QuantiFERON Gold Research Articles

Tuberculin test versus interferon gamma release assay in pregnant women with household contacts of tuberculosis patients.

Pregnant women who live in tuberculosis (TB)-affected households are more likely to develop latent TB infection (LTBI), which often escapes treatment. This study aims to determine if Interferon-gamma release (IGRA) is reliable in screening for LTBI in pregnant women, compare to the tuberculin skin test (TST). It was a cross-sectional study that involved 60 pregnant women with TB contact history as a proxy for LTBI and 30 pregnant women without contact history. Latent TB was detected using the TST 5 tuberculin units and IGRA using the QuantiFERON Gold Plus TB Test kit (QFT-Plus). The sensitivity and specificity of the two diagnostic methods and the agreement between them were estimated using SPSS version 20.0. The sensitivity 95% (95% confidence interval [CI]: 86.08%-98.96%) and specificity 26.7% (95% CI: 12.28%-45.89%) of TST were compared to that of the IGRA with 60% (95% CI: 46.54%-72.44%) and 73.3% (95% CI: 54.11%-87.72%) sensitivity and specificity, respectively in detecting LTBI in pregnancy. Although there was a significant difference (P < 0.05) between TST and IGRA, the agreement was fair (kappa 0.39; 95% CI: 0.24-0.45). TST assay is more sensitive than IGRA; however, the specificity of IGRA was superior to the TST method. In this study, a fair agreement of TST and IGRA was observed for detecting latent TB infection in pregnant women with household contact with TB patients.

TUBERCULOUS TAMPONADE WITH A TWIST: A CASE OF TB AND COVID-19

TUBERCULOUS TAMPONADE WITH A TWIST: A CASE OF TB AND COVID-19

REACTIVATION OF LATENT TB PRESENTING WITH BILATERAL PLEURAL EFFUSIONS

REACTIVATION OF LATENT TB PRESENTING WITH BILATERAL PLEURAL EFFUSIONS

S3328 An Atypical Etiology of Chronic Abdominal Pain: Peritoneal Tuberculosis

Introduction: Peritoneal tuberculosis (TB) is a rare presentation of extra-pulmonary TB, comprising only 5% of extra-pulmonary TB cases. Patients oftentimes present with non-specific complaints and without typical Mycobacterium tuberculosis risk factors. Additionally, diagnostic testing lacks high sensitivity and specificity with further invasive methods frequently necessitated. We present an unusual case of peritoneal TB presenting as non-localized abdominal pain, facilitating insight into this uncommon disease. Case Description/Methods: A 53-year-old female with a past medical history of hypothyroidism presented with joint pain diagnosed as seronegative rheumatoid arthritis and subsequently began treatment with methotrexate and adalimumab for one year. Within the following year, she experienced chronic right lower quadrant (RLQ) abdominal pain, fevers, night sweats, fatigue, and ascites. Extensive work-up revealed a positive QuantiFERON gold TB test. A diagnostic laparoscopy with peritoneal biopsy successively demonstrated elevated CA-125 and large-volume ascites. Mycobacterium tuberculosis PCR and Grocott methenamine silver staining were negative. One of two acid-fast bacillus (AFB) smear and cultures yielded a positive result. Our patient was treated for peritoneal TB. She continued to have several years of chronic RLQ abdominal pain several months after RIPE treatment completion, undergoing a cholecystectomy and three adhesion lysis procedures with mild symptomatic improvement and subsequent worsening thereafter. An operative note highlighted the large amount of adhesions from the patient’s liver to her diaphragm and anterior abdominal wall, appearing similar to Fitz-Hugh-Curtis syndrome. She continues to have chronic abdominal pain and is followed closely by her treatment team. Discussion: Our patient was on immunosuppressive medications and had a history of travel to Mexico, a high TB burden country. Notably, AFB smear and culture has a poor sensitivity for peritoneal TB, oftentimes necessitating laparoscopic peritoneal biopsy for further diagnosis. Our patient was empirically treated for peritoneal TB before AFB culture yielded positive results, given her B symptoms and positive QuantiFERON test. She also had an elevated CA-125 value, which is associated with peritoneal TB and may be used in patients with a negative AFB stain. Our patient experienced recurrent adhesions, an unfortunate and persistent consequence of the inflammatory nature of peritoneal TB.

HEMORRHAGIC PLEURAL EFFUSION IN A PATIENT WITH CHRONIC LYMPHOCYTIC LEUKEMIA ON IBRUTINIB THERAPY

HEMORRHAGIC PLEURAL EFFUSION IN A PATIENT WITH CHRONIC LYMPHOCYTIC LEUKEMIA ON IBRUTINIB THERAPY

S2917 Acute Alcoholic Hepatitis With Portal Hypertension Complicated by Tuberculous Peritonitis and Ascites

Introduction: Peritonitis related to tuberculosis (TB) infection is rare in the US and normally associated with immunocompromised states. We present a patient found to have TB peritonitis during evaluation of alcoholic hepatitis without evident lung disease. Case Description/Methods: The patient is a 39 yo male born in Mexico with no medical history who presented with three days of abdominal distention, jaundice, and fevers in the setting of alcohol use disorder. He had no other historic risk factors for TB or cough. Exam was remarkable for a distended abdomen. Laboratory results showed leukocytosis, total bilirubin 3.5 (mg/dL), alkaline phosphatase 295 (U/L), AST 147 (U/L), ALT 62 (U/L), and positive quantiferon gold. Chest x-ray had no pulmonary lesions. Ascites fluid studies were significant for high white count (2214 k/uL) with lymphocytic predominance (91%). The serum ascites albumin gradient was consistent with portal hypertension, and ascites total protein was elevated (3.6 g/dL). Fluid ADA was positive. Cross sectional imaging of the abdomen showed omental caking, peritoneal lining nodularity, and hepatosplenomegaly. Fine needle aspiration of the peritoneum showed necrotizing and non-necrotizing granulomas. Sputum gram stain was negative for acid fast bacilli although sputum and ascites cultures ultimately grew TB (Figure). The patient was started on rifampin, isoniazid, pyrazinamide and ethambutol for TB and abstained from further alcohol use. Three months after discharge, jaundice and ascites had resolved and his liver tests had significantly improved. Discussion: TB peritonitis makes up 4-10% of extrapulmonary TB infections. Though rare in the US, it has a high mortality rate (50-60%). Diagnosis can be complicated by difficulty isolating the organism and culture results can take weeks. TB peritonitis can be supported by ascites fluid studies with elevated lymphocyte count, total protein, and positive ADA; although for more definitive diagnosis peritoneal biopsy should be considered. This patient represents a unique confluence of portal hypertension related ascites, induced by acute alcoholic hepatitis, along with TB peritonitis. It is possible that transient immunosuppression from alcoholic hepatitis served as a risk factor in reactivation and dissemination of latent TB. An index of suspicion for TB infection, based on his foreign birth, along with his abnormal ascites fluid studies, led to the peritoneal biopsy and ultimate culture diagnosis of his infection that might otherwise have been overlooked.Figure 1.: Nodularity of the peritoneal lining.

TB REACTIVATION FOLLOWING COVID-19 INFECTION

TB REACTIVATION FOLLOWING COVID-19 INFECTION

Exploring alternative cytokines as potential biomarkers for latent tuberculosis infection in pregnant women.

Interferon gamma release assays (IGRAs) are widely used to determine latent tuberculosis infection status. However, its pregnancy-affected performance and cost-expensive nature warrants for different alternatives for pregnant women. This study aims to evaluate the diagnostic performance of several alternative cytokines, including interleukin 2 (IL-2), interleukin 10 (IL-10), and interferon gamma-induced protein 10 (IP-10) to identify latent tuberculosis status in pregnant women. 123 pregnant womens were recruited for this study. The IGRA status was determined by using QuantiFERON Gold In-Tube. Meanwhile, we measured the level IL-2, IL-10, and IP-10 by using sandwich-microELISA method. We performed normality and comparison test by SPSS. In addition, receiver-operator characteristic (ROC) analyses and the optimal cutoff scores were identified using the EasyROC webtool. We showed that IL-2, IL-10, and IP-10 were able to discriminate between IGRA-negative and IGRA-positive pregnant women. Moreover, IP-10 showed the highest discriminatory and diagnostic performance when compared to IL-2 and IL-10 with area under the curve (AUC) of 0.96 and cutoff point of 649.65 pg/mL. Our study showed that IP-10 can be considered as a promising alternative biomarker for IGRAs to diagnose LTBI in pregnant women.

The Pitfalls of Mining for QuantiFERON Gold in Severely Ill Patients With COVID-19

ObjectiveTo assess the proportion of indeterminate QuantiFERON-TB Gold Plus (QFT-Plus) results in patients admitted for severe coronavirus disease 2019 (COVID-19) pneumonia and evaluate the factors associated with indeterminate QFT-Plus results. Patients and MethodsData on COVID-19 admissions at Mayo Clinic in Florida were extracted between October 13, 2020, and September 20, 2021, and data from a prepandemic cohort were extracted between October 13, 2018, and September 20, 2019. A secondary analysis of the COVID-19 cohort was performed using gradient boosting modeling to generate variable importance and SHapley Additive exPlanations plots. ResultsOur findings demonstrated more indeterminate QFT-Plus test results in patients hospitalized for severe COVID-19 infection than in patients without COVID-19 (139 of 495, 28.1%). The factors associated with indeterminate QFT-Plus test results included elevated levels of C-reactive protein, ferritin, lactate dehydrogenase and interleukin-6 and included lower levels of leukocyte, lymphocyte, and platelet counts. ConclusionThe patients with severe COVID-19 had a higher likelihood of indeterminate QFT-Plus results, which were associated with elevated levels of inflammatory markers consistent with severe infection. Interferon-gamma release assay screening tests are likely confounded by COVID-19 infection itself, limiting the screening ability for latent tuberculosis infection reactivation. Indeterminate QFT-Plus results may also require follow-up QFT-Plus testing after patient recovery from COVID-19, increasing the cost and complexity of medical decision making and management. Additional risk assessments may be needed in this patient population for screening for latent tuberculosis infection in patients with severe COVID-19.

Non-pulmonary Disseminated Tuberculosis Complicated by Constrictive Pericarditis and Cutaneous Gumma.

A 23-year-old previously healthy male presented to the hospital with symptoms of heart failure. He was diagnosed with pericarditis and found to have a reduced left ventricular ejection fraction of 25%. He was noted to have mediastinal lymphadenopathy. Pulmonary and abdominal sampling were non-diagnostic for infection, autoimmune disease, or malignancy. A QuantiFERON Gold returned positive. After a thorough travel history and detailed exam, the patient was diagnosed with disseminated tuberculosis after the discovery of a cutaneous gumma that was found to have acid-fast bacilli present on biopsy with Fite’s stain. 18F-FDG PET CT and cardiac MRI were pursued given that pericardial and myocardial biopsy could not be safely performed due to the patient’s hemodynamics. 18F-FDG PET CT and cardiac MRI did not demonstrate any myocardial pathology responsible for the left ventricular ejection fraction. This case highlights that pulmonary involvement is not necessary for disseminated TB, Fite’s stain may be used to identify M. tuberculosis, and that cardiac MRI and 18F-FDG PET CT may be useful to delineate myocardial involvement in high-risk situations.

Hypovitaminosis D among newly diagnosed pulmonary TB patients and their household contacts in Uganda

An estimated one billion people globally live with hypovitaminosis D. Studies have indicated that vitamin D deficiency is a risk factor for active tuberculosis (TB) disease. The aim of this study was to determine the association between vitamin D deficiency and TB status among patients with active TB, latent TB infection (LTBI) and those without TB infection. In a cross-sectional study of active TB patients, LTBI, QuantiFERON GOLD testpositive and (QFN+TST+) household contact and controls QuantiFERON GOLD testnegative (QFN−TST−) samples vitamin D levels were compared. Vitamin D status was determined by measurement of total vitamin D levels with 56 samples of active TB patients, 17 with LTBI, and 22 without TB infection using electrochemiluminescence. The median interquartile range (IQR) age of the study participants was 28 (20–35) years, and the majority (63%) were females. The median (IQR) vitamin D levels were 18 ng/ml (14–24). All groups had vitamin D hypovitaminosis with significantly lower levels among active TB patients (17 ng/ml, 13, 2) than among LTBI individuals (23 ng/ml 16–29) and those without TB infection (22 ng/ml, 17–28).

Variability of interferon-γ release assays in people at high risk of tuberculosis infection or progression to tuberculosis disease living in the United States

ObjectivesInterferon-γ release assays, including T-SPOT.TB (TSPOT) and QuantiFERON Gold In-Tube (QFT), are important diagnostic tools for tuberculosis infection, but little work has been done to study the performance of these tests in populations prioritized for tuberculosis testing in the United States, especially those other than health care personnel. MethodsParticipants were enrolled as part of a large, prospective cohort of people at high risk of tuberculosis infection or progression to tuberculosis disease. All participants were administered a tuberculin skin test, TSPOT, and QFT test. A subset of participants had their QFT (n = 919) and TSPOT (n = 885) tests repeated when they returned to get their tuberculin skin test read 2 to 3 days later (repeat study). A total of 531 participants had a TSPOT performed twice on the same sample taken at the same time (split study). ResultsThe QFT repeat test interpretations were discordant (one test positive and the other negative) for 6.4% of participants (59 of 919), and the TSPOT tests were discordant for 60 of 885 participants in the repeat study (6.8%) and 41 of 531 participants in the split study (7.7%). There was a high degree of variability in the quantitative test results for both QFT and TSPOT, and discordance was not associated with both test results being near the established cut-offs. Furthermore, the proportion of discordance was similar when comparing participants in both the TSPOT repeat and TSPOT split studies. DiscussionBoth QFT and TSPOT were 6% to 8% discordant. The results should be interpreted with caution, particularly when seeing a conversion or reversion in serial testing.

Concordance of TST and QFT-Plus, Sensitivity and Specificity of TST and QFT-Plus in Detection of LTBI in MDR TB Contact

Background: Tuberculosis (TB) is an infectious disease and the main cause of world health problems. Not all individuals infected with Mycobacterium tuberculosis (Mtb) develop active TB. Latent tuberculosis infection (LTBI) is a state of persistent immune response to stimulation of the Mtb antigen with no evidence of clinically manifest active TB. Closed contact and household contact with MDR TB patients increases the risk of MDR TB transmission. There is no gold-standard test for LTBI. Tuberculin Skin Test (TST) and Quantiferon Gold Plus (QFT-Plus) examinations are used for LTBI diagnosis.Methods: A cross-sectional diagnostic test of 32 MDR TB contacts, consisting of 16 household contacts and 16 close contacts, was conducted in April 2020 at Dr. Moewardi Surakarta Hospital.Results: Positive TST results among MDR TB contacts were 18.8%, while QFT-Plus positive was 25%. The concordance level of TST and QFT-Plus was nearly perfect (κ=0.818, p&lt;0.001). The sensitivity and specificity of QFT-Plus with household contacts as the gold standard were 37.5% and 87.5%, respectively. The sensitivity and specificity of TST with household contacts as the gold standard were 25% and 87.5%, respectively.Conclusion: The concordance level of TST and QFT-Plus in the detection of LTBI in MDR TB contacts was very good. The TST can be used in place of QFT-Plus although QFT-Plus has better sensitivity. Both tests are useful for confirming TB infections. Both of these tests are not diagnostic, however they can be used to screen for LTBI in MDR TB contacts.

An Unusual Case of Small Intestinal Stricture Caused by Gastrointestinal Sarcoidosis.

A 29-year-old African-Caribbean male presented with right-sided flank pain and 20-lb weight loss over one year. Physical examination showed mild peri-umbilical tenderness. Laboratory studies showed hemoglobin 9.3 gm/dl, elevated erythrocyte sedimentation rate (65 mm/h), and C-reactive protein (15 mg/ml). QuantiFERON gold was negative. X-ray of the abdomen and pelvis showed dilated proximal small bowel with a stricture in the mid-jejunum (Figure A). Stricture could not be reached with a push enteroscopy.

1303. A Rare Case of Legionella micdadei Lung Abscess in an Immunocompromised Patient

Abstract Background Legionella micdadei is the most common legionella species causing infection after L. pneumophila. It usually causes infection in immunocompromised hosts and leads to nodules with tendency to cavitate. It is difficult to culture which makes diagnosis challenging. We report a case or L. micdadei in an immunocompromised host with cavitary pneumonia. Methods Case Report. An 82 year-old female presented with upper abdominal pain for one day duration. She has history of hypertension, coronary artery disease, hyperlipidemia, heart failure, and hypothyroidism. She was diagnosed with hypersensitivity pneumonia 5 months prior, treated with prednisone (40 mg daily). The pain was not associated with nausea, vomiting or diarrhea. She was found with hypoxia despite she denied shortness of breath, cough, hemoptysis or chest pain. There was no fever, chills, headache, myalgia or upper respiratory symptoms. She was afebrile, tachycardic 134/min and hypoxic to 88% on room air. White cell count was 22x10(3) /mcL (90% neutrophils), hemoglobin was 10.4 g/dL, creatinine was 1.23 mg/dL and lactic acid was 3.6 mmol/L. Chest CT scan showed left lower lobe cavitary lesion with surrounding infiltrates (image 1). Quantiferon gold, serum galagtomannan, B-D-glucan, and vasculitis work-up were negative. Bronchoscopy showed a patent airway. Bronchial smears and cultures were negative for bacteria, fungi and mycobacteria. The patient was treated with ceftriaxone and metronidazole with de-escalation to amoxicillin/clavulanate. Bronchial culture was positive for legionella micdadei after discharge, azithromycin was added. Image 1. Cavitary lesion on thoracic CT Results Our patient was considered immunocompromised given steroid use, predisposing her for L. micdadei infection. L. micdadei is considered an opportunistic infection and was reported in hematologic malignancy population. It can cause an invasive lung disease with lung cavities. It needs special media for growth making it difficult to diagnose especially it is not detected by legionella urine antigen. Conclusion L. micdadei should be considered in the differential diagnosis for cavitary lung lesions in immunocompromised patients. Disclosures All Authors: No reported disclosures

655. Patterns of Interferon-Gamma Release Assay (IGRA) Testing for Tuberculosis in Patients Less Than 2 Years Old

BackgroundThe American Academy of Pediatrics recommends use of Interferon-Gamma Release Assays (IGRAs) to diagnose tuberculosis (TB) infection in patients ≥2 years old. However, IGRAs are not currently recommended in younger patients due to limited data and concerns of invalid/indeterminate test results, which occur if there is a positive or negative control failure. We sought to characterize the patterns of IGRA use in clinical practice and results of IGRAs in patients < 2 years old. MethodsWe conducted a retrospective cohort study of children < 2 years old at two large health systems in the Boston area who had IGRA and/or tuberculin skin test (TST) performed from October 1, 2015 – January 31, 2021. We reviewed medical records to determine IGRA test type, IGRA result (positive, negative, invalid/indeterminate) and location of testing (outpatient primary care, outpatient subspecialty, inpatient). We summarized test interpretability, location, and changes in proportion of IGRA vs. TST. ResultsWe identified 330 IGRA (268 T-SPOT.TB, 62 QuantiFERON Gold) and 2029 TST results among 1982 patients who were < 2 years old (range: 11 days – 1.9 years). Monthly proportion of IGRAs among all TB tests ordered increased from 2015 to 2021 (Figure 1) (Pearson correlation coefficient 0.85, P < 0.001). Among IGRA results, 314 (95%) were negative, 3 (1%) were positive, and 13 (4%) were invalid/indeterminate (11 T-SPOT.TB, 2 QuantiFERON Gold). Of 324 IGRA tests for which testing location was known, 233 (72%) and 91 (28%) were ordered in outpatient and inpatient settings, respectively. Of tests in outpatient settings, 132 (57%) were ordered in primary care offices, 53 (23%) were ordered in subspecialist offices, and 48 (21%) were obtained in outpatient labs of unidentified clinics. Tuberculosis infection tests and proportion IGRA. Total number of tests and proportion of IGRA:TST obtained by month, from October 2015-January 2021.ConclusionWhile most TB infection tests in this age group were TSTs, the monthly proportion of tests that were IGRAs increased over time between 2015-2021. IGRAs were obtained in varied clinical settings. In this low-burden setting, rates of invalid/indeterminate IGRAs were low among children < 2 years old, which suggests that IGRAs are reasonable TB testing options for patients < 2 years old, and may be preferred given limitations of TSTs.Disclosures Gabriella S. Lamb, MD, MPH, Nothing to disclose

The burden and predictors of latent tuberculosis infection among immigrants in South Korea: a retrospective cross-sectional study

BackgroundApproximately one-fourth of the global population is latently infected with Mycobacterium tuberculosis. An understanding of the burden of latent tuberculosis infection (LTBI) among immigrants compared with the general Korean population should be the first step in identifying priority groups for LTBI diagnosis and treatment. The study aimed to compute the age-standardized LTBI prevalence and predictors among immigrants with LTBI in South Korea.MethodsIn 2018, the Korea Disease Control and Prevention Agency implemented a pilot LTBI screening project for immigrants using a chest radiography and the QuantiFERON Gold In-Tube assay. A standardized prevalence ratio (SPR) was computed to compare the LTBI burden in immigrants and the general Korean population.ResultsDuring the duration of the project, a total of 8108 immigrants (5134 males and 2974 females) underwent LTBI screening. The SPR of 1.547 (95% confidence interval [CI] 1.468–1.629) in males and 1.261 (95% CI 1.177–1.349) in females were both higher than the Korean reference population. Furthermore, among the immigrants, those aged < 40 years and Korean diaspora visa holders had a higher SPR.ConclusionThis study found a higher LTBI prevalence among immigrant population in South Korea compared to that in the general Korean population, and the SPR was higher among those aged < 40 years and the Korean diaspora. The findings can be used as baseline evidence for including immigrants in South Korea in the at-risk group with a priority need for LTBI screening and treatment.

Abstract 16926: Outside The Box But All Squeezed In: A 23-year-old Man With Progressive Dyspnea After Overseas Travel

Case Presentation: A 23-year-old previously healthy man presented with progressive dyspnea. Physical examination revealed jugular venous distension and lower extremity edema. Laboratory testing demonstrated elevated B-type natriuretic peptide (193 pg/mL) and normal high sensitivity troponin. Echocardiogram revealed small pericardial effusion, respiratory variation in diastolic flow across the mitral valve, diastolic septal bounce, and annulus reversus ( Figure ). The differential diagnosis for constrictive pericarditis was broadly considered in the context of a recent febrile illness and frequent travel to Hawaii and Vietnam; we included infectious, autoimmune, and malignant etiologies. Cardiac magnetic resonance imaging revealed thickening and diffuse enhancement in the pericardium as well as ventricular interdependence. Chest CT identified hilar and anterior mediastinal lymphadenopathy. Laboratory testing was positive for QuantiFERON gold and negative for COVID-19, HIV, and ANA. Transbronchial biopsy demonstrated non-necrotizing granulomas with negative acid-fast bacilli smear, culture, and polymerase chain reaction for mycobacterial DNA. Re-examination identified a red-brown plaque on the patient’s thigh; biopsy showed granulomatous inflammation and rod-shaped organism with positive FITE staining. A presumed unifying diagnosis was made of extrapulmonary tuberculosis (TB) complicated by constrictive pericarditis. Discussion: Despite being a primarily pulmonary disease, systemic involvement can occur with TB with the heart being one of the most common extrapulmonary sites. This case highlights 1) the utility of extra-cardiac diagnostic testing (e.g., dermatologic biopsy) in the diagnosis of constrictive pericarditis, and 2) the diagnostic challenge associated with extrapulmonary TB, particularly paucibacillary disease that requires a detailed social history with “out-of-the-box” thinking.

A RARE CASE OF COVID-19-ASSOCIATED PULMONARY ASPERGILLOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute respiratory distress syndrome (ARDS) caused by coronavirus disease (COVID-19) is known to predispose affected individuals to numerous secondary complications including bacterial superinfections. Less reported are the opportunistic fungal infections affecting a subset of patients lacking immunocompromising disease. COVID19-associated pulmonary aspergillosis (CAPA) is an underrecognized complication carrying high mortality in an otherwise healthy population. CASE PRESENTATION: A 55 year old male with history of obesity and type 2 diabetes mellitus presented to the hospital with a chief complaint of worsening dyspnea. In the ED, he was found to be afebrile, requiring high-flow nasal cannula and subsequently tested positive for COVID-19. The patient showed little improvement despite treatment with IV steroids, convalescent plasma, Remdesivir, and broad antibiotic coverage for suspected superimposed hospital acquired pneumonia. Chest CT without contrast on hospital day 23 revealed interval development of a complex cavitary lesion. HIV and Cryptococcus antigen were negative while QuantiFERON gold was intermediate. Follow-up testing with galactomannan returned elevated and the patient promptly initiated Voriconazole therapy for treatment of CAPA. The patient demonstrated marked clinical improvement and was discharged to a subacute rehabilitation center in stable condition on supplemental oxygen with plans for close monitoring of Voriconazole trough, galactomannan level and repeat chest imaging. DISCUSSION: Hallmarks of severe COVID-19 infection include ARDS, lymphopenia, systemic cytokine response and potential multiorgan failure often necessitating mechanical ventilatory support and ECMO in some cases. The manipulation and ultimate halt of the immunological cascade with the therapeutic agents, in combination with the direct viral damage to respiratory tract epithelium and eventual ciliary dysfunction, may in turn lead to complicated superinfections. Given the decreased use of diagnostic bronchoscopy to limit aerosolized exposure during the COVID-19 pandemic, clinicians have relied on less invasive means to diagnose CAPA including clinical, radiological and mycological criteria. CONCLUSIONS: COVID19 is a complex multiorgan process that descends on the patients with vastly varying clinical manifestations and progression. It is sagacious to raise awareness of the potential COVID19 has for co-infection with CAPA, as immunosuppressive drugs are the current strategy for treatment. Improved screening strategies can identify and enact early treatment of CAPA in critically ill patients who seem to clinically decline despite optimized supportive care. REFERENCE #1: Salmanton-Garcia, J., Sprute, R., Stemler, J., Bartoletti, M., Dupont, D., Valerio, M….Koehler, P. (2021). COVID-19–Associated Pulmonary Aspergillosis, March–August 2020. Emerging Infectious Diseases, 27(4), 1077-1086. https://doi.org/10.3201/eid2704.204895. REFERENCE #2: van Arkel, A., Rijpstra, T. A., Belderbos, H., van Wijngaarden, P., Verweij, P. E., & Bentvelsen, R. G. (2020). COVID-19-associated Pulmonary Aspergillosis. American journal of respiratory and critical care medicine, 202(1), 132–135. https://doi.org/10.1164/rccm.202004-1038LE REFERENCE #3: Machado, M., Valerio, M., Alvarez-Uria, A., Olmedo, M., Veintimilla, C., Padilla, B., De la Villa, S., Guinea, J., Escribano, P., Ruiz-Serrano, M. J., Reigadas, E., Alonso, R., Guerrero, J. E., Hortal, J., Bouza, E., Munoz, P., & COVID-19 Study Group (2021). Invasive pulmonary aspergillosis in the COVID-19 era: An expected new entity. Mycoses, 64(2), 132–143. https://doi.org/10.1111/myc.13213 DISCLOSURES: No relevant relationships by Muhammad Ehtesham, source=Web Response No relevant relationships by Dani Fribourg, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Bernadette Schmidt, source=Web Response

BIRD FANCIER'S DISEASE: A CASE OF HYPERSENSITIVITY PNEUMONITIS

TOPIC: Occupational and Environmental Lung Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: The immunologic lung disease through inhalation and sensitization of an aerosolized antigen is termed hypersensitivity pneumonitis (HP). Here we describe a case of HP from exposure to avian antigen. CASE PRESENTATION: A 42 y/o F presented with progressively worsening dyspnea at rest & exertion, pleuritic chest pain, dry cough for past 2 months. She denied sick contacts or recent travel. On exam BP: 122/76mmHg, HR 107bpm, RR 30bpm, SpO2 82% on room air. Physical exam, significant for b/l crackles. Labs: WBC 16.33 k/mm3, ABG PaO2 of 45mmHg. CXR showed b/l airspace opacities & CT-thorax showed b/l diffuse GGO. ECHO showed LVEF 55% with normal global systolic function with mildly elevated PASP. Treatment was initiated with hi-flo oxygen and her SpO2 improved to 97%. QuantiFERON Gold, urine legionella, Mycoplasma IgM, and respiratory multiplex viral panel were negative. Cardiac CT revealed patent coronaries. Spirometry revealed severe restrictive ventilatory defect. Further questioning revealed that patient got parakeets a few months prior to onset of symptoms. She was then started on methylprednisolone for possible HP. Bronchoscopy with BAL and transbronchial biopsies showed no bacterial/fungal/viral growth. Cytology was unremarkable and biopsies revealed mild inflammatory changes with lymphocytes and aggregates of intralaveolar foamy macrophages. The CD4:CD8 ratio was 0.89. Patient clinically improved with steroid therapy and gradually weaned from supplemental oxygen. She was discharged on oral prednisone with close follow up where she continued to improve after removal of her parakeets DISCUSSION: HP an immune-mediated response from repeated inhalation, sensitization, & hyperresponsiveness to various organic particles which can be mammalian or avian proteins, fungi, bacterial, or chemicals. Based on duration of exposure & symptoms onset, HP can be divided into acute, subacute, or chronic. Acute HP presents as flu-like illness, subacute HP has insidious onset of symptoms, dyspnea on exertion or reduced exercise capacity. Physical exam reveals inspiratory crackles. Imaging usually demonstrates GGO, mosaic attenuation and centrilobular nodules. BAL reveals lymphocytic predominant cells with CD8 alveolitis. Histopathology usually demonstrates cellular bronchiolitis with predominant lymphocytic or plasmocytic infiltrates. It can also present as interstitial mononuclear infiltrates or loosely-formed granulomas. Treatment for HP is avoidance of antigen exposure. Role of steroids in treating HP is not well known, however general practice is slow tapering steroid regimen for about 3-6 months duration. Prognosis is usually good with complete recovery in most patients; a few may progress to chronic fibrosing HP. CONCLUSIONS: A high level of suspicion should be present in diagnosing HP with a thorough history and prompt management must be initiated to prevent progression of disease. REFERENCE #1: Selman M, Pardo A, King TE Jr. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Is J Respir Crit Care Med. 2012; 186:314-24. REFERENCE #2: Costabel U, Bonella F, Guzman J. Chronic hypersensitivity pneumonitis. Clin Chest Med. 012; 33:15163. REFERENCE #3: Camarena A, Juárez A, Mejía M, Estrada A, Carrillo G, Falfán R, Zuñiga J, Navarro C, Granados J, Selman M. Major histocompatibility complex and tumor necrosis factor-alpha polymorphisms in pigeon breeder's disease. Am J Respir Crit Care Med. 2001;163:1528-33. DISCLOSURES: no disclosure on file for Jagadish Akella; No relevant relationships by Alex Diaz, source=Web Response no disclosure on file for Iqbal Javed; No relevant relationships by Raghavendra Sanivarapu, source=Web Response