal groundless opacification affecting mid to upper zones, bilateral cyst formation, solid nodularity, and mild septal thickening with no pleural effusion. There were multiple prominent bilateral axillary and mediastinal lymph nodes measuring upto15 mm. The spleen measured 15.4 cm. Six months later, she developed mild dyspnoea on exertion. Examination revealed fine basal crackles. Oxygen saturation remained 99% at rest. TLco was mildly reduced and Kco in lower limit of normal. Echocardiogram was normal. Ultrasound guided core biopsy of axillary lymph node showed benign reactive features with follicular hyperplasia and plasmacytosis.The diagnosis of lymphocytic interstitial pneumonitis was made. She was started on a reducing dose of Prednisolone 30 mg and Mycophenolate stepwise increment to 1 gm BD. Chest pain resolved shortly after starting glucocorticoid therapy and exercise tolerance improved.Liver enzyme normalised. Case report - DiscussionThe diagnosis of lymphocytic interstitial pneumonia (LIP) in this patient was incidental from the retrospective investigation of the persistently abnormal unexplained liver function test. Splenomegaly is a recognised manifestation of active systemic SS. The main differential diagnoses are lymphoma and other types of interstitial lung diseases (ILD). Her presentation was insidious and there were no constitutional symptoms. Her ANA, Ro, La and Rheumatoid factor were strongly positive. She has hypergammaglobulinemia which is commonly associated with LIP. Histological findings were typical reactive changes with characteristic polymorphic plasmacytosis. In the absence of malignant lymphoid cells and radiological features of ground glass changes and bilateral cysts formation suggested that the most likely diagnosis was LIP secondary to primary SS.The management strategies vary for different types of ILD based on their etiological conditions. There are no specific guidelines for the treatment of LIP. For initial acute stage, glucocorticoid therapy is usually prescribed for symptomatic improvement. For later stages and cysts, immunosuppressants are used and depending on the severity, azathioprine, cyclosporin, rituximab and cyclophosphamide have been used.Median survival for LIP is 11.2 years. Increased risk of secondary infection because of immunosuppressive therapy is common and there are recommendations for atypical chest infection prophylaxis.Case report - Key learning pointsInterstitial lung disease is commonly associated with SS and predicts a higher mortality rate.Glucocorticoid is the main stay of treatment for ILD acute stage with active inflammatory changes.For refractory cases and chronic cystic stages on radiological findings, further immunosuppression therapy may be required.Standardised treatment guidelines are not available.Secondary chest infections may be seen in those with cystic disease and on immunosuppression.Close monitoring and MDT approach is required in the management of LIP.LIP may transform into lymphoma or co-present with lymphoma associated with SS.