Past Medical History Of Asthma Research Articles

SAT617 Third Nerve Palsy As The Initial Presentation Of Pituitary Apoplexy, A Case Report

Abstract Disclosure: U. Siddiqui: None. M. Ahmad: None. K. Abiko: None. P. Ucciferro: None. Pituitary apoplexy is characterized by hemorrhage or infarction of the pituitary gland occurring after growth of a pre-existing adenoma. These adenomas are often asymptomatic, however, hemorrhage can compress surrounding cranial nerves and cause symptoms. We report a case of a 48-year-old male who presented with headache and third nerve palsy, found to have pituitary apoplexy despite negative initial CT imaging. Hospital Course: A 48-year-old man with a past medical history of asthma, cirrhosis, type 2 diabetes mellitus, hypertension and end stage renal disease presented to the emergency room for bitemporal headache. The headache was associated with right-sided blurry vision and ptosis. He was hypertensive to 166/79 mmHg, bradycardic to 58 beats per minute, afebrile with a temperature of 36.8 C with a respiratory rate of 18 breaths per minute. He was noted to have ptosis and inferolateral deviation of his right eye. Initial labs demonstrated the following: sodium 139 mmol/L, potassium 5.2 mmol/L, creatinine 8.44 mg/dL (baseline 6.5 mg/dL), bicarbonate 20 mmol/L, and hemoglobin 8.2 g/dL (baseline of 8-9 g/dL). The patient’s CT head without contrast and CT angiogram head and neck which were negative for acute infarct or hemorrhage, however, the patient’s MRI demonstrated a 2.1 x 2.1 x 1.4 cm macroadenoma with suprasellar extension and mild elevation of the optic chiasm. Further testing demonstrated a normal thyroid stimulating hormone level of 0.74 uIU/ml (normal 0.3-5.0 uIU/ml), low normal free t4 of 0.7 ng/dL (0.7-1.7 ng/dL), ACTH of <9 pg/ml (normal 9-46 pg/ml), morning cortisol of 1.3 mcg/dL (normal of >18 mcd/dL), total testosterone <10 ng/dL (normal 270-1070 ng/dL), follicular stimulating hormone of 2.2 mIU/ml (normal 1.5-12.4 mIU/mL) and a prolactin of 49 ng/ml (normal 0-19 mg/ml). Due to the patient’s symptoms and imaging findings he underwent transsphenoidal resection of tumor. Prior to the procedure he was placed on stress dosed steroids with IV hydrocortisone. After the procedure, the patient was weaned off IV hydrocortisone and continued on oral 15 mg of hydrocortisone in the morning and 5 mg in the evening. A repeat free T4 after the procedure was 0.9 ng/dl and the patient was not discharged on levothyroxine supplementation. He follows up with endocrinology as an outpatient and has had resolution of his right sided ptosis and vision changes. Discussion: Pituitary apoplexy presents in a variety of different ways including headache, nausea, altered mental status, and hormonal dysfunction. Third nerve palsy is a potential presentation of this uncommon condition and should be considered even with negative initial CT imaging. Through our case we hope to highlight this manifestation of pituitary apoplexy as, if the etiology of third nerve palsy remains elusive, pituitary apoplexy should be considered as a differential and further imaging should be obtained. Presentation: Saturday, June 17, 2023

Coronavirus disease 2019-associated nephropathy in an African American patient: a case report and review of the literature

BackgroundAcute kidney injury is now recognized as a common complication of coronavirus disease 2019, affecting up to 46% of patients, with acute tubular injury as the most common etiology. Recently, we have seen an increase in cases of collapsing glomerulonephritis in patients with coronavirus disease 2019, also known as coronavirus disease 2019-associated nephropathy. It has been noted to be seen with a higher incidence in African American patients who are carriers of the APOL1 variant allele.Case presentationA 47-year-old African American male with a past medical history of asthma presented to the emergency department with complaints of intermittent chest pain, shortness of breath, and worsening confusion. On admission, he was found to be hemodynamically stable, but labs were significant for elevated creatinine and blood urea nitrogen, signifying acute kidney injury. He was admitted and taken for emergent dialysis. During his hospitalization, he was found to be positive for coronavirus disease 2019. Renal biopsy was done, which showed collapsing glomerulopathy, and the patient continues to require outpatient dialysis after discharge.ConclusionCollapsing glomerulonephritis has emerged as a complication in patients with coronavirus disease 2019. This condition should be particularly suspected in African American patients who present with acute kidney injury, nephrotic-range proteinuria, and who are positive for coronavirus disease 2019. Current treatment options are limited to supportive treatment and renal replacement therapy. More clinical cases and trials are needed to better understand and improve therapeutic outcomes in these patients.

MANAGEMENT OF MAJOR AIRWAY HAEMORRHAGE WITH VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN A HEART TRANSPLANT RECIPIENT

<h3>Objective</h3> To report the successful use of venovenous extracorporeal membrane oxygenation in a heart transplant recipient with a catastrophic airway haemorrhage. <h3>Design and methods</h3> Review of hospital records and imaging. <h3>Results</h3> A 56 year-old man with a past medical history of asthma, bronchiectasis and immunoglobulin A deficiency presented with end-stage ischaemic cardiomyopathy and recurrent pulmonary oedema. He was assessed for and underwent a heart transplant. The donor graft was well matched, but a small soft left anterior descending coronary artery plaque was noted at retrieval. In the first 24 hours post-transplant, he had a falling cardiac index followed by dysrhythmias. He was placed on veno-arterial extracorporeal membrane oxygenation (VA ECMO) and underwent PCI to the LAD lesion and started on aspirin and prasugrel. 48 hours later, his oxygenation requirements increased, his chest x-ray showed infiltrates and differential hypoxia (Harlequin Syndrome) was diagnosed. VAV ECMO was established. Overnight following VAV ECMO, fresh blood and clots were suctioned from the endotracheal tube, with falling tidal volumes to the point he was effectively unventilated. A CT scan showed extensive bronchial casts. A rigid bronchoscopy removed the clot. No specific bleeding point was identified, but general ooze from both bronchi was observed. Antiplatelet agents and systemic heparin were stopped, whilst distal limb perfusion catheter heparin was continued. Serial bronchoscopies were performed daily, removing small quantities of clot and applying topical therapies to various bleeding points in the right upper lobe. Tidal volumes remained under 100ml. Disseminated intravascular coagulation was diagnosed and product replacement guided by laboratory results and thromboelastography was undertaken. With improving cardiac function, arterial decannulation was achieved, leaving the patient on VV ECMO. This was continued for a further week with repeated flexible bronchoscopy and clot retrieval. Bleeding resolved after several days with conservative therapy, avoiding surgical or interventional radiological procedures. Improvements in tidal volumes were observed and eventually VV ECMO was successfully weaned. Aspirin was restarted as single antiplatelet therapy. He subsequently made a good recovery. <h3>Discussion</h3> VV ECMO is well established as a treatment in respiratory failure and pulmonary haemorrhage. However, use of VAV and VV ECMO for a major airway bleed in a heart transplant patient has not, to our knowledge, been previously described. The risks of running circuits without anticoagulation in patients totally dependent on them are high and managing this risk, alongside the new stent in a crucial coronary artery, were challenging. This case highlights the importance of balancing thrombosis and bleeding risk, especially in the context of new coronary stents, and has prompted consideration whether short-acting agents such as tirofiban may have a role in these especially high-risk cases.

Minimal Change Disease Secondary to Either COVID-19 Infection or Pfizer-BioNTech COVID-19 Vaccination

Abstract Introduction/Objective Kidney injury has now become one of the known complications following COVID-19 infection and vaccination. Only few cases of minimal change disease following administration of COVID-19 vaccination and infection have been reported. This study was to highlight incidence of minimal change disease following COVID-19 infection or vaccination. Methods/Case Report Case 1:15 year-old female with past medical history of asthma and hypercholesterolemia presented for evaluation of periorbital edema, nephrotic-range proteinuria, hypoalbuminemia, elevated serum creatinine, elevated blood pressures, and hematuria after COVID-19 infection. Renal biopsy after 1 week of infection showed unremarkable glomeruli and negative immunofluorescent stains in glomeruli, and 20-30% fusion of foot processes. The biopsy was consistent with a minimal change disease with features of natural remission (her nephrotic-range proteinuria resolved soon after). Case 2: 18 year-old female with no significant past medical history presented with a chief complaint of generalized swelling, which started around the same time she received her 1st dose of Pfizer COVID vaccine (the 2nd dose 2 months later). She had a nephrotic range proteinuria and hypoalbuminemia, but normal level of serum creatinine. A renal biopsy after 4 months of vaccination showed unremarkable glomeruli by light microscopy, negative immunofluorescent study, but diffuse effacement of foot processes involving more than 80% of the examined loops by electron microscopy. This biopsy findings were consistent with a minimal change disease. Both patients did not receive any treatment before the renal biopsies. Results (if a Case Study enter NA) NA Conclusion Minimal change disease can be a rare complication following COVID-19 infection or Pfizer COVID-19 vaccination, raising a question if there are similar antigens induced by the infection or by the vaccination that trigger the minimal change disease. Further studies are needed to determine the incidence and pathophysiology of minimal change disease either post COVID-19 vaccines or following COVID-19 infections.

PSAT302 Hypothyroidism Induced Nontraumatic Rhabdomyolysis: a Rare Cause of a Potentially Fatal Condition

Abstract Introduction Severe hypothyroidism can present with a vast array of clinical presentations, including musculoskeletal symptoms in up to 80% of patients. These symptoms can vary from simple muscle weakness and myalgias to rare complications such as rhabdomyolysis. Rhabdomyolysis, a syndrome characterized by degradation of muscle tissue, can occasionally lead to life-threatening complications including hyperkalemia, cardiac arrhythmias, and acute renal failure. We describe an interesting case of an otherwise healthy 19-year-old female with a past medical history of asthma who presented with nontraumatic rhabdomyolysis secondary to untreated hypothyroidism. Case description A 19-year-old female and college athlete of Asian descent with a past medical history of asthma presented to her primary care provider for acute and progressive swelling in her face, hands, and lower extremities bilaterally. In addition, she reported the onset of oligomenorrhea, decreased concentration, and myalgias for the past year. After relevant labwork was sent, the patient was found to have an extremely elevated TSH of 491.6 mIU/L with an undetectable level of free T4. She was referred for emergent hospital evaluation where notable lab findings included: creatinine 1.35 mg/dL, AST 300 IU/L, ALT 155 IU/L, LDH 888 IU/L, prolactin 41 ng/dL, and creatine kinase 8,380 IU/L. She was also found to be bradycardic (heart rate of 48 beats per minute) with low voltage QRS complexes on electrocardiography. She was admitted for treatment of newly diagnosed, severe hypothyroidism complicated by significant rhabdomyolysis. During her hospitalization, TPO antibodies were found to be negative however she was found to have a positive TSI level of 263% from baseline and positive antithyroglobulin of 6.7 units. Following treatment with weight-based intravenous levothyroxine (70 mcg daily), oral liothyronine (5 mcg twice daily), and intravenous fluid replacement with normal saline, the patient's condition and lab abnormalities improved significantly. She was eventually discharged and transitioned to oral levothyroxine (88 mcg). Seen in subsequent outpatient endocrinology follow-up, the patient has had normalization of all labs, including TSH, free T4, prolactin, creatinine kinase, and creatinine levels. She has experienced a complete resolution of myxedema symptoms and has had resumption of normal menses. Discussion Untreated or suboptimally treated hypothyroidism can be causative of various musculoskeletal manifestations including rhabdomyolysis. Hypothyroidism can induce muscle damage via various mechanisms including impaired glucose and triglyceride metabolism, glycosaminoglycan deposition in type I and II muscle fibers, decreased contractility of the actin-myosin unit and slowed ATP turnover. It is important to recognize hypothyroidism as a potential cause of non-traumatic rhabdomyolysis as prompt treatment with thyroid hormone can help prevent worsening muscle injury. As typically seen alongside myxedema with or without coma, treatment should be done in the inpatient setting with close hemodynamic and clinical monitoring and should include intravenous thyroid hormone, intravenous fluids and supportive care. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A 5 YEAR-OLD BOY WITH ATYPICAL UPPER LIP SWELLING

<h3>Introduction</h3> Lip swelling is a common chief complaint in the allergy clinic, but not all swelling is angioedema. Clinicians should keep their differential diagnoses broad when evaluating these patients. This is a case of lymphatic malformation (LM) in a boy with atypical upper lip swelling. <h3>Case Description</h3> A 5-year-old boy with a past medical history of asthma, tree nut allergy, allergic rhinitis, and atopic dermatitis presented for evaluation of persistent upper lip and maxillary gingival swelling. His lip swelling started suddenly and persisted for two years. The family reported intermittent "white fluid" drainage from the affected gingiva. Physical examination showed diffuse upper lip swelling and maxillary gingival swelling. Given his clinical history, his family and pediatrician attributed this swelling to an allergic reaction. He reported no improvement with daily antihistamines, but he did experience transient improvement with oral steroids. Contrast enhanced facial MRI was nonspecific, demonstrating a poorly defined area of mucosal thickening involving the upper lip and anterior maxillary alveolar ridge. He was evaluated by pediatric ENT who referred him to pediatric neurointerventional radiology for suspicion of LM. An ultrasound demonstrated a microcystic LM, notable for tiny anechoic areas without internal flow in the superior lip. The parents are considering definitive diagnosis with a biopsy and treatment options such as sclerotherapy. <h3>Conclusion</h3> LMs can be misdiagnosed as angioedema and should be considered in the differential diagnoses in patients with atypical lip swelling. Contrast enhanced MRI and ultrasound with color Doppler imaging are the recommended imaging modalities for evaluation.

ODP522 Thyroid Sarcoidosis: A Rare Manifestation of Systemic Sarcoidosis

Abstract Introduction Sarcoidosis is a multisystem granulomatous disease of unknown aetiology characterized by noncaseating granulomas. Thyroid infiltration remains extremely rare. If present, it can cause diffuse goitre and rarely a solitarythyroid nodule. Almost all patients are euthyroid. Here, we report a case of systemic sarcoidosis with thyroid involvement. Case presentation A21-year-old female of Nepalese origin with past medical history of Asthma presented with painful eyes and was diagnosed with bilateral anterior uveitis. Symptoms improved with topical Dexamethasone and Cyclopentolate. A screening chest radiograph showed significant hilar adenopathy. Chest CT scan confirmed extensive mediastinal adenopathy particularly in the right paratracheal, subcarinal and hilar node suggestive of sarcoidosis. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) revealed non-necrotising granulomas. There was no evidence of tuberculosis on any materials obtained. TB-PCR and AFB were both negative. Further investigations showed raised serum ACE (163 units/L) with normal adjusted calcium levels and normal 24-hour urine calcium levels. During follow up, she developed palpable cervical and submandibular lymphadenopathy. Systemic examination revealed a smooth goitre and erythema nodosum. She did not have any neck pain and remained clinically euothyroid. Thyroid ultrasound showed several small microlobulated hypoechoic regions in both thyroid lobes, the largest measuring 7 mm in the right and left upper poles. Fine needle aspiration cytology revealed granulomata consistent with thyroid sarcoidosis. The thyroid MDT recommend conservative management with periodic clinical and biochemical assessment. She remains well at 6 months of follow up. Conclusion Sarcoid granulomata within the thyroid gland remains rare. This case report illustrates that in patients with known sarcoidosis, careful thyroid assessment should be carried out. Presentation: No date and time listed

July 2022 Medical Image of the Month: Pulmonary Nodule in the Setting of Pyoderma Gangrenosum (PG)

No abstract available. Article truncated after 150 words. A 70-year-old man presented with persistent cough productive of clear sputum which had persisted approximately 12 months after COVID-19 infection. The patient reported a more recent history of night sweats and had also recently developed what he described as “blisters” on his chest wall and right shoulder starting 4 weeks prior to presentation that “opened up” giving off a bloody discharge. The patient had been treated with Bactrim and Doxycycline without improvement and reported a 10-pound weight loss over the past several months. The patient was a never-smoker with no significant travel history and a past medical history of asthma, GERD, gout, and chronic rhinitis. Vital signs and physical exam were normal, except for a 1 cm open wound in the center of the patient’s chest [Figure 2A]. A chest CT performed as part of the patient’s workup demonstrated a spiculated mass in the left upper lobe with adjacent mediastinal …

July 2022 Medical Image of the Month: Pulmonary Nodule in the Setting of Pyoderma Gangrenosum (PG)

No abstract available. Article truncated after 150 words. A 70-year-old man presented with persistent cough productive of clear sputum which had persisted approximately 12 months after COVID-19 infection. The patient reported a more recent history of night sweats and had also recently developed what he described as “blisters” on his chest wall and right shoulder starting 4 weeks prior to presentation that “opened up” giving off a bloody discharge. The patient had been treated with Bactrim and Doxycycline without improvement and reported a 10-pound weight loss over the past several months. The patient was a never-smoker with no significant travel history and a past medical history of asthma, GERD, gout, and chronic rhinitis. Vital signs and physical exam were normal, except for a 1 cm open wound in the center of the patient’s chest [Figure 2A]. A chest CT performed as part of the patient’s workup demonstrated a spiculated mass in the left upper lobe with adjacent mediastinal …

Safety of an Alternative Care Protocol for EMS non-transport in the COVID-19 Pandemic

Aim: Our primary goal was to evaluate safety of a new emergency medical services (EMS) protocol directing non-transport of low-acuity patients during the COVID-19 pandemic. Methods: We performed a retrospective cohort analysis of all patients in Marion County, Indiana, from March 23, 2020 to May 25, 2020 for whom a novel non-transport protocol was used by EMS for patients with low-acuity COVID-19 symptoms. We assessed paramedic compliance with the protocol to determine numbers and types of deviations. We further reviewed a statewide health information exchange database to identify any patients with emergency department (ED) visits, hospital admissions, or death within 30 days of the EMS non-transport. For ED and hospital visits, we collected ED or admission diagnoses to determine if the etiologies were COVID-related. Results: Between March 24, 2020 and May 25, 2020, 222 patients were documented as “Treated, Released (per protocol).” The protocol was correctly applied 144 times (64.8%). The other 78 times, although the EMS clinicians documented use of the protocol, it was not actually used (e.g., another protocol such as “no medical emergency” was used). Of the 144 patients for whom the protocol was used, in 55 cases (38.2%), the clinicians documented patient factors that should have contraindicated use of the protocol (e.g., chest pain, past medical history of asthma). The protocol was applied 5 times (3.5%) in pediatric patients. Two patients were admitted to the hospital within 72 hours of incorrect application of the protocol; both were for COVID-related complaints. Two patients were admitted to the hospital within 72 hours of correct protocol use; one was for a COVID-related complaint. Conclusion: In this case series, paramedics demonstrated large deviations from the novel non-transport protocol. Several patients were admitted to the hospital within 72 hours of non-transport both when the protocol was used correctly, and when it was used incorrectly.

Persistent cough and asthma-like symptoms post COVID-19 hospitalization in children

BackgroundsRespiratory viruses are the main triggers of asthma. Coronavirus is shown to contribute to respiratory tract infections that can lead to prolonged cough and asthma.ObjectivesPresent study aimed to determine the risk of developing Persistent cough and asthma-like symptoms in hospitalized children due to COVID-19.MethodsThis prospective study was carried out in a tertiary referral center. During the COVID-19 pandemic, 69 hospitalized pediatric patients admitted with COVID-19 were observed from February 2020 to January 2021. Clinical and laboratory data were recorded, and after discharge, patients were followed and visited for cough and asthma evaluation one, 2 and 6 months later. Patients with asthma-like diagnoses in follow up defined as asthma-like groups, and patients without any sign of asthma were categorized as the non-asthma group. Asthma-like co-morbids and risk factors were evaluated and compared between the two groups.ResultsIn follow-up, most of the COVID-19 hospitalized patients (N = 42) (58.5%) were not affected by asthma-like symptoms. 60.9% of the COVID-19 patients were male. The asthma-like group cases had a significantly familial history of asthma (63.0%), past medical history of asthma (33.3%), and Allergic rhinitis (85.2%). Rates of signs and symptoms during hospitalization were significantly higher in patients with COVID-19 and past medical history of asthma.ConclusionsWe found an asthma-like prevalence of 41.5% in the cohort of COVID-19 hospitalized children. Family history of asthma and previous history of asthma and allergic rhinitis are risk factors for asthma-like after COVID-19 hospitalization. COVID-19 presentations are more severe in the asthma-like group.

A case report of myocardial infarction with non-obstructive coronary arteries as the initial presentation of eosinophilic granulomatosis with polyangiitis

BackgroundEosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem disorder commonly affecting the lung and skin, with cardiovascular involvement found in up to 60% of patients. We present a case of myocardial infarction with non-obstructive coronary arteries (MINOCA) as the initial presentation of EGPA.Case summaryA 52-year-old female with past medical history of asthma, recurrent sinusitis, and peripheral neuropathy presented to our hospital with chest pain, rash, acute vision loss, elevated troponin, and peripheral eosinophilia. Electrocardiogram showed no ischaemic changes and coronary angiography displayed normal coronary anatomy. On a subsequent visit, cardiac magnetic resonance (CMR) showed predominant focal anteroseptal and inferoseptal akinesis with focal sub-endocardial delayed enhancement, indicative of a myocardial infarction involving the septal branches of the left anterior descending artery. Due to the focal findings on CMR, peripheral eosinophilia, and rash, the patient was evaluated for EGPA. Rheumatologic workup and skin biopsy were suggestive of small vessel vasculitis. The patient was diagnosed with multi-organ EGPA, involving the coronaries, which was ultimately thought to be the aetiology of her MINOCA. Following steroid and monoclonal antibody therapy, the patient experienced notable improvement in her cardiac function at follow-up appointments.DiscussionThis is a unique case MINOCA as the initial presentation of EGPA. Considering the heterogeneous disease presentation of those diagnosed with MINOCA, utilization of CMR is essential to guide diagnosis and management of such patients.

Factors Associated With Hospitalization in Children and Adolescents With SARS-CoV-2 Infection.

In this retrospective study of 319 children with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we assessed whether age, asthma, obesity, diabetes, and socioeconomic status were associated with hospitalization for coronavirus disease 2019 (COVID-19). Demographic and clinical characteristics were assessed using univariate statistics, excluding incidental or unrelated positives. There was a bimodal distribution of age among hospitalized children. Obesity (P < .001) and a past medical history of diabetes (P = .001) were significantly more prevalent in hospitalized children, including cases of new-onset diabetes and diabetic ketoacidosis. Neither a past medical history of asthma nor lower socioeconomic status was associated with hospitalization. Although limited to a single center, the findings in this study may have important clinical implications. Targeted, proactive health outreach to children with obesity and diabetes, with prioritization of preventative efforts such as vaccination, may be important in preventing worse SARS-CoV-2 infection in this vulnerable group.

STRIDOR IN A PATIENT WITH PULMONARY TB: CHASING A TRACHEAL RODENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: TB is an airborne infectious disease caused by Mycobacterium tuberculosis with the respiratory system being the most commonly involved. The involvement of airways is much less common than the lung parenchyma CASE PRESENTATION: A 38-year-old female patient with a past medical history of asthma and recently diagnosed with active pulmonary tuberculosis 6 months prior, on treatment with pyrazinamide, isoniazid, and rifampicin presented with c/o noisy breathing for 3 months. Was initially treated with bronchodilator and steroids with marginal improvement. Radiological evaluation revealed multiple cavitary lung nodules with tracheal stenosis as well right bronchus intermedius stenosis. Bronchoscopy revealed a stenotic segment measuring 2.5 cm, in the proximal trachea with residual airway which was not amenable to be passed through by bronchoscope. The stenotic lesion was biopsied and sequentially dilated to permit further advancement of the scope. There were no other stenotic segments. Several areas most notably at the distal main trachea and right main stem had what appeared to be caseating material coming through the wall of the airway with significant inflammation. Microbiological examination of bronchial washings and tissue samples did not reveal acid-fast bacilli. And this was not unexpected as the patient has already been on antituberculous treatment. Differentials of the tracheal stenosis including wegners, and other connective tissue disorders were ruled out after extensive serological testing DISCUSSION: During the pre-antibiotic era tracheobronchial tuberculosis was reported in 10-20% of all patients with pulmonary tuberculosis. The development of effective antitubercular drugs paralleled the decline in the incidence of tuberculosis in general and that of the trachea and bronchus. The pathophysiological mechanism of tracheal involvement includes implantation of organisms from infected sputum, extension to the peribronchial region by lymphatic drainage from parenchymal infection, direct extension from adjacent parenchymal infection, lymph node erosion, or hematogeneous spread. The disease progress in stages from simple erythema and edema with lymphocytic infiltration of the submucosa followed by tubercle formation. The end result is trachea bronchial narrowing secondary to fibrosis ensuing from extensive mucosal and submucosal tissue destruction. The common CT findings in the acute stage are smooth or irregular wall thickening causing. The role of steroids in the treatment is controversial with variable reports of efficacy during the early granulomatous phase. The mainstay of treatment remains to be antituberculous chemotherapy. Airway patency can be achieved by serial staged bronchoscopic-guided dilatation or stent insertion. CONCLUSIONS: A high index of suspicion will aid in early diagnosis and possible prevention of debilitating airway narrowing in tracheobronchial Tuberculosis. REFERENCE #1: Lee JH, Park SS, Lee DH, et al. EndobronchialTuberculosis: Clinical and Bronchoscopic Features in 121Cases. Chest 1992;102:990-4. REFERENCE #2: Jung SS, Park HS, Kim JO, et al. Incidence and clinicalpredictors of endobronchial tuberculosis in patients withpulmonary tuberculosis. Respirology 2015;20:488-95. REFERENCE #3: Kashyap S, Solanki A. Challenges in EndobronchialTuberculosis: From Diagnosis to Management. Pulm Med2014;2014:594806. DISCLOSURES: No relevant relationships by Muhammad Ahsan, source=Web Response No relevant relationships by Nadish Garg, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by ARCHANA SREEKANTAN NAIR, source=Web Response

GADOLINIUM-INDUCED CARDIOPULMONARY ARREST IN A 57-YEAR-OLD FEMALE

TOPIC: Allergy and Airway TYPE: Medical Student/Resident Case Reports INTRODUCTION: Magnetic resonance contrast agents are used to better characterize disease processes during Magnetic Resonance Imaging (MRI). Gadolinium based contrast agents (GBCA) are widely used due to their safety profile. The incidence of adverse events after receiving GBCAs is less than 2%, most being mild and transient [1,2]. Here, we see a patient who developed cardiopulmonary arrest after GBCA administration. CASE PRESENTATION: A 57 year old female with a past medical history of asthma, hypertension, diabetes, hyperlipidemia and mild COVID19 infection, presented to outpatient brain MRI for evaluation of new hearing loss. After receiving Gadobutrol, she developed shortness of breath, abdominal pain, and emesis. In the emergency department, the patient was hypothermic, tachypneic, and hypoxic;no urticaria or rash noted. She was placed on non-invasive ventilation and treated for presumed anaphylaxis, but remained hypoxic and in respiratory distress. Subsequent intubation (without angioedema visualized) was complicated by cardiac arrest, requiring six minutes of cardiopulmonary resuscitation. Initial imaging was significant for CT chest showing diffuse ground glass and consolidative opacities and normal CT head. Despite standard care treatment, the patient's neurological exam worsened, one week into her admission she was observed to have minimal brainstem reflexes, with head CT showing findings of anoxic brain injury, cerebral edema and possible uncal herniation. She worsened clinically and expired thirteen days after admission. Autopsy performed showed clinicopathological correlation attributing anoxic brain injury secondary to anaphylaxis. DISCUSSION: Gadobutrol is approved for multiple indications in most ages. It was introduced in 1998, its safety profile has been studied in patients worldwide. The incidence of adverse events of GBCA has been reported to be 0.32-3.8%, commonly nausea, vomiting, urticaria and dizziness. Risk factors include patients' history of respiratory allergic disease, asthma, COPD, or prior history of reactions to iodinated contrast media [1,2]. The incidence of serious adverse drug reactions (ADR) involving the cardiopulmonary system is reported to be <0.1%;from 1998-2012 there were 614 cases of ADR of which 7.2% were fatal [3]. Our case presentation shows a severe ADR to gadolinium contrast for MRI. Though the patient's pre-existing history of asthma put her at slightly higher risk, proven safety of gadolinium contrast significantly weighs towards continued use of contrast enhanced MRI. Nevertheless, awareness and timely response to possible contrast-induced ADR is important for all clinicians. CONCLUSIONS: GBCA are widely used agents with good safety profiles. Although severe adverse events are rare, it's important for physicians to have a high index of suspicion and use caution in patients that are identified with risk factors for adverse reactions to these agents. REFERENCE #1: [1] Marie-France Bellin. MR contrast agents, the old and the new. European Journal of Radiology volume 60, Issue 3, 2006, 314-323. doi.org/10.1016/j.ejrad.2006.06.021. REFERENCE #2: [2] Endrikat, Jan MD, PhD*†;Vogtlaender, Kai PhD‡;Dohanish, Susan RA§;Balzer, Thomas MD, PhD∥;Breuer, Josy MD, PhD*Safety of Gadobutrol, Investigative Radiology: September 2016 - Volume 51 - Issue 9 - p 537-543 doi: 10.1097/RLI.0000000000000270 REFERENCE #3: [3] Raisch, D. W., Garg, V., Arabyat, R., Shen, X., Edwards, B. J., Miller, F. H.,… West, D. P. (2013). Anaphylaxis associated with GADOLINIUM-BASED contrast AGENTS: Data from the food and DRUG Administration's adverse event reporting system and review of case reports in the literature. Expert Opinion on Drug Safety, 13(1), 15-23. doi:10.1517/14740338.2013.832752 DISCLOSURES: No relevant relationships by Lauren Blackwell, source=Web Response No relevant relationships by Rostislav Gorbatov, source=Web Response No relevant relationships by Chinazor Iwuaba, source=Web Response

INTRACRANIAL HEMORRHAGE IN A YOUNG ADULT WITH COVID-19 PNEUMONIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) most commonly presents with respiratory involvement. However, reports indicate that the central nervous system can also be affected. Neurological manifestations such as altered mental status, strokes, seizures, and even intracranial hemorrhage (ICH) have been noted in the literature. CASE PRESENTATION: A 28-year-old female with a past medical history of asthma presented to the emergency department (ED) with shortness of breath (SOB) that began 10 days prior. Four days earlier the patient went to urgent care for SOB and tested positive for COVID-19. She was provided an albuterol inhaler and prednisone 40 mg for five days. However, the patient's symptoms continued to worsen. In the ED, she was found to be saturating at 60% on room air. Therefore, she was placed on a non-rebreather mask and then high-flow nasal cannula at 55 liters/minutes. This improved her oxygen saturation to 90%;however, she was tachypneic with a respiratory rate of 30 bpm. Labs were significant for a pH 7.5, pCO2 28.6 mm Hg, white blood cell 16.94 x10

MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN AND ADOLESCENTS (MIS-C) IN A YOUNG ADULT WITH RECENT VACCINATION

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: MIS-C is described as a clinical syndrome developing secondary to Coronavirus disease 2019 (COVID-19) in children and adolescents. The presentation is similar to Kawasaki syndrome, hemophagocytic lymphohistiocytosis (HLH) and toxic shock syndrome. We present a case of MIS-C in a young adult two weeks after receiving vaccination for COVID-19. CASE PRESENTATION: 21 year old female with a past medical history of asthma who presented to the emergency department (ED) with fevers, chills and photophobia since receiving the JJ223:14–19.e2 REFERENCE #2: CDC COVID-19 Response Team. Coronavirus disease 2019 in children—United States, February 12–April 2, 2020. Morb. Mortal. Wkly. Rep. 2020, 69, 422–426. DISCLOSURES: No relevant relationships by Bilal Bangash, source=Web Response No relevant relationships by Issa Makki, source=Web Response No relevant relationships by Joseph Pitcher, source=Web Response

MEDIASTINAL MASS-INDUCED T WAVE INVERSION: FROM A ROUTINE EKG TO A MEDIASTINAL MASS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: T-wave inversion (TWI) is a negative T-wave of ≥1 mm in depth in two or more contiguous leads, with exclusion of leads aVR, III, and V1[1]. TWI has a wide differential diagnosis that can range from benign causes including normal variants to life-threatening causes including coronary artery disease and rarely can be related to non-cardiac causes [1]. CASE PRESENTATION: Our patient is an 18-years-old female with a past medical history of asthma and major depressive disorder. She presented to the psych emergency department (ED) because of suicidal attempts. Patient complaints of worsening feelings of sadness, loss of interest, and decreased energy. Also, she reported having suicidal ideations. Review of systems was unremarkable She was vitally stable. On physical examinations, lungs were clear to auscultation, cardiovascular exam of normal heart sounds, no murmurs or gallops. Labs were within normal limits, including electrolytes, TSH, D-Dimer, and cardiac enzymes. The routine evaluation protocol in the psych ED includes Electrocardiogram (EKG) mainly to look for QTC intervals, as many of the medications that are used for the psych population may alter the QTC interval. Her EKG showed sinus rhythm with T wave inversion in leads II, III, aVF, and V3-V6 with QTc of 483; there were no previous EKGs for comparison. The EKG was repeated on different days and showed the same findings. The patient reported no family history of cardiovascular diseases. Cardiology was consulted, an echocardiogram showed a large extracardiac mediastinal mass which appears to press on the right ventricle; otherwise, ejection fraction was normal, and no significant valvular disease was observed. A computerized tomography scan of the chest revealed a large, 12 x 7 x 6 cm mediastinal mass along the inferior wall of the heart, exerting mass effect and displacing the heart superiorly. The patient was discharged and referred to a cardiothoracic surgeon for further evaluation. DISCUSSION: Different clinical conditions can cause T-wave inversions, ranging from life-threatening events, such as acute coronary ischemia and pulmonary embolism, to entirely benign conditions[1]. The mediastinum is a potential space in the thoracic cavity that is subdivided into anterior, middle, posterior, and superior mediastinum to form a differential diagnosis for the lesion [2]. In our case, our patient was presented with Inferolateral TWI that was investigated and was found to have a lesion in the middle mediastinum that could be a pericardial cyst, bronchogenic cyst, esophageal implications cyst or lymph node enlargement that can be secondary to tuberculosis or sarcoidosis or histoplasmosis. CONCLUSIONS: This case highlights that inferolateral TWI should always be investigated thoroughly, including by imaging studies when the cause is not clear to prevent life threatening conditions. REFERENCE #1: Hayden GE, Brady WJ, Perron AD, Somers MP, Mattu A. Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med. 2002 May;20(3):252-62. doi: 10.1053/ajem.2002.32629. PMID: 11992349. REFERENCE #2: Mediastinum. In: Gurney JW, Winer-Muram HT, Stern EJ, et al, editors. Diagnostic imaging: chest. Section I. Salt Lake City (Utah): Amirsys; 2006 DISCLOSURES: No relevant relationships by Hasan Abuamsha, source=Web Response No relevant relationships by Abdul Rahman Al Armashi, source=Web Response No relevant relationships by Isaac Alsallamin, source=Web Response No relevant relationships by Ameed Bawwab, source=Web Response No relevant relationships by Eleonora Demyda, source=Web Response No relevant relationships by Faris Hammad, source=Web Response

A SIZEABLE COMPLICATION OF UNTREATED PNEUMONIA: A VIRIDANS STREPTOCOCCI POST PNEUMONIC EMPYEMA THORACIS

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Community acquired pneumonia (CAP) can result in significant morbidity and mortality. Among the patients admitted with CAP, a rare complication is a parapneumonic or post pneumonic empyema thoracis. Although the course may vary patient to patient, these complications can lead to a prolonged treatment course thus leading to a longer hospital stay and increased mortality. Early detection of CAP is key to avoiding these fatal complications. CASE PRESENTATION: We describe a 36 year-old-male with a past medical history of asthma, tobacco and heroin abuse who presented with a chief complaint of shortness of breath. The patient was previously admitted to the hospital two months prior and he was treated for an asthma exacerbation and community acquired pneumonia. Upon discharge, the patient did not complete the antibiotic course he was prescribed. He also reportedly developed worsening dyspnea on exertion with associated fever, chills, unintentional weight loss and pleuritic chest pain. Due to his worsening dyspnea, he subsequently returned to the hospital to seek emergency treatment. On this presentation, a CT chest was ordered and demonstrated a 17 x 15 x 23.5 cm cystic structure. Along with this, a right middle and lower lobe collapse and leftward mediastinal shift were also noted. CT surgery was consulted and the patient underwent a right thoracoscopy that converted to a right thoracotomy, pulmonary decortication, and parietal pleurectomy with eventual chest tube placement. Per the operative report, three liters of purulent foul smelling material was drained from the lung during the procedure. The purulent material was sent for cultures and grew pan-sensitive Streptococcus intermedius. The patient was then treated with antibiotics and he was discharged home with close follow-up. DISCUSSION: Pneumonia is the leading cause of empyema thoracis, therefore, it is important to recognize this serious complication. Early intervention is crucial as mortality significantly rises the longer patients are without treatment. A subset of patients require urgent exploratory thoracotomy within 24 to 48 hour with indications including: parenchymal, multiple loculations or a trapped lung. CONCLUSIONS: Although empyema thoracis does not have any age preference, pneumonia is typically more common in the elderly population with comorbidities. Interestingly, our patient was younger than the expected age range and he demonstrated a rare complication of pneumonia that resulted from early termination of antibiotic therapy. REFERENCE #1: Garvia V, Paul M. Empyema. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459237/ DISCLOSURES: No relevant relationships by Sara Khalid, source=Web Response No relevant relationships by Mahnoor Khan, source=Web Response No relevant relationships by Robert Ondracek, source=Web Response

27395 ANCA-positive hemorrhagic vasculitis with severe myositis—Atypical presentation of eosinophilic granulomatosis with polyangiitis (Churg-Strauss)

Patient history: A 41-year-old female with a past medical history of asthma presented to the emergency department for diffuse myalgias and a cutaneous eruption gradually worsening over two weeks. Physical examination showed symmetric violaceous papules and nodules on the dorsal arms and hemorrhagic vesicles overlying palpable purpura on the lower extremities. During admission she developed profound dysphagia and severe systemic muscle weakness.