Small Pleural Effusion Research Articles

Metastatic Gastric Adenocarcinoma Mimicking Pulmonary Tuberculosis

Gastric Cancer is a leading cause of morbidity and mortality worldwide, which makes timely and accurate detection critical. The rare presentation of Gastric Adenocarcinoma (GA) with miliary pulmonary metastases, known as Bard's Syndrome, can be easily mistaken for more common primary pulmonary diseases, such as tuberculosis. We present a case of a 43 year old El Salvadorian male with persistent pleuritic chest pain and fevers despite treatment for disseminated infiltrates suggestive of TB. Diagnostic biopsies obtained after failed treatment confirmed GA which prompted initiation of palliative chemotherapy. A 43-year-old male from El Salvador with no significant PMH, presented with a two day history of fevers, chills and pleuritic chest pain. Chest imaging (Figures 1 and 2) revealed bilateral miliary infiltrates suggestive of TB as well as PE, which prompted initiation of RIPE therapy and anticoagulation. He returned two weeks later with worsening symptoms and repeat imaging of the chest raised suspicion for pneumonia. He improved and was discharged home on antibiotics. One week later, he developed severe abdominal pain and was found to have abdominal ascites. CT Abdomen revealed extensive clot formation throughout iliac venous system and omental caking, initially worrisome for TB peritonitis versus carcinomatosis. TB therapy was discontinued as prior AFB cultures came back negative. Omental biopsy was consistent with CK7 positive adenocarcinoma. Linitis plastica was observed on EGD (Figure 3) and EUS biopsy later confirmed malignant cells from primary gastric adenocarcinoma. The patient was initiated on palliative chemotherapy with Epirubicin, Oxaliplatin, Capecitabine (EOX). Given our patient's demographics, symptoms and radiographic imaging, a diagnosis of TB was initially made with differentials focused on primary pulmonary pathology. However, this limited differential caused an unintentional delay in detection and treatment of gastric adenocarcinoma, a disease of remarkable morbidity and mortality. Gastric carcinoma is the fourth leading cause of cancer worldwide, the second leading cause of cancer related death, and carries a significant cancer burden. GA has a 2:1 male predominance, and while incidence in North America has decreased there is a higher incidence in Hispanic populations. By adding Bard's Syndrome to the differential of miliary pulmonary infiltrates, the burden of this destructive and deadly disease can be decreased.2676_A Figure 1. Diffuse miliary pulmonary nodular opacities.2676_B Figure 2. Innumerable small bilateral pulmonary nodules with small bilateral pleural effusions.2676_C Figure 3. Linitis Plastica noted on Esophagogastroduodenoscopy

A Rare Case of Undifferentiated High-Grade Sarcoma Masquerading as Thrombus Resulting in Acute Budd-Chiari Syndrome

We present a rare case of Budd-Chiari Syndrome (BCS) from a high-grade undifferentiated sarcoma that invaded and obstructed the inferior vena cava (IVC), hepatic veins and right atrium. There are just 6 cases of venous undifferentiated intimal sarcomas reported in the literature. A 56-year-old Caucasian female with hypertension presented to her primary doctor with 2 weeks of abdominal bloating, abdominal pain, 10-pound weight gain and lower extremity swelling. On exam she had mild ascites, tender hepatomegaly and lower extremity edema. Liver tests were unremarkable, but abdominal ultrasound revealed both mild ascites and both IVC and hepatic vein thrombosis. She was referred to the hospital and a CT revealed extensive thrombus within the entire IVC extending into the right atrium showing a separate 5.0 cm right atrial mass, as well as thrombus extending into the right gonadal vein and the renal veins bilaterally. Imaging showed moderate ascites as well as heterogeneous liver appearance presumably related to passive congestion. A 2-D echocardiogram revealed an ejection fraction of 50-55% with IVC thrombus extending into the right atrium creating a functional tricuspid stenosis from inflow obstruction. The patient was started on a heparin drip to prevent further clot burden and transferred to a tertiary care facility for further intervention. During open heart surgery the right atrial portion of the 5.0cm mass was excised and freed from the tricuspid valve. The portion of the mass coming from the IVC was adherent to the wall of the vessel and right atrium and unresectable. Frozen section immunostains of the tumor cells revealed negative epithelial differentiation (pancytokeratin), endothelial cell markers (CD34, CD117), nerve sheath differentiation (S100), and smooth muscle actin (SMA). Additional stains were negative for actin (HHF), desmin, CD99, EMA and CAM 5.2. The histology showed that there was cell neoplasm with pleomorphism - bizarre, enlarged nuclei, high nuclear-cytoplasmic ratio and abundant mitoses indicative of undifferentiated high-grade sarcoma. The patient was referred to an oncology center for chemotherapy and the patient is doing well. Without surgical intervention this could have been misdiagnosed and treated with long term anticoagulation. This unique BCS case stresses the importance of using different image modalities such as ultrasound and CT imaging to promptly diagnosis and assess the surgical approach.2429_A Figure 1. High-grade undifferentiated sarcoma extension into the inferior vena cava (IVC) and the right atrium showing a separate 5.0 cm right atrial mass, which caused a functional tricuspid stenosis from inflow obstruction.2429_B Figure 2. CT imaging shows a massive high-grade sarcoma tumor continuously present within the dilated inferior vena cava and tumor occupation extending into the right atrium. Thrombus extends into the right gonadal vein and the renal veins bilaterally. Moderate ascites and subcutaneous edema with small bilateral pleural effusions and heterogeneous appearance to the liver presumably related to passive congestion.2429_C Figure 3. Frozen section immunostains of the tumor cells revealed negative epithelial differentiation (pancytokeratin), endothelial cell markers (CD34, CD117), nerve sheath differentiation (S100), and smooth muscle actin (SMA). Additional stains were negative for actin (HHF), desmin, CD99, EMA and CAM 5.2. The histology showed that there was cell neoplasm with pleomorphism - bizarre, enlarged nuclei, high nuclear-cytoplasmic ratio and abundant mitoses indicative of undifferentiated high-grade sarcoma.

Dysphagia: The Primary Indicator of Esophageal Compression by a Pericardial Effusion

Introduction: Dysphagia is a relatively common symptom seen in late adulthood and can be classified as oropharyngeal or esophageal. Esophageal dysphagia typically presents due to scarring from acid reflux, strictures within the lumen, a tumor causing obstruction or an infection causing inflammation. A rare occurrence of dysphagia is reported here as an outcome of extrinsic compression of the esophagus by a large pericardial effusion. Case: A 61-year-old male with a history of DM, epilepsy, schizophrenia, vertigo and hyperlipidemia presented with an episode of hemoptysis and dysphagia for 3 weeks duration. Although this was the first account of hemoptysis, he admitted to a dry cough for a few months. He noted his dysphagia was predominantly to solids and unless he ate slowly, he would regurgitate. He denied any fever, shortness of breath, chest pain, weight loss or night sweats. On initial examination the patient was an obese male with stable vitals except for a slightly low oxygen saturation of 94%. Inspection of the neck revealed no masses. On auscultation, heart sounds were difficult to appreciate. Labs initially revealed an elevated WBC of 15.3, platelet count of 110, a blood sugar of 222 and the remaining results were within normal limits. Chest X-Ray showed infra-hilar infiltrates suggesting pneumonia and cardiomegaly. Modified barium swallow was negative. An esophagogastroduodenoscopy revealed mild extrinsic compression in the mid-esophagus but no strictures. CT of the chest showed a large pericardial effusion of 3.3 cm compressing the esophagus and chronic atelectasis with small bilateral pleural effusions. An echocardiogram confirmed a worsening pericardial effusion from 1 year previous and a dropping left ventricular ejection fraction (40-45% to 20-25%). Initial option for treatment was a pericardial window, but a cardiac catheterization revealed 2-vessel CAD with left main involvement. The patient ended up having a CABG and having his pericardial effusion drained. Follow up echocardiogram one month later revealed no pericardial effusion and a complete resolve of his dysphagia. Discussion: While there are documented cases of pericardial effusion resulting in compression of the esophagus, it is a rare occurrence. This case emphasizes that while dysphagia is often an esophageal complaint, the origin of the symptom may be non-GI and communication between GI and cardiac specialists is essential.

Peritoneal Tuberculosis: A Challenging Diagnosis

Abdominal tuberculosis (TB) is a rare extra-pulmonary presentation of TB representing about 5% of all cases of extra-pulmonary TB. It is ranked sixth in incidence after lymphatic, pleural, osteoarticular, genitourinary and meningeal. It is usually secondary to reactivation of latent TB or ingestion of contaminated food. In cases of active pulmonary TB, abdominal involvement is usually due to hematogenous spread. The diagnosis is often delayed due to the nonspecific presentation and the poor yield of the conventional diagnostic techniques.An 88-year-old male from Nepal with history of end-stage renal disease on hemodialysis presented with subjective fevers, decreased appetite, early satiety and abdominal distention for 3 months. Physical examination was positive for ascites. Laboratory work up was significant for WBC 4.3 and elevated sedimentation rate at 41. Computed tomography (CT) abdomen showed large ascites. Paracentesis showed ascitic fluid (AF) with total nucleated cells 2400 with 5% neutrophils and 87% lymphocytes and his SAAG was <1.1. AF cytology was negative for malignancy. Three AF acid fast bacilli (AFB) smears and culture were negative, however serum QuantiFERON gold was positive. AFB sputum cultures were sent and came back positive for mycobacterium TB. CT thorax showed moderate right and small left pleural effusions. Thoracentesis was tried but was unsuccessful. He was started on isoniazid, rifampin, pyrazinamide and ethambutol and was discharged with a close follow up. Thoracentesis was done after discharge and pleural fluid AFB culture was negative.Abdominal TB can involve any part of the gastrointestinal tract with the most common sites being peritoneum, intestines and liver. A number of risk factors have been associated with peritoneal TB including cirrhosis, peritoneal dialysis, diabetes and malignancy. It often presents with ascites, abdominal discomfort and fevers. CT usually shows ascites, thickening of the peritoneum and lymphadenopathy. AF analysis usually shows elevated WBC with lymphocytosis and SAAG <1.1. AF stain and culture for AFB has poor sensitivity while adenosine deaminase testing has better sensitivity and is used to support the diagnosis in noncirrhotic patients. If AF analysis is nondiagnostic, peritoneal biopsy is pursued via laparoscopy. Treatment is similar to pulmonary TB with anti-TB medications for at least 6 months. Empiric treatment can be started in patients with high suspicion and negative diagnostic testing.

Pulmonary Complication following Drug-Eluting Bead Hepatic Chemoembolization

A 70-year-old man with a history of essential hypertension presented to his gastroenterologist with a 6-month history of unintentional weight loss. After an unremarkable colonoscopy, a computed tomographic (CT) scan of the abdomen was performed demonstrating a 6.2-cm arterially enhancing hepatic mass with delayed washout and extension into the hepatic vein ([Fig. 1a], [b]). The patient was found to have no associated liver disease or serologic evidence of viral hepatitis. A biopsy of the mass was performed demonstrating poorly differentiated hepatocellular carcinoma (HCC), and the patient was referred to interventional radiology for locoregional therapy. Prior to liver-directed therapy, imaging demonstrated a small pleural effusion felt to be related to venous invasion and narrowing of inferior vena cava (IVC). The drug-eluting beads transarterial chemoembolization (DEB-TACE) was performed with 100- to 300-µm drug-eluting beads loaded with 75 mg of doxorubicin (LC Beads, BTG, West Conshohocken, PA) followed by 300 to 500 µm “bland” particle (Embosphere; Merit Medical, Salt Lake City, UT) embolization. An angiographic endpoint of 5-beat stasis was reported. No angiographic images were stored demonstrating arteriovenous shunting; however, in retrospect, shunting could have been suspected based on attenuation of caval blood surrounding the tumor on arterial phase imaging on both CT and angiography ([Fig. 1c], [d]). Approximately 48 hours after discharge, the patient presented to his primary care physician with fevers and mild dyspnea. This was attributed to an increased right pleural effusion following DEB-TACE, which was managed conservatively without thoracentesis. The patient's oxygen saturation was incidentally noted to be decreased at 92%; however, patient was judged not to be symptomatic enough to require treatment and as such was discharged from medical care with instructions to follow up if symptoms worsened. The patient improved over the course of the next month, but follow-up imaging demonstrated a minimal response of the treated HCC. After discussion with the patient, repeat DEB-TACE was performed.

A Rare Case of Cyclical Hemothorax: Thoracic Endometriosis Syndrome

Endometriosis is a common condition in which endometrial cells and stroma are deposited in extrauterine sites. Its prevalence has been estimated to be 10% of reproductive age females. It is commonly found in the pelvis; however, it may be found in the abdomen, thorax, brain, or skin. Thoracic involvement is a relatively rare presentation of this common disease. Thoracic endometriosis commonly presents as pneumothorax in 73% of patients. A rarer presentation of thoracic endometriosis is hemothorax (<14%) or hemoptysis (7%). Thoracic endometriosis is an uncommon cause of a pleural effusion. We present a case of 28-year-old African American female with no other medical conditions. She presented to the hospital with worsening right-sided pleuritic chest pain, dyspnea, and menorrhagia. She had been complaining of pleuritic chest pain for 5 years, the onset of which corresponds to the start of her menstrual cycle and is relieved with cessation of menses. Initial laboratory studies revealed a severe microcytic anemia with normal coagulation profile. Chest X-ray showed small right pleural effusion and suspicious for airspace disease. A computed tomography (CT) of chest was ordered for further clarification and identified large right pleural effusion. CT-guided thoracentesis removed 500 ml of serosanguinous fluid consisting of blood elements. There can be multiple sites involved with endometriosis and can present with wide range of symptoms that occur periodically with menses in young woman. The history and pleural fluid findings of this case are suggestive of Thoracic Endometriosis Syndrome. The diagnosis of this is often missed or delayed by clinicians, which can result in recurrent hospitalization and other complications. As internists we should be suspicious of atypical presentations of endometriosis and treat them early before complications develop. This case also highlights the importance of suspecting atypical etiologies for pleural effusion.

Radiologic evaluation of pulmonary injury following carmustine- and cyclophosphamide-based preparative regimen for autologous peripheral blood stem cell transplantation in children.

Toxicity of carmustine and cyclophosphamide can cause pulmonary injury after hematopoietic stem cell transplantation. To evaluate the radiologic findings of pulmonary injuries following carmustine- and cyclophosphamide-based preparative regimens in children. From 2010 to 2014, 35 children received carmustine- and cyclophosphamide-based preparative regimens. Fourteen of 35 children presented with symptoms and radiologic abnormalities. Eight of 14 children had no evidence of infection, cardiogenic edema, or other explainable causes. We retrospectively analyzed their chest radiographs and CT scans for ground-glass opacity, consolidation, septal thickening and pleural effusion. Major chest radiographic findings were bilateral diffuse ground-glass opacity (n=8) and septal thickening (n=7). CT findings were multifocal patchy (n=4) or inhomogeneously diffuse (n=4) ground-glass opacity, multifocal consolidations (n=7) and septal thickening (n=7). All of these lesions at CT were bilateral, but showed lower lobe predominance in 88, 100, and 63%, respectively. There was no central/peripheral or anterior/posterior predilection. Six children had small pleural effusions, which were bilateral in five children. Bilateral ground-glass opacity with or without consolidation, septal thickening and pleural effusion were common radiologic findings in pulmonary injury following carmustine- and cyclophosphamide-based preparative regimens.

53-Year-Old Man With Progressive Dyspnea and Orthopnea

53-Year-Old Man With Progressive Dyspnea and Orthopnea

Images after unsuccessful left subclavian artery stenting show significant blood products/stranding around arch with wall thickening arch wall likely tracking blood products and small hemorrhagic left pleural effusion

Images after unsuccessful left subclavian artery stenting show significant blood products/stranding around arch with wall thickening arch wall likely tracking blood products and small hemorrhagic left pleural effusion

Waterpipe (narghile, hookah) tobacco smoking-induced acute eosinophilic pneumonia

Acute eosinophilic pneumonia (AEP) is characterized by a febrile illness, diffuse pulmonary infiltrates, hypoxemic respiratory failure, and pulmonary eosinophilia. A temporal relationship has been described in a number of patients between the development of AEP and the recent onset of cigarette smoking. A 22-year-old male patient with no known chronic disease was admitted to the emergency service for 3 days with the complaints of cough, fever, dyspnea, and pleuritic chest pain. He was formerly a nonsmoker but was a waterpipe (narghile, hookah) tobacco smoker as a new habit once a night for the last 2 months. The erythrocyte sedimentation rate and C-reactive protein are elevated. Arterial blood gases revealed moderate hypoxemia. Computed tomography scans included bilateral, random, and patchy ground-glass opacities and also small bilateral pleural effusions. Echocardiograhic examination was normal. We had accepted the patient as an acute eosinophilic pneumonia due to rapid response to corticosteroid treatment, no microorganism in bronchoalveolar lavage (BAL) culture, and predominant eosinophilia was observed (70%–80%) in BAL.

CT diagnosis and differentiation of benign and malignant varieties of solitary fibrous tumor of the pleura.

To investigate computed tomography (CT) characteristics of benign and malignant solitary fibrous tumors of the pleura (SFTPs).Preoperative CTs for 60 SFTP cases (49 benign and 11 malignant) with subsequently confirmed diagnoses were retrospectively analyzed.Tumor morphologies included mounded or mushroom umbrella-shape (19 cases, 31.7%), quasi-circular or oval-shape (30 cases, 50%), and growth resembling a casting mould (12 cases, 20%). Maximum tumor diameters were 1.1 to 18.9 cm (average: 6.4 ± 4.8 cm). Fifty-seven cases had clear boundaries, and 3 had partially coarse boundaries. Twenty-seven cases showed homogeneous density; 33, “geographic”-patterned inhomogeneous density; 6, calcifications; 12, intratumor blood vessels; and 3, thick nourishing peritumoral blood vessels. Pleural thickening (regular and irregular) was found adjacent to tumors in 4, compression of adjacent ribs with absorption and cortical sclerosis in 2, and location adjacent to ribs with bony destruction in 1. Four cases had a small amount of lung tissue enfolded along the boundary, 2 had multiple peritumoral pulmonary bullae, and 9 had small ipsilateral pleural effusions. Compared with benign and malignant SFTPs were larger (P < .001), had inhomogeneous density, and were more commonly associated with intratumor blood vessels and pleural effusions (P < .01).CT revealed characteristic patterns in SFTPs, including casting mould-like growth, rich blood supply, and “geographic”-patterned enhancement. In addition, larger tumor size, inhomogeneous intensities, abundant intratumor blood vessels, and pleural effusions were more common with malignancy. Lastly, multislice CT angiography can reveal feeding arteries and help guide surgical management.

There is a Fungus Among Us

SESSION TITLE: Fungal Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Coccidioidomycosis, also known as “Valley Fever,” is a fungal infection contracted by the inhalation of spores found in the soil of the Southwestern United States, Mexico and Central America. Symptoms are nonspecific and can include cough, night sweats and dyspnea. In immunocompetent patients, infection often resolves without intervention1. This case highlights an unusual presentation of coccidioidomycosis and the importance of obtaining a thorough travel history. CASE PRESENTATION: A 36-year-old male from the Philippines with no past medical history presented to a hospital in Rhode Island with one day of shortness of breath and left-sided pleuritic chest pain. He was found to have a small left lower lobe infiltrate and pleural effusion and was discharged home on azithromycin for suspected community acquired pneumonia. He represented 9 days later with fevers and worsening dyspnea despite antibiotics and repeat chest X-ray showed an enlarging left-sided pleural effusion. Thoracentesis revealed an exudative effusion with protein 5.19 g/dL (serum 7.26), LDH 848 U/L (serum 482), with 75% lymphocytes. Cytology and fluid cultures were negative and he was discharged with Augmentin. Over the next month he had two additional hospitalizations for fevers, chest pain and recurrent left sided pleural effusion. Over this time he lost 25 lbs. On further history, the patient noted travel to both the Philippines and Thailand in the past six months. He also had travelled to California two weeks prior to his initial presentation. Extensive infectious disease evaluation was performed and he received multiple courses of broad spectrum antibiotics without improvement. He was HIV negative but was found to have a positive quantiferon gold. This raised concern for tuberculosis, however, induced sputum and pleural fluid samples were all negative for acid fast bacilli and pleural fluid adenosine deaminase was only moderately elevated at 29.7 U/L (normal < 9.2). Given his persistent symptoms he ultimately underwent pleural biopsy which revealed granulomatous inflammation and fungal organisms consistent with Coccidioides immitis (image 1). Blood titres for coccidioides, sent after biopsy, peaked at 1:512. After three months of anti-fungal therapy his symptoms have resolved. DISCUSSION: Coccidioidomycosis is seldom seen in the northeastern United States, and rarely presents as a recurrent pleural effusion. The diagnosis is often delayed, as in this case, due to failure to consider this infection in the differential diagnosis. In this case we were mislead by the patient’s positive quantiferon gold and recent travel to a tuberculosis endemic area and overlooked his more recent travel to the west coast. CONCLUSIONS: This case serves as a reminder to take the time to record a thorough travel history, and recognize when diagnostic anchoring obscures clinical judgment. Reference #1: 1. Clin Infect Dis. 2016 Sep;63(6):e112-46 DISCLOSURE: The following authors have nothing to disclose: Dennis Guadarrama, Humnah Khudayar, Melissa Tukey, Andrew Schiff No Product/Research Disclosure Information

Severe Back Pain, Epigastric Distress and Refractory Nausea: An Unusual Presentation of Mediastinal Bronchogenic Cyst

Bronchogenic cysts are congenital malformations from abnormal budding of embryonic foregut and tracheobronchial tree. We present a case of bronchogenic cyst with severe back pain, epigastric distress and refractory nausea and vomiting. A 44-year-old Hispanic female presented with a 3-week history of recurrent sharp interscapular pain radiating to epigastrium with refractory nausea and vomiting. She underwent cholecystectomy 2-years ago. Computed tomography (CT) abdomen at that time showed a subcarinal mass measuring 5.4 X 5.0 cm. Subsequent endoscopic ultrasound (EUS) diagnosed it as a bronchogenic cyst. Endobronchial ultrasound (EBUS) guided aspiration resulted in incomplete drainage and she was discharged after partial improvement. Current physical examination showed a heart rate of 126/min and respiratory rate of 20/min. Labs showed white cell count of 10.58X103/uL, elevated inflammatory markers, and hypokalemic metabolic alkalosis. Electrocardiogram showed non-specific T wave changes. CT chest showed increased size of the bronchogenic cyst (9.64 X 7.7 cm) with small right pleural effusion. This was consistent with partial cyst rupture or infected cyst. X-ray esophagram ruled out esophageal compression or contrast extravasation. Patient's symptoms were refractory to conservative management. The patient ultimately underwent right thoracotomy with cyst excision that resulted in complete resolution of symptoms. Cyst pathology was consistent with severe inflammatory changes. Bronchogenic cysts are the most common primary cysts of mediastinum with prevalence of 6%. The most common symptoms are chest pain, dyspnea, cough, and stridor. Our patient presented with back pain, epigastric distress, refractory nausea and vomiting. Back pain is caused by stretching of nerves supplying parietal pleura; while nausea is caused by stimulation of vagus nerve. Diagnosis is made by Chest X-Ray and CT chest. Magnetic resonance imaging (MRI) chest and EBUS are more sensitive and specific. Symptomatic cysts should be resected unless surgical risks are high. Asymptomatic cysts in younger patients should be removed due to low surgical risk and potential late complications (infection, hemorrhage or neoplasia). Watchful waiting has been recommended for asymptomatic adults or high-risk patients. Bronchogenic cyst can cause severe back pain and refractory nausea and vomiting. Prompt surgical excision can lead to complete symptom resolution and avoidance of future complications.Figure: Chest Xray showing right posterior mediastinal cyst (April 2017).Figure: CT Chest with contrast showing right posterior mediastinal cyst measuring 5.4 X 5.0 cm (May 2015).Figure: CT Chest with contrast showing right posterior mediastinal cyst measuring 9.64 X 7.7 cm (April 2017).

An Uncommon Initial Manifestation of Eosinophilic Esophagitis: Spontaneous Esophageal Tear

Background: Eosinophilic esophagitis (EoE) is a clinicopathologic disease characterized by dense eosinophilic infiltration of the esophageal mucosa. Patients usually present with long standing dysphagia or food impaction. Mucosal tears or perforation can occur as rare complications of endoscopic dilation. Spontaneous tears are an uncommon initial manifestation of EoE. Case: A 22 year old male presented with sudden onset severe midsternal chest pain, without emesis, shortly after a meal. Prior history included intermittent dysphagia to solid foods in the preceding year. Upon arrival he was afebrile, normotensive but tachycardic with chest computed tomography scan with contrast showing pan-esophageal thickening with small bilateral pleural effusions. Barium swallow showed features of thickened distal esophagus, without strictures or perforation. Esophagogastroduodenoscopy (EGD) was performed which showed a large, cratered ulcer, 30cm from the incisors in the distal esophagus. Also pallor, linear furrowing and felinization of the mucosa was seen, with proximal and distal biopsies showing 45 and 30 eosinophils per high power field (EPHPF) respectively. The clinical presentation along with endoscopic findings were concerning for a contained esophageal perforation. Patient improved with conservative management of nil oral intake and antibiotics, and was discharged a week later with pantoprazole 40mg twice daily. On EGD evaluation 2 months later, the prior ulcer had resolved. The changes of circular rings and linear furrows remained and repeat proximal and distal esophageal biopsies showed >50 EPHPF respectively. A diagnosis of eosinophilic esophagitis (EoE) was made and the patient was initiated on fluticasone therapy.Figure: Barium swallow image showing ulceration in distal esophagus.Figure: Esophagogastroduodenoscopy image showing deep esophageal ulceration.Discussion: Our patient exemplifies a rare manifestation of EoE, that can be associated with significant morbidity. Increased fragility of the esophageal mucosa from eosinophilic infiltration and subsequent remodeling alters wall compliance and can predispose to mucosal tears. While tears can occur in 0.3% of cases after endoscopic dilation, spontaneous tears are uncommon and sparsely reported. Non-surgical management leads to improvement in 50% of patients. Increased awareness of this rare but serious complication can lead to earlier diagnosis and timely intervention. Also, an evaluation of the factors that may predict early tears or perforation in EoE, is essential to minimize the incidence of this serious complication.Figure: Repeat esophagogastroduodenoscopy showing resolution of prior ulceration.

Pyopneumothorax With Bronchopleural Fistula Secondary to Streptococcus Constellatus Infection

SESSION TITLE: Pleural Effusions SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Streptococcus constellatus is a member of the S. milleri group that is recognized as normal human flora of the oral cavity, genitourinary and gastrointestinal tract. Infection due to S. constellatus can range from minor oral infections to life-threatening suppurative infections. We present a rare case of pyopneumothorax with a bronchopleural fistula associated with S. constellatus. CASE PRESENTATION: 54 years old woman with history of brucellosis presented with shortness of breath and left sided back pain for two weeks. She denied fever, cough, arthralgias, illicit drug use or recent travel. She had prior exposure to sheep and cattle over 30 years ago and was treated for brucellosis in Mexico at 18 years old. Two weeks prior to admission she presented to another hospital with similar complaints and chest X-ray was normal. Chest computed tomography (CT) showed small left pleural effusion. On admission she was afebrile, tachycardic (100-110 bpm) and other vitals were within normal limits. Physical examination showed decreased breath sounds and dullness to percussion over the left hemithorax. Laboratory data showed leukocytosis with neutrophil predominance (WBC 25.0 K/uL; 95.0% neutrophils), hemoglobin 11.0 g/dL and abnormal liver function tests (albumin 1.6 g/dL, aspartate aminotransferase 65 U/L, alanine aminotransferase 52 U/L, alkaline phosphatase 193 U/L). Chest x-ray was concerning for a large left hydropneumothorax. Left 14 french chest tube was placed and drained putrid, purulent fluid consistent with empyema. Pleural fluid analysis showed WBC 212 k/UL, glucose <1mg/dL, lactate dehydrogenase 8399 U/L and pH 7.2. She was started on broad-spectrum antibiotics. CT Chest was obtained due to lack of re-expansion after chest tube placement. Imaging showed persistence of left pyopneumothorax and small bronchopleural fistula in the left upper lobe. Pleural fluid gram stain showed multiple organisms suggestive of aspiration. Pleural fluid culture grew S. constellatus. Pleural acid-fast bacilli stain/culture, fungal stain/culture and anaerobic culture were negative. Blood cultures showed no growth. CT maxillofacial showed multiple periapical lucencies. She underwent left thoracotomy with decortication of left lung and drainage of empyema. DISCUSSION: S. constellatus is part of the normal oral flora and aspiration may lead to severe thoracic infections. Our case highlights a rare occurence of pyopneumothorax with a bronchopleural fistula associated with S. constellatus that was likely secondary to aspiration. CONCLUSIONS: Thoracic infections secondary to S. constellatus are associated with significant morbidity and mortality, and often require prolonged antimicrobial therapy, early abscess drainage and operative intervention [1]. Reference #1: Ripley RT et al. Streptococcus milleri infections of the pleural space: operative management predominates. Am J Surg 2006;192(6):817-21. DISCLOSURE: The following authors have nothing to disclose: Joanna Scoon, Jennifer Duke, Maryam Kaous No Product/Research Disclosure Information

A Case of Adenocarcinoma in a Patient With Sarcoidosis Presenting as a Mandibular Lesion

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis is a disease characterized by the presence of noncaseating granulomas in affected organs, most commonly lung and lymph nodes with symptoms commonly manifesting in the skin, joints, and eyes.1 The variability of symptoms mimic a long list of other disorders, making the disease challenging to diagnose and manage, even confounding the diagnosis of other disease processes in a patient with Sarcoidosis. We present a case of a patient with Sarcoidosis diagnosed with primary lung adenocarcinoma that was discovered secondary to complaints of a rapidly growing mandibular mass. CASE PRESENTATION: A 64 year old male, former smoker, with a PMHx of Sarcoidosis with uveitis, skin, and joint involvement on chronic prednisone therapy presented to his pulmonologist for cough with phlegm production, fatigue, and a chronic toothache for three months. He was recently seen by his dentist for complaints of toothache in a right lower molar. No improvement was noted even after tooth extraction. His chest x-ray showed a small right pleural effusion with no other acute findings so the patient was treated for bronchitis. He returned one week later with worsening fatigue and hemoptysis. His steroid dose was increased and he was given antibiotics. He presented to his PCP four days later for sudden worsening of his tooth pain and new lesion on his right mandible. The lesion was biopsied and pathology demonstrated adenocarcinoma, poorly differentiated, CK7+ suggesting lungs as a primary source. Secondary to concerns of a pulmonary primary, investigation was initiated with a CT chest that was significant for right pleural effusion and a pleural nodularity possibly representing Sarcoidosis vs malignant neoplasia. Thoracentesis, bronchoscopy with washings, and EBUS studies were then obtained. Cells with similar histology and staining pattern were found in his pleural fluid and right hilar lymph node. PET scan revealed primary malignancy in the right lower lung with further metastatic disease in lung, mediastinum, liver, bone and retroperitoneal space. While treatment was initially aggressive, the patient’s condition continued to deteriorate and he eventually transitioned to hospice care. DISCUSSION: Our patient, who had relatively well-controlled Sarcoidosis, presented with new onset tooth pain, cough, phlegm production progressing to hemoptysis and joint pain. All were easily attributable to Sarcoidosis but in fact represented fairly advanced metastatic adenocarcinoma. CONCLUSIONS: We highlight this case first as an example of a rare presentation of adenocarcinoma presenting as dental pain in a patient with Sarcoidosis. Secondly, as an illustration that the varied presentation of Sarcoidosis can act as an imposter distracting the clinician from the diagnosis of an important underlying pathology. Reference #1: N/A. (2013, June 14). National Heart, Lung, and Blood Institute. Retrieved 2017, from What Is Sarcoidosis?: https://www.nhlbi.nih.gov/health/health-topics/topics/sarc DISCLOSURE: The following authors have nothing to disclose: Jason Taylor, Nooreen Hussain, Subramanyam Chittivelu No Product/Research Disclosure Information

Unusual Cause of Non-healing Tongue Ulcer in a Cirrhotic Patient

Introduction: Histoplasmosis is an endemic fungal infection caused by inhalation of microconidia of Histoplasma capsulatum, a dimorphic fungus. It generally presents as acute or chronic pulmonary infection; disseminated histoplasmosis (DH); and mediastinal fibrosis. Here we present an unusual case of histoplasmosis presenting as a non-healing tongue ulcer along with bilateral adrenal gland involvement in a cirrhotic patient. Case: 59 yr old male with a past medical history of cirrhosis and type 2 diabetes mellitus presented with a tongue ulcer associated with intermittent dry cough and fever since 1 year. At admission, he had normal vitals and on physical examination, a large tongue ulcer on the right lateral border (4x5cm) with granulation tissue and smooth margins was noted. He had moderate ascites. Lab studies showed Hb of 9.2 g/dl, total bilirubin 2.2 mg/dl and CRP increased at 29.2 mg/l. CT chest with contrast showed small right pleural effusion and enlarged bilateral adrenal glands which were lobulated, heterogeneously enhancing and necrotic. Endoscopic Ultrasound(EUS) guided FNAC from adrenal gland aspirated purulent material which was sent for cytology. Tongue lesion biopsy was done. Adrenal FNAC showed small sized fungal spores with occasional budding yeast forms which were seen both intracellularly within macrophages and extracellularly in the necrosis. Giemsa stain highlighted the fungal spores. Tongue biopsy revealed similar findings. Findings were consistent with adrenal and tongue Histoplasmosis. Patient was treated with itraconazole and clinical improvement was seen within 4 weeks. Discussion: Non-healing tongue ulcer has a high suspicion for malignancy, especially in India where the oral cancer is widely prevalent. In our case, workup revealed Histoplasmosis in the setting of immunocompromised state due to underlying cirrhosis. Besides oropharyngeal involvement, H.capsulatum has also been reported to affect adrenal glands resulting in adrenal insufficiency. In India, where oral cancer is widely prevalent, oral histoplasmosis masquerading as carcinoma is not unknown. These lesions show complete resolution with itraconazole. DH has not been reported to the best of our knowledge in a patient with cirrhosis. Histoplasmosis is a rare differential diagnosis which should be considered in an immunocompromised host presenting with a non-healing oral cavity ulcer with adrenal mass in addition to other differentials of tuberculosis and malignancy.Figure. 4x5: cm tongue ulcer.Figure: EUS guided FNAC.Figure: Adrenal FNAC. Small sized fungal spores with occasional budding yeast forms seen both intracellularly within macrophages and extracellularly in the necrosis.

Still a Challenge: Adult Onset Still Disease as a Cause of Respiratory Failure

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Adult Onset Still’s Disease (AOSD) is a rare systemic inflammatory disorder and is a diagnosis of exclusion. Patients commonly present with a fever, a macular or maculopapular evanescent rash and a sore throat. Additional symptoms may include myalgia, lymphadenopathy, hepatosplenomegaly, pleurisy, pericarditis, weight loss and abdominal pain. [1]. These nonspecific findings present a significant challenge in diagnosing a patient and subsequently starting the appropriate treatment regimen in a timely manner. CASE PRESENTATION: A 21 year old male developed fevers, chills and myalgias. Subsequently, diarrhea, sore throat, and an abdominal rash occurred. One month later, he presented to our institution with fever to 101.6F, a violacious macular abdominal rash, and evidence of respiratory distress. No arthritis was noted. Laboratory data showed a serum ferritin = 12,731, WBC = 17.9, ESR = 75, CRP >30, and negative ANA/dsDNA. Imaging studies were significant for small bilateral pleural and pericardial effusions. Rheumatology consultant initiated steroid therapy due to suspicion of AOSD, and the patient’s respiratory status improved. However, the following day steroids were discontinued by the primary team due to suspected typhus. Workup for infectious causes was negative, including bacterial cultures, typhus titers and HIV antibodies. The patient remained febrile despite broad antibacterial therapy, and thoracentesis produced 450 mL of purulent fluid with negative cultures. The patient’s corticosteroids were resumed, and he rapidly improved again over the next 72 hours. He was eventually started on anakinra in the outpatient setting. DISCUSSION: Pulmonary manifestations of AOSD range from pleurisy to adult respiratory distress syndrome. While pleural effusions are not uncommon complications of the disease, the incidence of empyema is not well established. Only a few isolated case reports attribute empyemas to AOSD, and their pathogenesis are not well understood. Pleural fluid analysis can therefore delay treatment while infectious causes of empyema are ruled out before starting appropriate immunosuppressive therapy. CONCLUSIONS: A high index of suspicion must be present to be able to diagnose and prevent complications in patients with AOSD. Due to the difficulty in diagnosing this disorder, patients with pulmonary manifestations can often present or progress to respiratory failure before the appropriate treatment can be initiated. More research into the exact etiology of this syndrome and its complications may lead to more accurate diagnosis and timely initiation of fitting therapies. Reference #1: [1] Gerfaud-Valentin M, Jamilloux Y, Iwaz J, Sève P. Adult-onset Still’s disease. Autoimmun Rev. 2014;13:708-22. DISCLOSURE: The following authors have nothing to disclose: Kara Zabelny, Grigoriy Rapoport, Adolfo Kaplan No Product/Research Disclosure Information

Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes

Introduction: Diagnosis of SBP is made if the ascitic fluid shows polymorph nuclear cell count more than 250 cells/mm. Listeria monocytogenes, is an uncommon cause of SBP in the United States. Case Presentation: Patient is a 57-year-old man with a past medical history significant for non-Hodgkin's lymphoma diagnosed three years prior to hospital presentation status post six rounds of Rituximab, Cyclophosphosphamide, Doxorubicin Hydrochloride, Vincristine Sulfate and Prednisone therapy. He presented to the hospital secondary to generalized weakness, consistent temperature of 99.2 Fahrenheit and chills. He had a tunneled indwelling peritoneal catheter for recurrent ascites secondary to peritoneal metastasis. During presentation his vitals were temperature: 98.2 F, heart rate of 101 beats/ min, BP 84/40 mmHg while on norepinephrine, and saturating at 94% on 2 L of nasal cannula. His abdomen was distended, tense with ascites and tender to palpation. His laboratory results were as noted in Table 1. Evaluation with a CT abdomen and pelvis showed moderate ascites and small bilateral pleural effusion. His serum-ascites albumin gradient was 1.3. He was further worked up for an infectious etiology with thoracentesis and peritoneal tap. He was found to have listeria bacteremia as well as positive pleural and ascites cultures for listeria. He initially had received an empiric dose of ceftriaxone and gentamicin, but was transitioned to ampicillin and gentamicin once listeria was identified in the peritoneal fluid and blood cultures. After 7 days of treatment with ampicillin, he remained afebrile with resolution of general weakness and myalgia. He was discharged on ampicillin 2g intravenous every 4 hours for a total of 14 days of treatment. At the time of discharge his repeat blood and peritoneal cultures remained sterile.Table: Table. Laboratory resultsDiscussion: SBP caused by listeria monocytogenes should be considered when there is an inappropriate response to treatment in the first 48-72 hours with patients treated for SBP. Third generation cephalosporin are commonly used for treatment of SBP, however these antibiotics do not have a reliable action against listeria. Ampicillin with or without an aminoglycoside is the treatment of choice. In conclusion listeria is a rare but potentially fatal cause of spontaneous bacterial peritonitis. This case emphasizes the importance of looking beyond meningitis when approaching listeriosis in immunocompromised hosts.

Paragonimiasis: An Unexpected Cause of Cardiac Tamponade

SESSION TITLE: Lung Infections 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Paragonimiasis (lung fluke disease) is a potentially serious infection caused by lung fluke of the genus Paragonimus. It is endemic in Asia and Africa. In the United States (US), the disease is observed most frequently in immigrants from endemic countries, but local transmission has been described. CASE PRESENTATION: A 53 year- old man presented to an emergency department in the Mid-Atlantic United States complaining of a productive cough, shortness of breath, chest pain, abdominal bloating and diarrhea. A review of systems was notable for fatigue, weight loss and night sweats. His past medical history was significant only for hypertension. He grew up in East Africa and later immigrated to the US. He was afebrile, tachycardic and normotensive. Heart sounds were distant. A complete blood count showed a normal white cell count with normal eosinophil count. A comprehensive metabolic panel was normal. Stool was negative for ova and parasites. Chest radiography showed an enlarged heart. Computed tomography of the chest and abdomen showed a large pericardial effusion, small right pleural effusion, numerous small pulmonary nodules, and mass in the spleen (Figure 1). An echocardiogram showed signs of cardiac tamponade. The patient underwent urgent placement of a pericardial window. Pericardial fluid, pleural fluid and bronchoalveolar lavage were negative for bacteria, virus, acid fast bacilli, fungus and malignant cells. A transbronchial biopsy was non diagnostic. An open lung biopsy was performed, which revealed the presence of eggs consistent with Paragonimus. The patient was started on praziquantel after which his symptoms gradually resolved. DISCUSSION: Paragonimiasis may mimic a number of diseases, especially tuberculosis and neoplasm. Cough, hemoptysis, and pleural effusions are common. Diagnosis may require open lung biopsy. Pericardial infiltration, especially to the extent that cardiac tamponade develops, is quite rare. To our knowledge, this is the first reported case of paragonimiasis-induced cardiac tamponade in the US. CONCLUSIONS: Paragonimiasis is a rare cause of lung disease in the US. However, because of immigration from endemic areas and local spread of the disease, it is occasionally encountered in clinical practice. Because many clinical and radiographic abnormalities are non-specific, physicians must maintain a high index of suspicion. Reference #1: Gary Procop. North American Paragonimiasis. Clin Microbiol Rev. 2009 Jul; 22(3): 415-446 DISCLOSURE: The following authors have nothing to disclose: Abdalsamih Taeb, Joshua Sill No Product/Research Disclosure Information