Normal Vital Signs Research Articles

IMPACT OF TRIKAFTA ON LUNG FUNCTION IN A CYSTIC FIBROSIS TRANSPLANT PATIENT

SESSION TITLE: Fellows Transplantation Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cystic fibrosis (CF) patients with at least one copy of F508del are eligible for Tezacaftor/Ivacaftor/Elexacaftor (Trikafta), a novel CFTR corrector/potentiator drug associated with increased lung function1 and likely improved sinus clearance. Trikata effects in lung transplant patients are unknown. We report a CF transplant patient, who developed reversible profound leukopenia, severely decreased lung function, and CT findings of peribronchial thickening and gas trapping after starting Trikafta for recurrent severe sinus disease. CASE PRESENTATION: A 30 year old CF female (homozygous F508del), underwent bilateral orthoptic lung transplant for end-stage lung disease and was treated with tacrolimus, azathioprine, prednisone valganciclovir, and sulfamethoxazole/trimethoprim for immunosuppression and infection prophylaxis. FEV1/FVC 3 months post-op were 3.36L/3.58L. Complaints of severe chronic sinusitis persisted and Trikafta was initiated with symptomatic benefit. 4 weeks later, she developed profound neutropenia, despite no antecedent changes in myelosuppressive drug therapy. Despite G-CSF, she was admitted with worsening respiratory symptoms and declining PFTs. She was afebrile with normal vital signs. Initial testing for bacterial and viral infections was negative. Azathioprine, Bactrim and Valcyte were held. Eravacycline was started empirically based on prior cultures. FEV1/ FVC declined to 2.62L/2.80L. Initial CT chest was essentially normal. Leucocyte counts slowly recovered with G-CSF. During this time, she began expectorating copious greenish ’sea-foam’ liquid. Repeat expiratory CT chest showed diffuse bronchial wall thickening and extensive air trapping. Bronchoscopy showed diffuse frothy secretions. Bronchoalveolar lavage had >80% return. Cell counts showed 100 nucleated cells/ml with benign differential. Following a negative cardiac and other etiologic workup, antibiotics were stopped and Trikata was discontinued as causation was suspected. Respiratory symptoms resolved and FEV1/FVC improved to supra-normal baseline over 2 weeks. DISCUSSION: Trikafta’s effect on transplanted lungs (where CFTR function is intrinsically normal) is unknown. Inflammatory cell-derived mediators are known to augment native CFTR function and increase airway epithelial cell fluid secretion in vitro2. We hypothesize that our patient’s symptoms and findings were due to exaggerated airway fluid secretion associated with repopulation of inflammatory cells. We propose that this led to airway edema, and bronchial wall thickening + gas trapping observed on imaging. Improvement in symptoms/PFTs after drug discontinuation support this. Etiology of profound leukopenia is less clear, though a previously undescribed direct drug-effect or altered GI absorption of other myelosuppressive medications are possible. CONCLUSIONS: Trikafta may have unexpected detrimental effects on a lung transplant physiology in CF patients Reference #1: Heijerman HGM, McKone EF, Downey DG, et al. Efficacy and safety of the elexacaftor plus tezacaftor plus ivacaftor combination regimen in people with cystic fibrosis homozygous for the F508del mutation: a double-blind, randomised, phase 3 trial. Lancet. 2019. Reference #2: Abdullah LH, Coakley R, Webster MJ, et al. Mucin Production and Hydration Responses to Mucopurulent Materials in Normal versus Cystic Fibrosis Airway Epithelia. Am J Respir Crit Care Med. 2018; 197(4):481–491. doi:10.1164/rccm.201706-1139OC DISCLOSURES: No relevant relationships by Raymond Coakley, source=Admin input No relevant relationships by Christina Doligalski, source=Web Response No relevant relationships by Kunal Jakharia, source=Web Response No relevant relationships by leonard lobo, source=Web Response

SALMONELLA LUNG ABSCESS IN AN IMMUNOCOMPETENT PATIENT

SESSION TITLE: Late-breaking Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Non typhoidal salmonella (NTS) usually causes self-limiting gastroenteritis. Rarely it can cause invasive infections in adults with specific risk factors. We report a case of a multiple lung and paracardiac abscesses caused by NTS in an immunocompetent patient METHODS: A 66-year-old Qatari lady with Diabetes Mellitus, Hypertension and End Stage Renal Disease came for her regular hemodialysis session. She had an abnormal chest X-ray which was done for her history of cough with minimal amount of whitish sputum for the preceding four weeks. She denied any history of fever, chest pain, shortness of breath or weight loss. She did not recollect any recent or remote history of gastrointestinal symptoms. On examination, she was comfortable at rest with normal vital signs. Her chest auscultation revealed decreased breath sounds in the right infra scapular area. Blood tests were significant for leukocytosis of 12,700/mm3 with 75% neutrophils and elevated inflammatory markers with CRP of 137 mg/dl. Chest X-ray showed cavitary lesions with multiple air fluid levels in the right hemithorax silhouetting the right heart border and right hemidiaphragm with mild pleural effusion. This was confirmed on CT scan of the chest as multiple cavitary lesions containing air and fluid in right lower and middle lobe with largest one measuring 5.5 x 4.2 cm and a similar right pericardial cavitary lesion along the right heart border measuring 8.5 x 6.2 cm. Septic work up including sputum culture and two sets of blood cultures were negative RESULTS: She underwent bronchoscopy which revealed normal anatomy. The bronchoalveolar lavage (BAL) from right middle and lower lobe cultured Salmonella species type D which was sensitive to Ceftriaxone. Tuberculosis work up from the induced sputum and BAL was negative. She was started on parenteral Ceftriaxone 2 gm once daily with improvement in leukocytosis and in inflammatory markers. She was discharged on parenteral Ceftriaxone for a total of 2 weeks duration with follow up arranged in clinic to assess for clinical and radiological improvement. CONCLUSIONS: Extraintestinal Salmonellosis is uncommon and pulmonary involvement accounts for only 10% of this. Pulmonary manifestations are likely in immunocompromised patients and usually occur due to hematogenous spread which can be transient leading to negative blood cultures in 25%-45% of the cases as in our patient. Most common presentation is Salmonella pneumonia. Lung abscess is rare with less than 10 cases of Salmonella lung abscess reported in the literature to our knowledge in an immunocompetent host. Duration of antimicrobial treatment is not well defined with minimum of two weeks and to be extended until resolution of abscess with a success rate of 80% - 90%. Surgical drainage is considered an adjunct option CLINICAL IMPLICATIONS: This case highlights NTS as a potential causative agent for lung abscess even in immunocompetent host. DISCLOSURES: No relevant relationships by Raza Akbar, source=Web Response No relevant relationships by Elrazi Awadelkarim Ali, source=Web Response No relevant relationships by Fatma Ben Abid, source=Web Response No relevant relationships by Shanima Ismail, source=Web Response No relevant relationships by Almurtada Razok, source=Web Response No relevant relationships by Merlin Thomas, source=Web Response No relevant relationships by Godwin Wilson, source=Web Response

S2481 A Case of Sertraline-Induced Hepatotoxicity Correlated With Pharmacogenomic Testing

INTRODUCTION: Sertraline is a commonly used medication for depression and anxiety and is a type of selective serotonin reuptake inhibitor (SSRI). SSRIs are generally well tolerated, but there have been a few reports of drug induced liver injury (DILI) from this exposure. There is no reliable mechanism to predict the risk of DILI from SSRIs. Pharmacogenomic (PGx) testing is a form of genetic testing analyzing alleles of enzymes involved in metabolism. This is a case of Sertraline-induced DILI further correlated by PGx testing. CASE DESCRIPTION/METHODS: A 73 year old woman with fibromyalgia and anxiety presented for evaluation of cholestatic hepatitis. 2 months prior to presentation, she was started on sertraline 75 mg daily for chronic anxiety. 4 weeks after starting the medication, she noticed pruritus and dark urine. The SSRI was discontinued, but she continued to have symptoms. Her physical exam was notable for normal vital signs with a BMI of 20.90 kg/m2, scleral icterus and excoriations but no hepatospenomegaly or stigmata of chronic liver disease. Prior to presentation, she had normal liver function testing. Her labs were notable for total bilirubin 4.7 mg/dL, direct bilirubin 3.1 mg/dL, ALP 509 U/L, AST 280 U/L, ALT 468 U/L, INR 0.9. Viral hepatitis serologies, ANA, ASMA, ceruloplasmin, liver kidney microsomal antibody, SPEP were all unremarkable. MRCP showed no biliary ductal dilation. A liver biopsy was done showing resolving cholestatic hepatitis with no evidence of autoimmune liver disease or fibrosis. Given the slow improvement in enzymes, she was referred for PGx testing. Testing revealed that the patient was an intermediate metabolizer of serotonin with an allelic variation of the SLC6A4 as well as the HTR2A gene. Eventually, her liver enzymes normalized, and she was recommended to avoid SSRIs. DISCUSSION: Sertraline is a rare yet known culprit of DILI. There is no current reliable way of predicting one’s risk of developing DILI from SSRIs. PGx testing showed that she two polymorphisms in sertraline metabolism. SLC6A4 encodes a serotonin transporter and augments the synaptic concentration of the drug. HTR2A changes also are associated with an increase in antidepressant response of higher serotonin levels. This possibly led to increased drug levels and side effects from poor metabolism of SSRIs. With further affordability, PGx testing can be considered prior to starting medications associated with DILI to avoid prescribing it to those who may be higher risk of developing it.

RECURRENT PNEUMOTHORACES IN A YOUNG, NON-SMOKING WOMAN

SESSION TITLE: Medical Student/Resident Genetic and Developmental Disorders Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Alpha-1 antitrypsin deficiency (AATD) is known to affect the lungs and liver by causing the early development of emphysema and liver disease. We present a case of a non-smoker who developed emphysema in her early 40s. CASE PRESENTATION: 42 year old non-smoking female with a past medical history of multiple spontaneous pneumothoraces presented to her primary care physician (PCP) with complaints of right-sided chest pain and was found to have decreased breath sounds on the right side. She was sent for a 2-view chest x-ray and d-dimer. The posteroanterior and lateral chest x-ray showed a right side pneumothorax and she was instructed to go to the emergency department (ED) for chest tube placement. Examination in the ED revealed normal vital signs and no breath sounds on the right chest. D-dimer was unremarkable. She was seen by pulmonology who recommended further imaging. CT chest with contrast demonstrated small subpleural blebs along the medial aspect of the right lung apex, the suspected source of the spontaneous pneumothorax, and a lobulated lesion in the posterior segment of the right lobe of the liver. Given the liver findings, a MRI abdomen was done showing a mildly complex, septated cyst in the posterior right hepatic lobe measuring up to 4.4cm without enhancement consistent with a biliary cystadenoma. Serial chest x-rays were done to monitor the pneumothorax regression. The chest tube was removed three days later after absence of pneumothorax on water seal. She was discharged with a referral to thoracic surgery and had an office visit two weeks later for right-sided robotic-assisted thoracoscopic surgery with wedge excision of right apical bleb and mechanical pleurodesis. Pathology from the bleb tissue showed subpleural fibrosis and emphysematous change. AATD testing sent during her hospitalization was significant for alpha-1 antitrypsin (AAT) phenotype of SS, with an incidence of 0.1% and an AAT level of 105 mg/dL, the lower end of the normal range for her age. Pulmonary function testing did not reveal any obstructive findings. DISCUSSION: Our case demonstrates a rare presentation of the development emphysema in a non-smoker found to have the SS phenotype with low normal level of alpha-1 antitrypsin. This patient developed emphysema earlier than expected given the phenotype of AATD. Although our patient did not have classic liver manifestations, she was found to have a biliary cystadenoma. Patients with the SS phenotype are at risk to develop liver disease and early manifestations of emphysema; however they have a minimally increased risk of developing COPD, as the SS allele is related to a mild decrease in alpha-1 antitrypsin levels. CONCLUSIONS: Given the rarity of the SS phenotype, more research is needed in order to truly determine the incidence of developing lung and/or liver disease. It will be vital to help prognosticate and treat patients with alpha-1 antitrypsin deficiency. Reference #1: Fregonese L, Stolk J. Hereditary alpha-1-antitrypsin deficiency and its clinical consequences. Orphanet J Rare Dis. 2008;3:16. Reference #2: Parr DG, Stoel BC, Stolk J, Stockley RA. Pattern of Emphysema Distribution in alpha1-Antitrypsin Deficiency Influences Lung Function Impairment. Am J Respir Crit Care Med. 2004;170:1172-8. Reference #3: Kelly E, Greene CM, Carroll TP, McElvaney NG, O’Neill SJ. Alpha-1 antitrypsin deficiency. Respir Med. 2010;104:763-72. DISCLOSURES: No relevant relationships by Patrick Koo, source=Web Response No relevant relationships by Jetina Okereke, source=Web Response

RAPID ONSET MILIARY TB: A MANIFESTATION OF IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tuberculosis (TB) is now an uncommon entity in the United States, with an estimated incidence of 2.7 per 100,000 persons. (1) Infection with human immunodeficiency virus (HIV) is a significant risk factor for TB infection. The initiation of antiretroviral therapy (ART) may be associated with immune reconstitution inflammatory syndrome (IRIS), with the subsequent unmasking of previously subclinical infections, including TB. We present an uncommon case that dramatically presented with miliary TB shortly following the initiation of ART. CASE PRESENTATION: A 68-year-old female immigrant with a history depression, parkinson's disease, and known acquired immunodeficiency syndrome (AIDS)/HIV infection not treated for 6 years, presented with weakness, night sweats, and progressive dry cough for two weeks. She had been started on ART (bictegravir/emtricitabine/tenofovir) one month prior, with a pre-treatment viral load of 84,000 copy/mL, and CD4 count of 69 /µL. Physical examination at presentation revealed normal vital signs and bilateral rhonchi. Laboratory testing was notable for leukopenia (3.99 x10^6 /µL). Chest radiograph showed multiple bilateral nodules. Chest computed tomography (CT) revealed innumerable bilateral nodules, with mediastinal and axillary lymphadenopathy. (Fig 1) Three consecutive sputum samples were positive for acid fast bacilli. The diagnosis of miliary tuberculosis was made, and she was started on rifampin, isoniazid, ethambutol, and pyrazinamide (RIPE therapy), along with pyridoxine. Given the potential for drug interaction between rifampin and bictegravir, the latter was switched to dolutegravir for the duration of six planned months of antibiotic treatment. DISCUSSION: Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) is an early complication of antiretroviral therapy in patients with TB, that results from the rapid restoration of immune function, with a consequent exaggerated immune response, causing an exacerbation of pre-existing infections, or the unmasking of subclinical infections. TB-IRIS is characterized by severe localized or systemic inflammatory reactions against Mycobacterium tuberculosis antigens. One retrospective study showed an incidence of 8% in HIV and TB co-infected patients who were started on ART. (2) Our case notably had a dramatic presentation, with severe miliary TB on chest imaging, with no known history of TB. Additionally, chest radiography obtained merely one month prior to her presentation had been normal, demonstrating the rapidity with which miliary TB may develop following the initiation of ART. CONCLUSIONS: Patients with risk factors, such as immigration, should be monitored closed following the initiation of ART, for the manifestation of previously subclinical infections, such as TB. Reference #1: Schwartz, MD, Price SF, Pratt RH, et al. Tuberculosis - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69:286-289 Reference #2: Kumarasamy N, Chaguturu S, Mayer KH, et al. Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India. J Acquir Immune Defic Syndr. 2004 Dec 15;37(5):1574-6. DISCLOSURES: No relevant relationships by Rohan Kataria, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response No relevant relationships by Pandi Todhe, source=Web Response

Eye Discharge in a 9-day-old Twin Boy.

1. Eleanor A. Sharp, MD* 2. Jessica L. Garrison, MD* 1. *Paul C. Gaffney Division of Pediatric Hospital Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA A 9-day-old infant boy presents to the emergency department with a 1-day history of bilateral eye redness and yellow discharge. The morning before presentation, his mother noted his right eye to be crusted shut with dried yellow discharge. She applied a warm compress that removed the discharge and allowed him to open his eye normally. However, over the next several hours he developed bilateral eyelid swelling and yellow drainage from both eyes. He seemed to be trying to rub his eyes and was fussier than usual. The day of presentation, his mother noted both his eyes were red, swollen, and draining yellow fluid, so she brought him to the emergency department for evaluation. The patient has not been breastfeeding as long or as frequently as usual over the past day but has still had normal stool and urine output. The patient has not had fever, nasal congestion, rhinorrhea, rash, or sick contacts. His twin sister is asymptomatic. The patient was born full term via spontaneous vaginal delivery. He was the firstborn twin. The mother received routine prenatal care, and both the pregnancy and delivery were uncomplicated. Maternal screening for gonorrhea and chlamydia at the first prenatal visit was negative, and the patient received ophthalmic erythromycin after delivery. In the emergency department, the infant is afebrile with normal vital signs for age. He is fussy but consolable. He has periorbital swelling with overlying erythema, conjunctival injection, and mucopurulent discharge from both eyes, right worse than left. The reminder of his examination is unremarkable. Due to his age, evaluation for possible serious bacterial infection is completed. His white blood cell count is …

S2944 A Rare Disease Caused by Treatment of a Common Problem

INTRODUCTION: Collagenous gastritis (CG) is a histologic diagnosis that is defined as subepithelial thickening to >10 μm due to the deposition of collagen tissue. It is a rare disease with unclear etiology but has strong association with autoimmune diseases. We present a case of collagenous gastritis induced by Olmesartan. CASE DESCRIPTION/METHODS: A 62- years-old woman with hypertension presented with nausea, epigastric pain, weight loss, and odd-tasting saliva for 1 month. Pertinent physical examination revealed normal vital signs and tenderness of the epigastric area without signs of peritonitis. Workup for all potential infectious causes and celiac disease was negative. An upper endoscopy showed gastritis with umbilications in the antrum and gastric mucosal atrophy in the gastric body and fundus. Gastric histopathology revealed collagenous gastritis with mucosal atrophy and eosinophilic infiltrate without intestinal metaplasia (Figure 1). Duodenal biopsy revealed preserved villi. In light of negative celiac disease and after review of the patient’s medication, the diagnosis of Olmesartan induced collagenous gastritis was considered. Olmesartan was discontinued and her symptoms resolved. Two months later her weight had returned to normal. DISCUSSION: Olmesartan associated collagenous gastritis (OACG) is a rare disease that was initially reported in 2012. In adults, OACG without small and/or large bowel involvement is exceptionally rare. Presenting symptoms are abdominal pain, nausea, vomiting, weight loss, and anemia. Symptoms develop months to years after the initiation of olmesartan therapy. The presumptive diagnosis of OACG is made in patients who develop symptoms while taking olmesartan with a supportive histologic finding on gastrointestinal biopsies. Discontinuation of olmesartan has been the mainstay of treatment.Figure 1.: High power view: Thickened basement membrane (green arrow), and eosinophils (red arrow), lymphoplasmacytic infiltrate (white arrows head).

S1434 Hemosuccus Pancreaticus From the Minor Papilla

INTRODUCTION: Hemosuccus Pancreaticus (HP), typically defined as bleeding from the major papilla, is an exceedingly rare cause of gastrointestinal bleeding. Even rarer, is the subset due to bleeding from the minor papilla via the duct of Santorini, with data limited to few case reports. We present a case of HP with bleeding from the minor papilla secondary to rupture of a gastroduodenal artery (GDA) branch pseudoaneurysm into a pancreatic pseudocyst from a previous episode of gallstone pancreatitis. CASE DESCRIPTION/METHODS: A 63-year-old female with history of end stage renal disease on hemodialysis, coronary artery disease status post recent drug eluting stent on dual antiplatelet therapy, and remote history of gallstone pancreatitis with known pseudocysts presented with 1 day of nonspecific abdominal pain and 4 episodes of small volume black stool. Exam revealed normal vital signs, benign abdomen, and black stool in the rectal vault. Labs notable for hemoglobin 7.6g/dL (baseline 8.5), and elevated lipase to 282 unit/L [13–60]. Endoscopy with side viewing scope revealed bile from the major papilla and frank bleeding from the minor papilla. CT angiogram demonstrated a lobulated pancreatic head, with multiple cysts and 1cm enhancing nodule concerning for a pseudoaneurysm or islet cell tumor. IR angiography identified the blood supply of the nodule as a branch of the GDA with visible blush treated successfully with coil embolization. MRI of the abdomen showed fullness of the pancreatic head without a discrete mass or evidence of pancreas divisum. Endoscopic ultrasound was recommended, but patient declined. Overall, her presentation was consistent with ruptured pseudoaneurysm into a pseudocyst causing HP from the minor papilla. DISCUSSION: HP occurs from an abnormal communication between the pancreatic duct and a vascular structure. Pancreatitis (acute or chronic) is the most common cause of HP; others include arterial aneurysm, pancreatic tumors, iatrogenic, trauma, and pseudoaneurysm of the GDA seen in 20-25% of cases. Endoscopic visualization of bleeding from the papilla is diagnostic but occurs in only 30% of cases. CT is utilized to identify etiology and infrequently reveals a sentinel clot in the pancreatic duct. IR is the gold standard for therapy with immediate success rates of 79–100% and surgery reserved for hemodynamic instability. Effective therapy is crucial; left untreated, the mortality rate is as high as 90%.Figure 1.: Side-viewing gastroduodenoscopy of the minor duodenal papilla with frank blood (left) and major duodenal papilla with bile (right).Figure 2.: CT angiography of the abdomen and pelvis with IV contrast demonstrating arterial enhancing pancreatic head nodule (arrow).Figure 3.: IR angiography of gastroduodenal artery branch pre (left) and post (right) successful coil embolization.

RECURRENT SPONTANEOUS PNEUMOTHORAX IN A YOUNG FEMALE PATIENT

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous pneumothorax (PTX) has an incidence of 1.2 to 6 cases per 100,000 females. Catamenial PTX is a rare type of secondary spontaneous PTX concomitant with menstruation, with an incidence of 3-6% among women initially diagnosed with primary spontaneous PTX. The pathophysiology of catamenial PTX involves the presence of endometrial tissue within the thoracic cavity, involving the pleura, diaphragm, or tracheobronchial tree, also known as thoracic endometriosis. These symptoms occur within 72 hours before or after menstruation. Due to the rarity of catamenial PTX, this condition represents a diagnostic & therapeutic challenge. CASE PRESENTATION: A 30 year old African American female presents with chief complaint of right (Rt) sided chest pain & dyspnea. The patient had experienced bilateral chest pain one day after beginning menstruation, with the left-sided chest pain resolving & progression of Rt-sided chest pain over the following days. She also had a cough for one week that had resolved at the time of presentation. Past medical history was remarkable for a previous episode of PTX on the left side 2 yrs prior, treated initially with chest tube drainage & subsequently requiring Video-Assisted Thoracoscopic Surgery (VATS) pleurodesis for recurrence. Pleural biopsy at that time showed acute & chronic pleuritis with inflammatory cells and fibrin. Chest Computed Tomography (CT) showed no other significant pulmonary parenchymal abnormality or cystic disease. Other co-morbidities included obesity, hay fever and acid reflux disease. Besides occasional marijuana use, no cigarette smoking or alcohol use reported. Family history was negative for pulmonary disease, endometriosis or PTX. Physical exam upon admission showed normal vital signs & diminished breath sounds on the Rt side suspicious for PTX. Chest x-ray (CXR) showed large Rt PTX with 7 cm pleuropulmonary separation without mediastinal shift. Small bore pigtail chest tube was placed with resolution of PTX. Right-sided VATS with pleurodesis was performed for definitive treatment. Post-operative course was unremarkable & the patient was discharged 2 days later. Follow-up CXR a week later showed complete resolution of small right apical PTX. DISCUSSION: Catamenial PTX should be suspected in the differential for young women with recurrent PTX coinciding with menstrual periods & in the absence of other common etiologies. Early identification, acute management with chest tube insertion, & definitive treatment with VATS pleurodesis is usually needed. Other preventative treatment may include hormonal therapy. CONCLUSIONS: This case illustrates an example of diagnosis & management of catamenial PTX, a rare type of spontaneous PTX in women associated with menstruation & caused by thoracic endometriosis. Reference #1: Noppen, M. (2010). Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. European Respiratory Review, 19(117), 217–219. DISCLOSURES: No relevant relationships by Asok Dasgupta, source=Web Response No relevant relationships by Reed Geisler, source=Web Response No relevant relationships by Ty Gilkey, source=Web Response No relevant relationships by Chelsea Leipold, source=Web Response No relevant relationships by Paresh Timbadia, source=Web Response

S1547 When and Where to Look? Hepato-Biliary Malignancy in Lynch Syndrome

INTRODUCTION: Patients with Lynch Synrome have well established germline mutations in DNA mismatch repair genes that put them at higher risk for the development of multiple different types of malignancy. Risk of development of colorectal cancer is probably the most well described followed by associations with endometrial, stomach, renal pelvis, brain, skin, amongst others. Current guidelines recommend screening based on probability of these malignancies. CASE DESCRIPTION/METHODS: A 34 year old male known to carry the mutation for Lynch Syndrome was admitted with generalized fatigue. The patient reported feeling progressively worse and described associated symptoms of pruritus, dark urine and light colored stools. As part of his surveillance for Lynch Syndrome, he undergoes a colonoscopy every 2 years and an EGD every 4 years; both of which were recently normal. He otherwise has no other past medical history and takes no medications. Exam notable for normal vital signs, scleral icterus and jaundice. Labs significant for AST 112 IU/L, ALT 299 IU/L, ALP 137 IU/L, total bilirubin 8.3 mg/dL, direct bilirubin 5.4 mg/dL. A CT scan showed moderate intra and extra hepatic biliary ductal dilatation, pancreatic ductal dilatation, and an ampullary lesion. Ampullary mass seen and biopsied via ERCP, pathology showing moderately differentiated adenocarcinoma of pacnreatobiliary type. He was treated with Whipple surgery and FOLFIRINOX chemotherapy regimen. DISCUSSION: Lynch Syndrome is diagnosed in patients and families with germline mutations in DNA mismatch repair genes. This mutation puts patients at much higher risk of developing multiple types of cancer. Our case describes a patient with pancreatobiliary type adenocarcinoma of the ampulla. Small intestinal cancer is thought to affect a small population of patients with Lynch syndrome (anywhere from 0.4-12%) and society guidelines differ on appropriate screening with some recommending periodic capsule endoscopy. Routine screening for pancreatic cancer is only recommended in patients and families with Lynch syndrome who have a family member or members diagnosed with pancreatic disease. As patients with Lynch Syndrome are at risk for malignancy in virtually any location, data on less common presentations and development of noninvasive testing will be more and more valuable.

Point-of-care Lung Ultrasound Is Useful to Evaluate Emergency Department Patients for COVID-19.

IntroductionCoronavirus disease 2019 (COVID-19) can be a life-threatening lung disease or a trivial upper respiratory infection depending on whether the alveoli are involved. Emergency department (ED) evaluation of symptomatic patients with normal vital signs is frequently limited to chest auscultation and oro-nasopharyngeal swabs. We tested the null hypothesis that patients being screened for COVID-19 in the ED with normal vital signs and without hypoxia would have a point-of-care lung ultrasound (LUS) consistent with COVID-19 less than 2% of the time.MethodsWe performed a retrospective, structured, blinded ultrasound review and chart review in patients 14 years or older with symptoms prompting ED evaluation for COVID-19. We excluded those with known congestive heart failure or other chronic lung conditions likely to cause excessive B-lines on LUS. We used a two-sided exact hypothesis test for binomial random variables. We measured LUS diagnostic performance using computed tomography as the gold standard.ResultsWe reviewed 77 charts; 49 met inclusion criteria. Vital signs were normal in 30/49 patients; 10 (33%) of these patients had LUS consistent with viral pneumonitis. We rejected the null hypothesis (p-value <0.001). The treating physicians’ interpretations of their own point-of-care LUS had a sensitivity of 100% (95% confidence interval (CI), 74%, 100%), specificity 88% (95% CI, 47%, 100%), likelihood ratio (LR) positive of 5.8 (95% CI, 1.3, 25), and LR negative of 0.05 (95% CI, 0.03, 0.71) when compared to CT findings.ConclusionLUS had a meaningful detection rate for pneumonitis in symptomatic ED patients with normal vital signs who were being evaluated for COVID-19. We recommend at least LUS be used in addition to polymerase chain reaction testing when evaluating symptomatic ED patients for COVID-19.

COVID-19 Early After a Deceased Donor Kidney Transplant Surgery

Many transplant centers reduced their solid organ transplant procedures in response to the coronavirus disease 2019 pandemic.1,2 We describe the course of a kidney transplant recipient who presented with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection 10 days after transplant surgery. The patient is a 41-year-old Hispanic woman with end-stage kidney disease secondary to lupus nephritis on maintenance hydroxychloroquine 200 mg daily who presented for a zero HLA A, B, DR mismatched deceased donor kidney transplant. The donor was involved in a motor vehicle accident and sustained multiple injuries resulting in his death. He had a negative SARS-CoV-2 nasopharyngeal swab. The patient denied symptoms of SARS-CoV-2 infection or exposure to SARS-CoV-2-positive individuals and stayed at home before transplant except for going to her dialysis unit. Her preoperative nasopharyngeal swab for SARS-CoV-2 was negative and her chest X-ray was normal. She received induction immunosuppression with intravenous high-dose steroids and reduced-dose rabbit anti-thymocyte globulin, 3 mg/kg per our center’s protocol for zero antigen-mismatched transplants, and maintenance tacrolimus, mycophenolate 500 mg twice daily and prednisone taper in addition to hydroxychloroquine. She had immediate allograft function and was discharged 5 days following her transplant with serum creatinine of 1.7 mg/dL. Her absolute lymphocyte count at the time of discharge was 550 cells/mm3. Ten days posttransplant, she developed a fever of 100°F, dry cough, sore throat, and 2 episodes of diarrhea. A nasopharyngeal swab was obtained and was positive for SARS-CoV-2. It is thought that she acquired SARS-CoV-2 infection from contact with a family member who worked in a grocery store. Her oxygen saturation was 97% on room air and she had normal vital signs. Chest X-ray showed a new discoid opacity within the right lower lung (Figure 1). Mycophenolate was held, prednisone dose was immediately reduced from 20 mg to 10 mg and then to 5 mg maintenance, tacrolimus was dosed to maintain trough levels of 7–10 ng/mL, and hydroxychloroquine was increased to 200 mg twice daily, based on earlier reports in the pandemic about its presumed effectiveness. C-reactive protein was 0.4 mg/dL, absolute lymphocyte count was 1200 cells/mm3, and serum creatinine was 1.1 mg/dL. She received 1 unit of convalescent plasma transfusion through Food and Drug Administration expanded access pathway under a protocol that was approved by our Institutional Review Board; however, after completion, she developed urticaria, which was treated with antihistamines. She had a positive direct antiglobulin test confirming the transfusion reaction. She remained clinically stable and was discharged after 1 day of hospitalization with a pulse oximeter to monitor her oxygen saturation at home. More than 60 days have passed since discharge, and she continues to do well.FIGURE 1.: Left, Preoperative chest X-ray. Right, Chest X-ray at the day of presentation with COVID-19 symptoms.This report demonstrates that despite acquiring SARS-CoV-2 at the “peak” of immunosuppression, which included lymphocyte depletion, our patient had only mild symptoms and did not develop serious complications. The utility of convalescent plasma in renal transplant recipients with SARS-CoV-2 is not well defined. A recent report described successful recovery in a kidney transplant recipient who had severe infection with SARS-CoV-2 and was treated with 2 units of convalescent plasma.3 In view of the very recent and “heavy” immunosuppression in our patient, we decided to utilize convalescent plasma, despite her mild illness. More data are needed to better describe SARS-CoV-2 infection and treatment in peritransplant period. Finally, it is crucial to highlight the importance of taking meticulous measures and precautions in this patient population, especially in the presence of household contacts working at potentially “high risk” jobs for acquiring and transmitting SARS-CoV-2. Self-quarantine, physical distancing, and frequent hand hygiene should be undertaken at the highest potential levels.

The safety of home discharge for low-risk emergency department patients presenting with coronavirus-like symptoms during the COVID-19 pandemic: A retrospective cohort study.

ObjectiveThere is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID‐19) infection who are not hospitalized. The study objective was to assess 30‐day outcomes (ED revisit, admission, ICU admission, and death) for low‐risk patients discharged after ED evaluation for COVID‐19.MethodsThis was a retrospective cohort study of patients triaged to a COVID‐19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well‐appearing with few comorbidities. Data were collected from review of medical records and phone follow‐up, and the analysis was descriptive.ResultsOf 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow‐up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3–7, range 1–17). There were no known deaths.ConclusionsA minority of low‐risk patients with suspected COVID‐19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well‐appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.

Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden

BackgroundThere has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data.MethodsA descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test.ResultsOut of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women.ConclusionsFewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.

Serious conditions among patients with non-specific chief complaints in the pre-hospital setting: a retrospective cohort study

BackgroundEmergency Medical Services (EMS) are faced daily with patients presenting with a non-specific chief complaints (NSC); i.e. decreased general condition, general malaise, sense of illness, or just being unable to cope with usual daily activities. Patients presenting with NSCs often have normal vital signs. It has previously been established that however, NSCs may have a serious underlying condition that has yet to be identified. The primary outcome of this study was to determine the prevalence of serious conditions in patients presenting with NSCs to the EMS.MethodA retrospective cohort study of patients ≥18 years of age who were reported as presenting with chief complaints compatible with NSCs to the EMS in Stockholm Region and transported to an emergency department between January 1st, 2013 and December 31st, 2013. Patients were identified via the EMS electronic health care record and followed via records from the National Patient Registry and Causes of Death Registry at Sweden’s National Board for Health and Welfare. The definition of serious condition was defined by expert consensus. Descriptive statistics as well as regression analyses were used.ResultsA total of 3780 patients were included, with a median age of 77 years. A serious condition was present in 35.3% of the patients. The in-hospital mortality rate for the group with serious conditions was 10.1% (OR 6.8, CI 95%, 4.1–11.3), and the 30-day mortality rate was 20.2% (OR 3.1, CI 95%, 2.3–4.0). In the group with no serious conditions the rates were 1.0 and 4.2%, respectively. The total hospitalization rate was 67.6%. The presence of serious conditions as well as increased mortality rates were associated with Rapid Emergency Triage and Treatment system (RETTS) as well as National Early Warning Score (NEWS) irrespective of triage score.ConclusionMore than one-third of the patients presenting with NSCs to EMS had a serious underlying condition which was associated with increased mortality and hospitalization rates.Trial registrationNot applicable.

Magnetic sphincter augmentation device malfunction

A 72-year-old woman underwent repair of a 4-cm hiatal hernia with placement of a magnetic sphincter augmentation (MSA) device for persistent symptoms of gastroesophageal reflux (GERD). Four months after her procedure, she experienced an acute episode of severe noncardiac chest pain followed by recurrent symptoms of heartburn, belching, and regurgitation. She did not recall any significant symptoms or events that triggered her pain. Notably, she had lost and regained 3.5 kg after the procedure. Her physical examination results were notable for normal vital signs, a body mass index of 33.5 kg/m2, and a soft, nontender abdomen.

Sickle cell disease and COVID-19: Atypical presentations and favorable outcomes.

Sickle cell disease and COVID-19: Atypical presentations and favorable outcomes.

An Unusual Cause Of Lower Leg Pain - Long Distance Running

HISTORY: A 42 yr runner presented to the sports medicine clinic two weeks after having successfully completed an ultra-marathon complaining of left calf pain. The onset of the pain occurred the day after the race but within a short period the pain was present after walking short distances. The pain was claudicant, with accompanying foot paraesthesia and leg weakness. Rest pain was absent. Besides hypercholesterolaemia and previous kidney stones, the patient was well, a non-smoker with some symptoms of atopy but no other relevant medical or family history. PHYSICAL EXAMINATION: The patient appeared to be generally well, with normal vital signs. On inspection of his limbs, there was no obvious swelling, discoloration or evidence of tissue loss. On palpation the left limb was slightly cooler to touch with a prolonged capillary refill time. On examination of his pulses, his upper limb pulses where symmetrical and equal but on examination of his lower limbs his left femoral pulse was slightly diminished, with a soft bruit. The left popliteal and dorsalis pedis pulses were absent. He was unable to run, and was only able to walk approximately 100 m. No left foot pulses felt post exercise or heard on office Doppler examination. DIFFERENTIAL DIAGNOSIS: 1.Musculoskeletal injury eg gastroc tear 2.Vascular occlusion: popliteal artery entrapment, atherosclerotic occlusion, other occlusive disease 3.Posterior chronic compartment syndrome 4. Referred pain TEST AND RESULTS: 1. Duplex Doppler was performed but was obscured by bowel gas, yet aorta and proximal common iliac was patent. The distal common iliac and proximal external iliac could not be visualized. Distal external iliac and common femoral vessels were patent. 2. Angiogram performed of the external iliac artery, demonstrated a string-like appearance pathognomonic of fibromuscular dysplasia. A full visceral angiogram was normal. FINAL WORKING DIAGNOSIS: Fibromuscular dysplasia of the external iliac artery TREATMENT AND OUTCOMES: 1. A transverse arteriotomy was initially made in the CFA which revealed a 50% stenosis caused by a medial soft plaque. Fogarty thrombectomy was performed on the SFA resulting in good backflow 2. A long saphenous venous patch used. 3. Anticoagulation 3. Initial rest with gentle mobilization 4. Return to sport programme

An Explosive Workup for Diarrhea: The Cascade Effect From an Incidental Finding on a Laboratory Panel.

A 19-month-old boy with a medical history of 1 febrile seizure presented to the emergency department (ED) with 2 days of vomiting and 1 day of diarrhea. He was accompanied by his non–English-speaking mother, who reported several episodes of nonbloody, nonbilious emesis and dark brown, watery stools. The patient had decreased intake of solid foods, but he had been breastfeeding well. Because of his diarrhea, the patient’s mother was unsure how many voids he had had in the past day. He had not had fevers. The family history was significant for the patient’s father recently being diagnosed with hepatitis C. The patient’s mother brought him into the ED because of his symptoms and concern that he looked “yellow.” In the ED, the patient was afebrile with normal vital signs for his age (including heart rate of 146 beats per minute), and he was “well appearing and active” with moist mucous membranes and a capillary refill of <2 seconds. However, the ED provider additionally documented that the patient appeared “moderately dehydrated [and] slightly jaundiced,” and he ordered a comprehensive metabolic panel (CMP). All values were within normal limits, including total bilirubin, except for a low bicarbonate of 16 mmol/L (normal 21–30 mmol/L) and an elevated alkaline phosphatase (ALP) of 926 U/L (normal 129–291 U/L). The provider consulted endocrinology for the elevated ALP, who noted a broad differential for elevated ALP and that transient hyperphosphatasemia is a diagnosis of exclusion. They recommended checking 25-hydroxyvitamin D, phosphate, and parathyroid hormone to evaluate for underlying parathyroid, vitamin D, and bone disease. They also wrote that the team could check total and isoenzymes of ALP “if desiring further testing to help confirm [the] diagnosis of transient hyperphosphatasemia.” The ED provider obtained these recommended laboratories, including the ALP laboratories, as well as a gamma-glutamyl transferase, acute …

“My Rapidly Growing Neck”

“My Rapidly Growing Neck”