Reaccumulation Of Fluid Research Articles

Dietary treatment of congenital chylothorax with skimmed breast milk

BackgroundCongenital chylothorax (CC) is a rare but potentially life-threatening condition in newborns. It is defined as an accumulation of chyle in the pleural cavity. The few publications regarding medical management and therapeutic dietary intervention motivated us to share our experience.MethodsNeonates diagnosed with congenital chylothorax and treated at Innsbruck Medical University Hospital between 2013 and 2020 (n = 6, gestational age: 36 3/7, 32 5/7, 36 4/7, 35 0/7, 35 4/7, 37 3/7 weeks) were eligible for this report.The cornerstones of treatment for chylothorax conventionally consist of chest tube drainage (CTD), respiratory support, dietary restriction of long-chain triglycerides (LCT) or total parenteral nutrition (TPN). In further course the introduction of a medium-chain triglyceride (MCT)-based formula followed by an overlapping switch to a formula with low LCT and high MCT, containing the essential long-chain fatty acids (LCFA), is attempted. In three patients we used fat-modified (skimmed) breast milk to provide a high protein and low fat diet and to avoid the discontinuation of breast milk.ResultsThe outcome of an early introduction of LCFA in the form of skimmed breast milk after resolution of chylothorax diverse. One patient had a favourable outcome, meaning no recurrence of pleural effusion, adequate weight gain and a content mother, while another patient had a relapse of pleural effusion after the administration of skimmed milk and was therefore transitioned back to Basic F® .The CC of patient 5 was difficult due to Noonan syndrome. Two weeks after the introduction of skimmed breast milk the mother wanted to stop to express breast milk, so nutrition was changed to Basic F®.ConclusionThe first-line therapy of chylothorax is a combination of respiratory stabilization and dietary modification. The use of skimmed breast milk is advisable in CC and feasible by means of a simple milk defatting procedure. It offers benefits to mothers who wish to resume breast feeding after resolution of chylothorax and has proven positive effects, above all in preterm infants as optimal nutrition with protective components superior to formula feeding. However, the nutritional analysis of the skimmed milk and the correlation to a re-accumulation of pleural fluid remains a question to be answered.

P15. Can cervical and lumbar epidural blood patches help avoid revision surgery for symptomatic postoperative dural tears?

<h3>BACKGROUND CONTEXT</h3> Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks are a known sequela of spine surgeries. Treatments include bedrest, subarachnoid lumbar drain, epidural blood patch, and most commonly, surgical reexploration for durotomy closure. Surgical reexploration carries the inherent consequences of an additional surgical procedure. The theory behind epidural blood patches is to form a clot over the tear in a minimally invasive manner and to allow the dura to heal without the need for additional surgery. Within the literature, there is a paucity of data available evaluating the efficacy of epidural blood patches for CSF leaks secondary to incidental durotomies. <h3>PURPOSE</h3> The purpose of this study is to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series. <h3>PATIENT SAMPLE</h3> All patients undergoing cervical, thoracolumbar, or posterior lumbar spine surgeries at an academic institution between 10/2012 and 12/2020 were included. <h3>OUTCOME MEASURES</h3> Rate of dural tears, type of dural repair, use of blood patches for dural tears, intraoperative/perioperative complications, length of hospital stay, discharge status. <h3>METHODS</h3> Patients undergoing cervical, thoracolumbar, and posterior lumbar surgeries performed by a single surgeon at an academic institution between 10/2012 and 12/2020 were included. Their charts were reviewed retrospectively for demographic information, type of surgery, rate of dural tear, type of repair, and use of blood patches postoperatively. <h3>RESULTS</h3> A total of 1,392 patients (726 males, 666 females, average age: 56.3 ±15.4 years old) were included who received cervical, thoracolumbar, or posterior lumbar surgeries. Of the 436 cervical spine surgeries, there were 236 anterior cervical fusions, 183 posterior cervical surgeries, and 17 anterior and posterior cervical surgeries. Of the 956 thoracolumbar and posterior lumbar spine surgeries, there were 207 laminectomies, 458 fusions and 291 microdiscectomies. There were 6 (1.4%) cervical, 65 (6.8%) lumbar, a total of 71 (5.1%) patients identified with incidental dural tears/blebs. Durotomies were fixed primarily, or if they were inaccessible, then treated with duraseal and/or fat graft. Persistent CSF leaks were indicated by positive beta-2 transferrin or clinical symptoms of positional headaches; these patients were referred to interventional radiology for a blood patch. We identified 2 (2 males) cervical spine and 8 (4 females and 4 males) lumbar spine patients who received blood patches in this study. Nine of 10 patients had resolution of symptoms without reaccumulation of fluid (90%). One lumbar spine surgery patient had a persistent pseudomeningocele after a blood patch and subsequently underwent primary repair with no relief. A second blood patch was then performed, which alleviated his symptomatic pseudomeningocele. Of the10 total patients who received blood patches, the mean length of hospital stay was 10.4 days, and three were discharged to rehabilitation. <h3>CONCLUSIONS</h3> The rate of dural tears/blebs within this series was 1.4% in cervical spine, 6.8% in lumbar spine, and 5.1% in total spine surgeries. Of the 10 patients with symptomatic postoperative CSF leaks, 9 out of 10 were successfully treated with a blood patch. Targeted epidural blood patch is an effective option to treat symptomatic CSF leaks that minimizes the morbidity of surgical reexploration. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Identifying Actionable Causes of Potentially Avoidable Readmissions to an Oncology Service at a Safety Net Hospital.

Hospital readmissions occur commonly in those receiving cancer care and result in impaired quality of life and increased costs. Causes of readmission in safety net hospitals that serve vulnerable populations are not well understood. The primary goal of this project was to identify potentially avoidable and intervenable causes of readmissions to an urban safety net hospital. A retrospective chart review was performed on patients who were readmitted within 30 days of discharge from the hematology and oncology service at Boston Medical Center over the 6-month period between October 2018 and March 2019. Charts were reviewed by three internal medicine residents and discussed under the supervision of an attending oncologist. Two hundred ninety-one patient encounters involving 203 unique patients were identified in the 6-month study period. Of these 291 encounters, 80 encounters (27.5%) were followed by a readmission within 30 days and occurred in 61 (30.0%) unique patients. Nineteen (31.1%) of these 61 patients experienced two readmissions within 30 days of discharge. Twenty-five readmissions (31.3%) were classified as potentially avoidable, with the most common cause of potentially avoidable readmissions attributed to ascitic or pleural fluid reaccumulation (8, 32%). The majority of presumed nonpreventable readmissions were due to expected complications of cancer progression and treatment-related side effects. In conclusion, readmissions were common, and a modifiable reason for 30-day readmissions was identified. Addressing recurrent ascitic and pleural fluid reaccumulation in the outpatient setting could help to reduce inpatient hospital readmission on an inpatient oncology service.

UNEXPECTED EFFUSION: BILOTHORAX IN PATIENT WITH METASTATIC BREAST CANCER

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bilothorax is a rare cause of pleural effusion. It is thought to be caused by translocation of bilious fluid through a diaphragmatic defect, whether passive, congenital or iatrogenic [1,2]. It is often described as a rapidly-accumulating, right-sided pleural effusion occurring after instrumentation near to or on the biliary tree. Patients are at high risk of developing empyema and can present with signs of infection. We describe a case of a slowly-accumulating right-sided bilothorax in a patient without signs of infection. CASE PRESENTATION: A 39 y/o lady with history of triple-negative breast cancer, metastasized to the brain and spine, was referred to our clinic for dyspnea on exertion for 1 month. She had been treated with multiple lines of chemotherapy & proton beam radiation to her metastases. A staging PET/CT scan 3 months prior revealed a liver lesion that was suspicious for metastases. A CT-guided percutaneous liver biopsy was recommended. An abdominal scan incidentally caught segmental pulmonary emboli (PE), for which a chest CT was performed. Due to a post-procedural complication of hepatic sub-capsular hematoma, the patient was not anti-coagulated & had IVC filter placement instead. Her chest imaging at this time was revealing of minimal, trace bilateral effusions. She presented 1 month later for staging scans. Chest imaging at this time was significant for a trace right-sided pleural effusion. The patient did not have any respiratory symptoms. When she was seen by her oncologist for follow-up one month thereafter, she reported feeling dyspnea on exertion. At this point, a CT chest confirmed a small-to-moderate right pleural effusion. She had no fevers, cough, or constitutional symptoms except chronic fatigue and weakness which preceded her dyspnea. In our clinic, we appreciated a moderate-sized right pleural effusion on ultrasound. Given the insidious nature of her dyspnea, we postulated that her effusion was likely malignant. We performed thoracentesis for both diagnostic and therapeutic purposes. A total of 1.1L of dark green fluid was drained. Fluid studies returned with a pleural fluid to serum bilirubin ratio greater than one, confirming bilothorax. Cytology of the effusion was negative for cancer cells. Repeated chest imaging at 1 and 2 months post-thoracentesis did not reveal re-accumulation of pleural fluid, and patient’s dyspnea did not return. DISCUSSION: We describe a case of a slowly accumulating bilothorax after percutaneous CT-guided liver biopsy. Fortunately, our patient did not develop an empyema from this effusion. CONCLUSIONS: A high suspicion for bilothorax should be maintained when patients develop a novel pleural effusion within the days to months following an abdominal procedure in close proximity to the biliary tree. Prompt diagnosis and drainage lends to both symptomatic relief & prevention of further complications of infection in the pleural space. Reference #1: Jenkinson MRJ, Campbell W, Taylor MA. Bilothorax as a rare sign of intra-abdominal bile leak in a patient without peritonitis. Ann R Coll Surg Engl. 2013;95(7):e12-e13. doi:10.1308/003588413X13629960047678 Reference #2: Basu S, Bhadani S, Shukla VK. A dangerous pleural effusion. Ann R Coll Surg Engl. 2010;92(5):W53-W54. doi:10.1308/147870810X12699662980637 DISCLOSURES: No relevant relationships by Saamia Hossain, source=Web Response No relevant relationships by Robert Lee, source=Web Response

Thoracic ultrasound as a predictor of pleurodesis success at the time of indwelling pleural catheter removal.

IPC in patients with MPE are removed within 3 months in 30-58% of cases, usually due to decreased pleural fluid output as a result of pleurodesis. Disease control can also account for the lack of fluid output, potentially explaining why 4-14% of patients undergo repeat pleural intervention for fluid re-accumulation (at the time of disease recurrence or progression). The aim of our pilot study is to determine the accuracy of thoracic ultrasound (TUS) in predicting pleurodesis success in patients with MPE at the time of IPC removal. This is a single-centre, prospective observational cohort study that enrolled consecutive patients with confirmed MPE treated with IPC at the time of IPC removal. TUS was performed to calculate a PAS. Patients were followed up for a minimum of 3 months. Failure was defined as pleural fluid recurrence within 3 months. Twenty-seven patients were screened and 25 were included in the final analysis. Pleurodesis success was observed in 88% (n = 22) and failure in 12% (n = 3) of patients. The mean PAS was higher in patients with pleurodesis success (22.0 vs 9.3, P = 0.01). A PAS greater than 10 predicted pleurodesis success with a sensitivity of 100% and specificity of 86%. This pilot study suggests that TUS at the time of IPC removal accurately identifies patients who have achieved pleurodesis and therefore will not have re-accumulation of pleural effusion or require an ipsilateral pleural intervention for at least 3 months post-IPC removal.

Drainage of amniotic fluid delays vocal fold separation and induces load-related vocal fold mucosa remodeling

In the present study, we investigated the role of mechanical load as generated by amniotic fluid in the vocal fold embryogenesis. In utero, amniotic fluid flows through the laryngeal inlet down into the lungs during fetal breathing and swallowing. In a mouse model, the onset of fetal breathing coincides with epithelial lamina recanalization. The epithelial lamina is a temporal structure that is formed during early stages of the larynx development and is gradually resorbed whereby joining the upper and lower airways. Here, we show that a temporary decrease in mechanical load secondary to drainage of amniotic fluid and subsequent flow restoration, impaired timing of epithelial lamina disintegration. Moreover, re-accumulation of fluid in the laryngeal region led to VF tissue deformation triggering remodeling of the epithelium and pressure generated changes in the elastic properties of the lamina propria, as measured by atomic force microscopy. We further show that load-related structural changes were likely mediated by Piezo 1 –Yap signaling pathway in the vocal fold epithelium. Understanding the relationship between the mechanical and biological parameters in the larynx is key to gaining insights into pathogenesis of congenital laryngeal disorders as well as mechanisms of vocal fold tissue remodeling in response to mechanotransduction.

Outcome of ultrasound-guided, single session pleurodesis in malignant pleural effusion

BackgroundChemical pleurodesis is frequently indicated to relieve symptoms imposed by large/recurrent malignant pleural effusion (MPE). Traditionally, a drain is left in the pleural space till the cessation of fluid accumulation before pleurodesis. Chest ultrasound can detect an amount of pleural fluid as less as 50 ml and can confirm apposition of the pleural surfaces which is required for successful pleurodesis. This work assessed the efficiency and safety of ultrasound-guided, single-session pleurodesis in cases with MPE.ResultsSeventeen of the patients completed a 2-month follow-up. The technique demonstrated a high success rate (88.2%). The mean duration from the start of pleural drainage till pleurodesis was 1.65 ± 0.70 h ranging from 1 to 3 h. A duration of 2.5 h or less was statistically proposed as a cutoff value not to exceed to predict success (sensitivity 100%, specificity 100%). The mean time for total hospital stay related to pleurodesis was 9.88 ± 3.12 h (range 4–12 h). No complications attributed to the procedure were recorded. Pleural Adherence Score and Absent Sliding Score (ASS) had a highly statistically significant correlation (p value < 0.001).ConclusionsAn ultrasound-guided completion of the process of pleurodesis in a single session with a shorter duration of pleural fluid drainage and shorter hospital stay (can be done on a day-care basis) is efficient, safe, and cost-effective. This technique is strongly recommended to replace the traditional practice of keeping the indwelling pleural drain for several days waiting for the cessation of pleural fluid reaccumulation. An ultrasound-derived ASS can be used as early as day 1 and day 15 to confirm pleural adherence and to expect the outcome of pleurodesis.

Echo-Guided Pericardiocentesis: When and How Should It Be Performed?

Abnormal accumulation of pericardial fluid is a common cardiac condition with different etiologies. Draining of the pericardial fluid (pericardiocentesis) is often indicated for diagnostic and therapeutic purposes and is performed in an elective or emergent setting. Echocardiography is the primary imaging method for diagnosing, localizing, and quantifying pericardial effusion as well as evaluating its hemodynamic effects, including the presence of cardiac tamponade. In this manuscript, we review the indications for pericardiocentesis and provide practical step-by-step guidance for echo-guided pericardiocentesis. Echo-guidance is an effective method to improve the safety and efficacy of pericardiocentesis. In experienced hands and with a stepwise approach, procedural outcomes are excellent, and complication rates are very low. Asymptomatic small idiopathic effusions have a benign course and can be left untreated. Prolonged drainage with an indwelling pericardial catheter is key for preventing fluid re-accumulation, and the use of colchicine to prevent fluid recurrence is encouraged whenever possible. Understanding how to evaluate the significance of a pericardial effusion as well as the procedural steps in the performance of a pericardiocentesis are essential for optimal outcomes in treating patients with pericardial effusions and tamponade.

SAT-479 Atypical Presentation of Recurrent Cardiac Tamponade Following Pericardial Window in the Setting of Uncontrolled Hypothyroidism

INTRODUCTION:Classically, cardiac tamponade presents with hypotension, distant heart sounds and tachycardia (Beck’s triad). Pericardial window is considered effective treatment. Pericardial effusions are relatively common in hypothyroidism (3-6%) (1). Cardiac tamponade, however, is rarely seen in patients with hypothyroidism secondary to pericardial distensibility and the slow accumulation of fluid, allowing significant fluid accumulation without hemodynamic compromise (2).CLINICAL CASE:A 84 year-old female with history of post-surgical hypothyroidism (on levothyroxine 150 mcg) following total thyroidectomy for thyroid cancer, cardiac tamponade requiring pericardial window formation two years prior, presented for dyspnea on exertion and pedal edema for several days. She was tachypneic to 22/min with heart rate 47/min and blood pressure 92/62. Distant heart sounds were noted on exam.EKG demonstrated sinus bradycardia, low voltage QRS and T wave flattening. Further workup revealed TSH elevated to 44 uIU/mL (N:0.27–4.2 uIU/mL), free T4 0.17 ng/dl (N:0.93-1.7 ng/dl) and undetectable T3 (N: 80-100 ng/dl). Echocardiogram unexpectedly demonstrated a large circumferential pericardial effusion with diastolic collapse of the right atrial, right ventricular free wall, significant respiratory variations and interventricular dependence. These findings were consistent with cardiac tamponade physiology. She underwent a video assisted left thoracotomy pericardial window formation along with drainage of 400cc of yellow pericardial fluid. Fluid cytology and tissue histopathology were negative for malignancy. Her uncontrolled hypothyroidism was considered the cause for recurrence of cardiac tamponade and her levothyroxine dose was increased to 175 mcg. At two week follow up, she reported symptomatic improvement on the higher levothyroxine dose. Echocardiogram did not show reaccumulation of fluid.CONCLUSIONS:Sinus tachycardia is found in most patients with cardiac tamponade, except in hypothyroid patients (2). A high degree of suspicion is needed to diagnose cardiac tamponade in hypothyroidism, even in patients who have undergone presumed definitive therapy with a pericardial window in the past. The recent onset of pedal edema and low blood pressure were important indicators of impending cardiac compromise in our patient.Hypothyroid patients may be at higher risk of pericardial window failure compared to patients with cardiac tamponade of other etiologies, especially if thyroid replacement therapy is inadequate. The scientific literature is lacking in this regard and warrants further investigation.

Ablation of Cystic Thyroid Nodules With N-Butyl Cyanoacrylate: A Preliminary Study

Objective: Generally recommended treatment options for cystic nodules with compressive symptoms are simple aspiration, percutaneous ethanol injection, or surgery. N-butyl cyanoacrylate (NBCA) is a glue-like substance widely used in neurointerventions, mainly for treating arteriovenous malformations. It obstructs and attaches to the vessel walls, preventing recanalization. Our purpose was to investigate the efficacy and safety of NBCA in volume reduction of benign cystic thyroid nodules with compressive symptoms. Methods: Twenty patients with 21 benign pure or partially cystic nodules were enrolled. After simple cyst aspiration, NBCA/lipiodol mixture was injected within the cyst cavity. Success was defined as at least 50% volume reduction after the intervention. Pre- and postintervention longest diameter and volume (calculated with ultrasonography after measuring three dimensions) of the nodules were compared. Posttreatment measurements were made at the 9-month final visit. Results: Median largest diameter of the nodules measured before and after NBCA treatment was 4.8 cm (min-max, 3.1 and 6.3 cm) and 3.4 cm (min-max, 2.4 and 5.6 cm), respectively. Pre-NBCA treatment median volume was 24.8 mL (min-max, 10.9 and 46.1 mL), whereas post-treatment median volume was 5.5 mL (min-max, 2.1 and 29.6 mL). Median volume reduction was 72.6% (min-max, 21.0 and 95.4%). Intervention was successful in 20 of 21 nodules according to the predefined criteria. The changes in pre- and postintervention median longest diameter and volume were statistically significant. Conclusion: For large cystic thyroid nodules, ablation with NBCA may be an effective treatment choice, as it significantly reduces the cyst volume and prevents fluid re-accumulation. There is need for further studies with a larger number of patients and longer follow-up. Abbreviations: NBCA = N-butyl cyanoacrylate; PEI = percutaneous ethanol injection; US = ultrasonography.

Long-Term Outcome of Pericardial Drainage in Cases of Chronic, Large, Hemodynamically Insignificant, C-Reactive Protein Negative, Idiopathic Pericardial Effusions

Pericardial effusion (PE) prognosis depends on the underlying etiology. We sought to assess the outcome of patients with chronic (>3 months), large (diastolic echo-free space >2 cm), idiopathic (without apparent etiology), C-reactive protein (CRP) negative PE, a topic where data are lacking. A total of n = 74 patients were enrolled in this study. Patients were treated by pericardiocentesis (n = 39) or surgical pericardial "window" (PW) (n = 13) or conservatively (n = 22). The median follow-up was 24 months (interquartile range: 15 to 38). Among those patients who had PE drained (n = 52), PE re-accumulation occurred in 32 cases (61.5%) and the rate was significantly higher in the pericardiocentesis subgroup (76.9% for pericardiocentesis vs 15.4% for PW group, p <0.001). Patients with re-accumulation had longer disease duration (32.1 ± 25.7 months vs 19.5 ± 23.8 months, p = 0.01), higher maximum PE diameter (32.2 ± 9.4 mm vs 26.1 ± 4.9 mm, p = 0.003) and larger PE volume drained at baseline (1,912 ± 707 mL vs 1,508 ± 387 mL, p = 0.04). Large PE re-accumulation occurred in 41% of patients who underwent pericardiocentesis and in 7.7% of those who underwent PW. In Cox survival analysis the only independent predictor of fluid re-accumulation was the type of intervention, with PW being associated with significantly reduced risk (hazard ratio 0.115, 95% confidence interval 0.015 to 0.875, p = 0.037). Major complications needing treatment were recorded in 12.8% and 15.4% (p = 0.999) of patients who underwent pericardiocentesis and PW, respectively. Moreover, invasive procedures were not helpful in establishing new diagnoses and guide treatment. In conclusion, in asymptomatic patients with chronic, large, hemodynamically insignificant, CRP negative, idiopathic PE, conservative management seems a more reasonable approach in most cases.

CLINICAL FEATURES OF FLAT IRREGULAR PIGMENT EPITHELIAL DETACHMENT ASSOCIATED WITH CHOROIDAL NEOVASCULARIZATION IN CHRONIC CENTRAL SEROUS CHORIORETINOPATHY.

To describe the multimodal imaging characteristics of flat irregular pigment epithelial detachment (FIPED) in patients with chronic central serous chorioretinopathy and determine the risk factors for vascularized FIPED and to explore the activity of vascularized FIPED before and after half-dose photodynamic therapy. Multimodal imaging data of 185 eyes of 155 consecutive patients with chronic central serous chorioretinopathy included spectral domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography. Optical coherence tomography angiography was available for 56 eyes. Flat irregular PED was classified into two types based on indocyanine green angiography or optical coherence tomography angiography findings: avascular FIPED and vascularized FIPED. The avascular FIPED and vascularized FIPED were detected in 127 (68.6%) and 42 (22.7%) eyes, respectively. Age (P = 0.001), visual acuity (P = 0.048), subfoveal choroidal thickness (P = 0.032), height (P < 0.001) and width (P < 0.001) of FIPED, choriocapillary thickness (P = 0.015), and maximum vessel diameter (P = 0.009) beneath the FIPED were significantly different between avascular and vascularized FIPEDs. Old age was an independent risk factor for vascularized FIPED. On optical coherence tomography angiography, all vascularized FIPEDs manifested the pattern of mature choroidal neovascularization (CNV). After half-dose photodynamic therapy, vascularized FIPED remained stable without the reaccumulation of subretinal fluid at the last follow-up. In chronic central serous chorioretinopathy, vascularized FIPED was closely associated with Type I CNV. Old age was an independent risk factor for vascularized FIPED. Vascularized FIPED is suggested as "quiescent" CNV, and half-dose photodynamic therapy may be recommended as the first-line therapy in chronic central serous chorioretinopathy complicated with quiescent CNV, except when the activity of CNV becomes evident.

Early versus delayed removal of the pericardial drain in patients with cardiac tamponade complicating radiofrequency ablation of atrial fibrillation

Cardiac tamponade is a common life-threatening complication during radiofrequency ablation of atrial fibrillation (RAAF) and is mostly managed by pericardiocentesis. Thus far, the optimal timing for drain removal has not been established. We retrospectively enrolled patients with cardiac tamponade complicating RAAF. The ablation was performed with interrupted novel oral anticoagulants, interrupted warfarin or uninterrupted warfarin protocols. An observation period of at least 30 minutes after the last aspiration via the drain was used to monitor the reaccumulation of pericardial fluid, and then, the patients were divided into an early removal (ER) group in the electrophysiology (EP) laboratory and a delayed removal (DR) group in the ward. A total of 51 patients were included: 25 patients in the ER group and 26 patients in the DR group. There were no significant differences in baseline demographics between the two groups, and no cardiac tamponade reoccurred in either group in the ward. Unlike the DR group, the ER group showed an association with a decreased rate of chest pain (P = .000), fever (P = .001), nausea (P = .000), in-hospital recurrent AF (P = .010), and antibiotic use (P = .012). Anticoagulation was earlier (P = .009), and the median in-hospital stay was shorter (P = .001) in the ER group than in the DR group. ER of the pericardial drain after no evidence of pericardial bleeding for at least 30 minutes in the EP laboratory is safe and associated with a better early hospital course.

P1262 If anything can go wrong, it will: management of a pericardial effusion in a young patient

Abstract Case Report A 25 year-old male patient with an unremarkable past medical history presented to the Emergency Department due to a hemodynamically stable wide complex tachycardia at 260bpm with no response to adenosine, which was successfully treated with synchronized electrical cardioversion. Post cardioversion EKG revealed a pre excitation pattern and the transthoracic echocardiogram showed a large pericardial effusion with diastolic right atrial collapse. The patient was admitted in the Cardiology Department for emergent pericardiocentesis and further investigation. A total of 800 mL of bloody pericardial fluid was removed, compatible with an exudate, but fluid culture and cytology were inconclusive. Due to a rapid reaccumulation of pericardial fluid, the patient underwent a pericardial window, after which he developed an intractable pleuritic thoracalgia, refractory to the combination of ibuprofen, colchicine and oral steroid, despite the resolution of the pericardial effusion. He was also submitted to an electrophysiologic study with successful ablation of a right sided accessory pathway. Analysis of the pericardial fluid and biopsy were inconclusive once again, including a low level of adenosine deaminase and negative acid-fast bacilli test and nucleic acid amplification test for Mycobacterium tuberculosis. The patient was afebrile and denied any constitutional symptoms or relevant epidemiological context. The remainder etiological study was unremarkable, with the exception of fluctuating antibody titers for adenovirus, Borrelia burgdorferi and Mycoplasma pneumoniae, which were interpreted as a result of cross-reactivity. Nevertheless, a course of 21 days of doxycycline was tried without any significant improvement. Thoracic-abdominal-pelvic CT and PET scan were normal. Direct inoculation in guinea pig led to positive results for Mycobacterium tuberculosis and antituberculous therapy was started. Despite pathogen directed antibiotic treatment, there was no clinical improvement and the pericardial effusion gradually relapsed, evolving to cardiac tamponade requiring emergent drainage. Histologic examination of pericardial fragments finally revealed massive infiltration by an undifferentiated malignant tumor compatible with a malignant epithelioid hemangioendothelioma. Due to the patient’s poor performance status and rapidly deteriorating clinical course, it was decided not to start chemotherapy. The patient eventually died, 6 months after his admission to the ED and 2 weeks after the neoplasm’s diagnosis. Conclusion In regions with a high Tuberculosis incidence, there should be a high degree of suspicion for tuberculous pericarditis, especially in cases of recurrent pericardial effusion. Immunosuppressed individuals, such as oncologic patients, are at an increased risk for tuberculosis. The management of relapsing pericardial effusion remains a diagnostic challenge as described in this clinical case.

Safety and Feasibility of Performing Pericardiocentesis on Patients with Significant Pulmonary Hypertension.

Pericardial effusion (PE) is a complication of pulmonary hypertension (PHT) and, specifically, pulmonary arterial hypertension (PAH), that confers a worse prognosis. The safety of performing pericardiocentesis in patients with PHT has not been established. We aimed to assess the safety and feasibility of performing pericardiocentesis in patients with significant PHT. We performed a retrospective analysis from August 2013 to December 2018 at our tertiary-care center of patients who underwent a pericardiocentesis procedure. Patients, procedure, echocardiographic findings, any major intraprocedural complications, and post-procedural related complications up to 30 days were recorded. Specifically, we studied patients with significant PHT. The cohort included 170 patients, with an average age of 62.6 years and an even distribution of gender and co-morbidities. The etiology for the PE varied. Major complications were rare (1.7%) and only 10 patients (5.9%) required re-intervention for reaccumulation of fluid. There were 27 patients (15.9%) with significant PHT, 5 with World Health Organization (WHO) Group I PAH (2.94%). In the entire cohort, there were only 3 major complications (1.7%), none among PHT patients. Pericardiocentesis is a safe procedure, including in patients with significant PHT, including those with WHO Group I PAH. We advocate the use of invasive hemodynamic monitoring in patients with significant PHT. Pericardiocentesis tends to be a safe procedure. However, the safety of performing pericardiocentesis in patients with significant pulmonary hypertension has not been well established. We aimed to assess the safety and feasibility of performing pericardiocentesis, and specifically in patients with significant PHT out our tertiary center by performing a retrospective analysis.

1380 Delayed Presentation of a Traumatic Complete Pancreatic Duct Disruption Successfully Treated With Endoscopic Cystogastrostomy and Long-Term Plastic Stenting

INTRODUCTION: Blunt trauma injuries to the pancreas are rare but carry a significant mortality and high complication rate. Motor vehicle collisions are the leading cause for blunt pancreatic trauma in adults. Patients with pancreatic trauma typically present with features of acute pancreatitis, which is often difficult to diagnose due to other intra-abdominal injuries. The Organ Injury Scale is the most widely accepted grading system for pancreatic trauma. The higher the grade of injury, the more likely surgical intervention is required. Pancreatic duct (PD) disruption has traditionally required surgery if PD stenting during ERCP was not feasible. We report a case of delayed complete PD disruption following blunt trauma that was successfully treated endoscopically. CASE DESCRIPTION/METHODS: A 58 year-old female with no prior history of pancreatitis presented with intermittent abdominal pain four months after a motor vehicle collision. CT showed a 6.7 × 8 cm pancreatic body cyst. ED evaluation at the time of the MVC had not included abdominal imaging and a CBC and CMP were normal. EUS revealed a 7.5 × 6.7 cm pancreatic body cyst without septation or mural nodule. FNA with a 19 Ga needle fully collapsed the cyst. A pancreatic pseudocyst was confirmed with an amylase of 7500 U/L and CEA of 0.4 ng/mL. Patient reported alleviation of her pain following cyst aspiration, however MRCP 4 days after FNA revealed complete re-accumulation of cyst fluid (Figure1). ERCP with pancreatogram confirmed complete PD disruption (Figure2). Following surgical consultation, the patient opted for EUS-guided intervention for long-term cyst stenting. EUS with cystogastrostomy was successfully performed with a 15 × 10 mm Axios lumen-apposing metal stent (LAMS) and 7 Fr × 7 cm double pigtail stent. At planned LAMS removal, the pigtail stent had migrated making repeat pigtail stenting challenging, but successful. Three month follow-up imaging showed the pigtail stent in the prior cyst cavity with plan to leave the stent indefinitely (Figure 3). DISCUSSION: This is a rare case of PD disruption presenting 4 months after blunt trauma and without preceding pancreatitis. While PD disruption has traditionally required surgical intervention, endoscopic cystogastrostomy with long-term plastic stenting is a novel option to avoid surgery. Given difficulty placing the plastic pigtail at the time of LAMS removal and to avoid a second procedure, it is worth considering placement of plastic pigtail stents rather than a LAMS during the initial procedure.

BLINDED BY THE LIGHT: A CASE OF MALIGNANT PLEURAL EFFUSION WITH TRANSUDATIVE PROPERTIES

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Light’s criteria is routinely used to help aid in the diagnosis and treatment of pleural effusions by categorizing them into transudates or exudates. Pleural effusions due to malignancy and infection are classically exudative, while effusions from heart failure, cirrhosis, and renal failure are examples of usual transudates (1). When exceptions to this pattern do occur, it is most often that a transudate is misclassified as an exudate (1). Presented is a case where a transudative effusion was later discovered to be malignant due to likely concurrent hepatic hydrothorax. CASE PRESENTATION: A 59 year-old male with a history of alcoholic cirrhosis presented with respiratory distress and right upper quadrant pain was found to have complete opacification of the left hemithorax on chest X-ray. Upon admission, the pulmonary service was consulted where bedside evaluation confirmed a large right pleural effusion anechoic by ultrasound. Diagnostic thoracentesis was consistent with a transudative effusion with pleural protein 1.1, serum protein 5.6, pleural lactate dehydrogenase 76, and serum lactate dehydrogenase 269. Hepatic hydrothorax was considered to be the likely etiology given presence of ascites and a history of cirrhosis. Medical cytology however later revealed atypical neoplastic cells. Abdominal imaging revealed a large mass in the right hepatic lobe. IR-guided biopsy revealed metastatic adenocarcinoma with a primary cholangiocarcinoma. Prior to oncologolical evaluation for chemotherapeutic options, the patient decompensated with worsening encephalopathy and respiratory distress from re-accumulation of pleural fluid and abdominal ascites. Given overall grave prognosis, goals of care discussions were held and comfort care was initiated with the patient passing comfortably shortly thereafter. DISCUSSION: Light’s criteria are routinely used to help aid in the diagnosis and treatment of pleural effusions by categorizing them into transudates or exudates. Certain etiologies of pleural effusions are classically transudative, while others are exudative (1). When pleural studies do not meet Light’s criteria for an exudative effusion, physicians will tend to consider that malignancy and infection are ruled out (2, 3). This can lead to a missed or incorrect diagnosis since malignant effusions have been described in the literature to be transudative in as much 10.6% (4) of cases. We describe a case where pleural studies did not meet criteria for an exudative effusion, so a malignant etiology was initially considered to be unlikely. However, medical cytology later showed malignant cells, leading to further work-up revealing the primary underlying cholangiocarcinoma. CONCLUSIONS: When an effusion is transudative, one cannot assume that malignancy is ruled out, otherwise a deadly diagnosis may be missed. Reference #1: Light RW. “The Light criteria. The beginning and why they are useful 40 years later.” Clinical Chest Medicine 2013; 34(1): 21-6. Reference #2: McGrath EE, Anderson PB. “Diagnosis of pleural effusion: a systematic approach.” American Journal of Critical Care 2011; 20(2): 119-27. Reference #3: Thomas R, Cheah HM, Creaney J, Turlach BA, Lee YCG. “Longitudinal measurement of pleural fluid biochemistry and cytokines in malignant pleural effusions.” Chest 2016; 149(6): 1494-500. DISCLOSURES: no disclosure on file for Alfredo Astua; No relevant relationships by Dawn Maldonado, source=Web Response No relevant relationships by Michael Megally, source=Web Response

A CASE OF TSUKAMURELLA PULMONIS MASQUERADING AS PLEURAL TB IN AN IMMUNOCOMPETENT PATIENT

SESSION TITLE: Interesting Presentations of Infectious Diseases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/20/2019 1:00 PM - 2:00 PM INTRODUCTION: Respiratory infections due to Tsukamurella have been described in immunodeficient patients. To our knowledge, only one other case report of respiratory infection has been described in an immunocompetent patient. We hereby present a case of Tsukamurella infection causing tuberculosis like syndrome in an immunocompetent patient. CASE PRESENTATION: A 42-year-old male with a past medical history of hyperthyroidism who recently moved to the United States from India presented to the hospital with chest pain and shortness of breath (SOB). The patient had a viral upper respiratory infection three weeks before presentation and eventually developed worsening sharp chest pain and SOB. He saw a provider in the clinic who recommended a chest X-ray which revealed a right-sided pleural effusion. He underwent an outpatient thoracentesis, a liter of fluid was drained and revealed an eosinophilic predominant exudative fluid. A Quantiferon gold test was negative during that time. At our hospital, the patient was again found to have a right-sided pleural effusion, underwent repeat thoracentesis and eventually, a chest tube was placed. Pleural fluid analysis revealed a monocyte predominant exudative fluid. He later underwent a decortication procedure due to re-accumulation of fluid. Cultures from the fluid and the tissue were negative for acid-fast bacilli. Pathology of the pleura revealed benign tissue with fibrinous pleuritis. Initially, testing for Acid Fast Bacilli (AFB) on three sputum samples and nucleic acid amplification testing (NAAT) remained negative. Throughout this, the patient remained under airborne precautions and was being empirically treated for pleural tuberculosis. Eventually one of the sputum cultures grew acid-fast bacilli within the first week, and this was deemed to be a rapid grower and not Mycobacterium tuberculosis. The culture was sent to Mayo clinic for identification and came back positive for Tsukamurella pulmonis. His antitubercular therapy was discontinued, and he was treated with levofloxacin and rifabutin for 3-6 months. He remained stable and disease free on follow up at 2 months. DISCUSSION: Tsukamurella species are obligate, aerobic, gram-positive, weakly acid-fast Actinomycetales. Infections are mostly related to immunocompromised state and use of intravascular catheters and prosthetic devices. Diagnosis remains a challenge as demonstrated in our case and the infection can mimic tuberculosis like syndrome leading to inappropriate treatment with anti-tubercular therapy. No guidelines exist regarding appropriate treatment, but levofloxacin and rifabutin have been described for treatment of pulmonary infection. CONCLUSIONS: As outlined in our case, Tsukamurella can mimic tuberculosis and diagnosis remains a challenge. A high index of suspicion is required to diagnose this infection in patients with high risk for tuberculosis as it changes management significantly. Reference #1: Inchingolo R., Nardi I., Chiappini F., Macis G., Ardito F., Sali M. First case of Tsukamurella pulmonis infection in an immunocompetent patient. Respir Med CME Reference #2: Chen C.H., Lee C.T., Chang T.C. Tsukamurella tyrosinosolvens bacteremia with coinfection of Mycobacterium bovis pneumonia: case report and literature review. SpringerPlus. 2016;5:2033. Reference #3: Safaei, S., Fatahi-Bafghi, M., & Pouresmaeil, O. (2017). Role of Tsukamurella species in human infections: first literature review. New microbes and new infections, 22, 6-12. https://doi.org/10.1016/j.nmni.2017.10.002 DISCLOSURES: Speaker/Speaker's Bureau relationship with Gilead Please note: $1-$1000 Added 03/15/2019 by Paul Anthony, source=Web Response, value=Honoraria No relevant relationships by Gaurav Manek, source=Web Response No relevant relationships by Anand Muthu Krishnan, source=Web Response No relevant relationships by Nihar Shah, source=Web Response

1318 Pancreaticopleural Fistula in a Patient With Recurrent Alcoholic Pancreatitis: Combined Endoscopic and Medical Management

INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, resulting from disruption of the pancreatic duct. This injury may be secondary to acute/chronic pancreatitis, trauma, or surgery. Here we describe a patient with a PPF, and our workup and treatment for this rare condition. CASE DESCRIPTION/METHODS: A 61-year-old male with COPD, alcohol misuse, and history of recurrent acute alcoholic pancreatitis complicated by pseudocysts was admitted with one month of worsening shortness of breath from a large left pleural effusion, which reaccumulated within four days after a 1.6 L thoracentesis. On examination he had mild abdominal tenderness in the RUQ and epigastrium. Labs were notable for serum amylase 1105 U/L, lipase &gt;1000 U/L, and WBC 10.8. He underwent another thoracentesis, removing 1.5 L of fluid which was an exudate with amylase greater than 2000 U/L. CT of the chest and abdomen showed a subdiaphragmatic LUQ fluid collection with communication to the pancreatic body and duct. A chest tube was then placed to prevent fluid re-accumulation. MRCP confirmed a PPF from the proximal pancreatic body duct to the left pleura. He was started on octreotide. ERCP confirmed a fistula originating from the distal pancreatic duct but attempts to pass a wire into the dorsal pancreatic duct were unsuccessful, and a ventral pancreatic sphincterotomy was performed. His chest tube was removed after one day, and he was discharged to continue octreotide at home. Unfortunately, he returned the following day with complaints of dyspnea. Pancrelipase was then added in an attempt to minimize pancreatic exocrine secretions. On follow-up 1 and 2 months later, the pleural fluid is much smaller, and the patient's dyspnea has resolved. DISCUSSION: Here we present a novel management of PPF without pancreatic duct stent placement and instead with pancreatic sphincterotomy to divert pancreatic secretions away from the fistula tract and medical therapy (octreotide and pancrelipase) to reduce the pancreatic secretion. The diagnosis was reached through a combination of clinical history, lab studies (particularly, the elevated amylase in the pleural fluid), and CT and MR imaging. This was further confirmed with ERCP, which is useful especially if a stent can be placed to divert secretions away from fistula tract. Ultimately, this diagnosis requires a high index of suspicion, particularly in patients who present with recurrent effusions in the setting of pancreatitis.

Atraumatic Calf Swelling In Recreational Cyclist

HISTORY: 51 year-old male presented with intermittent left calf pain and swelling for the past 2 months. The pain and swelling became constant the week preceding his presentation. He had no known injury but first noticed the pain after a spin class 2 months ago. The pain was worse with cycling, jogging, and swimming and at the end of the day. He had no knee pain, ankle pain, or hip pain. He denied lower extremity weakness or numbness. The pain did not radiate. PHYSICAL EXAMINATION: There was a soft tissue enlargement in posterior medial aspect of left calf that was mildly tender to palpation, soft, and non-mobile. Transillumination of the area was positive. No overlying erythema or skin changes were noted. Calf musculature and strength were normal. There was no tenderness along the rest of the gastrocnemius or Achilles tendon and no pretibial edema was present. Neurovascular examination was unremarkable. DIFFERENTIAL DIAGNOSIS: 1. Deep Vein Thrombosis 2. Synovial Cyst 3. Abscess 4. Morel-Lavallée lesion 5. Lipoma 6. Hematoma TESTS AND RESULTS: - Knee x-rays: Grossly normal; generally preserved joint space, with osteophyte formation and mild patellofemoral arthritis - Bedside ultrasound of calf: Large, hypoechoic, cystic appearance; connected with a small stalk to the posterior knee joint capsule (popliteal); no vascularity seen on Color Flow Doppler - Fluid analysis: Yellow, hazy; no crystals seen; minimal nucleated cells FINAL/WORKING DIAGNOSIS: Synovial cyst connected to the popliteal aspect of the knee joint TREATMENT AND OUTCOMES: 1. Bedside ultrasound evaluation 2. Aspiration of popliteal cyst, 85cc of straw-colored fluid, sent for analysis 3. ACE wrap recommended in attempt to prevent re-accumulation of fluid 4. Orthopedic evaluation due to re-accumulation of fluid, recommended continued monitoring given asymptomatic nature 5. Could consider surgical excision if becomes symptomatic