Multiple Nodular Opacities Research Articles

Clinical analysis of 20 cases of perinatal tuberculosis

BackgroundTo analyze the clinical manifestations, diagnostic and therapeutic processes of perinatal tuberculosis in children, providing reference for clinicians in the diagnosis and treatment of this disease.MethodsA retrospective analysis was conducted on the epidemiological history, clinical manifestations, laboratory and imaging findings, and treatment follow-up of 20 cases of perinatal tuberculosis diagnosed in the Second Department of Infectious Disease, Kunming Children’s Hospital, from February 2014 to September 2021.ResultsOf the 20 cases, 13 were male (65.0%) and 7 were female (35.0%). The average age at onset was 35.35 ± 23.03days, with an average time from onset to diagnosis of 24.75 ± 15.55days. Tuberculin skin test (TST) was positive in 1 out of 4 cases (25.0%). Gamma interferon release assays (IGRAs) were positive in 9 out of 17 cases (52.9%).acid-fast staining was positive in 7 out of 16 cases (43.7%), and Mycobacterium tuberculosis nucleic acid polymerase-chain-reaction(PCR) was positive in 14 out of 20 cases (70.0%). Chest CT showed miliary changes in 4 out of 19 cases (21.0%), multiple nodular and patchy opacities in 6 out of 19 cases (31.6%), and pulmonary consolidation and atelectasis in 10 out of 19 cases (52.6%). After anti-tuberculosis treatment, 16 out of 20 cases (80.0%) improved, and no recurrence of tuberculosis was observed during follow-up periods ranging from 9 months to 3 years. The growth and development of these children were similar to those of healthy children.ConclusionThe clinical manifestations and chest imaging features of perinatal tuberculosis are nonspecific. In suspected cases, it is crucial to investigate the mother’s condition thoroughly and complete etiological examinations to achieve early diagnosis and timely treatment, which can improve prognosis.

Pulmonary consolidations – differential diagnosis of respiratory infections and bronchopulmonary neoplasm – clinical case

Abstract Bronchopneumonia is defined as an acute infection of the lung parenchyma involving the alveolar territory, associating an inflammation at the level of the bronchioles, most often grafting on a weakened area. The symptoms can be very variable, depending on the severity of the condition. Imaging, the chest X-ray shows multiple nodular or reticulonodular opacities that tend to be irregular and/or confluent. The distribution is often bilateral and asymmetric, predominantly involving the lung bases. The differential diagnosis of bronchopneumonia or the multiple pulmonary nodules described in the presented case is mainly made with pulmonary metastases, due to the increased frequency of diagnosis of pulmonary metastases in the case of multiple pulmonary nodules detected by chest CT; the lung being one of the main sites of metastasis of neoplasms.

PULMONARY LIMITED SERONEGATIVE GRANULOMATOSIS WITH POLYANGIITIS VASCULITIS

PULMONARY LIMITED SERONEGATIVE GRANULOMATOSIS WITH POLYANGIITIS VASCULITIS

S2301 Dysphagia: An Unusual Primary Presentation of Non-Small Cell Lung Cancer

Introduction: Respiratory symptoms predominate in patients with lung malignancies. Dysphagia as a presenting symptom is rare with only about 1%-2% of patients presenting with dysphagia as their cardinal symptom. We describe a rare case of a 56-year-old male presenting with only dysphagia in the setting of extrinsic esophageal compression secondary to non-small cell lung cancer. Case Description/Methods: A 56-year-old male with past medical history of hypertension, chronic obstructive pulmonary disease, and chronic tobacco use presented to the emergency department with complaint of persistent emesis for the past 3 months. The patient described the emesis as occurring minutes after eating a meal. He also admitted to loss of appetite, unintentional weight loss, and dysphagia to solids. On admission, the patient was normotensive and tachycardic to a heart rate of 108. CT chest was performed and revealed an 8.0 x 7.5 cm right mediastinal mass with obliteration of the right main pulmonary artery and right main bronchus along with multiple irregular and nodular opacities in the right lung and left lower lobe concerning for metastases. Pulmonology was consulted and performed a bronchoscopy which showed a large obstructing endobronchial lesion of the right mainstem bronchus; biopsies of the lesion were sent. The patient was diagnosed with metastatic non-small cell lung cancer. The patient’s hospital course was complicated by intractable emesis and development of shock. Repeat CT was performed and was remarkable for a moderate volume pneumomediastinum and a small to moderate size right pneumothorax. Gastroenterology was consulted for concerns of esophageal perforation vs. invasion. Esophagogastroduodenoscopy was performed and showed severe extrinsic stenosis 30-32 cm from the incisors. The area of stenosis measured 2 cm in length and was dilated. A 23mm x 120mm EndoMAXX fully covered stent was placed at the 26 cm to 38 cm region of the esophagus. Following stabilization, the patient was able to tolerate mechanical soft diet and thin liquids (Figure). Discussion: Dysphagia associated with lung cancer can occur via 3 mechanisms: mediastinal extrinsic esophageal compression, upper esophageal compression by lymph nodes, and radiation induced esophageal stenosis. Patients may experience decreased quality of life due to poor oral intake, malnutrition, and increased risk for infection. Lung malignancy associated dysphagia can be improved by both surgical and non-surgical interventions such as dilatation or esophageal stenting.Figure 1.: (A) Initial CT Chest findings of a right 8.0 x 7.5 cm mediastinal mass (B) Repeat CT Chest remarkable for a moderate volume pneumomediastinum and a small to moderate size right pneumothorax and (C) EGD imaging of a 23mm x 120mm EndoMAXX fully covered stent placed at the area of severe esophageal stenosis.

Elderly Male: An Immune-Compromise Sufficient Enough to Have Hemorrhagic Varicella.

Elderly Male: An Immune-Compromise Sufficient Enough to Have Hemorrhagic Varicella.

Multidrug-resistant tuberculosis in childhood: A case report

Introduction
 Multi-resistant tuberculosis is a major problem of public health concern and an endless cycle that ravages the population, particularly children because of the difficulty of controlling the disease. Thus, early detection of cases helps ensure adequate treatment and prevent the spread of the strain in the community.
 Methods 
 We present here the case of a child with multidrug-resistant tuberculosis monitored at the Medical Center of Medical Center of the company RVA.
 Results
 It is a case of 4-year-old patient with general signs and had an aunt who died of multidrug-resistant tuberculosis. On admission, the child was in good general condition, weighing 14 kg and 90 Cm height. The clinical examination noted crackling rales at the level of two pulmonary bases and the chest x-ray showed multiple confluent nodular opacities in places with excavations. Laboratory workup showed 8.5 mg% microcytic hypochromic anemia and inflammatory syndrome. Sputum was tested for Koch's Bacillus on direct examination and both smears were positive. The Mycobacterium tuberculosis strain was isolated on Lowenstein Jenssen's medium. The Gen-Xpert MTB / RIF detected resistance to rifampicin and the Hain test performed showed resistance to rifampicin and Isoniazid. The child was put on ethambutol, ciprofloxacin, kanamycin, ethionamide, cycloserine, pyrazinamide and Vitamin B6 with good tolerability. The course was marked by weight gain (2 kg) and BK negativation in the second month of treatment.
 Conclusion 
 Early detection of tuberculosis, especially multidrug-resistant tuberculosis is a crucial element in ensuring adequate treatment of cases and preventing the spread of germs in the population.

A DIFFERENTIAL OF PULMONARY NODULES UNTOLD: NECROBIOTIC LUNG NODULES IN THE SETTING OF CROHN'S DISEASE

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Crohn's disease (CD) has been rarely associated with varying forms of inflammatory lung disease.(1) Increasing in concern is its rare association with necrobiotic lung nodules (NLN). The objective of this report is to describe a rare case of lung nodules found to be NLN in the setting of CD. CASE PRESENTATION: A 36 year old Caucasian female presented with a history of cough productive of thick green sputum, chest pain, subjective fever, fatigue and night sweats. Past medical history included hypertension, hypothyroidism, and diarrhea under investigation. Physical examination was significant for swollen painful joints, nail pitting and a pruritic rash on her palms.Chest computed tomographic (CT) imaging revealed multiple bilateral nodular opacities (Figure 1), two of which were cavitating. Serologic workup for an underlying cause of her cavitary lesions revealed negative ANA, C-ANCA, P-ANCA, acid-fast bacilli smear, fungal battery and culture. Sputum culture revealed rare germinating yeast and few candida albicans for which she was started on a 21-day course of fluconazole. As she showed no signs of improvement, bronchoscopy and broncho-alveolar lavage were performed. Findings revealed abundant bland cells in favor of benign bronchial hyperplasia with no evidence of malignant cells.A subsequent VATS and surgical wedge biopsy of right upper and middle lobe nodules was performed. Histopathology revealed an acute and organizing lung injury with necrobiotic nodules consisting of neutrophilic abscess, scattered histiocytes and giant cells. Serologies for Saccharomyces cerevisiae IgA and IgG were positive, suggestive of underlying CD.She was started on prednisone (40mg daily), which led to marked improvement in her symptoms. She was also treated with infliximab infusion and azathioprine while her steroid course was tapered. A follow up CT-chest at six months showed resolution of her lung nodules. DISCUSSION: This was a case of a 36-year-old Caucasian female who presented with NLN in the setting of CD. It is a rare presentation with only seven cases reported previously. Histologically, NLNs are composed of sterile aggregates of inflammatory cells with necrosis, as was seen with our patient.(1-3) Both cavitating and non-cavitating lung nodule presentations have been described on radiographic imaging.(2) Treatment with steroids or mesalamine has been associated with disease resolution, with infliximab reserved for disease refractory to systemic steroids.(1-3) CONCLUSIONS: This case highlights the importance of awareness of NLN as a differential of pulmonary nodules in persons with suspected CD. REFERENCE #1: El-Kersh, Fraig M, Cavallazzi R et al. Pulmonary Necrobiotic nodules in Crohn's Disease: A rare extra-intestinal manifestation. Respir Care. 2014 Dec;59(12):e190-2. REFERENCE #2: Warwick G, Leecy T, Silverstone E et al. Pulmonary necrobiotic nodules: a rare extraintestinal manifestation of crohn's disease. Eur Respir Rev. 2009 Mar;18(111):47-50. REFERENCE #3: Sanjeevi A, Roy H. Necrobiotic nodules: A rare pulmonary manifestation of crohn's disease. Am J Gastroenterol. 2003 Apr;98(4):941-3. DISCLOSURES: No relevant relationships by Tanya Marshall, source=Web Response No relevant relationships by Joseph Parambil, source=Web Response

Utility of 2-Deoxy-2-[18F]fluoro-Dglucose positron emission tomography/computed tomography scan in the systemic evaluation of patients with post-COVID-19 endogenous presumed fungal endophthalmitis.

A 48-year-old nondiabetic male presented with persistent breathlessness, cough, intermittent pyrexia, and grossly reduced vision in the right eye. Based on the available records, he had been diagnosed with COVID-19 earlier (based on a positive RT-PCR) and had received domiciliary care for an initial five days. Following clinical deterioration, he was admitted, treated with systemic steroids, antibiotics, and ventilatory support. Ten days post discharge, he developed a gross reduction in vision in the right eye (CF: 1 m). Five days later, he underwent a vitrectomy for endophthalmitis with intravitreal voriconazole (100 mcg), vancomycin (1 mg), and ceftazidime (2.25 mg) with a reported postoperative vision of 6/24 (20/80). Microbiology of the vitreous fluid for KOH, gram staining, and culture/sensitivity were reported as negative. He was readmitted in our tertiary care center on the 14th day postoperatively. On admission, he was afebrile, with tachycardia (heart rate: 91/min), dyspneic (respiratory rate: 21/minute) with inspiratory basilar crackles with decreased air entry bilaterally. His oxygen saturation was normal (99%). The visual acuity was HMCF in the right eye and 6/6 (20/20) in the left eye. Dilated fundus exam showed significant vitreous haze (3+) that obscured the fundus view [Fig. 1]. A large yellowish preretinal lesion was seen in the superonasal quadrant [Fig. 2]. The fundus of the left eye was normal.Figure 1: Fundus photo of the right eye revealing vitreous haze grade 3+Figure 2: Fundus photo revealing a yellow-white preretinal lesion in the superonasal quadrantBlood investigations included assessment of the hemoglobin (11.30 gm/dl), white cell counts (11,170/mm3), and serum creatinine (1.05 mg/dl), which were normal. Specific tests included C-reactive protein (45.56 mg/l), D-dimer (2910 ng/ml), and serum fibrinogen (590 mg/dl). Blood cultures for aerobic, anaerobic, and fungal cultures were negative. He underwent a whole-body 2-Deoxy-2-[18F]fluoro-D-glucose (FDG) Positron Emission Tomography/Computed Tomography (PET/CT) scan to detect a possible focus of infection. A high-grade uptake was seen in an area of patchy consolidation, and additional moderate grade uptake was seen in large cavitary lesions in each lung [Fig. 3]. Multiple nodular opacities through the rest of the lung fields demonstrated low-grade uptake. A CT-guided biopsy at an area of high uptake (right lung; lower lobe) was performed [Fig. 4]. Histopathological study showed extensive areas of necrosis enmeshed with broad aseptate hyphae. Scattered granulomas were also seen. The picture was consistent with invasive fungal infection. Fungal cultures of the lung biopsy revealed Rhizopus species. The isolates were analyzed by MALDI TOF MS (Matrix-assisted laser desorption ionization-time of flight-mass spectroscopy) to confirm a species identification of Rhizopus microsporus. The patient underwent two intravitreal amphotericin B injections (5 mcg, a week apart) along with an intravenous amphotericin B course (3 mg/kg/day) for six weeks, with no clinical improvement (perception of light only). Subsequent ultrasound examination revealed a large multilobular intraocular mass attached to the posterior pole with a thickened membrane in the mid-vitreous [Fig. 5]. The patient opted to be treated elsewhere and was discharged.Figure 3: (a-c) High-grade uptake (white arrowhead; SUV max 11.45) seen in patchy consolidation within the posterior aspect of the right lung lower lobe. Moderate grade uptake seen in large cavitary lesions in the right lung middle and lower lobes (red arrows; SUV max 7.8). (b-d) CT scans revealing multiple cavitary lesions of the right lung (red arrows)Figure 4: CT scan showing biopsy needle placement within the cavitary lesion (white arrowhead)Figure 5: Ultrasound image of the eye showing a large multilobular mass attached to the posterior pole and to a thickened mid-vitreal membranePost-COVID-19 endogenous endophthalmitis is increasingly being recognized, and identification of the systemic focus and its treatment is an integral part of treatment.[1] Fungal endophthalmitis due to mucor species has only rarely been reported.[2] The use of a FDG PET/CT scan allowed identification of a pulmonary focus and suggested potential sites of biopsy, thus increasing the possibility of a positive diagnosis. 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.

Paradoxical Formation of a Pleuroparenchymal Fibroelastosis-like Lesion in the Chronic Course of Pulmonary Sarcoidosis

We herein report the long-term changes in chest computed tomography (CT) findings from early sarcoidosis lesions to pleuroparenchymal fibroelastosis (PPFE)-like lesions in a 30-year-old man with granulomas on a transbronchial lung biopsy. Multiple bilateral micronodular and nodular opacities around the bronchovascular bundle in the upper lobes detected by chest CT in 2004 disappeared, but paradoxically, peripheral consolidations continued to grow at the periphery of the original lesions. Chest CT in 2017 confirmed the progression of bilateral shrinkage of the upper lobe, spread of peripheral consolidations and wedge-shaped opacities below the first rib, and bronchiectatic air bronchograms, confirming PPFE-like lesions.

Clinico-radiologic Characteristics of Pulmonary Visceral Larva Migrans Caused by Ascaris suum.

Objective Visceral larva migrans (VLM) caused by Ascaris suum is a major health problem in pig farming regions. The clinical characteristics of pulmonary VLM caused by A. suum, however, are unclear. We assessed the clinico-radiologic features of this disease. Methods Medical records, including the results of chest radiography and high-resolution computed tomography (HRCT), were retrospectively reviewed from January 2000 through June 2019, at the University of Miyazaki Hospital and Kyoritsuiin Hospital in Miyazaki Prefecture, Japan. Results Seven patients with VLM caused by A. suum were identified. All seven patients had a unique habit of consuming raw foods, such as organic vegetables, chicken, turkey, wild boar, and venison. All but one patient, who had eosinophilic pneumonia with a fever and severe fatigue, had only mild or no respiratory symptoms. All 7 patients had remarkable eosinophilia (median, 1,960 /μL) and high serum IgE levels (median, 1,346 IU/mL). Chest HRCT revealed multiple nodules and multiple nodular ground-glass opacities in 57% and 29% of the patients, respectively. The pulmonary lesions were located predominantly in subpleural areas. All seven patients were treated with albendazole, which led to improvement within two to three months. Neither eggs nor parasites were detected in the feces or sputum of any patient. Conclusion Consumption of raw organic vegetables or raw meat is a possible route of A. suum infection. Infected patients exhibit mild respiratory symptoms, and multiple nodules with a halo in the subpleural area are a common finding on chest HRCT. Treatment with albendazole was effective in these cases.

Multiple nodular opacities only involving the right middle pulmonary lobe: Unusual manifestation of tuberculosis.

Bronchoscopy should be actively performed to differentiate pulmonary tuberculosis in patients with lesions in the middle lobe, which are unaccompanied by bronchiectasis or present without obvious lesions in other lobes.

Pulmonary Involvement in Secondary Syphilis.

The clinical and radiological presentation of pulmonary involvement in secondary syphilis is non-specific, described as solitary or multiple subpleural nodular opacities that are rarely infiltrating.We confirm here that for this localization, biopsy of these nodules is not necessary for diagnosis.

Invasive pulmonary aspergillosis in heart transplant recipients: Is mortality decreasing?

IntroductionInfection remains a major complication among heart transplant (HT) recipients, causing approximately 20% of deaths in the first year after transplantation. In this population, Aspergillus species can have various clinical presentations including invasive pulmonary aspergillosis (IPA), which has high mortality (53-78%). AimsTo establish the characteristics of IPA infection in HT recipients and their outcomes in our setting. MethodsOf 328 heart transplantations performed in our center between 1998 and 2016, five cases of IPA were identified. Patient medical records were examined and clinical variables were extracted. ResultsAll cases were male, with a mean age of 62 years. The most common indication for HT was nonischemic dilated cardiomyopathy. Productive cough was reported as the main symptom. The imaging assessment was based on chest radiography and chest computed tomography. The most commonly reported radiological abnormality was multiple nodular opacities in both techniques. Bronchoscopy was performed in all patients and A. fumigatus was isolated in four cases on BAL culture. Treatment included amphotericin in four patients, subsequently changed to voriconazole in three patients, and posaconazole in one patient, with total treatment lasting an average of 12 months. Neutropenia was found in only one patient, renal failure was observed in two patients, and concurrent cytomegalovirus infection occurred in three patients. All patients survived after a mean follow-up of 18 months. ConclusionsIPA is a potentially lethal complication after HT. An early diagnosis and prompt initiation of aggressive treatment are the cornerstone for better survival.

The implications of preliminary screening and diagnosis: Clinical characteristics of 33 mild patients with SARS-CoV-2 infection in Hunan, China.

In December 2019, coronavirus Disease 2019 (COVID-19) occurred in Wuhan, Hubei Province, China. The disease has rapidly spread from Wuhan to other regions. To describe the clinical manifestations and epidemiological characteristics of patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in Hunan Province in 2020. From January 19 to February 7, 2020, 33 patients with positive in nucleic acid test of pharyngeal swab were retrospectively collected and analyzed. There are 33 COVID-19 patients (16 male, 17 female), and the median age was 46 years. Nineteen patients (48 %) were associated with a family cluster outbreak. Seventeen patients (52 %) had traveled or lived in Hubei Province. These patients are early mild cases, most common symptoms are fever [23 (70 %)] and cough [13 (39 %)]. Most patients' white blood cell counts are normal, while they manifest as significant reduction in lymphocytes [17/28 (61 %)]. The levels of c-reactive protein and erythrocyte sedimentation rate suggest a typical viral infection. Procalcitonin did not increase and D-dimer increased slightly. Lactate dehydrogenase (LDH) levels have elevated in most patients. CT images of these patients showed bilateral multiple plaques or nodular ground-glass opacities (68.4 %). Fecal nucleic acid results were positive in eight COVID-19 patients accompanied with diarrhea. Tear nucleic acid results were negative in six COVID-19 patients. And four asymptomatic patients were infected with SARS-CoV-2. The clinical symptoms, laboratory results and imaging reports of patients with COVID-19 in Hunan area are significantly different from those in Wuhan area. For non-Wuhan epidemic areas, more attention should be paid to nucleic acid test results of throat swabs and stools, and it is not easily to diagnose based on clinical symptoms and CT results. Reduced whole blood lymph count can be used as an adjuvant diagnosis of early SARS-CoV-2 infection. Attention should be paid to asymptomatic carriers, which is of great significance for the control of the global epidemic.

Retracted: Clinical and epidemiological characteristics of 34 children with 2019 novel coronavirus infection in Shenzhen

Objective: To describe the characteristics of clinical manifestations and epidemiology of children with 2019 novel coronavirus (2019-nCoV) infection. Methods: All 34 children with laboratory-confirmed 2019-nCoV infection by quantitative real-time reverse transcription-PCR through nasopharyngeal swab specimens were admitted to the Third People's Hospital of Shenzhen from January 19 to Febuary 7, 2020. Clinical data and epidemiological history of these patients were retrospectively collected and analyzed. Results: Among the 34 cases, 14 were males, and 20 were females. The median age was 8 years and 11 months. No patients had underlying diseases. There were 28 children (82%) related with a family cluster outbreak. There were 26 children (76%) with a travel or residence history in Hubei Province. These patients could be categorized into different clinical types, including 22 (65%) common cases, 9 (26%) mild cases and 3 (8.8%) asymptomatic cases. No severe or critical cases were identified. The most common symptoms were fever (17 cases, 50%) and cough (13 cases, 38% ). In the 34 cases, the white blood cell counts of 28 cases (82%) were normal. Five cases had white blood cell counts more than 10×10(9)/L. One case had white blood cell counts less than 4×10(9)/L. Neutropenia and lymphopenia was found in one case, respectively. C-reactive protein levels and erythrocyte sedimentation rates were elevated in 1 and 5 case, respectively. Elevated procalcitonin was found in 1 case and D-Dimer in 3 cases. The levels of lactic dehydrogenase (LDH) were more than 400 U/L in 10 cases. The CT images of these patients showed bilateral multiple patchy or nodular ground-glass opacities and/or infiltrating shadows in middle and outer zone of the lung or under the pleura. Twenty patients were treated with lopinavir and ritonavir. Glucocorticoids and immunoglobulin were not used in any cases. All the cases improved and were discharged from hospital. Further following up was need. Conclusions: The clinical manifestations in children with 2019-nCoV infection are non-specific and are milder than that in adults. Chest CT scanning is heplful for early diagnosis. Children's infection is mainly caused by family cluster outbreak and imported cases. Family daily prevention is the main way to prevent 2019-nCoV infection.

RELAPSING CRYPTOGENIC ORGANIZING PNEUMONIA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Organizing pneumonia is a form of Interstitial lung disease. It has equal prevalence in men and women. Adults 40-60 years are most commonly affected. It can be idiopathic, called cryptogenic organizing pneumonia(COP), or secondary to other factors; secondary organizing pneumonia. CASE PRESENTATION: 77-year-old female with history of hypertension, CHF, COPD presented with 3 weeks of dyspnea. She was hospitalized 3 weeks prior and treated for CAP.CXR at that time demonstrated b/l upper lobe consolidations. She was discharged on 4L O2 and PO cefpodoxime. Pt reported subjective improvement, however she was not back to her baseline. CT chest revealed patchy consolidation in the b/l upper lobes, and multiple nodular opacities in lower lobes. On initial evaluation patient was afebrile, hypoxic, with PaO2:91 on non-rebreather saturating at 95%. WBC count of 8.9. Bronchoscopy was performed. BAL revealed WBC: 693, lymphocytes: 35%, cultures: negative. BAL analysis was supportive of a diagnosis of COP. Biopsy not done due to high FiO2 requirements and unstable condition. Patient was started on prednisone 40 mg x 4 weeks followed by 20 mg x 4 weeks. Patient was lost to follow up, and steroids stopped by PCP. 3 months later she was re hospitalized for hypoxia. CXR showed worsening opacities and she required 5 L O2 via NC. A tapering course of Prednisone was started. Patient seen on follow up at 3 months with resolution of symptoms. DISCUSSION: COP has an insidious onset. Risk factors include infections, connective tissue disease, malignancies, chronic recurrent aspiration, radiation, cocaine etc. The radiographic appearance of COP is variable. On chest CT scan patchy consolidation, is seen in 90% of patients. Nodules and irregular linear opacities or ground-glass attenuation may be seen. Diagnosis is made on history, Imaging, PFTs, Bronchoscopy with BAL and biopsy findings. PFTs may show obstructive vs restrictive defect. DLCO is usually decreased. Typical BAL findings include increases in lymphocytes (20 to 40 percent), neutrophils (5 to 10 percent), and eosinophils (5 to 25 percent). Foamy macrophages, mast cells, and a decreased CD4/CD8 T cell ratio may be seen. BAL neutrophilia (>10%) tends to correlate with relapse. Transbronchial/surgical lung biopsy provides a definitive diagnosis. Patients with minimal symptoms can be monitored without therapy as spontaneous remission may occur. For patients with severe disease: Long term course of steroids: 0.75-1 mg/kg/day for 4-8 weeks then 0.5 mg/kg/day for 4-8 weeks. Most patients respond to therapy with recovery usually occurring in two-thirds of patients. Approximately one-third of patients experience persistent symptoms, abnormalities on pulmonary function testing, and radiographic disease. CONCLUSIONS: Close monitoring is essential to ensure response and completion of therapy, as early discontinuation of steroids may result in recurrence of symptoms. Reference #1: 1. Cordier, J. F. "Cryptogenic organising pneumonia." European Respiratory Journal 28, no. 2 (2006): 422-446. Reference #2: 2. Drakopanagiotakis, Fotios, Koralia Paschalaki, Muhanned Abu-Hijleh, Bassam Aswad, Napoleon Karagianidis, Emmanouil Kastanakis, Sidney S. Braman, and Vlasis Polychronopoulos. "Cryptogenic and secondary organizing pneumonia: clinical presentation, radiographic findings, treatment response, and prognosis." Chest 139, no. 4 (2011): 893-900 Reference #3: 3. Epler, Gary R. "Bronchiolitis obliterans organizing pneumonia: definition and clinical features." Chest 102, no. 1 (1992): 2-6. DISCLOSURES: No relevant relationships by Siddique Chaudhary, source=Web Response No relevant relationships by Bhavna Sharma, source=Web Response No relevant relationships by Paul Kristan Valestra, source=Web Response

Invasive pulmonary aspergillosis in heart transplant recipients: Is mortality decreasing?

IntroductionInfection remains a major complication among heart transplant (HT) recipients, causing approximately 20% of deaths in the first year after transplantation. In this population, Aspergillus spp. can have various clinical presentations including invasive pulmonary aspergillosis (IPA), with high mortality (53-78%). ObjectivesTo establish the characteristics of IPA infection in HT recipients and their outcomes in our center. MethodsAmong 328 HTs performed in our center between 1998 and 2016, we identified five cases of IPA. Patient medical records were examined and clinical variables were extracted. ResultsAll cases were male, and mean age was 62 years. The most common indication for HT was non-ischemic dilated cardiomyopathy. Productive cough was reported as the main symptom. The radiological assessment was based on chest X-ray and chest computed tomography. The most commonly reported radiographic abnormality was multiple nodular opacities in both techniques. Bronchoscopy was performed in all patients and Aspergillus fumigatus was isolated in four cases on bronchoalveolar lavage culture. Treatment included amphotericin in four patients, subsequently changed to voriconazole in three, and posaconazole in one patient, with total treatment lasting an average of 12 months. Neutropenia was found in only one patient, renal failure was observed in two patients, and concurrent cytomegalovirus infection in three patients. All patients were alive after a mean follow-up of 18 months. ConclusionsIPA is a potentially lethal complication after HT. Early diagnosis and prompt initiation of aggressive treatment are the cornerstone of better survival.

PULMONARY AND SPLENIC SARCOIDOSIS MIMICKING LYMPHOMA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Sarcoidosis is a chronic multisystem disease of unknown etiology. It is characterized by noncaseating granulomas mainly involving lungs but any organ might be affected. As a diagnosis of exclusion extrapulmonary sarcoidosis might be challenging to diagnose based on the site of involvement. Here a case of pulmonary and splenic Sarcoidosis is presented that was mimicking lymphoma (1). CASE PRESENTATION: 51 Y.O F with PMH of ADHD, beta thalassemia, morbid obesity, former smoker stopped 15 years ago and left hip OA s/p replacement was referred to pulmonary clinic for abnormal CT findings. Physical exam was benign and she did not have any active complaints. CT chest was remarkable for multiple bilateral nodular and ground glass opacities measuring up to 5-6 mm, mild diffuse mediastinal and bilateral hilar lymphadenopathy measure up to 47 x 18 mm with focal low density changes suggestive of cystic or necrotic components. CT abdomen revealed enlarged spleen with multiple hypodense lesions measuring up to 21 mm and a stable left renal cyst. Labs were noticeable for Normal ACE level, microcytic anemia, negative quantiferon, normal LDH and the rest were unremarkable. Lymphoma and sarcoidosis at this time were on the top of differential diagnosis list. Bronchoscopy was done with EBUS and transbronchial biopsy revealed noncaseating granulomatous inflammation suggestive of sarcoidosis with no evidence of malignancy. With impression of pulmonary and extra pulmonary sarcoidosis she was started on prednisone. 4 months later patient stopped the prednisone on her own since she was gaining weight so she was stared on methotrexate. Interval changes were followed with CT imaging that was significant for resolution of some of the pulmonary opacities with no increase in the size of remaining. Mediastinal and hilar lymphadenopathy resolved and size of lesions in spleen decreased. Patient remained asymptomatic and is still following up for further management. DISCUSSION: In more than 90 % of patients with sarcoidosis pulmonary involvement was reported. Ocular, lymph-node, and cutaneous findings are the more frequent involved organ systems respectively. more than 50% of cases has co existing pulmonary and extra pulmonary manifestations while only 2% of patients present with isolated extra pulmonary sarcoidosis (2). Prednisone is considered the first-line therapy. Side effects of chronic steroid use and lack of response are limiting factors that can cause significant morbidity in long term treatments. Steroid sparing treatments are increasingly used in these instances. Methotrexate is the disease-modifying antisarcoid drugs that is usually used by most sarcoidosis experts (3). CONCLUSIONS: Extra pulmonary sarcoidosis is mainly coexistent with pulmonary disease. lymphoma is on the differentials with splenic and lymph node involvement and biopsy is needed to confirm and exclude the other possibilities. Reference #1: Baughman RP, Teirstein AS, Judson MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001;164(10 Pt 1):1885–1889. Reference #2: Valeyre D, Prasse A, Nunes H, Uzunhan Y, Brillet PY, Müller-Quernheim J. Sarcoidosis. Lancet. 2014;383(9923):1155–1167. Reference #3: Korsten P, Mirsaeidi M, Sweiss NJ. Nonsteroidal therapy of sarcoidosis. Curr Opin Pulm Med. 2013;19(5):516–523. DISCLOSURES: No relevant relationships by Jonathan Arnedo, source=Web Response No relevant relationships by Sara Khademolhosseini, source=Web Response No relevant relationships by Seyedmohammad Pourshahid, source=Web Response No relevant relationships by Theo Trandafirescu, source=Web Response

Large Solitary Pulmonary Cryptococcoma Mimicking Lung Carcinoma in an Immunocompetent Patient

Cryptococcosis is a life-threatening mycosis typically seen in immunocompromised patients. Pulmonary cryptococcosis generally presents as multiple or solitary nodular opacities. Cryptococcal infection presenting as a destructing cavernoma (cryptococcoma) without diffuse infiltration of the lung is an extremely rare presentation, even in immunocompromised patients. This report presents a healthy, HIV negative, immunocompetent patient who presented with a large solitary lung mass provisionally diagnosed as a lung malignancy on radiological imaging that proved to be a large cryptococcoma after biopsy. The patient was treated with liposomal Amphotericin B and fluconazole, and the lesion showed regression on serial imaging. This case report thus highlights an unconventional presentation of pulmonary cryptococcosis in an immunocompetent individual.

Nocardiosis: The Great Imitator

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Nocardia species are filamentous gram positive bacteria which typically infect immunocompromised individuals. Lung is the primary site of infection in more than two-thirds of the patients.1 We present a case of pulmonary nocardiosis in a patient with non-resolving chronic obstructive pulmonary disease (COPD) exacerbation. CASE PRESENTATION: A 65-year-old female with history of very severe COPD secondary to alpha 1 antitrypsin deficiency and sulfonamide allergy presented with shortness of breath and productive cough for 2 weeks. She had 4 episodes of COPD exacerbation over last 1 year treated with systemic steroids. After treatment for COPD exacerbation with cefuroxime and prednisone for 1 week, and later with dexamethasone, moxifloxacin and doxycycline for 6 days, she had no improvement in symptoms. Initial sputum culture was negative and chest X-ray (CXR) revealed chronic interstitial scarring with no focal infiltrate. On exam, she was ill-appearing, with oxygen saturation of 89% on 4 liters of oxygen and bilateral end-expiratory wheezing on lung auscultation. CXR showed a new density in right lung base. Repeat sputum culture was positive for partially acid-fast staining, filamentous, branching rods. Computed tomography (CT) of chest demonstrated multiple inflammatory-appearing nodular opacities throughout right lung field. She was started on amikacin and minocycline for presumptive diagnosis of pulmonary nocardiosis. After desensitization, antibiotics were changed to trimethoprim-sulfamethoxazole (TMP-SMX) and imipenem. After 3 weeks imipenem was stopped. Final sputum culture grew Nocardia cyriacigeorgica, sensitive to TMP-SMX, amikacin, and imipenem, with intermediate sensitivity to minocycline. After 6 weeks, TMP-SMX was switched to minocycline as patient developed a rash. Patient completed 6 months of therapy and follow-up CT scan showed resolution of infiltrates. She has since been doing well. DISCUSSION: Pulmonary nocardiosis is often difficult to diagnose as it presents with non-specific symptoms, such as fever, cough, and dyspnea, as well as non-specific radiographic findings, like nodular and/or consolidative infiltrates. More so, given the fastidious nature of Nocardia, it can take up to 21 days to grow on routine cultures. A high index of suspicion is warranted in immunocompromised patients, including those with frequent steroid use, as well as those with structural lung disease.1 CONCLUSIONS: Nocardiosis may imitate COPD exacerbation which can make diagnosis challenging. Moreover, glucocorticoids used for treatment of underlying lung disease may worsen the infection. TMP-SMX is first-line treatment for pulmonary nocardiosis, with minocycline as a well-established alternative.1 Neither of these antibiotics are part of typical empiric regimens which may explain initial treatment failure in our patient. Reference #1: Lederman ER, Crum N. A case series and focused review of nocardiosis: clinical and microbiologic aspects. Medicine. 2004;83(5):300-313 DISCLOSURE: The following authors have nothing to disclose: Mayanka Kamboj, Lydia Winnicka, Sukriti Kamboj, Amirahwaty Abdullah No Product/Research Disclosure Information