TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung abscesses develop when necrosis of lung tissue caused by underlying infections form cavitary spaces of the lung parenchyma. A bronchopleural fistula (BPF) is a complication of cavitary lesions where a sinus tract forms between the bronchus and pleural space. We present the first reported case of a patient with severe COVID-19 who developed a lung abscess with a BPF and spontaneous pneumothorax requiring video-assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 60-year-old male with a history of hypertension and dyslipidemia presented to the hospital with shortness of breath after a recent diagnosis of COVID-19. The patient was hypoxic on room air and his chest x-ray (CXR) revealed bilateral infiltrates. The patient was admitted to the medical floors and treated with methylprednisolone, Remdesivir, piperacillin/tazobactam and DVT prophylaxis doses of enoxaparin. Methylprednisolone was increased to higher doses over the next few days in response to worsening inflammatory markers and hypoxia, as high as 125mg IV 4 times a day and was subsequently tapered to 160mg IV daily in divided doses for 30 days. On day 40, a new cavitary lesion of the right middle lobe (RML) was seen on CXR, and blood cultures grew methicillin sensitive staphylococcus aureus (MSSA) for which linezolid, meropenem and micafungin were started. On day 42, the patient developed a right sided pneumothorax which required chest tube insertion. On day 47 the patient developed respiratory distress and worsening pneumothorax, the pleural drainage system demonstrated continuous air leak and the patient was subsequently intubated due to worsening respiratory failure. VATS was performed which revealed a RML abscess; the procedure was converted to open thoracotomy with RML wedge resection. Histopathological analysis showed organizing pneumonia, interstitial fibrosis, alveolar damage and a BPF. Cultures taken from the abscess grew MSSA. On day 49, the patient became hypotensive and required the initiation of vasopressors. In the following days he developed a new air leak noted on the pleural drainage system. He remained in the ICU for several days and did not exhibit clinical improvement, thus his family transitioned him to comfort measures and he passed away soon after. DISCUSSION: High dose corticosteroids are used to treat severe COVID-19 with the goal of preventing cytokine storm and subsequent ARDS. Immunosuppression is a complication of prolonged treatment with high dose corticosteroids and may result in bacterial superinfection. Lung abscesses are typically treated conservatively with broad spectrum antibiotics. In cases such as those with BPF and pneumothorax, treatment with surgical intervention may be required. CONCLUSIONS: While corticosteroids have been used widely in the treatment of COVID-19, clinicians should be cautious in the consequences of prolonged utilization and should monitor for related complications. REFERENCE #1: Kuhajda, I., Zarogoulidis, K., Tsirgogianni, K., Tsavlis, D., Kioumis, I., Kosmidis, C., . . . Kuhajda, D. (2015, August). Lung abscess-etiology, diagnostic and treatment options. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543327/ REFERENCE #2: Salik, I. (2020, August 27). Bronchopleural fistula. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK534765/ DISCLOSURES: No relevant relationships by Arslan Chaudhry, source=Web Response No relevant relationships by Rajapriya Manickam, source=Web Response No relevant relationships by Christopher Millet, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Sherif Roman, source=Web Response No relevant relationships by Anish Samuel, source=Web Response