Subpleural Areas Research Articles

A case of pulmonary visceral subpleural hematoma treated by hematoma evacuation during care of post-cardiopulmonary resuscitation

BackgroundThe occurrence of pulmonary visceral subpleural hematoma during care of post-cardiopulmonary resuscitation including chest compressions and anticoagulant and antiplatelet therapies is extremely rare. Also, there are few reports of treatment of visceral subpleural hematoma, most of which are treated by lung resection. Here we describe a rare case that pulmonary visceral subpleural hematoma arose during post-cardiopulmonary resuscitation care and was treated by hematoma evacuation.Case presentationA 58-year-old male with no smoking history and, past medical histories of rheumatoid arthritis, chronic atrial fibrillation, hypertension, diabetes, and dyslipidemia developed ventricular fibrillation due to myocardial infarction and fainted. He received bystander cardiopulmonary resuscitation and defibrillation by the ambulance crew and had return of spontaneous circulation. After transfer to our hospital, the patient underwent percutaneous catheter intervention and stenting with a diagnosis of myocardial infarction, followed by anticoagulant and antiplatelet therapies. On the 8th hospital day, chest radiography suggested right lower lobe pneumonia, and subsequent chest computed tomography revealed pulmonary hematoma in the visceral subpleural area from S6 to S10. Since no improvement was observed in hypoxemia, treatment was considered necessary. First, an attempt at computed tomography-guided drainage of hematoma was made, but insertion of the Pig-tail catheter was difficult due to hardness of the hematoma. Next, evacuation of hematoma was performed on the 13th hospital day. The hematoma was located in the visceral subpleural area and was removed by incising the pleura. TachoSil Tissue Sealing sheet and Polyglycoal acid sheet were applied to the sites of air leakage and oozing after hematoma evacuation. No re-bleeding or air leakage was observed after the treatment, and the patient was discharged on the 26th hospital day after an uneventful course.ConclusionsPulmonary visceral subpleural hematoma may occur during post-cardiopulmonary resuscitation care, including chest compressions and anticoagulant and antiplatelet therapies. In our case, CT-guided puncture and drainage was difficult and surgical treatment by incision of the visceral pleura and hematoma evacuation alone was done successfully.

Erdheim-Chester disease initially discovered at extraskeletal locations: a clinicopathological analysis of four cases

Objective: To investigate the clinicopathological features of Erdheim-Chester disease (ECD) initially diagnosed at extraskeletal locations. Methods: Clinical and pathological data of four cases of ECD diagnosed initially in extraskeletal locations were collected at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from January 2013 to June 2023. BRAF V600E gene was detected by reverse transcription polymerase chain reaction (RT-PCR). Pertinent literatures were reviewed. Results: Four ECD patients included two males and two females ranging in ages from 2 years 11 months to 69 years. The lesions located in the lung (two cases), central nervous system (one case), and the testicle (one case) were collected in the study. One patient had occasional fever at night, one had nausea and vomiting, and two were asymptomatic. Radiologically, the two pulmonary ECD showed diffuse ground-glass nodules in both lungs, and the lesions in central nervous system and testicle both showed solid masses. Microscopically, there were infiltration of foamy histiocyte-like cells and multinucleated giant cells in a fibrotic background, accompanied by varying amounts of lymphocytes and plasma cells. The infiltration of tumor cells in pulmonary ECD was mainly seen in the subpleural area, interlobular septa, and perivascular and peribronchiolar areas. The fibrosis was more pronounced in the pleura and interlobular septa, and less pronounced in the alveolar septa. Immunohistochemical staining showed that all tumor cells expressed CD68, CD163 and F􀃼a; one case showed S-100 expression; three cases were positive for BRAF V600E; all were negative for CD1α and Langerin. RT-PCR in all four cases showed BRAF V600E gene mutation. Conclusions: Extraskeletal ECD is often rare and occult, and could be easily misdiagnosed, requiring biopsy confirmation. The radiologic findings of pulmonary ECD is significantly different from other types of ECD, and the histopathological features of pronounced infiltration in the subpleura area, interlobular septa, perivascular and peribronchiolar areas can be helpful in the differential diagnosis from other pulmonary diseases. Detection of BRAF V600E gene mutation by RT-PCR and its expression by immunohistochemical staining are also helpful in the diagnosis.

Paraseptal Emphysema in Indium Lung: Tracing the Pathological Footprints of Chronic Exposure.

Indium lung is an occupational lung disease caused by exposure to indium-tin-oxide (ITO) dust. Compared to other occupational lung diseases, indium lung has a shorter latency period and the respiratory status continues to worsen even after exposure to the work environment improves. Paraseptal emphysema which affects mainly the subpleural area is seen on chest images obtained via computed tomography (CT), regardless of the smoking history. However, the pathogenesis of emphysema in indium lung is still unclear. Therefore, we re-evaluated the pathology of three previously reported cases of indium lung. Paraseptal emphysema was observed in both smokers and nonsmokers. Obstructive respiratory impairment worsened over time in the cases with paraseptal emphysema. Many alveolar walls were destroyed independent of the presence or absence of emphysetamous changes or fibrosis. Moreover, bronchiolitis was found to be less common in indium lung than in asbestosis (the most common occupational lung disease) or common cases of chronic obstructive pulmonary disease caused by smoking. It has been shown that ITO causes protease anti-protease imbalance, oxidant-antioxidant imbalance, and continuous, abnormal inflammation (the three major causes of emphysema). In addition, nano-sized ITO is less likely to be trapped in the upper airways and may easily reach the subpleural alveoli. Furthermore, ITO may continue to cause sustained tissue injury at the alveolar level potentially resulting in emphysema. Further studies are needed to elucidate the detailed pathogenesis of indium lung by comparing it with other occupational lung diseases.

Clinical characteristics and high-resolution computed tomography findings of 805 patients with mild or moderate infection from SARS-CoV-2 Omicron subvariant BA.2.

COVID-19 is a global pandemic. Currently, the predominant strain is SARS-CoV-2 Omicron subvariant BA.2 in many countries. Understanding its infection characteristics can facilitate clinical management. This study aimed to characterize the clinical, laboratory, and high-resolution computed tomography (HRCT) findings in patients with mild or moderate infection from SARS-CoV-2 Omicron subvariant BA.2. We performed a retrospective study on patients infected with SARS-CoV-2 Omicron subvariant BA.2 between April 4th and April 17th, 2022. The clinical characteristics, laboratory features, and HRCT images were reviewed. A total of 805 patients were included (411 males and 394 females, median age 33 years old). The infection was mild, moderate, severe, and asymptomatic in 490 (60.9%), 37 (4.6%), 0 (0.0%), and 278 (34.5%) patients, respectively. Notably, 186 (23.1%), 96 (11.9%), 265 (32.9%), 11 (3.4%), 7 (0.9%), and 398 (49.4%) patients had fever, cough, throat discomfort, stuffy or runny nose, fatigue, and no complaint, respectively. Furthermore, 162 (20.1%), 332 (41.2%), and 289 (35.9%) patients had decreased white blood cell counts, reduced lymphocytes, and elevated C-reactive protein levels, respectively. HRCT revealed pneumonia in 53 (6.6%) patients. The majority of the lung involvements were ground-glass opacity (50, 94.3%) mostly in the subpleural area. The grade of lung injury was mainly mild (90.6%). Short-term follow-ups showed that most patients with pneumonia recovered. Most patients with mild or moderate infection from SARS-CoV-2 Omicron subvariant BA.2 were adults, with fever and upper respiratory symptoms as the main clinical presentations. Lower respiratory infection was mild, with ground-glass opacity in the subpleural area as the main finding.

P392 POST–THROMBOEMBOLIC PULMONARY HYPERTENSION: A COMPLEX CASE

Abstract Introduction Patients with post–thromboembolic pulmonary hypertension (CTEPH) achieve functional recovery after pulmonary endarterectomy (PEA). 40% of them are inoperable (1,2). Clinical case 66–year–old man admitted in 2012 to our ward for dyspnea on exertion and high echocardiographic probability of pulmonary hypertension (PI). Medical history: smoking; thalassemia trait; COPD; splenectomy at 13; diagnosis of chronic myeloproliferative syndrome. BP: 120/70 mmHg. NYHA class III. Blood tests: Hb: 9.4 g/dl; MCV: 70; HCT: 30%; PLT: 511; WBC: 14.84 (Mo 13%).NT–pro BNP:933. Autoantibodies and tests –HIV: negative. EGA in AAPaO2: 53 mmHg, PaCO2: 32 mmHg, SO2: 87%. PFR: FEV1: 68% FVC:74%, FEV1/FVC:72.DLCO:75%.6MWT:450m,Borg:0/3;Baseline SO2: 86%,final SO2 74%. On ECG: sinus r. at 64 beats/min. Echocardiogram: left sections within limits; right ventricle:DTD:30mm; RV/LV< 1; right atrial area: 19cm2, PAPs: 70+5 mmHg (Vel: 4.1 m/s), AcT: 90 msec. TAPSE: 16mm. Performs pulmonary CT scan with contrast medium: negative for pulmonary embolism; some 1 cm bubbles of emphysema in the subpleural area of the right middle lobe; right heart catheterization: PAD: 13mm; PAPM: 50mm; IC: 4.1l /min/m2; RVPtot:11WU;RVP:art:5.2WU;WP:11mmHg.Haematological diagnosis of thalassemia intermedia and exclusion of myeloproliferative syndrome/P lung scintigraphy is positive for multiple bilateral perfusion defects. The possibility of PEA for peripheral lesions at the referral Centre, therapy with warfarin (TAO), riociguat and bronchodilators was started., discontinued therapy with TAO. Finding of recurrence of pulmonary micro embolism on scintigraphy. At the end of the intravitreal treatments with resumption of TAO, at control catheterization evidence of PAD:5mm PAPm19mmHg;WP:9mmHg;IC: 3.4l/min/m2; RVPart:2.9 WU;NYHA:II. Discussion Not all CTEPH from thalassemia intermedia can perform PEA (3). Hypercoagulability is an important pathogenetic mechanism in the genesis of PH (4) and comorbidities have a significant role in the prognosis and response to medical therapy. COPD is the comorbidity that favors hypercoagulability, worsens pulmonary ventilation and gaseous exchanges (5). Conclusions In thalassemia intermedia with inoperable CTEPH, hypercoagulability is the condition that most influences the prognosis and efficacy of vasodilator therapy.

Wilms Tumor 1-Driven Fibroblast Activation and Subpleural Thickening in Idiopathic Pulmonary Fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease that is often fatal due to the formation of irreversible scar tissue in the distal areas of the lung. Although the pathological and radiological features of IPF lungs are well defined, the lack of insight into the fibrogenic role of fibroblasts that accumulate in distinct anatomical regions of the lungs is a critical knowledge gap. Fibrotic lesions have been shown to originate in the subpleural areas and extend into the lung parenchyma through processes of dysregulated fibroproliferation, migration, fibroblast-to-myofibroblast transformation, and extracellular matrix production. Identifying the molecular targets underlying subpleural thickening at the early and late stages of fibrosis could facilitate the development of new therapies to attenuate fibroblast activation and improve the survival of patients with IPF. Here, we discuss the key cellular and molecular events that contribute to (myo)fibroblast activation and subpleural thickening in IPF. In particular, we highlight the transcriptional programs involved in mesothelial to mesenchymal transformation and fibroblast dysfunction that can be targeted to alter the course of the progressive expansion of fibrotic lesions in the distal areas of IPF lungs.

Organizing pneumonia

Organizing pneumonia is a nonspecific pathologic pattern of response to lung damage. It can be idiopathic, or it can occur secondary to various medical processes, most commonly infections, connective tissue disease, and pharmacological toxicity.Although there is no strict definition of the pattern of organising pneumonia as in other idiopathic interstitial pneumonias, the characteristic pattern of this disease could be considered to include patchy consolidations and ground-glass opacities in the peribronchial and subpleural areas of both lungs. Moreover, studies of the course of the disease show that these lesions respond to treatment with corticoids, migrate with or without treatment, and tend to recur when treatment is decreased or withdrawn.Other manifestations of organising pneumonia include nodules of different sizes and shapes, solitary masses, nodules with the reverse halo sign, a perilobular pattern, and parenchymal bands.

Histopathological Features of the Lung Parenchyma in a 64-Year-Old Male Patient with Post-COVID-19 Infection with Spontaneous Pneumothorax Dextra Due to AlveolarPleural Fistula (APF): A Case Report

Introduction: Histopathological features of the lung parenchyma due to the Alveolar-Pleural Fistula (APF) in a patient with post-COVID-19 infection have not been reported. APF usually occurs after a spontaneous pneumothorax. Spontaneous pneumothorax is an abnormal traumatic accumulation of air within the pleural space. It is classified as primary or secondary pneumothorax based on multiple risk factors.Case Presentation: A sixty-four-year-old patient was referred from one of the remote hospitals in the west of Bali due to spontaneous simple pneumothorax dextra. A week after being diagnosed with COVID-19 infection, the patient underwent a bullectomy procedure and was clinically diagnosed with recurrent spontaneous pneumothorax dextra due to APF. Then, the bullectomy specimen was sent to the anatomical pathology laboratory. Histopathology test revealed extensive areas of necrosis and fibrosis with scattered lymphocytes and emphysematous alveoli found in APF lesions. Conclusions: In conclusion, the evidence of extended fibrosis, which destroys the pulmonary parenchymal septum and dilated alveoli with diffuse fibrosis in the subpleural and intraparenchymal areas, may cause impairment of both perfusion and ventilation. Unfortunately, viral cytopathic like-changes related to COVID-19, such as multinucleated cells with large nuclei, amphophilic cytoplasm, and prominent nucleoli in alveolar spaces with intranuclear inclusions, were not found in this case. In this case, surgery is needed in case of fistula, either related or unrelated to infection of the pleural cavity indicating the patient’s functional recovery.

Neumonía organizada

Organizing pneumonia is a non-specific pathologic pattern of response to lung damage. It can be idiopathic, or it can occur secondary to various medical processes, most commonly infections, connective tissue disease, and pharmacological toxicity.Although there is no strict definition of the radiological pattern of organizing pneumonia as in other idiopathic interstitial pneumonias, the characteristic pattern of this disease could be considered to include patchy consolidations and ground-glass opacities in the peribronchial and subpleural areas of both lungs. Moreover, follow-up examinations show that these lesions respond to treatment with corticoids, migrate with or without treatment, and tend to recur when treatment is decreased or withdrawn.Other manifestations of organizing pneumonia include nodules of different sizes and shapes, solitary masses, nodules with the reversed halo sign, a perilobular pattern, and parenchymal bands.

With the Increasing Health Awareness: Clinical and Computed Tomography Findings in Primary Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma Lymphoma.

The objective of this study is to investigate the clinical manifestations, computed tomography (CT) findings, and prognosis of primary pulmonary mucosa-associated lymphoid tissue lymphoma (MALToma) with the improved health awareness nowadays. Clinical data and CT images of patients with pathologically confirmed MALToma from October 2012 to October 2021 were retrospectively analyzed. Eighteen MALToma patients were included in the study (8 men and 10 women; mean age, 56.17 years; range, 33-73 years). Six men had a long-term history of smoking (>20 years). One patient had an autoimmune disease (Sjögren syndrome). Eight patients (44.44%) were asymptomatic, and 10 (55.56%) had mild chest or systemic symptoms. Most lesions (88.89%) were subpleural or located along the bronchovascular tree. According to the CT characteristics, the lesions were divided into 4 groups: nodular type (n = 8; 44.44%, including 5 solid nodules and 3 ground-glass nodules), mass type (n = 4, 22.22%), patch or consolidate type (n = 5, 27.78%), and mixed type (n = 1, 5.56%). Air bronchogram (11/18, 61.11%) and angiogram sign (8/16, 50%) were the most frequent CT findings and may help differential diagnosis. The patients were misdiagnosed with lung cancer (n = 11, 61.11%), inflammatory or chronic inflammatory disease (n = 4, 22.22%), bronchiectasis accompanied by infection (n = 1, 5.56%), diffuse interstitial lung disease (n = 1, 5.56%), and granuloma or tuberculosis (n = 1, 5.56%). The prognosis of all patients was favorable; 1 patient was lost to follow-up. Nowadays, patients with MALToma are usually asymptomatic or paucisymptomatic. Nodular lesions, including ground-glass nodules, are the most common presentation. Mucosa-associated lymphoid tissue lymphoma is most likely misdiagnosed as lung cancer. Lesions located in the subpleural areas or along the bronchovascular tree and presenting with an air bronchogram or angiogram sign could indicate a MALToma diagnosis.

Characteristics of X-ray pattern of lung lesion in COVID-19 in adult patients with cystic fibrosis

Background. Patients with cystic fibrosis (CF) fall into the risk group of breathing passages infection as a result of clinical features of the disease. During the period of COVID-19 pandemic,the necessity of understanding how infection affects the course of the main disease has appeared, taking into account that viability of patients is essentially determined by the degree of lung lesion. Early diagnostics and complex therapy of coronavirus infection increase the lifespan of CF patients and improve quality of life. X-ray examinations play the leading role in solving this problem.
 Purpose – to establish risk factors of the main pathological process aggravation by determining diagnostic significance of roentgen sings of lung lesion in COVID-19 in CF adult patients.
 Materials and methods. Theanalysis of radiography and computed tomography results of 11 adult patients with CF of moderate and severe degree who were also diagnosed with coronavirus infection.
 Results. The main X-ray symptoms in observed patients with CF with confirmed diagnosis of coronavirus infection was pneumonic infiltration of different degrees in the setting of diffuse changes of lung pattern and features of pulmonary emphysema. Besides symptoms of the main disease, computed tomography allowed us to find the signs, which we consider to be the signs of pneumonia caused by COVID-19 infection – induration of lung tissue in the form of ground-glass opacity, presence of ground-glass areas of different shapes with reticular changes and consolidation of lung tissue, bilateral localization of pathological changes, predominantly in basal and subpleural areas.
 Conclusions. Lung lesion conditioned by COVID-19 in radiography of CF patients may be disguised by the features of the main disease manifestations. Therefore, any X-ray evidence of inflammatory lung changes in CF patients during the epidemic period must be regarded as COVID-19 suspected, and polymerase chain reaction and computed tomography must be performed.

The characteristics and clinical value of chest CT images of novel corona virus pneumonia: An update

Aim: To investigate the characteristics of chest Computed Tomography (CT) images of corona virus pneumonia in India. Materials and methods: Clinical data and CT images of 1000 cases of NCP were collected. Lesions were scored and characterized. The clinical manifestations and laboratory test results of the patients were analysed. Results: The main clinical manifestations were fever, dry cough, and fatigue. A total of 15000 scored lesions were found in the first chest CT images of patients. The lesions were located mainly in the subpleural area of the lungs (90%). Most of the lesions were ground-glass opacity. Pulmonary consolidation accounted for 40% of all of the lesions. Of the 1000 cases, 900 patients (90%) had bilateral lung disease, 100 (1%) patients had unilateral lung disease Conclusion: The chest CT of NCP patients is characterized by bilateral ground-glass lesions located in the subpleural area of the lung, and progressive consolidation with no migratory lesions. Pleural effusions and mediastinal lymphadenopathy are rare. As patients can have a negative early nucleic acid test, chest CT, in combination with epidemiological and laboratory tests, is a useful examination to evaluate the disease and curative effect.

SARS-CoV-2 pneumonia with large pneumothorax\u2014a case report

The pandemic of severe acute respiratory virus (SARS-CoV-2) is characterized by respiratory symptoms with serious consequences, mainly associated with pneumonia and extreme ARDS. There is a lack of data about pneumothorax associated with COVID-19 infections in current literature. Radiological features in SARS-CoV-2 include subpleural bilateral ground-glass appearance and many areas of irregular consolidation in the lungs. We here present a case of SARS-CoV-2 that was complicated by acute pneumothorax, and despite prompt treatment, that patient could not be saved. A 55-years-old male with no previous lung disease or any other history confirmed to have SARS-CoV-2 pneumonia developed a large pneumothorax on the third day of his presentation and was immediately intubated via a chest tube but could not be saved. SARS-CoV-2 by RT-PCR was positive. The patient expired around 12 h after chest intubation. Recommended treatment could not be started yet as the patient expired before it could be decided.

Imaging Findings of Fibrosis in Pulmonary Sarcoidosis.

In pulmonary sarcoidosis, respiratory tract lesions almost always appear, and residual lung shadows require treatment in about 20% of cases. Pulmonary fibrosis is among the three leading causes of death. Treatment strategies are urgently needed to inhibit the progression of pulmonary fibrosis by combining antifibrotic drugs and immunosuppressive drugs such as corticosteroids. Establishing consensus on the process of pulmonary fibrosis progression is important for determining the most effective treatment. Among more than 2500 cases of sarcoidosis treated at our hospital, cases that led to chronic respiratory failure were analyzed for CT findings of pulmonary fibrosis. Early in sarcoidosis, granulomatous lesions appeared along the bronchovascular bundle. As pulmonary fibrosis progressed, a central consolidation developed on the central side in the direction of lymph flow, a peripheral consolidation developed on the pleural side, and a central-peripheral band developed connecting the two. Infiltrative or wedge-shaped shadows sometimes formed in the immediate subpleural area, appearing as a pleuroparenchymal fibroelastosis-like lesion. Traction bronchiectasis may form cysts at the periphery or may congregate to form a honeycomb lung-like structure. Combination of these lesions led to shrinkage of the upper lobe. Patients with multiple peripheral cysts/bullae had a unique disease course characterized by wheezing and concomitant pulmonary hypertension and pulmonary aspergillosis. Further understanding of the process of pulmonary fibrosis progression is needed. Summarizing imaging findings and understanding their contribution to respiratory impairment will contribute to comprehensively evaluating the stages of pulmonary fibrosis progression and establishing an optimal treatment strategy.

Abstract 17160: Cardiac Sarcoidosis Mimicking Arrhythmogenic Right Ventricular Cardiomyopathy Presenting With Syncope

A 35-year-old previous healthy man presented with palpitations and nearly syncope. Electrocardiography showed first degree atrioventricular block (PR interval 316 milliseconds) and premature ventricular complex (PVC) possibly originating from right ventricle (RV). The transthoracic echocardiography disclosed dilated RV with preserved right ventricular systolic function with a RV systolic pressure of 33mmHg, and thickened interventricular septum (12.7mm) with normal left ventricular size and function. At this point, the initial diagnosis was arrhythmogenic right ventricular cardiomyopathy (ARVC) with ventricular arrhythmias. The 24-hour Holter study showed 904 monomorphic PVCs and short-run ventricular tachycardia. The chest computed tomography demonstrated dilated RV with scalloping over free wall and multiple lung nodules mainly located in both upper lung fields (Figure A&B). Radiofrequency catheter ablation and implantation of implantable cardioverter defibrillator were suggested under the impression of ARVC. Therefore, he visited our hospital for second opinion. Since the diseased conduction system was unusual in patient with ARVC, CMR imaging was performed which revealed late gadolinium enhancement over both ventricles and basal interventricular septum (Figure C), raising the suspicion of cardiac sarcoidosis. Thereafter, the 18F-fluorodeoxyglucose (FDG)-Positron Emission Tomography study was arranged and showed FDG uptake over basal septum and lateral wall of LV, and multiple lung nodules (Figure D). Endomyocardial biopsy of RV showed myocardial fibrosis without a specific diagnosis. Thoracoscopic wedge resection of the lung nodule was performed, and pathology showed non-necrotizing granulomas distributed along with broncho-vascular bundles and subpleural area. No microorganism could be demonstrated. Sarcoidosis with cardiac and pulmonary involvement was impressed. Further steroid treatment will be initiated.

P076 SARS-COV-2 infection in two patients with juvenile lupus

Abstract Background The new SARS-COV-2 pandemic affects both children and adults, with a low pediatric percentage of < 1%. The severity and death rate of this disease are lower in this age range. The pediatric populations who are most likely to develop severe COVID 19 are those with particularly immunosuppressive comorbidities. Juvenile systemic lupus erythematosus “jSLE” which represents the prototype of autoimmune diseases, constitutes a predisposing ground for severe viral infections, related to immune dysfunction; linked on one hand to the disease, and on the other hand to the numerous immunosuppressive treatments prescribed. In this context, a great risk was incurred by patients with jSLE. The aim of this work is to assess the severity of COVID 19 infection in our patients with jSLE Methods and results Among 20 cases of jSLE hospitalized during the year 2020, we report 2 medical cases report of patients aged 9 and 8, respectively, followed-up in our tertiary care unit for jLES based on the criteria of the Systemic Lupus International Collaborating Clinics “SLICC 2012” and the American College of Rheumatology “ACR 2019”, and who developed a cough, progressing dyspnea and feverish. The Covid 19 was confirmed by a positive PCR for SARS-COV-2. The chest X-ray showed a systematized right cavity in 1 case. Thoracic CT showed foci of alveolar condensation systematized with air bronchogram sign extended to > 25%, associated with bilateral subpleural ground glass areas centrally and peripherally compatible with moderate pneumonia type COVID 19 in one case. The patients were in flare of their lupus disease, proven by the consumption of the C3 and C4 fractions of the complement. They were treated according to the national COVID 19 infection management plan comprising azithromycin at a dose of 20 mg/kg/day on D1 then 10 mg/kg/day for 6 days, increasing the doses of hydroxychloroquine, associated with vitamin therapy (vitamin C, Zinc, vitamin D), the evolution was favorable after 7 days of treatment. Conclusion Reassuringly, several studies have shown that the clinical course of covid 19 in SLE does not appear to be more severe than in the general population. The hydroxychloroquine prescribed routinely in patients with SLE does not protect against covid 19, but may prevent the occurrence of severe forms.

Diagnostic accuracy of pocket-sized ultrasound for aspiration pneumonia in elderly patients without heart failure: A prospective observational study.

AimTo investigate the diagnostic accuracy of pocket‐sized ultrasound (PsUS) for aspiration pneumonia in elderly patients without heart failure.MethodsThis prospective observational study included patients with aspiration pneumonia. PsUS was performed in six areas (bilateral chest, four dorsal areas) by an independent examiner, blinded to the computed tomography (CT) results as a reference standard. Patients with heart failure were excluded.ResultsPsUS findings of 34 patients (median age, 87.5 years) and 204 areas were analyzed. Three or more B‐lines (comet tail artifacts) were strongly suggestive (positive likelihood ratio [LR+] 17.302) of consolidation on CT (CT‐consolidation, subpleural hypoechoic area with tissue‐like echostructure) or pleural change on CT. Consolidation on US (US‐consolidation) was suggestive of CT‐consolidation or pleural changes on CT (LR+ 6.453). Pleural effusion on US was strongly suggestive (LR+ 10.989) of CT‐consolidation or pleural change on CT. Absence of either three or more B‐lines, US‐consolidation, or US pleural effusion could not rule out CT‐consolidation or pleural change on CT (negative likelihood ratio [LR−] 0.482‐0.683). However, absence of all three findings could rule out abnormal CT findings (LR− 0.230). Chest radiograph findings proved difficult to confirm or exclude CT‐consolidation or pleural changes on CT (LR+ 1.584, LR− 0.489); when combined with PsUS findings, LR− improved to 0.124.ConclusionsThree or more B‐lines or US‐consolidation on PsUS in elderly patients with aspiration pneumonia without heart failure suggested CT‐consolidation or pleural changes on CT. When both PsUS and chest radiograph findings were negative, CT‐consolidation and pleural change could be excluded. Geriatr Gerontol Int 2021; 21: 1118–1124.

IGG4-RELATED DISEASE: A CHALLENGING DIAGNOSIS

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: IgG4-Related Disease (IgG4-RD) is a recently recognized chronic fibroinflammatory disease that can be difficult to diagnose. We present a case of a fifty-one-year-old female diagnosed with IgG4-RD despite normal serum IgG4 levels. CASE PRESENTATION: A fifty-one-year-old female with history of chronic kidney disease stage 2, membranous glomerulonephropathy (MGN), Type 2 Diabetes Mellitus, Hypertension, and Rheumatoid Arthritis was referred to pulmonology for evaluation of abnormal findings on CT. She was diagnosed with MGN three years prior to presentation and her renal function improved with cyclophosphamide 50mg and prednisone 60mg daily. Two years later she was admitted to an outside hospital for acute hypoxic respiratory failure secondary to presumed PNA, resulting in intubation. She recovered and the decision was made to discontinue her cyclophosphamide due to concerns of pneumonia. Six months later her kidney function began to worsen resulting in a repeat kidney biopsy. Pathology showed glomeruli positive for IgG4 and negative for PLA2-R. During this time, she lost 20 pounds within 3 months and had CT C/A/P done to rule out malignancy. The CT showed diffuse ground glass infiltrates, for which she was referred to pulmonology. Repeat high resolution CT showed thickening of the interstitium mainly in the subpleural areas of the bilateral lungs with lower lung predominance, consistent with ILD. Of note, serum IgG4 levels returned normal. DISCUSSION: IgG4-Related disease (IgG4-RD) is a rare immune-mediated disease that can affect multiple organs. Clinical presentation may include any of the following: autoimmune pancreatitis, head/neck gland tumors, retroperitoneal fibrosis, glomerulonephropathy, and ILD. Diagnosis of IgG4-RD should not be solely based on serum IgG4 levels since the levels can be normal in up to 30% of cases. Diagnosis can be established with clinical suspicion and histopathological analysis of tissue biopsy. IgG4-RD has no established incidence or prevalence as there are no reliable studies likely due to disease being recently recognized or under diagnosed. CONCLUSIONS: IgG4-RD should be considered as a differential diagnosis in patients with ILD and nephropathy, despite a normal serum IgG4 level. Delay of diagnosis and treatment could be life-threatening as in our patient with multiple episodes of acute hypoxic respiratory failure requiring intubation. REFERENCE #1: Opriţă R, Opriţă B, Berceanu D, Diaconescu IB. Overview of IgG4 - Related Disease. J Med Life. 2017;10(4):203-207. REFERENCE #2: Legatowicz-Koprowska M. IgG4-related disease: why is it so important?. Central European Journal of Immunology. 2018;43(2):204-208. doi:10.5114/ceji.2018.77391. DISCLOSURES: No relevant relationships by Prangthip Charoenpong, source=Web Response No relevant relationships by Cesar Davila-Chapa, source=Web Response No relevant relationships by Diana Song, source=Web Response

Bronchiolitis Obliterans Organizing Pneumonia after Breast Cancer Radiotherapy and letrozole: A Case Report and Literature Review

Objectives: Bronchiolitis obliterans organizing pneumonia occurs with prevalence rate 1–3% after breast conservative treatment in series. In response to radiation of a lung or surrounding tissues, an inflammatory reaction can affect both lungs and is located within the radiation field. Characteristic imaging features include multiple alveolar opacities and diffuse ground-glass shadows. Letrozole may induce iatrogenic organizing pneumonia. Materials and methods: we report the case of a 76-year-old female who underwent conservative treatment for an invasive ductal carcinoma of the left breast. Hypofractionated radiotherapy was delivered with a total dose of 42.5 Gy in 16 sessions of 2.65 Gy using a three-dimensional technique. After the radiotherapy ended letrozole was indicated. Results: Several weeks after the radiotherapy ended and letrozole was introduced, she described a flu-like syndrome. Samples were negative, and there was no improvement after four courses of antibiotics. Imaging suggested bronchiolitis obliterans organizing pneumonia. Her symptomatology lessened after the letrozole was discontinued, and 11 months after radiotherapy finished, her imaging results were clear. Conclusion: Physicians must consider bronchiolitis obliterans organizing pneumonia. Cases may increase with hypofractionated radiation treatment and new drugs. Letrozole may potentiate the risk. Dosimetry may be adapted to the lung and subpleural areas for patients with risk factors and taking adjuvant or concurrent drugs with potential pneumotoxicity.

Bronchiolitis Obliterans Organizing Pneumonia after Breast Cancer Radiotherapy and letrozole: A Case Report and Literature Review

Objectives: Bronchiolitis obliterans organizing pneumonia occurs with prevalence rate 1–3% after breast conservative treatment in series. In response to radiation of a lung or surrounding tissues, an inflammatory reaction can affect both lungs and is located within the radiation field. Characteristic imaging features include multiple alveolar opacities and diffuse ground-glass shadows. Letrozole may induce iatrogenic organizing pneumonia. Materials and methods: we report the case of a 76-year-old female who underwent conservative treatment for an invasive ductal carcinoma of the left breast. Hypofractionated radiotherapy was delivered with a total dose of 42.5 Gy in 16 sessions of 2.65 Gy using a three-dimensional technique. After the radiotherapy ended letrozole was indicated. Results: Several weeks after the radiotherapy ended and letrozole was introduced, she described a flu-like syndrome. Samples were negative, and there was no improvement after four courses of antibiotics. Imaging suggested bronchiolitis obliterans organizing pneumonia. Her symptomatology lessened after the letrozole was discontinued, and 11 months after radiotherapy finished, her imaging results were clear. Conclusion: Physicians must consider bronchiolitis obliterans organizing pneumonia. Cases may increase with hypofractionated radiation treatment and new drugs. Letrozole may potentiate the risk. Dosimetry may be adapted to the lung and subpleural areas for patients with risk factors and taking adjuvant or concurrent drugs with potential pneumotoxicity.