Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2005
G. Aftab, M. Ahmad, K. A. Hamid
Introduction:Patients with chronic lung disease are at risk of developing severe COVID 19 infection, and are likely to have poor outcomes. There is, however, little data available on the progression of interstitial lung disease (ILD) after severe COVID 19 infection. Here, we present the case of a patient with known ILD (chronic hypersensitivity pneumonitis, in this case), which progressively worsened after COVID 19 infection.Case Report:A 65 year old male presented to our clinic for management of chronic hypersensitivity pneumonitis in December 2018. In 2017, he had a video assisted thoracoscopic surgery performed, when it was diagnosed that the changes in his lungs were due to chronic hypersensitivity pneumonitis. On evaluation in our clinic, the patient reported dyspnea on exertion. He had mild crackles bilaterally and was saturating 94% on room air. A prior CT scan showed mild fibrosis. The patient was asked to come for a follow-up, but he was unable to do so due to the COVID 19 pandemic.In May 2020, the patient was diagnosed with severe COVID 19 pneumonia, and was admitted into the hospital, where he required supplementary oxygen. He was treated with Remdesivir and steroids, and was later discharged home on oxygen. When the patient was examined one month after discharge, he continued reporting worsening dyspnea and cough. At this time, a repeat CT scan of the chest showed worsening pulmonary fibrosis.Today, even though the patient has recovered from COVID-19, he remains dependent on supplementary oxygen.The patient has never been a smoker;he is an immigrant from Central America, having moved to the US in 2016. Back in Central America, he reported having a pet parrot in his home.Discussion:We suspect that continued exposure to the parrot may have been a cause of chronic hypersensitivity pneumonitis in our patient. Further, our case report indicates that COVID 19 may cause progression of ILD even after COVID 19 itself has been cured.Since the prevalence of ILD in general (and hypersensitivity pneumonitis in specific) is low, limited research has been carried out on the correlation of this disease with COVID 19. While a recent study did indicate that adults with preexisting ILD were at an increased risk of severe COVID 19, limited data is available on the long term consequences of COVID 19 infection for ILD patients.
{"title":"Progression of Hypersensitivity Pneumonitis Due to COVID 19","authors":"G. Aftab, M. Ahmad, K. A. Hamid","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2005","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2005","url":null,"abstract":"Introduction:Patients with chronic lung disease are at risk of developing severe COVID 19 infection, and are likely to have poor outcomes. There is, however, little data available on the progression of interstitial lung disease (ILD) after severe COVID 19 infection. Here, we present the case of a patient with known ILD (chronic hypersensitivity pneumonitis, in this case), which progressively worsened after COVID 19 infection.Case Report:A 65 year old male presented to our clinic for management of chronic hypersensitivity pneumonitis in December 2018. In 2017, he had a video assisted thoracoscopic surgery performed, when it was diagnosed that the changes in his lungs were due to chronic hypersensitivity pneumonitis. On evaluation in our clinic, the patient reported dyspnea on exertion. He had mild crackles bilaterally and was saturating 94% on room air. A prior CT scan showed mild fibrosis. The patient was asked to come for a follow-up, but he was unable to do so due to the COVID 19 pandemic.In May 2020, the patient was diagnosed with severe COVID 19 pneumonia, and was admitted into the hospital, where he required supplementary oxygen. He was treated with Remdesivir and steroids, and was later discharged home on oxygen. When the patient was examined one month after discharge, he continued reporting worsening dyspnea and cough. At this time, a repeat CT scan of the chest showed worsening pulmonary fibrosis.Today, even though the patient has recovered from COVID-19, he remains dependent on supplementary oxygen.The patient has never been a smoker;he is an immigrant from Central America, having moved to the US in 2016. Back in Central America, he reported having a pet parrot in his home.Discussion:We suspect that continued exposure to the parrot may have been a cause of chronic hypersensitivity pneumonitis in our patient. Further, our case report indicates that COVID 19 may cause progression of ILD even after COVID 19 itself has been cured.Since the prevalence of ILD in general (and hypersensitivity pneumonitis in specific) is low, limited research has been carried out on the correlation of this disease with COVID 19. While a recent study did indicate that adults with preexisting ILD were at an increased risk of severe COVID 19, limited data is available on the long term consequences of COVID 19 infection for ILD patients.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85538547","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1994
P. Gupta, I. A. Sanchez, K. Kovitz, K. Haas
Since 2005, the number of lung cancer deaths in the United States has decreased1 due to advances in therapeutics and early detection. The COVID-19 pandemic has affected the prognosis of patients with lung cancer by delaying elective diagnostic procedures. A 66 year old man with past medical history of tobacco and polysubstance abuse initially presented to the emergency department with bilateral pedal edema. Chest imaging showed a right apical, spiculated cavitary mass. The patient missed his initial scheduled biopsy appointment and wanted to wait until pandemic subsided to reschedule. Ten weeks later, he presented to the hospital with rightsided sharp chest pain, associated with hemoptysis. CT-guided biopsy confirmed the diagnosis of adenocarcinoma. Cardiothoracic surgery was consulted, and the patient was initially planned to undergo surgical resection, however his functional status declined while pursuing pre-operative workup. He had progressive worsening hemoptysis, despite radiation treatment, requiring multiple transfusions of blood products. Interventional radiology performed bronchial artery embolization with interval improvement, however he progressed requiring endotracheal intubation with endobronchial blocker placement. Bleeding continued despite local treatment and family decided on palliative extubation. The COVID-19 pandemic contributed to delayed diagnosis of lung cancer. Analysis of 20 institutions in the United States showed a 46.8% decrease in new lung cancer diagnoses in April 2020 versus April 20192. In Korea, three university hospitals found a significant increase in patients with stage III-IV non-small cell lung cancer compared to prior years3. UK Health Service data modeling predict 4.8-5.3% increased lung cancer related mortality from pandemic delayed diagnosis5. In our case, the diagnosis was delayed due to the patient's uncertainty about accessing the medical system during a pandemic. This is not uncommon-the pandemic has been cited as a reason for refusing breast lesion biopsy4. Clinicians need to be aware of this fear and make efforts to reassure patients of the additional safety protocols in place. The American College of Surgery recommends that procedures for high risk cancers, such as lung cancer, are high acuity on the Elective Surgery Acuity Scale and diagnosis and staging to start treatment not be delayed, if feasible, during the pandemic6,7. Lung cancer may be uniquely impacted by pandemic staffing shortages as pulmonologists are deployed to surging ICUs. Our patient delayed care during a surge and did not have a risk/benefit discussion with a clinician. This highlights the need to develop additional patient outreach systems to ensure timely access to care during a pandemic.
自2005年以来，由于治疗方法和早期发现的进步，美国肺癌死亡人数有所下降。COVID-19大流行推迟了选择性诊断程序，影响了肺癌患者的预后。66岁男性，既往有吸烟和多种药物滥用史，最初以双足水肿就诊于急诊室。胸部影像学显示右侧根尖有一个针状空洞肿块。患者错过了最初安排的活检预约，并希望等到大流行消退后重新安排。10周后，患者以右侧剧烈胸痛伴咯血就诊。ct引导下活检确诊为腺癌。咨询了心胸外科，患者最初计划进行手术切除，但在进行术前检查时，其功能状态下降。尽管进行了放射治疗，但他的咯血情况仍在恶化，需要多次输血。介入放射学进行了支气管动脉栓塞术，间歇期有所改善，但病情进展需要气管插管并置入支气管阻断剂。尽管当地治疗，出血仍在继续，家人决定姑息拔管。新冠肺炎大流行导致肺癌诊断延迟。对美国20家机构的分析显示，与2019年4月相比，2020年4月肺癌新诊断减少了46.8%。在韩国，三所大学医院发现，与前几年相比，III-IV期非小细胞肺癌患者显著增加。英国卫生服务数据模型预测，由于大流行延迟诊断，肺癌相关死亡率将增加4.8-5.3% 5。在我们的病例中，由于患者在大流行期间不确定是否能进入医疗系统，诊断被推迟了。这并不罕见——流感大流行被认为是拒绝乳腺病变活检的一个原因。临床医生需要意识到这种恐惧，并努力使患者对现有的额外安全方案放心。美国外科学会(American College of Surgery)建议，高风险癌症(如肺癌)的手术在选择性手术敏锐度量表上属于高敏锐度，如果可行，在大流行期间不应推迟开始治疗的诊断和分期6,7。肺癌可能受到流行病人员短缺的独特影响，因为肺病学家被部署到激增的icu。我们的患者在激增期间延迟了护理，并且没有与临床医生进行风险/收益讨论。这突出表明需要建立额外的患者外展系统，以确保在大流行期间及时获得护理。
{"title":"Fatal Massive Hemoptysis in a Patient with Delayed Diagnosis of Lung Adenocarcinoma Due to COVID-19 Pandemic","authors":"P. Gupta, I. A. Sanchez, K. Kovitz, K. Haas","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1994","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1994","url":null,"abstract":"Since 2005, the number of lung cancer deaths in the United States has decreased1 due to advances in therapeutics and early detection. The COVID-19 pandemic has affected the prognosis of patients with lung cancer by delaying elective diagnostic procedures. A 66 year old man with past medical history of tobacco and polysubstance abuse initially presented to the emergency department with bilateral pedal edema. Chest imaging showed a right apical, spiculated cavitary mass. The patient missed his initial scheduled biopsy appointment and wanted to wait until pandemic subsided to reschedule. Ten weeks later, he presented to the hospital with rightsided sharp chest pain, associated with hemoptysis. CT-guided biopsy confirmed the diagnosis of adenocarcinoma. Cardiothoracic surgery was consulted, and the patient was initially planned to undergo surgical resection, however his functional status declined while pursuing pre-operative workup. He had progressive worsening hemoptysis, despite radiation treatment, requiring multiple transfusions of blood products. Interventional radiology performed bronchial artery embolization with interval improvement, however he progressed requiring endotracheal intubation with endobronchial blocker placement. Bleeding continued despite local treatment and family decided on palliative extubation. The COVID-19 pandemic contributed to delayed diagnosis of lung cancer. Analysis of 20 institutions in the United States showed a 46.8% decrease in new lung cancer diagnoses in April 2020 versus April 20192. In Korea, three university hospitals found a significant increase in patients with stage III-IV non-small cell lung cancer compared to prior years3. UK Health Service data modeling predict 4.8-5.3% increased lung cancer related mortality from pandemic delayed diagnosis5. In our case, the diagnosis was delayed due to the patient's uncertainty about accessing the medical system during a pandemic. This is not uncommon-the pandemic has been cited as a reason for refusing breast lesion biopsy4. Clinicians need to be aware of this fear and make efforts to reassure patients of the additional safety protocols in place. The American College of Surgery recommends that procedures for high risk cancers, such as lung cancer, are high acuity on the Elective Surgery Acuity Scale and diagnosis and staging to start treatment not be delayed, if feasible, during the pandemic6,7. Lung cancer may be uniquely impacted by pandemic staffing shortages as pulmonologists are deployed to surging ICUs. Our patient delayed care during a surge and did not have a risk/benefit discussion with a clinician. This highlights the need to develop additional patient outreach systems to ensure timely access to care during a pandemic.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85110331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2004
P. Modi, B. Tuppekar, G. Nair, A. Uppe
Introduction: While most cases of COVID-19 recover completely within 2-6 weeks, some may develop complications including residual lung fibrosis. We describe an interesting case of late-onset post-COVID fibrosis that presented more than 4 months after the initial infection. Case: A 52-year-old male, an operating room technician by profession tested positive for COVID-19 after coming in contact with an infected patient early in May 2020. He was asymptomatic, vitally stable with no comorbidities, and was given a course of oral hydroxychloroquine, oseltamivir, and multivitamins. He remained asymptomatic for a week in the isolation ward with all investigations within normal range and was discharged home. HRCT thorax on the first follow-up at 2 weeks was normal and the patient resumed work as usual for the next 3 months. In mid-September, the patient presented to the outpatient clinic with a sudden onset of dyspnea on exertion that was progressive for 5 days with an oxygen saturation of 93% on room air. He was unable to perform a 6-minute walk test (6MWT). Spirometry was suggestive of moderate restriction and reduced DLCO. HRCT thorax at this point revealed bilateral extensive reticular opacities with few ground-glass opacities (GGO's) in all lobes bilaterally with a basal predominance. These findings were suggestive of late-onset of residual fibrosis more than 4 months after the initial infection. RT-PCR for COVID-19 was negative and ruled out re-infection. The patient was unwilling for admission and was started on oral pirfenidone, a tapering dose of oral prednisolone, and was advised home oxygen therapy. He did not take home oxygen but was compliant with oral steroids and antifibrotic. In the 7th-month of post-COVID follow-up, HRCT showed significant improvement as compared to the previous scan with reduced reticular opacities and minimal GGO's. The patient was symptomatically better with a saturation of 98% on room air and could perform 6MWT satisfactorily. Spirometry showed mild restriction and improvement in FVC. The antifibrotic dose was stepped up and the patient was referred for pulmonary rehabilitation. Discussion Despite an uncertain natural history of post-COVID sequelae, it has been observed that post-COVID fibrosis can develop as early as 3 weeks after the initial infection. This case was unique in its late presentation during the second post-COVID follow up at 4 months with normal imaging and clinical parameters during the first follow up. Hence a meticulous long-term follow-up should be done for all patients.
{"title":"Late Onset Post-COVID Fibrosis - A Case Report","authors":"P. Modi, B. Tuppekar, G. Nair, A. Uppe","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2004","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2004","url":null,"abstract":"Introduction: While most cases of COVID-19 recover completely within 2-6 weeks, some may develop complications including residual lung fibrosis. We describe an interesting case of late-onset post-COVID fibrosis that presented more than 4 months after the initial infection. Case: A 52-year-old male, an operating room technician by profession tested positive for COVID-19 after coming in contact with an infected patient early in May 2020. He was asymptomatic, vitally stable with no comorbidities, and was given a course of oral hydroxychloroquine, oseltamivir, and multivitamins. He remained asymptomatic for a week in the isolation ward with all investigations within normal range and was discharged home. HRCT thorax on the first follow-up at 2 weeks was normal and the patient resumed work as usual for the next 3 months. In mid-September, the patient presented to the outpatient clinic with a sudden onset of dyspnea on exertion that was progressive for 5 days with an oxygen saturation of 93% on room air. He was unable to perform a 6-minute walk test (6MWT). Spirometry was suggestive of moderate restriction and reduced DLCO. HRCT thorax at this point revealed bilateral extensive reticular opacities with few ground-glass opacities (GGO's) in all lobes bilaterally with a basal predominance. These findings were suggestive of late-onset of residual fibrosis more than 4 months after the initial infection. RT-PCR for COVID-19 was negative and ruled out re-infection. The patient was unwilling for admission and was started on oral pirfenidone, a tapering dose of oral prednisolone, and was advised home oxygen therapy. He did not take home oxygen but was compliant with oral steroids and antifibrotic. In the 7th-month of post-COVID follow-up, HRCT showed significant improvement as compared to the previous scan with reduced reticular opacities and minimal GGO's. The patient was symptomatically better with a saturation of 98% on room air and could perform 6MWT satisfactorily. Spirometry showed mild restriction and improvement in FVC. The antifibrotic dose was stepped up and the patient was referred for pulmonary rehabilitation. Discussion Despite an uncertain natural history of post-COVID sequelae, it has been observed that post-COVID fibrosis can develop as early as 3 weeks after the initial infection. This case was unique in its late presentation during the second post-COVID follow up at 4 months with normal imaging and clinical parameters during the first follow up. Hence a meticulous long-term follow-up should be done for all patients.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89270835","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1992
J. Chiles, S. Gandotra, D. Russell
INTRODUCTION: Uncertainty and discovery have been two fundamental processes in the response to the Covid-19 pandemic. We continue to recognize new manifestations and complications of this syndrome and its respiratory manifestations. Two recently recognized complications of Covid-19 are pneumothorax and pneumomediastinum with the interesting caveat that these diagnoses can be early manifestations, complications of mechanical ventilation, or can develop late in disease course after other clinical signs have long since begun to improve. Here, we present the case of a young man whose Covid-19 convalescence was disrupted by development of a pneumothorax with early tension physiology. CASE: Our patient was a 34-year-old white, nonsmoking male with a history of asthma and morbid obesity. Five weeks before presentation he was diagnosed with an asymptomatic case of Covid-19 after his symptomatic wife tested positive. Seven days later, he required admission to the ICU for worsening respiratory failure and spent a total of eight days in the ICU receiving oxygen via high-flow nasal cannula but did not require intubation. He was weaned to four liters of oxygen via nasal cannula after a ten day hospitalization and discharged home with instructions to follow up with his outpatient pulmonologist. He was convalescing well with reduced oxygen requirements until 18 days later, when he experienced the sudden onset of worsening dyspnea, prompting him to return to the emergency department. Initial imaging revealed a large left-sided pneumothorax with mediastinal shift and early tension physiology, for which emergency chest tube decompression was performed. His left lung re-expanded immediately after chest tube placement and he was able to rapidly tolerate a clamping trial followed by removal three days later. He was subsequently discharged home. DISCUSSION: The lingering sequelae of Covid-19 infection, including radiographic abnormalities, dyspnea, hypoxemic respiratory failure, and fatigue continue to present challenges for patients and providers. In this case, the sudden worsening of the patient's previously improving clinical course was a key clue to a new etiology of his dyspnea and resulted in appropriate treatment after discovery of the cause. Providers should remain vigilant for pneumothorax in patients with Covid-19, even after their discharge from the hospital.
{"title":"Covid Convalescence Interrupted","authors":"J. Chiles, S. Gandotra, D. Russell","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1992","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1992","url":null,"abstract":"INTRODUCTION: Uncertainty and discovery have been two fundamental processes in the response to the Covid-19 pandemic. We continue to recognize new manifestations and complications of this syndrome and its respiratory manifestations. Two recently recognized complications of Covid-19 are pneumothorax and pneumomediastinum with the interesting caveat that these diagnoses can be early manifestations, complications of mechanical ventilation, or can develop late in disease course after other clinical signs have long since begun to improve. Here, we present the case of a young man whose Covid-19 convalescence was disrupted by development of a pneumothorax with early tension physiology. CASE: Our patient was a 34-year-old white, nonsmoking male with a history of asthma and morbid obesity. Five weeks before presentation he was diagnosed with an asymptomatic case of Covid-19 after his symptomatic wife tested positive. Seven days later, he required admission to the ICU for worsening respiratory failure and spent a total of eight days in the ICU receiving oxygen via high-flow nasal cannula but did not require intubation. He was weaned to four liters of oxygen via nasal cannula after a ten day hospitalization and discharged home with instructions to follow up with his outpatient pulmonologist. He was convalescing well with reduced oxygen requirements until 18 days later, when he experienced the sudden onset of worsening dyspnea, prompting him to return to the emergency department. Initial imaging revealed a large left-sided pneumothorax with mediastinal shift and early tension physiology, for which emergency chest tube decompression was performed. His left lung re-expanded immediately after chest tube placement and he was able to rapidly tolerate a clamping trial followed by removal three days later. He was subsequently discharged home. DISCUSSION: The lingering sequelae of Covid-19 infection, including radiographic abnormalities, dyspnea, hypoxemic respiratory failure, and fatigue continue to present challenges for patients and providers. In this case, the sudden worsening of the patient's previously improving clinical course was a key clue to a new etiology of his dyspnea and resulted in appropriate treatment after discovery of the cause. Providers should remain vigilant for pneumothorax in patients with Covid-19, even after their discharge from the hospital.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82334064","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2011
L. Mikhaleva, O. Zayratyants, O. Vasyukova, G. N. Mednikov
Currently, there are only scarce data on pulmonary COVID-19 lesions in pregnant women in the literature although the disease hasn't spared any country. This study aimed to provide insight into this issue. We carried out a retrospective analysis of the clinical data, autopsy, and microscopic findings in 4 pregnant women with severe COVID-19. Patients were admitted 4-5 days after COVID-19 onset with fever, dry cough, and reduced saturation. Positive SARSCoV2 nasopharyngeal swab PCRs were obtained. Chest CT revealed bilateral 'ground glass' pneumonia, CT 3-4. The women were diagnosed with severe COVID-19 requiring ALV and ECMO. They underwent emergent C-section with subsequent therapy. Patient 1, 37 y.o., 28-29 gestation weeks (GW), had comorbid conditions-obesity and arterial hypertension, died on the 11th bed-day (BD) due to pulmonary embolism. Patient 2, 31 y.o., 27 GW, developed bacterial pneumonia and acute pansinusitis with multiple organ failure resulting in death on 15th BD. Patient 3, 22 y.o., 35 GW, had ventilatorassociated pneumonia, lymphopenia, thrombocytopenia, anemia, and phlebothrombosis as COVID-19 complications. Later, she developed sepsis, which resulted in a lethal outcome (on 26th BD). Patient 4, 38 y.o., 32 GW, was diagnosed with pneumothorax on the 10th BD requiring pleural cavity drainage. The disease was complicated by bacterial pneumonia leading to respiratory failure and death (on the 30th BD). At autopsy, all four women had 'shock lungs' and diffuse alveolar damage at microscopy. Microscopic evaluation of the 1st patient's lung specimens revealed hyaline membranes corresponding to exudative DAD phase combined with proliferative DAD signs. In the 2nd case, we observed a pronounced cytopathic effect resulting in 'ugly' multinucleated cell formation, and multiple hemosiderophages in the alveolar lumens, as well as alveolar and bronchial metaplasia, confirmed by positive CK5-6 IHC staining. Third patient lung specimens demonstrated organizing viral pneumonia (with interalveolar granulation tissue, numerous interalveolar siderophages, indicating an alveolar-hemorrhagic syndrome) combined with massive bacterial pneumonia. Organizing viral pneumonia with mature interalveolar granulation tissue and sarcoid-like granulomas was diagnosed in 4 patient. Clinical and morphological analysis demonstrated that COVID-19 pneumonia features are similar for pregnant and non-pregnant patients of the same age group. The proliferative DAD phase was detected in three of 4 cases. However, of special interest is the first case, in which a combination of DAD phases was determined. At the same time, no severe obstetric complications were identified, which we associate with the timely diagnosis and prevention measures.
{"title":"Lung Lesions in 4 Pregnant Women with Severe COVID-19 - Autopsy Case","authors":"L. Mikhaleva, O. Zayratyants, O. Vasyukova, G. N. Mednikov","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2011","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2011","url":null,"abstract":"Currently, there are only scarce data on pulmonary COVID-19 lesions in pregnant women in the literature although the disease hasn't spared any country. This study aimed to provide insight into this issue. We carried out a retrospective analysis of the clinical data, autopsy, and microscopic findings in 4 pregnant women with severe COVID-19. Patients were admitted 4-5 days after COVID-19 onset with fever, dry cough, and reduced saturation. Positive SARSCoV2 nasopharyngeal swab PCRs were obtained. Chest CT revealed bilateral 'ground glass' pneumonia, CT 3-4. The women were diagnosed with severe COVID-19 requiring ALV and ECMO. They underwent emergent C-section with subsequent therapy. Patient 1, 37 y.o., 28-29 gestation weeks (GW), had comorbid conditions-obesity and arterial hypertension, died on the 11th bed-day (BD) due to pulmonary embolism. Patient 2, 31 y.o., 27 GW, developed bacterial pneumonia and acute pansinusitis with multiple organ failure resulting in death on 15th BD. Patient 3, 22 y.o., 35 GW, had ventilatorassociated pneumonia, lymphopenia, thrombocytopenia, anemia, and phlebothrombosis as COVID-19 complications. Later, she developed sepsis, which resulted in a lethal outcome (on 26th BD). Patient 4, 38 y.o., 32 GW, was diagnosed with pneumothorax on the 10th BD requiring pleural cavity drainage. The disease was complicated by bacterial pneumonia leading to respiratory failure and death (on the 30th BD). At autopsy, all four women had 'shock lungs' and diffuse alveolar damage at microscopy. Microscopic evaluation of the 1st patient's lung specimens revealed hyaline membranes corresponding to exudative DAD phase combined with proliferative DAD signs. In the 2nd case, we observed a pronounced cytopathic effect resulting in 'ugly' multinucleated cell formation, and multiple hemosiderophages in the alveolar lumens, as well as alveolar and bronchial metaplasia, confirmed by positive CK5-6 IHC staining. Third patient lung specimens demonstrated organizing viral pneumonia (with interalveolar granulation tissue, numerous interalveolar siderophages, indicating an alveolar-hemorrhagic syndrome) combined with massive bacterial pneumonia. Organizing viral pneumonia with mature interalveolar granulation tissue and sarcoid-like granulomas was diagnosed in 4 patient. Clinical and morphological analysis demonstrated that COVID-19 pneumonia features are similar for pregnant and non-pregnant patients of the same age group. The proliferative DAD phase was detected in three of 4 cases. However, of special interest is the first case, in which a combination of DAD phases was determined. At the same time, no severe obstetric complications were identified, which we associate with the timely diagnosis and prevention measures.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75734984","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a1988
V. Pathak, S. Chalise
Introduction: Coronavirus Disease 2019 (COVID 19) is a viral illness caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). We report a patient with COVID-19 pneumonia leading to ARDS and subsequent development of an alveolopleural fistula who was successfully treated with multiple endobronchial valves. Case: The Patient was a 55-year-old Hispanic male who presented with 2 days of dry cough and shortness of breath. Vital signs on admission showed an oxygen saturation of 68% on ambient air and respiratory rate of 30 breaths per minute. He was admitted with acute hypoxic respiratory failure and found to have a positive SARS-Cov2 infection. Initial CT chest without contrast showed diffuse bilateral ground-glass opacities. His oxygen requirement increased as well as his work of breathing requiring BiPAP, and subsequent intubation. On the 10th day of admission, he developed a right-sided pneumothorax, requiring chest tube placement. A tracheostomy was completed on day 14 for further ventilator weaning. On day 20, he developed persistent air leak concerning for an alveolopleural fistula, repeat CT chest concerning for a moderate-sized pneumothorax and findings concerning for post ARDS fibrotic lungs. He continued to have persistent air leak but was not deemed to be a surgical candidate hence he was referred for endobronchial valve placement to facilitate chest tube removal and ventilator weaning. Bronchoscopy was done on day 41 of admission. Total 6 endobronchial valves were placed (right middle and lower lobes). Over next few days his leak completely resolved. Patient was weaned off of positive pressure a week later to trach collar, and the chest tube was subsequently removed. Discussion: Alveolopleural fistula is a communication or fistula between a alveoli and the pleural space. Patient's with ARDS secondary to COVID-19 requiring high amounts of PEEP and are at higher risk in developing a pneumothorax. Endobronchial valves (EBV) have been used since 2005 to treat alveolopleural and bronchopleural fistula in patients who are not considered a good surgical candidate. This is the first documented use of an EBV in the setting of COVID-19 that we could find. The placement of the valves, allowed a significant reduction in the air leak. This assisted in the patient's breathing trials on the ventilator and tracheostomy collar trials by reducing the overall volume loss through the fistula, ultimately allowing the patient to successfully liberated from the ventilator and have his chest tubes removed.
{"title":"Use of Endobronchial Valve to Treat COVID-19 Adult Respiratory Distress Syndrome Related Alveolopleural Fistula","authors":"V. Pathak, S. Chalise","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a1988","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a1988","url":null,"abstract":"Introduction: Coronavirus Disease 2019 (COVID 19) is a viral illness caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). We report a patient with COVID-19 pneumonia leading to ARDS and subsequent development of an alveolopleural fistula who was successfully treated with multiple endobronchial valves. Case: The Patient was a 55-year-old Hispanic male who presented with 2 days of dry cough and shortness of breath. Vital signs on admission showed an oxygen saturation of 68% on ambient air and respiratory rate of 30 breaths per minute. He was admitted with acute hypoxic respiratory failure and found to have a positive SARS-Cov2 infection. Initial CT chest without contrast showed diffuse bilateral ground-glass opacities. His oxygen requirement increased as well as his work of breathing requiring BiPAP, and subsequent intubation. On the 10th day of admission, he developed a right-sided pneumothorax, requiring chest tube placement. A tracheostomy was completed on day 14 for further ventilator weaning. On day 20, he developed persistent air leak concerning for an alveolopleural fistula, repeat CT chest concerning for a moderate-sized pneumothorax and findings concerning for post ARDS fibrotic lungs. He continued to have persistent air leak but was not deemed to be a surgical candidate hence he was referred for endobronchial valve placement to facilitate chest tube removal and ventilator weaning. Bronchoscopy was done on day 41 of admission. Total 6 endobronchial valves were placed (right middle and lower lobes). Over next few days his leak completely resolved. Patient was weaned off of positive pressure a week later to trach collar, and the chest tube was subsequently removed. Discussion: Alveolopleural fistula is a communication or fistula between a alveoli and the pleural space. Patient's with ARDS secondary to COVID-19 requiring high amounts of PEEP and are at higher risk in developing a pneumothorax. Endobronchial valves (EBV) have been used since 2005 to treat alveolopleural and bronchopleural fistula in patients who are not considered a good surgical candidate. This is the first documented use of an EBV in the setting of COVID-19 that we could find. The placement of the valves, allowed a significant reduction in the air leak. This assisted in the patient's breathing trials on the ventilator and tracheostomy collar trials by reducing the overall volume loss through the fistula, ultimately allowing the patient to successfully liberated from the ventilator and have his chest tubes removed.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81352188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2010
B. Bangash, I. Makki, R. Girgis
Introduction: Persistent radiographic and pulmonary function abnormalities are increasingly recognized following Corona Virus Disease (COVID-19) pneumonia. We present a case of rapidly progressive pulmonary fibrosis in a Usual Interstitial Pneumonia (UIP) pattern. Successful lung transplantation was performed two months following COVID-19 infection. Description: 68 years old with known history of mild Interstitial Lung Disease (ILD) , not on home oxygen, initially presented in July 2020 with worsening shortness of breath and cough. There was a strong family history for Interstitial pulmonary fibrosis (IPF). Her last pulmonary function tests showed a Forced Expiratory Volume in one second (FEV1) of 2.24 Liters (99%) and Forced Vital Capacity of 2.69 Liters (92%). Her last High Resolution Computed Tomography (HRCT) showed chronic stable mild interstitial fibrosis. On admission, she was positive for COVID 19 on her Polymerase Chain Reaction (PCR). Initial CT chest showed diffuse new ground glass changes. She was treated with remdesavir, dexamethasone and antibiotics. She did not require endotracheal intubation and showed improvement in her symptoms. Unfortunately, she could not be weaned off oxygen and was discharged on six liters flow oxygen through a nasal cannula. She presented again to the hospital, one month later with worsening shortness of breath. Her PCR was negative for COVID 19. Her CT angiogram of thorax however showed interval worsening of her interstitial changes. An urgent inpatient evaluation for lung transplantation was completed and she deemed to be a suitable candidate. After 4 days into her stay, acute deterioration in her respiratory status developed with tachypnea and increased work of breathing requiring endotracheal intubation and mechanical ventilation. Repeat CT chest showed fibrotic interstitial disease with associated traction bronchiectasis and a large amount of ground glass. She was subsequently placed on veno-venous Extra Corporeal Membrane Oxygenation (VV ECMO) which allowed extubation. A donor offer for bilateral lungs was accepted after one day on ECMO. She successfully underwent bilateral lung transplant in September 2020. Her post-operative course was uncomplicated. She is doing well 3 months post transplant without evidence of cellular rejection. Her explant pathology showed Diffuse Alveolar Damage plus UIP Discussion: Persistent and progressive pulmonary fibrosis may develop following COVID-19 pneumonia. Risk factors may include underlying ILD and family history of IPF. In suitable candidates, lung transplantation is a viable option.
{"title":"Lung Transplant for Corona Virus Diseases (COVID-19) Pulmonary Fibrosis","authors":"B. Bangash, I. Makki, R. Girgis","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2010","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2010","url":null,"abstract":"Introduction: Persistent radiographic and pulmonary function abnormalities are increasingly recognized following Corona Virus Disease (COVID-19) pneumonia. We present a case of rapidly progressive pulmonary fibrosis in a Usual Interstitial Pneumonia (UIP) pattern. Successful lung transplantation was performed two months following COVID-19 infection. Description: 68 years old with known history of mild Interstitial Lung Disease (ILD) , not on home oxygen, initially presented in July 2020 with worsening shortness of breath and cough. There was a strong family history for Interstitial pulmonary fibrosis (IPF). Her last pulmonary function tests showed a Forced Expiratory Volume in one second (FEV1) of 2.24 Liters (99%) and Forced Vital Capacity of 2.69 Liters (92%). Her last High Resolution Computed Tomography (HRCT) showed chronic stable mild interstitial fibrosis. On admission, she was positive for COVID 19 on her Polymerase Chain Reaction (PCR). Initial CT chest showed diffuse new ground glass changes. She was treated with remdesavir, dexamethasone and antibiotics. She did not require endotracheal intubation and showed improvement in her symptoms. Unfortunately, she could not be weaned off oxygen and was discharged on six liters flow oxygen through a nasal cannula. She presented again to the hospital, one month later with worsening shortness of breath. Her PCR was negative for COVID 19. Her CT angiogram of thorax however showed interval worsening of her interstitial changes. An urgent inpatient evaluation for lung transplantation was completed and she deemed to be a suitable candidate. After 4 days into her stay, acute deterioration in her respiratory status developed with tachypnea and increased work of breathing requiring endotracheal intubation and mechanical ventilation. Repeat CT chest showed fibrotic interstitial disease with associated traction bronchiectasis and a large amount of ground glass. She was subsequently placed on veno-venous Extra Corporeal Membrane Oxygenation (VV ECMO) which allowed extubation. A donor offer for bilateral lungs was accepted after one day on ECMO. She successfully underwent bilateral lung transplant in September 2020. Her post-operative course was uncomplicated. She is doing well 3 months post transplant without evidence of cellular rejection. Her explant pathology showed Diffuse Alveolar Damage plus UIP Discussion: Persistent and progressive pulmonary fibrosis may develop following COVID-19 pneumonia. Risk factors may include underlying ILD and family history of IPF. In suitable candidates, lung transplantation is a viable option.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82028740","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1998
K. Ruppert, S. Kadlecek, F. Amzajerdian, Y. Xin, H. Hamedani, L. Loza, T. Achekzai, R. Baron, I. Duncan, Y. Qian, M. Ismail, M. Cereda, B. Abramoff, R. Rizi
Introduction: There are a growing number of reports of persistently reduced exercise capacities, dyspnea or cough in a small fraction of Covid-19 survivors, suggesting ongoing impaired lung function long after the acute infection has resolved. The cause of these symptoms is unclear, though they likely originate in subtle damage to alveolar septa or vasculature. Here, we present the case of a patient with persistent post-COVID-19 symptoms who was evaluated with hyperpolarized xenon-129 MRI methods, which are sensitive to both ventilation and exchange in both non-specific tissue-plasma and red-blood-cell bound compartments in the lungs. Case: A 58-year-old never-smoker female patient was diagnosed COVID-19 positive in August 2020. She continued to experience nonspecific symptoms of fatigue, pins-and-needles in the feet, dyspnea, and daily productive cough (green, non-bloody sputum). Chest x-ray showed clear lungs without focal consolidation, pleural effusion, or pneumothorax. The subject underwent xenon-129 MR imaging on December 11, 2020 using a multi-breath scheme, in which sets of 6 ad libitum breaths containing 50mL of hyperpolarized xenon-129 (balance room air) were followed by four breaths of room air, and that 10-breath sequence was repeated until the polarized xenon-129 gas supply was exhausted. As shown in Figure 1, ventilated lung volumes are visually patchy, with heterogeneity corresponding to lobar structures or segmental and subsegmental volumes that are likely fed by airways with varying degrees of blockage. This is consistent with the persistent sputum production experienced by the patient. Further, saturation pulses at the frequency of hemoglobin-bound and tissue-plasma xenon-129 resonances selectively destroy signal in their respective compartments, which is subsequently exchanged to the gas phase. Compared to a healthy volunteer, the fractional depolarization achieved when applying identical saturation pulses is reduced by an average of approximately 40% in the patient. The response to saturation pulses also exhibits significant spatial heterogeneity. Discussion: Although a single case study is unable to determine the origin of alterations seen in a recovered COVID-19 patient, these changes are consistent with an overall reduction in the rate of gas exchange into dissolved compartments, as well as with a somewhat heterogeneous pattern of ventilation characteristic of mild obstructive disease. Further studies will be required to determine if these changes are associated with severe or persistent morbidity, and if correspondence to an age-matched healthy cohort increases as recovery continues.
{"title":"First Experience with Hyperpolarized 129Xe Imaging in a Recovered COVID-19 Patient","authors":"K. Ruppert, S. Kadlecek, F. Amzajerdian, Y. Xin, H. Hamedani, L. Loza, T. Achekzai, R. Baron, I. Duncan, Y. Qian, M. Ismail, M. Cereda, B. Abramoff, R. Rizi","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1998","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A1998","url":null,"abstract":"Introduction: There are a growing number of reports of persistently reduced exercise capacities, dyspnea or cough in a small fraction of Covid-19 survivors, suggesting ongoing impaired lung function long after the acute infection has resolved. The cause of these symptoms is unclear, though they likely originate in subtle damage to alveolar septa or vasculature. Here, we present the case of a patient with persistent post-COVID-19 symptoms who was evaluated with hyperpolarized xenon-129 MRI methods, which are sensitive to both ventilation and exchange in both non-specific tissue-plasma and red-blood-cell bound compartments in the lungs. Case: A 58-year-old never-smoker female patient was diagnosed COVID-19 positive in August 2020. She continued to experience nonspecific symptoms of fatigue, pins-and-needles in the feet, dyspnea, and daily productive cough (green, non-bloody sputum). Chest x-ray showed clear lungs without focal consolidation, pleural effusion, or pneumothorax. The subject underwent xenon-129 MR imaging on December 11, 2020 using a multi-breath scheme, in which sets of 6 ad libitum breaths containing 50mL of hyperpolarized xenon-129 (balance room air) were followed by four breaths of room air, and that 10-breath sequence was repeated until the polarized xenon-129 gas supply was exhausted. As shown in Figure 1, ventilated lung volumes are visually patchy, with heterogeneity corresponding to lobar structures or segmental and subsegmental volumes that are likely fed by airways with varying degrees of blockage. This is consistent with the persistent sputum production experienced by the patient. Further, saturation pulses at the frequency of hemoglobin-bound and tissue-plasma xenon-129 resonances selectively destroy signal in their respective compartments, which is subsequently exchanged to the gas phase. Compared to a healthy volunteer, the fractional depolarization achieved when applying identical saturation pulses is reduced by an average of approximately 40% in the patient. The response to saturation pulses also exhibits significant spatial heterogeneity. Discussion: Although a single case study is unable to determine the origin of alterations seen in a recovered COVID-19 patient, these changes are consistent with an overall reduction in the rate of gas exchange into dissolved compartments, as well as with a somewhat heterogeneous pattern of ventilation characteristic of mild obstructive disease. Further studies will be required to determine if these changes are associated with severe or persistent morbidity, and if correspondence to an age-matched healthy cohort increases as recovery continues.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79893129","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2012
K. Patel, D. Morris, A. Iardino
Introduction: Sars-Cov-2 infection has been found to present differently in many patients. Patients have been found to have different degrees of response, likely having to do with variable levels of inflammation within the body. Patients who have recovered from the initial infection can develop long-term symptomatology and chronic conditions. Today, we will describe a unique case of a middle aged-healthy man who developed complications of ANCA-associated vasculitis after recovering from a mild COVID-19 infection. Case: A 51-year-old Hispanic male with no previous past medical history presented to the ED with productive sputum and hemoptysis. The patient had previously tested positive for COVID-19 one month prior, but did not require hospitalization. Physical exam findings were significant for diffuse, bilateral lower extremity palpable purpura. Initial workup was significant for CT Chest findings of diffuse patchy consolidations throughout both lungs with cavitary lesions. Additionally, the patient was found to have an acute kidney injury, with Cr 5.80 and GFR less than 10. UA revealed many red blood cells, +1 protein. Nephrology was consulted, started the patient on hemodialysis, and began workup for suspected acute glomerulonephritis (GN). Pulmonology was consulted and began workup for pulmonary renal syndrome in the setting of acute kidney injury with pulmonary disease.Infectious workup results included;a now negative COVID-19, negative Tuberculosis PCR, Respiratory culture revealing yeast. Additional workup revealed;CRP of greater than 200, D-Dimer of 6.41, Fibrinogen of 561. Notably, the patient had decreased complement C3 and C4 levels, negative Anti-GBM antibody, negative Anti-streptolysin O, positive ANCA assay, positive Proteinase antibody, and mildly positive Myeloperoxidase antibody.The patient was subsequently scheduled for renal biopsy to obtain a definitive diagnosis, but this was delayed due to increased INR. The patient's respiratory status worsened during hemodialysis. CTA at that time revealed markedly increased pulmonary infiltrates. The decision was made to intubate the patient, upon which active frank red bleeding arising from the trachea was noted. Shortly after intubation, the patient continued to hemorrhage and sustained 2 cardiac arrests;unfortunately, the patient expired. Discussion: This case is significant because it highlights a unique complication of COVID-19 leading to a possible ANCA-associated vasculitis. Much is to be learned from the Novel Sars-COV-2 virus and suspected complications and this case highlights the importance of keeping a broad differential when treating patients who have recovered from initial infection.
{"title":"Post-Covid-19 Complications: Hemoptysis in a Middle-Aged Man","authors":"K. Patel, D. Morris, A. Iardino","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2012","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2012","url":null,"abstract":"Introduction: Sars-Cov-2 infection has been found to present differently in many patients. Patients have been found to have different degrees of response, likely having to do with variable levels of inflammation within the body. Patients who have recovered from the initial infection can develop long-term symptomatology and chronic conditions. Today, we will describe a unique case of a middle aged-healthy man who developed complications of ANCA-associated vasculitis after recovering from a mild COVID-19 infection. Case: A 51-year-old Hispanic male with no previous past medical history presented to the ED with productive sputum and hemoptysis. The patient had previously tested positive for COVID-19 one month prior, but did not require hospitalization. Physical exam findings were significant for diffuse, bilateral lower extremity palpable purpura. Initial workup was significant for CT Chest findings of diffuse patchy consolidations throughout both lungs with cavitary lesions. Additionally, the patient was found to have an acute kidney injury, with Cr 5.80 and GFR less than 10. UA revealed many red blood cells, +1 protein. Nephrology was consulted, started the patient on hemodialysis, and began workup for suspected acute glomerulonephritis (GN). Pulmonology was consulted and began workup for pulmonary renal syndrome in the setting of acute kidney injury with pulmonary disease.Infectious workup results included;a now negative COVID-19, negative Tuberculosis PCR, Respiratory culture revealing yeast. Additional workup revealed;CRP of greater than 200, D-Dimer of 6.41, Fibrinogen of 561. Notably, the patient had decreased complement C3 and C4 levels, negative Anti-GBM antibody, negative Anti-streptolysin O, positive ANCA assay, positive Proteinase antibody, and mildly positive Myeloperoxidase antibody.The patient was subsequently scheduled for renal biopsy to obtain a definitive diagnosis, but this was delayed due to increased INR. The patient's respiratory status worsened during hemodialysis. CTA at that time revealed markedly increased pulmonary infiltrates. The decision was made to intubate the patient, upon which active frank red bleeding arising from the trachea was noted. Shortly after intubation, the patient continued to hemorrhage and sustained 2 cardiac arrests;unfortunately, the patient expired. Discussion: This case is significant because it highlights a unique complication of COVID-19 leading to a possible ANCA-associated vasculitis. Much is to be learned from the Novel Sars-COV-2 virus and suspected complications and this case highlights the importance of keeping a broad differential when treating patients who have recovered from initial infection.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76505613","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2007
M. A. Ahmed, D. Verghese, Chenyu Sun, A. Mohan, D. Djondo
Coronavirus Disease 2019 (COVID-19) is known to have severe outcomes in patients with underlying comorbidities. Particularly, patients with compromised humoral immunity may face an increased risk for severe illness, as antibodies are essential for antiviral responses. Here, we present a COVID-19 patient with Bruton's X-linked agammaglobulinemia (XLA). A 46-year-old male with XLA receiving immunoglobulin replacement (IVIG) every three weeks, who contracted COVID-19 1-month ago, was admitted for 10-days of severe diarrhea and 3-days of exertional dyspnea. Repeat SARS-Co-V-2 PCR on admission was positive. Workup showed leukopenia and negative blood cultures. CT Chest Angiogram, performed for elevated D-dimer, revealed patchy bilateral ground-glass opacities, suggestive of viral/atypical pneumonia without pulmonary embolism. He received a 7-day course of Ceftriaxone and Azithromycin for community-acquired pneumonia and IVIG for low immunoglobulin levels. CT Abdomen and Pelvis, as well as a workup for infectious causes of diarrhea, were unremarkable. Colonoscopy ruled out microscopic and inflammatory colitis. Two stool SARS-Co-V-2 PCRs were negative. COVID IgG was negative, so he received COVID-19 Convalescent Plasma (CCP). Given his persistent fever spikes, bronchoscopy was performed, which was unremarkable;however, the bronchoalveolar lavage sample was positive for SARS-Co-V-2 PCR. The patient was hypoxemic and was started on Dexamethasone 6mg for 10-days. He was not a candidate for Remdesivir due to his delayed presentation. Tagged white blood cell (WBC) nuclear scan revealed mild pneumonia and mild sigmoid colonic WBC accumulation. The patient underwent prolonged hospitalization before improvement. As per the CDC's current recommendation to discontinue isolation 10-days from symptom onset, his isolation precautions were discontinued on the 16th day of hospitalization, 42 days after the first SARS-CoV-2 positive test. Given his underlying immunodeficiency, there was high suspicion that the patient was still infectious, putting frontline healthcare workers at risk. This was confirmed when an RT-PCR cell cycle threshold value (Ct) of 10.03 was obtained, which correlates to a highly culturable viral load and a highly infectious state. Isolation precautions were reinstated, and he was later discharged after another dose of CCP. Strict self-isolation for an additional ten days was advised. In summary, this patient with XLA had a lengthy hospital stay and prolonged viral shedding, likely due to an insufficient antibody response. In such patients, caution must be exercised when following the CDC recommendations for removing isolation precautions. RT-PCR Ct could be a valuable proxy in evaluating the state of infection and implementing appropriate infection control measures.
{"title":"The 'X' Factor: Exploring COVID-19 Viral Shedding in X-Linked Agammaglobulinemia. Can PCR Cell Cycle Threshold Play a Role?","authors":"M. A. Ahmed, D. Verghese, Chenyu Sun, A. Mohan, D. Djondo","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2007","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2007","url":null,"abstract":"Coronavirus Disease 2019 (COVID-19) is known to have severe outcomes in patients with underlying comorbidities. Particularly, patients with compromised humoral immunity may face an increased risk for severe illness, as antibodies are essential for antiviral responses. Here, we present a COVID-19 patient with Bruton's X-linked agammaglobulinemia (XLA). A 46-year-old male with XLA receiving immunoglobulin replacement (IVIG) every three weeks, who contracted COVID-19 1-month ago, was admitted for 10-days of severe diarrhea and 3-days of exertional dyspnea. Repeat SARS-Co-V-2 PCR on admission was positive. Workup showed leukopenia and negative blood cultures. CT Chest Angiogram, performed for elevated D-dimer, revealed patchy bilateral ground-glass opacities, suggestive of viral/atypical pneumonia without pulmonary embolism. He received a 7-day course of Ceftriaxone and Azithromycin for community-acquired pneumonia and IVIG for low immunoglobulin levels. CT Abdomen and Pelvis, as well as a workup for infectious causes of diarrhea, were unremarkable. Colonoscopy ruled out microscopic and inflammatory colitis. Two stool SARS-Co-V-2 PCRs were negative. COVID IgG was negative, so he received COVID-19 Convalescent Plasma (CCP). Given his persistent fever spikes, bronchoscopy was performed, which was unremarkable;however, the bronchoalveolar lavage sample was positive for SARS-Co-V-2 PCR. The patient was hypoxemic and was started on Dexamethasone 6mg for 10-days. He was not a candidate for Remdesivir due to his delayed presentation. Tagged white blood cell (WBC) nuclear scan revealed mild pneumonia and mild sigmoid colonic WBC accumulation. The patient underwent prolonged hospitalization before improvement. As per the CDC's current recommendation to discontinue isolation 10-days from symptom onset, his isolation precautions were discontinued on the 16th day of hospitalization, 42 days after the first SARS-CoV-2 positive test. Given his underlying immunodeficiency, there was high suspicion that the patient was still infectious, putting frontline healthcare workers at risk. This was confirmed when an RT-PCR cell cycle threshold value (Ct) of 10.03 was obtained, which correlates to a highly culturable viral load and a highly infectious state. Isolation precautions were reinstated, and he was later discharged after another dose of CCP. Strict self-isolation for an additional ten days was advised. In summary, this patient with XLA had a lengthy hospital stay and prolonged viral shedding, likely due to an insufficient antibody response. In such patients, caution must be exercised when following the CDC recommendations for removing isolation precautions. RT-PCR Ct could be a valuable proxy in evaluating the state of infection and implementing appropriate infection control measures.","PeriodicalId":23189,"journal":{"name":"TP31. TP031 INTERESTING CASES ASSOCIATED WITH SARS-COV-2 INFECTION","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91011719","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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