Consolidation Of Upper Lobe Research Articles

Tuberculosis presenting with multiple osteolytic lesions in an adolescent boy with fanconi anemia

Tuberculosis (TB) is well known to present with varied clinical and radiological features. Multifocal bone involvement in tuberculosis is rare. Multiple lytic lesions raise the possibility of malignancy usually, especially, in children with predisposing conditions like Fanconi anemia. However, a thorough evaluation with repeated attempts at histopathological confirmation and microbiological evaluation is mandatory in children with unique presentations with inconclusive initial diagnostic tests. We report an adolescent boy with an underlying Fanconi anemia who presented with fever, cough and respiratory distress. On evaluation, he had pallor, wasting, features of right upper lobe consolidation and multiple lytic lesions. Initial diagnostic evaluation including bone marrow evaluation and a diagnostic biopsy from ribs and bronchoalveolar lavage failed to yield a conclusive diagnosis. After nearly 5 weeks of broad-spectrum antibiotics and antifungals, as the clinical signs were progressing, a complete re-evaluation including biopsy from the rib lesion was done and further, he was diagnosed to have skeletal tuberculosis based on the Mycobacterium Growth Indicator Tube (MGIT) culture for Acid Fast bacilli (AFB). Child was empirically started on anti-tuberculous therapy pending cultures, which have led to significant clinical improvement in 2 weeks of therapy. Low bacterial load in skeletal TB reduces the chance to diagnosis, hence making clinical judgment imperative in diagnosis; and repeated testing is mandatory when there is high index of suspicion.

Socio-Demographic and Clinical Profile of Patients with Pulmonary Tuberculosis in A Tertiary Care Hospital

Background: Worldwide, tuberculosis (TB) is one of the leading causes of mortality. It is caused by bacteria and most often affects the lungs resulting in pulmonary tuberculosis (PTB). Pulmonary tuberculosis (PTB) spreads from person to person by coughing, spitting, and sneezing. Patients with active pulmonary tuberculosis (PTB) can be asymptomatic. Prior conception regarding the socio-demographic and clinical profile of patients with pulmonary tuberculosis may be helpful in the management of such cases. Aim of the Study: This study aimed to assess the socio- demographic and clinical profile of patients with pulmonary tuberculosis. Methods: This descriptive cross-sectional study was conducted in the Department of Medicine, Dhaka Medical College Hospital for the period of March 2018 to September 2020. Of all the patients admitted to the medicine department with lung infiltrates, 100 pulmonary tuberculosis patients were selected as the study population. All the necessary diagnosis was performed in Dhaka medical College Hospital (DMCH), Dhaka, Bangladesh. All final data were collected in the semi-structured and pretested case record form. After data collection, data were checked for errors, and analysis was done. Results: In this study, male participants were dominant in number and the male-female ratio was 2.7:1. The mean age of the participants was 42.59±12.73 years. The majority of our participants were married (88%), about one-third (30%) of our participants were service holders and only 9% were unemployed. The majority (51%) of our participants were from middle-income status. As the most common symptom, cough was found among 100% of our patients. Besides this, sputum (81%) and fever (73%) were also found in more than 50% of cases. In most of the cases, ESR was found between 50-100 mm, CRP was found between 50-100 mg/L, and the MT test was positive in 67% of cases. In chest X-rays- patchy opacity, consolidation in different lobes, and upper lobe consolidation .....

S9.1d Chronic pulmonary aspergillosis in post-TB and retreatment TB patients in Lagos, Nigeria

S9.1 Chronic Pulmonary Aspergillosis - where do we stand?, September 23, 2022, 4:45 PM - 6:15 PM ObjectivesChronic pulmonary aspergillosis (CPA) is a known complication of post-TB treatment. It is a progressive disease characterized by progressive cavitation, fibrosis, and pleural thickening among others. Globally, an estimated 3 million people are affected. This study determined the burden of CPA amongst the post-TB and retreatment TB patients in two facilities in Lagos, Nigeria.MethodsThis was a prospective longitudinal study that was carried out at two TB clinics (LUTH and NIMR) in Lagos, Nigeria between February 2021 and March 2022. The study cohorts were patients that had been previously managed (2-4 years earlier) for TB, they were clinically classified as retreatment TB and post-TB patients. Patients were seen in clinics every 3 months and the following data were collected: Quality of life (WHO and SGRO questionnaires used), 5 mls of blood for Aspergillus IgG level (using Bordier; cut-off of 0.8 AU/ML), sputum for culture (those with productive cough), and chest X-ray. Infectious disease society of America (IDSA) case definition was used to determine cases of CPA.ResultsA total of 112 post-TB treatment patients were recruited, 60 (53.1%) were retreatment TB and 52 (46.0%) post-TB patients. The mean age was 41.14 years; with the majority between the ages of 21-30 years. The male/female ratio was 0.9/1. 98 (87.5%) were HIV negative, and only 40 patients had GeneXpert testing done. In all 32/40 were GeneXpert negative; of which 24/32 and 8/32 belonged to the retreatment, and post-TB groups respectively. Cough was the predominant symptom with 39 (34.8%) having productive cough. Hemoptysis occurred in 11 (9.8%), 10 in the retreatment group with 2 having frank hemoptysis. Chest imaging revealed that 27/112 of the studied cohort presented with multiple cavities, 4/112 had single cavities, 26/112 had cavities with surrounding opacities and 23/112 had upper lobe consolidation. A total of 17/112 of them had bilateral lung infiltrates and 13/112 had pleural thickening. Sputum culture yielded growth of Aspergillus spp, with A. flavus (n-11; 36.7%) being the predominant species followed by A. fumigatus (n-10; 33.3%), and A. niger (n-9; 30%). In all 38/112 (33.93%) patients had Aspergillus IgG titer above the cut-off level, while 6 symptomatic patients had borderline Aspergillus IgG levels. A total of 11/112 (9.82%) of the study cohorts with positive Aspergillus IgG levels were also culture positive; 8/68 of the Aspergillus IgG negative patients were culture positive and had abnormal chest imaging reported. A total of 38 (33.93%) were confirmed cases of CPA using IDSA criteria. Of the GeneXpert positive; 7/40 were retreatment TB; 16/32 of GeneXpert negative and 8/40 of GeneXpert positive met the criteria for CPA.ConclusionOur findings demonstrate that CPA is easily misdiagnosed as treatment failure TB or TB relapse. There is a need for further follow-up of post-TB patients for early identification of post-TB lung disease. It is also imperative to educate our clinicians to screen patients who have persistent symptoms and are GeneXpert negative for other post-TB lung diseases.

P14 A case of myositis in patient with atypical bacterial pneumonia

Case report - IntroductionBacterial community-acquired atypical pneumonia is sometimes complicated by myositis or by renal parenchymal disease. They can present with myositis and present with muscle weakness, pain or swelling, and elevated muscle enzymes. We present the case of a patient with lower limb weakness and raised creatinine kinase with atypical pneumonia caused by Legionella pneumophila.Case report - Case descriptionA 76-year-old Caucasian man, who was previously fit and independent and walked 3 miles every day presented with a 1-week history of progressive leg weakness, and inability to mobilize. He had a fall and was on the floor for 2 hours. He had a background history of hypercholesterolemia and was on atorvastatin for 15 years. On his vital observation, he was found tachypnoeic, tachycardic, and hypoxic. He had a right upper lobe crackle but he didn’t have respiratory symptoms. His muscle power in his leg was 3/5 with carpet burns on knees and elbow. Initial investigation showed raised inflammatory marker CRP 412mg/L, AKI stage 1, and CK 43400 IU/L. His CXR showed dense right upper lobe consolidation. Legionella urinary antigen was positive. Myositis myoblot, ANA, ANCA negative. COVID-19 swab negative.Treated with IV antibiotic, supplemental oxygen, and IV fluid. Transferred to ITU due to worsening of hypoxia and kidney function. Interestingly, the CK level had improved significantly within 48 hours along with clinical improvement in his symptoms. There was no role of steroid or immunosuppressant due to his significant clinical improvement. On day 7 he was off oxygen, kidney function improved, had physiotherapy, and transferred to ward and on day 10 he was ambulant and discharged home.Case report - DiscussionTo date, very few case reports of myositis in a patient with atypical pneumonia have been reported. The mechanism underlying acute myositis in atypical pneumonia is still unknown. The present analysis points out that the organism underlying atypical bacterial pneumonia may occasionally invade the muscle tissue thereby inducing both myositis and secondary kidney damage.Case report - Key learning pointsWe should be aware of this rare complication of atypical pneumonia and the resolution of symptoms that occur with the treatment of pneumonia. This would avoid unnecessary investigation and use of steroid.

Tuberculous pleural effusion in a patient with sympathetic ophthalmia on immunosuppression:\xa0a case report

BackgroundTuberculous pleural effusion (TPE) is paucibacillary, making its diagnosis difficult based on laboratory investigations alone. We present a case of a patient with a TPE who was initially misdiagnosed to have azathioprine-induced lung injury. The diagnosis of TPE was arrived at with the help of clinical assessment, laboratory and radiological investigations.Case presentationA 25-year-old chronic smoker with sympathetic ophthalmia on long-term immunosuppression, latent tuberculosis infection and a significant family history of tuberculosis presented with a three-week history of productive cough, low-grade fever, night sweats and weight loss. Examination of the lungs showed reduced breath sounds at the right lower zone. Chest x-ray showed minimal right pleural effusion with a small area of right upper lobe consolidation. The pleural fluid was exudative with predominant mononuclear leukocytes. Direct smears of sputum and pleural fluid; polymerase chain reaction of pleural fluid; and sputum, pleural fluid and blood cultures were negative for M. tuberculosis (MTB) and other organisms. As he did not respond to a course of broad-spectrum antibiotics, he was then treated as a case of azathioprine-induced lung injury. However, his condition did not improve despite the cessation of azathioprine. A contrast-enhanced computed tomography of the thorax showed right upper lobe consolidation with tree-in-bud changes, bilateral lung atelectasis, subpleural nodule, mild right pleural effusion and mediastinal lymphadenopathy. Bronchoalveolar lavage was negative for malignant cells and microorganisms including, MTB. However, no pleural biopsy was done. He was empirically treated with anti-tubercular therapy for 9 months duration and showed complete recovery.ConclusionA high index of suspicion for TPE is required in individuals with immunosuppression living in regions endemic to tuberculosis. Targeted investigations and sound clinical judgement allow early diagnosis and prompt treatment initiation to prevent morbidity and mortality.

SUPERINFECTED MEDIASTINAL ABSCESS IN A PREGNANT PATIENT WITH A HISTORY OF FIBROSING MEDIASTINITIS

TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fibrosing Mediastinitis (FM) is a rare but serious condition characterized by idiosyncratic inflammation and aggressive fibrosis of mediastinal structures. Due to the lack of standardized diagnostic criteria, and variable clinical presentation and complications, FM is often misdiagnosed. We present a case of a superinfected mediastinal abscess with Streptococcus intermedius in a pregnant patient with a history of FM. CASE PRESENTATION: A 30-year-old woman (33 weeks pregnant, G1P0) with a history of FM secondary to presumed histoplasmosis diagnosed 4 years prior based on imaging with typical mediastinal lymph nodes and splenic calcifications presented with pleuritic chest pain and progressive right sided head/neck pressure. She had multiple prior presentations and was treated with courses of antibiotics and prednisone for presumed infection. Her symptoms progressed and presented to the ED where she was afebrile, tachycardic, and had diffuse ST elevations and PR depressions on EKG. CT noted a large mediastinal mass with SVC and tracheal compression, pericardial effusion, as well as right upper lobe consolidation concerning for post-obstructive pneumonia. She was started on broad spectrum antibiotics and given concerns for airway compromise she underwent successful delivery by cesarean section. Bronchoscopy with washing, transbronchial needle aspiration and pericardial fluid was negative for malignancy and infection. Given risk for re-accumulation of the pericardial effusion and progression of the mass she underwent a cervical mediastinoscopy with I&D of the abscess which was positive for Streptococcus intermedius. Patient was discharged home with complete resolution of the mediastinal abscess and clinical symptoms. DISCUSSION: We present a case of superinfected mediastinal abscess in a pregnant patient with FM. Because FM has variable complications our case highlights the importance of a high degree of clinical suspicion for progressive symptoms in patient with known history of FM. There are no curative treatments for FM but symptoms and complications can be medically and in rare cases surgically managed. Pregnancy is considered an immunocompromised state and plays a significant role in patient immunomodulation which suppression which may have contributed to the development of the superinfected mediastinal abscess in our patient. CONCLUSIONS: FM is a rare condition with variable presentations and complications which can be progressive and life-threatening if left untreated. Patients with a known history of FM should be frequently monitored for progression of symptoms with a low threshold to further evaluate and treat these complications should they arise. REFERENCE #1: Armstrong PA, Jackson BR, Haselow D, et al. Multistate Epidemiology of Histoplasmosis, United States, 2011–20141. Emerging Infectious Diseases. 2017;24(3):425-431. REFERENCE #2: Schowengerdt CG, Suyemoto R, Main FB. Granulomatous and fibrous mediastinitis. A review and analysis of 180 cases. J Thorac Cardiovasc Surg. 1969;57(3):365-379 DISCLOSURES: No relevant relationships by Alejandro Bribriesco, source=Web Response No relevant relationships by Lin Chen, source=Web Response No relevant relationships by Henrik Hahamyan, source=Web Response No relevant relationships by Mani Latifi, source=Web Response

DELAYED DIAGNOSIS OF COCCIDIODES IMMITIS INFECTION WITH PULMONARY ABSCESS AND ARDS DIAGNOSED IN CHICAGO

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Coccidiodes immitis is a highly pathogenic fungus that is found in western and southern California's desert's regions. It frequently presents as a pneumonia that does not get better after anti-biotic therapy. With less than 5% of immunocompetent patient's progressing to have disseminated or severe infections (1). A disseminated Coccididiodes infection can be treated with liposomal amphotericin B, fluconazole, and steroids when there is Acute Respiratory Distress Syndrome (ARDS) (1,2). CASE PRESENTATION: In this case, a relatively healthy 80-year-old male with a past medical history of gastroesophageal reflux disease, hypertension, and hyperlipidemia who comes in shortness of breath, cough, and congestion. He had completed a course of azithromycin without resolution of symptoms. His initial chest x-ray showed a right upper lobe consolidation (Figure 1a). Bronchoscopy with transbronchial biopsies was performed which showed an acute organizing pneumonia (Figure 2). Despite antibiotic therapy and steroids, the patient did not have significant clinical improvement. So liposomal amphotericin B was started. An open lung biopsy was performed on day 14 as his chest X-ray was significantly worse with significant hypoxia (Figure 1b). Open lung biopsy showed a large abscess. A chest tube was placed. The abscess was irrigated with saline containing antibiotics. Pathology reported numerous coccidiodes spores (Figure 3). Antibiotics were discontinued. The patient's hospital course was complicated by a persistent air leak post lung biopsy and ARDS. Adjunctive steroids were added with improvement of his hypoxia. The patient was transitioned to a lower dose of steroids and to high dose fluconazole for long term treatment of his Coccidiodes infection. He was stable for placement of a tracheostomy and discharged to a long term acute care hospital (LTACH) for further care. His chest x-ray showed significant fibrosis (Figure 1c). DISCUSSION: When we re-examined the patient's history, he had a short trip to the southwestern United states for a total of 10 days with his family. This is the source of the patient's exposure. A thorough history may have helped, but urine Coccidiodes antigen testing was negative even after the open lung biopsy was performed. Despite clinical improvement, the patient passed 6 weeks after discharge to long term acute care hospital. CONCLUSIONS: Severe Coccoidiodes pulmonary infections can progress to ARDS. While, it is responsive to liposomal amphotericin B and steroids, it is still associated with a high morbidity and mortality (2). A high index of suspicion for a fungal infection should be maintained in patient's who have pneumonia refractory to antibiotic therapy. Speaking directly with the pathologist will also aide in the diagnosis of fungal infections non-endemic to the area especially like in this case (3). REFERENCE #1: Kirkland TN, Fierer J. Coccidioides immitis and posadasii; A review of their biology, genomics, pathogenesis, and host immunity. Virulence. 2018;9(1):1426-1435. doi:10.1080/21505594.2018.1509667 REFERENCE #2: Shibli M, Ghassibi J, Hajal R, O'Sullivan M. Adjunctive corticosteroids therapy in acute respiratory distress syndrome owing to disseminated coccidioidomycosis. Crit Care Med. 2002 Aug;30(8):1896-8. doi: 10.1097/00003246-200208000-00037. PMID: 12163812. REFERENCE #3: Pitcher JH, Zuckerman JB. Coccidioides Immitis Infection with Involvement of the Airway. Conn Med. 2016 Oct;80(9):539-541. PMID: 29772139 DISCLOSURES: No relevant relationships by Justin Ching, source=Web Response

Melioidosis: A Fulminant Infection in a Patient with Uncontrolled Diabetes

AbstractMelioidosis is an endemic infection in Southeast Asia and Northern Australia commonly manifesting with pneumonia and localized skin infection. Though most exposures do not lead to severe illness, a fulminant infection can occur among patients with risk factors. A 59-year-old male presented with cough with expectoration and fever for 1 week. He had diabetes for 10 years with poorly controlled blood sugars. Contrast-enhanced computerized tomography (CECT) of thorax showed right upper lobe consolidation with diffuse ground-glass opacities in right upper lobe along with microabscesses in liver and spleen. Sputum culture and Xpert mycobacterium tuberculosis complex and resistance to rifampin (MTB/RIF) for tuberculosis were negative. Bronchoalveolar lavage culture grew Burkholderia pseudomallei. He was treated with initial intensive therapy with injection amoxicillin-clavulanic acid for 2 weeks and subsequently started on eradication therapy with tablet trimethoprim-sulfamethoxazole. Diagnosis of melioidosis should be considered in a patient of pneumonia with multiorgan involvement in an endemic area, especially with underlying risk factors.

AN UNUSUAL PRESENTATION OF ENDOBRONCHIAL ASPERGILLOMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial aspergilloma (EBA) is a rare manifestation of pulmonary Aspergillosis characterized by growth of an Aspergillus species as a space-occupying lesion into the bronchial lumen. This can be an isolated manifestation of aspergillus, or occurs in association with parenchymal aspergilloma, allergic broncho-pulmonary aspergillosis, or necrotizing forms of pulmonary aspergillus.1 The clinical presentation of EBA is quite diverse, ranging from an asymptomatic state to dyspnea, cough, hemoptysis and weight loss. In most cases, EBA is found incidentally when patients undergo bronchoscopy for evaluation of other pulmonary symptoms. EBA can mimic endobronchial cancer or carcinoid due to similar clinical and radiographic presentation.1 CASE PRESENTATION: A 46-years-old female was admitted to hospital for surgical fixation of hip fracture after a fall. She also had exertional dyspnea with non-productive cough for past six months. She denied hemoptysis, chest pain, fever, chills and night sweats. Her past medical history included recurrent pneumonia, type I diabetes, end stage renal disease on hemodialysis, and right heart failure. Laboratory evaluations were unremarkable. Chest x-ray showed right upper lobe opacity superior to minor fissure. Computerized tomography (CT) scan of the chest (Figure 1) revealed right upper lobe consolidation with partial occlusion of the right upper lobe bronchus. A diagnostic bronchoscopy was performed to confirm the etiology. It demonstrated complete endobronchial obstruction of the anterior segment of the right upper lobe with cobblestone appearing white material. A biopsy demonstrated pseudohyphae (Figure 2). Polymerase chain reaction (PCR) of material was diagnostic of Aspergillus species. A final diagnosis of EBA was made and the patient was treated with antifungal (Voriconazole) therapy for 6 weeks with subsequent resolution of her symptoms. DISCUSSION: Aspergillus spp. have been associated with a wide spectrum of lung disorders, especially in immunosuppressed patients. Our patient had multiple comorbidities, but did not have typical risk factors for opportunistic infection, resulting in a low index of suspicion for invasive fungal disease. The diagnosis of EBA is challenging on cross-sectional imaging. Bronchoscopy with biopsy is mandatory to confirm the diagnosis of EBA.2 The morphology of fungal form found in our case was atypical for aspergillus, which required further confirmation with PCR testing. Medical management with antifungal therapy may be effective, however, a surgical approach is recommended in patients with massive hemoptysis and adequate lung reserve.3 CONCLUSIONS: A high index of suspicion is required for diagnosing EBA. Bronchoscopic evaluation of endobronchial masses, followed by histologic examination is critical in establishing a diagnosis of EBA. Early medical management with antifungal therapy may hasten resolution of infection. Reference #1: Huang D, Li B, Chu H, et al. Endobronchial aspergilloma: A case report and literature review. Exp Ther Med 2017;14(1):547-54. doi: 10.3892/etm.2017.4540 [published Online First: 2017/06/01] Reference #2: Ma JE, Yun EY, Kim YE, et al. Endobronchial aspergilloma: report of 10 cases and literature review. Yonsei Med J 2011;52(5):787-92. doi: 10.3349/ymj.2011.52.5.787 [published Online First: 2011/07/26] Reference #3: Pohl C, Jugheli L, Haraka F, et al. Pulmonary aspergilloma: a treatment challenge in sub-Saharan Africa. PLoS Negl Trop Dis 2013;7(10):e2352. doi: 10.1371/journal.pntd.0002352 [published Online First: 2013/11/10] DISCLOSURES: No relevant relationships by Yumna Gulzar, source=Web Response No relevant relationships by Richa Purohit, source=Web Response No relevant relationships by stephen Selinger, source=Web Response No relevant relationships by Muhammad Yousaf, source=Web Response

Lobar Pneumonia in a Farmer Responded to Anti-melioidosis Antibiotics

A 46-year-old male, farmer, with no prior medical illness presented with a one-month history of intermittent right-sided pleuritic chest pain and productive cough. He complained of fever and breathlessness 3 days before current presentation to the district hospital. He denied any haemoptysis, night sweats, or contact with pulmonary tuberculosis. On examination, the vital signs were normal and lung auscultation revealed bronchial breath sounds and crepitation over the right upper zone. Chest radiograph demonstrated a right upper lobe consolidation with presence of air bronchogram and abdominal ultrasonography was normal. He was admitted for intravenous antibiotic therapy for a presumptive diagnosis of community-acquired pneumonia. He was initially treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours. Differential diagnosis of pulmonary tuberculosis was also considered but later ruled out as the sputum for direct smear microscopy, GenXpert and culture for Mycobacterium tuberculosis were negative. The melioidosis IgM (ELISA), multiple blood and sputum cultures were also negative. A PCR-based confirmatory test for melioidosis was however not available at our setting. In the ward, he continued to have persistent fever and repeated chest radiograph after 1 week of antibiotic showed worsening of right upper lobe consolidation. At this point in time, melioidosis was suspected due to the risk factor of farming. Antibiotic was then changed to intravenous ceftazidime 2 g every 6 hours. The patient responded positively as evidenced by the resolution of fever and respiratory symptoms, and repeated chest radiograph showed improving consolidation at 2 weeks. He was discharged after completing a 2-week course of intravenous ceftazidime, and simultaneously started on oral trimethoprim-sulfamethoxazole as eradication therapy. Upon review in the outpatient clinic 6 weeks later, chest radiograph showed marked improvement with minimal residual right upper lobe consolidation. He was clinically well and did not show any symptoms of relapse. He was planned for eradication therapy of 20 weeks’ duration.

Multiday maintenance of extracorporeal lungs using cross-circulation with conscious swine

ObjectivesLung remains the least-utilized solid organ for transplantation. Efforts to recover donor lungs with reversible injuries using ex vivo perfusion systems are limited to <24 hours of support. Here, we demonstrate the feasibility of extending normothermic extracorporeal lung support to 4 days using cross-circulation with conscious swine. MethodsA swine behavioral training program and custom enclosure were developed to enable multiday cross-circulation between extracorporeal lungs and recipient swine. Lungs were ventilated and perfused in a normothermic chamber for 4 days. Longitudinal analyses of extracorporeal lungs (ie, functional assessments, multiscale imaging, cytokine quantification, and cellular assays) and recipient swine (eg, vital signs and blood and tissue analyses) were performed. ResultsThroughout 4 days of normothermic support, extracorporeal lung function was maintained (arterial oxygen tension/inspired oxygen fraction >400 mm Hg; compliance >20 mL/cm H2O), and recipient swine were hemodynamically stable (lactate <3 mmol/L; pH, 7.42 ± 0.05). Radiography revealed well-aerated lower lobes and consolidation in upper lobes of extracorporeal lungs, and bronchoscopy showed healthy airways without edema or secretions. In bronchoalveolar lavage fluid, granulocyte-macrophage colony-stimulating factor, interleukin (IL) 4, IL-6, and IL-10 levels increased less than 6-fold, whereas interferon gamma, IL-1α, IL-1β, IL-1ra, IL-2, IL-8, IL-12, IL-18, and tumor necrosis factor alpha levels decreased from baseline to day 4. Histologic evaluations confirmed an intact blood–gas barrier and outstanding preservation of airway and alveolar architecture. Cellular viability and metabolism in extracorporeal lungs were confirmed after 4 days. ConclusionsWe demonstrate feasibility of normothermic maintenance of extracorporeal lungs for 4 days by cross-circulation with conscious swine. Cross-circulation approaches could support the recovery of damaged lungs and enable organ bioengineering to improve transplant outcomes.

DISSEMINATED MAC IN A YOUNG IMMUNOCOMPETENT PATIENT

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Disseminated MAC (dMAC) is a disease usually seen in HIV infected patients with a CD4 count less than 50 cells/microL. In immunocompetent hosts, the usual presentation is of an isolated pulmonary infection, that usually presents as upper lobe lesions resembling mycobacterium tuberculosis. It has also been described to present as solitary pulmonary nodule, but virtually all the cases were older females. We describe a case of a young immunocompetent 31 years old female with no known risk factors presenting with dMAC. CASE PRESENTATION: A 31 years old female with type 1 diabetes presented with nausea, vomiting, diarrhea, abdominal pain and a high anion gap suggestive of DKA. DKA resolved with IV fluid resuscitation and insulin drip, but the patient was noted to have high grade fevers that did not resolve with empiric broad spectrum antibiotics. On further questioning, she reported a 13 pound weight loss in the last 2 months. Multiple sets of blood cultures obtained were negative. CT scan imaging of chest abdomen & pelvis noted ground glass opacities in bilateral lower lobes with superimposed multiple pulmonary nodules & infiltration of the mesenteric fat without lymphadenopathy or hepatosplenomegaly. Patient underwent cholecystectomy after a HIDA scan showed acute cholecystitis as a possible source of sepsis syndrome. She was also noted during her admission to have pancytopenia with elevated LFTS which prompted a bone marrow biopsy to be done. Repeat CT scan chest demonstrated a new right upper lobe consolidation, an increase in the size of the pulmonary nodules and new splenomegaly. Patient underwent bronchoscopy with BAL for fungal and bacterial cultures. Patient was diagnosed with dMAC infection after her gallbladder, bone marrow biopsy and her BAL grew Mycobacterium Avium Intracellular. She was started on azithromycin, ethambutol, rifapentine and amikacin with significant improvement. DISCUSSION: The usual presentation of Disseminated MAC is with persistent fevers (>80%), weight loss (>25%) & non- specific symptoms such as fatigue, anorexia. Organs such as bone marrow, lung, lymphoreticular and gastrointestinal tract can be involved. Diagnosis is made by peripheral blood cultures, but care should be taken to order mycobacterial blood cultures to hasten the diagnosis and spare the patient invasive procedures. Susceptibility testing should be done as macrolide resistant isolates have been identified. Macrolide susceptible MAC treatment consists of a macrolide plus ethambutol plus a rifamycin. Amikacin can be added during the initial treatment course if the disease is life threatening. The duration of treatment is at least 6 months. CONCLUSIONS: High clinical suspicion is required to diagnose disseminated MAC with multi-organ involvement in immunocompetent hosts. Mycobaterial blood culture should be ordered and is the least invasive test to diagnose this possible life threatening disease. Reference #1: Teirstein AS, Damsker B, Kirschner PA, et al. Pulmonary infection with Mycobacterium avium-intracellulare: diagnosis, clinical patterns, treatment. Mt Sinai J Med 1990; 57:209. Reference #2: Nightingale SD, Byrd LT, Southern PM, et al. Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients. J Infect Dis 1992; 165:1082. Reference #3: Yabes JM, Farmer A, Vento T. Disseminated Mycobacterium avium complex in an immunocompetent host. Int J Mycobacteriol 2017;6:202-6 DISCLOSURES: No relevant relationships by Wafic Itani, source=Web Response no disclosure on file for Thomas Smith; No relevant relationships by Ali Wazir, source=Web Response

AN UNUSUAL CASE OF MALIGNANT ESOPHAGO-PULMONARY FISTULA SECONDARY TO ESOPHAGEAL CARCINOMA

Esophageal cancer is an aggressive cancer and has a poor survival rate. An esophago-pulmonary fistula is a rare complication of this cancer. This fistula causes pulmonary abscess formation and death in most patients. We are reporting a case of esophago-pulmonary fistula in a 55-year-old male patient who presented to us with complaints of fever and cough with expectoration. Chest radiographs initially showed right upper lobe consolidation which further progressed to cavitation and later on contrast-enhanced multi-detector computed tomography scan was used to diagnose this condition. An esophago-respiratory fistula is a rare complication of esophageal cancer, and esophago-pulmonary fistula is an even rarer subtype of this complication. It is essential to diagnose this condition early to avoid development of further complications and death.

Life-Threatening Everolimus-Associated Pneumonitis: A Case Report and a Review of the Literature

IntroductionNoninfective pneumonitis is a class-related effect within mammalian target of rapamycin (mTOR) inhibitors, including everolimus, and can occasionally be severe. Case ReportA 62-year-old man, medicated with everolimus due to a heart transplantation 17 years previously and with chronic kidney disease, was admitted to the intensive care unit (ICU) with acute respiratory failure, cardiovascular shock, and impaired renal function requiring dialysis. Computed tomography (CT) scan revealed right upper lobe consolidation. Extensive microbiological workup, autoimmune testing, and cytology were negative and echocardiography showed preserved heart function. Everolimus levels were normal (5.7–6.1 ng/mL) and the drug was suspended at day 9. The patient was difficult to ventilate and responded poorly to broad-spectrum antibiotic and antifungal therapy. On day 25, CT scan and bronchoscopy revealed left-sided alveolar hemorrhage, and corticosteroid pulses were performed. The patient gradually improved. After discharge and 6 months of follow-up, clinical recovery was complete and chest imaging substantially improved. DiscussionPneumonitis occurs in up to 4.3% of transplant recipients using everolimus for immunosuppression. Despite usually presenting as a mild and self-limited disease, severe cases have been described. Alveolar hemorrhage can occur and is associated with poor outcome. Everolimus levels do not seem to accurately predict toxicity. Corticosteroid therapy has been used with success in severe disease. We review the pathophysiological, clinical, and management-related aspects of this entity with emphasis on its potential severity. ConclusionOur case was a rare occurrence of severe life-threatening pulmonary disease related to everolimus. Awareness of the potential severity of this entity is important for the management of patients using mTOR inhibitors.

&amp;lt;i&amp;gt;Pseudomonas aeruginosa&amp;lt;/i&amp;gt; Community Acquired Pneumonia with Septicemia in a Previously Healthy Woman

A previously healthy 53-year-old woman was urgently hospitalized due to septic shock. She was diagnosed with bacterial pneumonia based on chest radiograph and computed tomography findings of right upper lobe consolidation. Sputum Gramstain at the time of admission showed gram-negative rods with phagocytosis. Intravenous meropenem was immediately initiated as empiric antibacterial therapy. Bacterial culture specimens from sputum and blood were positive for Pseudomonas aeruginosa. Following appropriate antibiotic therapies, the patient recovered from a shock state and gradually became well. There has been no evidence of recurrence at 6 months after discharge. P. aeruginosa community acquired pneumonia with septicemia is rapidly progressive and often fatal. The choice of initial empiric antibiotic treatment that is active against P. aeruginosa is critical in improving outcome.

Infusion of Pegylated Bovine Carboxyhemoglobin (PEG-COHb) Is Associated with Rapid Reversal of Progressive Acute Chest Syndrome in a Jehovah's Witness Patient with Hemoglobin SC Sickle Cell Disease

Acute chest syndrome (ACS) is a potentially fatal complication of sickle cell disease (SCD) and is characterized by opacification of the chest x-ray (CXR) and progressive pulmonary failure due, in part, to intra-pulmonary sickling. The ACS process can proceed very rapidly from a small area of lung involvement in one lobe to total opacification of the lung and pulmonary failure within 12 to 24 hours. In the early phases of this process, oxygenation and pulmonary function may be preserved. In the face of rapidly progressing CXR changes, the ACS process may be reversed if diagnosed early and managed by emergent transfusion to decrease the percent of sickle red blood cells (SRBC).A 10 years old African American child with hemoglobin SC type SCD was transferred to our institution with fever and right upper lobe consolidation. Her respiratory rate was 23 breaths/min, SpO2 was 95% breathing room air. Serial CXR showed opacification of the entire right lung and part of the left lower lobe over a 12-hour period (Panel A). Because of the rapid progression, transfusion was recommended. However, because of the family's Jehovah's Witness religious faith, transfusion was refused.PEG-COHb is in clinical development for the treatment of SCD and is designed to deliver preloaded carbon monoxide (CO), pick up O2, and deliver O2 to hypoxic tissue. PEG-COHb serves as a vasodilator and anti-inflammatory agent. It has been shown to have anti-sickling properties in vitro (ASH Abstract 1372, 2014). The agent was obtained from Prolong Pharmaceuticals via an emergency IND (16432) from the FDA. The agent was acceptable to the family and church elders. After written consent was obtained, 500 cc were infused according to dosing information obtained from Prolong Pharma. The CXR (Panel A) 3 hours before infusion shows opacification of the right lung and the left lower lobe. A CXR obtained one hour after infusion showed no worsening, and the CXR (Panel B) obtained 29 hours after Panel A shows significant improvement in the opacification of the lower lobes. The right upper lobe consolidation was likely bacterial pneumonia, and would not be expected to clear rapidly.The patient was mildly hypertensive for age (138/72 mmHg) prior to PEG-COHb infusion. Her blood pressure rose to 153/85 mmHg during infusion; the infusion was stopped and anti-hypertensives were administered. The infusion was restarted at a lower infusion rate and completed in 6 hours instead of the planned 4 with no untoward effects. She was discharged 4 days after the infusion. There were no other serious adverse events clearly related to the drug. There were significant laboratory abnormalities and transaminases that were most likely falsely elevated due to interference of the PEG-COHb with the laboratory methods. Continuous non-invasive monitoring of carboxyhemoglobin showed basal levels of 7% rose to 24% during infusions and returned to normal prior to discharge. Continual recording of SpO2, methemoglobin, heart-rate variability and blood rheological measures showed no significant abnormalities.The rapid reversal of radiographic features consistent with progressive "pure ACS" secondary to the right upper lobe infectious process suggests that PEG-COHb may be an effective treatment for sickle cell related ACS.SHAPE [Display omitted] DisclosuresOff Label Use: SANGUINATE (pegylated carboxyhemoglobin bovine) is 40 mg/mL of purified bovine hemoglobin that has been pegylated, saturated with carbon monoxide, and dissolved in a buffered saline solution.. Abuchowski:Prolong Pharmaceuticals: Employment. Parmar:Prolong Pharmaceuticals: Employment.

A 66-Year-Old Man With a Past History of Relapsing Polychondritis Presented With Right Upper Lobe Consolidation, Nodular Airway Lesions, and a Corticosteroid-Responsive Chronic Cough

A 66-year-old male nonsmoker from Arizona was referred to our practice for evaluation of chronic cough. He had a history of biopsy-proven relapsing polychondritis manifesting as right auricular and nasal pain and swelling 9 months prior to presentation. The onset of his cough coincided with the diagnosis of relapsing polychondritis, and he was prescribed prednisone 90 mg/d, which promptly relieved his rheumatologic and respiratory symptoms. A chest radiograph, obtained prior to the initiation of therapy, was normal. Any attempts at decreasing the dose of the glucocorticoid to < 30 mg/d resulted in recurrence of the cough but not of the auricular or nasal symptoms. A second chest radiograph done 6 months before presentation, while the patient was receiving prednisone 20 mg/d, was normal as well. In anticipation of our evaluation, he stopped all glucocorticoids for 7 days. He was not receiving any other medications, and he had no history of an atopic diathesis.

Mimicking the great mimicker: Disseminated coccidioidomycosis masquerading as classic tuberculosis

A correct diagnosis can be elusive when a rare disease is present. Such was the case when two teenagers were admitted to a children's hospital. Due to their clinical presentation, imaging, and laboratory results, final diagnoses and treatment were delayed. The first patient, a 15-year old Chinese female with systemic lupus erythematosus, presented with cough and fever. She was found to have a right upper lobe consolidation with central cavitation. Subsequent chest imaging revealed a miliary pattern, and RIPE therapy was started to cover Mycobacterium tuberculosis. The second patient was a previously healthy, 14-year old African American female, who presented with progressive spinal deformity and an enlarging right parietal scalp lesion. An AFB sputum sample was positive, and spinal imaging showed a gibbus deformity, prompting the initiation of RIPE therapy for tuberculosis. Both patients were later found to have disseminated Coccidioidomycosis, a rare diagnosis that is often mistaken for other etiologies. Both patients responded well to fluconazole therapy.

A 35-year old woman with productive cough and breathlessness.

A 35-year-old lady was seen in the outpatient clinic owing to fever, cough with mucopurulent expectoration, and breathlessness for the duration of 1 month. She had history of similar episodes treated with antibiotics four times during last 2 years. There was no history of recurrent sinusitis, diarrhea, and skin or soft tissue infection. She had no history of diabetes mellitus or steroid intake. She denied any history of facial trauma or dental infection in the past. There was no history of tuberculosis in her or in the family. Radiograph and CT scan of the chest revealed right upper lobe consolidation. Flexible fibreoptic bronchoscopy revealed multiple nodules at opening of right upper lobe bronchus. This clinicopathological conference describes the details of differential diagnoses, difficulties in achieving the final diagnosis and management of such patient.

An adolescent with persistent cough, abdominal pain and refusal to walk from Salesi Children's Hospital

A 12-year-old boy was admitted to our unit for a 3-day history of abdominal and right groin pain, refusal to walk and relapse of fever. His clinical history was uneventful...