Pub Date : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2142
J. Spoons, S. Treat, M. McNabney, J. Horner, N. Smith
In mid-2019, cases of acute eosinophilic pneumonia caused by the vaporization and inhalation of tetrahydrocannabinol (THC) containing products began to rapidly appear. E-cigarette or vaping product useassociated lung injury, or EVALI as it became known, was eventually linked to substances such as vitamin E used in illicit manufacture of THC containing vaping products. A previously healthy 20 year old male presented with complaints of worsening nausea, vomiting, abdominal pain, fevers, and dry cough of several months. Symptoms began 3 months prior with periods of intractable nausea and vomiting that lasted from 24 hours to 1 week without complete resolution. An extensive outpatient workup was completed by gastroenterology without definitive diagnosis, including endoscopy. The patient had attempted therapy with ondansetron, phenergan, metoclopromide, cannabidiol (CBD) gummy candies, vaporized CBD and THC without success. Physical exam was remarkable for nystagmus on far lateral gaze, prompting concern for a central cause of his persistent nausea and vomiting. Chest x-ray was unremarkable, and laboratory examination was remarkable for mild leukocytosis. Neurology was consulted and MRI brain was unremarkable. Seventy-two hours after admission, with supportive care, his nausea and vomiting had improved, but he developed new fever of 101.9°F. CT angiogram of the thorax revealed diffuse ground glass opacities with an upper lobe predominance and opacification in the lower lobes without pulmonary embolism. COVID-19 nasal swab was obtained, and treatment for community acquired pneumonia was started empirically. CRP was elevated to 34.9 mg/dl, urine L. pneumophila, S. pneumoniae, respiratory virus PCR panel, H. capsulatum, Aspergillus antigen, Fungitell assay, and COVID-19 PCR testing, with subsequent repeat, were negative. On the 4th day of admission, he became short of breath with increasingly worse cough leading to desaturation in the low 80%'s requiring 6 L oxygen via nasal cannula. Pulmonology was consulted, and given his THC exposure, negative laboratory testing and CT thorax appearance, a diagnosis of EVALI was made. Prednisone (0.5 mg/kg) was started, and over the next 72 hours, the patient's cough improved with continued supportive care. He was discharged to complete a 15 day prednisone taper. The rapid rise in cases lead to nationwide reporting of manufacturing processes and consumer awareness, which has subsequently lead to a decrease in the number of reported EVALI cases. Our patient's presentation with prolonged gastrointestinal distress left an initially broad differential and reminds us to discuss vaping of THC-containing products with all patients with vaping exposure.
{"title":"EVALI Masquerading as Cannabinoid Hyperemesis Syndrome","authors":"J. Spoons, S. Treat, M. McNabney, J. Horner, N. Smith","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2142","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2142","url":null,"abstract":"In mid-2019, cases of acute eosinophilic pneumonia caused by the vaporization and inhalation of tetrahydrocannabinol (THC) containing products began to rapidly appear. E-cigarette or vaping product useassociated lung injury, or EVALI as it became known, was eventually linked to substances such as vitamin E used in illicit manufacture of THC containing vaping products. A previously healthy 20 year old male presented with complaints of worsening nausea, vomiting, abdominal pain, fevers, and dry cough of several months. Symptoms began 3 months prior with periods of intractable nausea and vomiting that lasted from 24 hours to 1 week without complete resolution. An extensive outpatient workup was completed by gastroenterology without definitive diagnosis, including endoscopy. The patient had attempted therapy with ondansetron, phenergan, metoclopromide, cannabidiol (CBD) gummy candies, vaporized CBD and THC without success. Physical exam was remarkable for nystagmus on far lateral gaze, prompting concern for a central cause of his persistent nausea and vomiting. Chest x-ray was unremarkable, and laboratory examination was remarkable for mild leukocytosis. Neurology was consulted and MRI brain was unremarkable. Seventy-two hours after admission, with supportive care, his nausea and vomiting had improved, but he developed new fever of 101.9°F. CT angiogram of the thorax revealed diffuse ground glass opacities with an upper lobe predominance and opacification in the lower lobes without pulmonary embolism. COVID-19 nasal swab was obtained, and treatment for community acquired pneumonia was started empirically. CRP was elevated to 34.9 mg/dl, urine L. pneumophila, S. pneumoniae, respiratory virus PCR panel, H. capsulatum, Aspergillus antigen, Fungitell assay, and COVID-19 PCR testing, with subsequent repeat, were negative. On the 4th day of admission, he became short of breath with increasingly worse cough leading to desaturation in the low 80%'s requiring 6 L oxygen via nasal cannula. Pulmonology was consulted, and given his THC exposure, negative laboratory testing and CT thorax appearance, a diagnosis of EVALI was made. Prednisone (0.5 mg/kg) was started, and over the next 72 hours, the patient's cough improved with continued supportive care. He was discharged to complete a 15 day prednisone taper. The rapid rise in cases lead to nationwide reporting of manufacturing processes and consumer awareness, which has subsequently lead to a decrease in the number of reported EVALI cases. Our patient's presentation with prolonged gastrointestinal distress left an initially broad differential and reminds us to discuss vaping of THC-containing products with all patients with vaping exposure.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76836495","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2151
X. Ying, R. Wozniak, H. Swerdloff, R. Kalil, T. Wong
Introduction: Radiation induced pulmonary fibrosis typically develops between 6-12 months after completion of radiation therapy (RT), and typically affects only the irradiated lung. We present a rare case of bilateral radiation induced pulmonary fibrosis occurring only one month after completion of unilateral RT. Case Presentation: A 75-year-old male with pleural mesothelioma treated with five cycles of neoadjuvant carboplatin and pemetrexed followed by thoracotomy, pleurectomy, decortication and six weeks of RT (28 fractions, total 50.4 Grays) (Figure 1A) presented 33 days after completing RT with five days of dyspnea and dry cough. Vitals were notable for oxygen saturation of 86% on room air with improvement to 97% on 4 L/min via nasal cannula. Review of his pre-RT computed tomography (CT) demonstrated left-sided bronchiectasis and basilar ground glass attenuation representing post-inflammatory changes (Figure 1B). Repeat CT 27 days after completion of RT showed new bilateral diffuse ground-glass opacities with left upper and lower lobe fibrosis (Figure 1C);CT upon current presentation revealed increased ground-glass opacities and bilateral fibrosis (Figure 1D). Blood cultures, SARSCoV-2 PCR, respiratory pathogen panel (including influenza A/B and respiratory syncytial virus), cryptococcal antigen, galactomannan and 1,3-beta-d-glucan were all unrevealing. Transthoracic echocardiogram revealed septal E/e' ratio 12.6 and estimated pulmonary artery systolic pressure 30 mmHg, and serum b-type natriuretic peptide level was 48 pg/ml. Detailed reconciliation confirmed he was not taking any new medications, including statins. Hypersensitivity pneumonitis panel was negative. His working diagnosis was radiation induced lung injury with features of both early pneumonitis and late fibrosis. Therapy with short-acting bronchodilators and systemic corticosteroids was initiated with significant clinical improvement;patient was discharged home on hospital day six off oxygen. Discussion: Radiation induced lung injury can generally be divided into acute and late phases. The former is commonly known as radiation pneumonitis and manifests as ground-glass opacities 4-12 weeks after completion of RT, and the latter presents as bronchiectasis and fibrosis 6-12 months later. Ours is a rare case of pneumonitis and fibrosis that developed within one month of completing RT. Additionally, this patient developed pneumonitis and fibrosis of his right lung, which did not receive any radiation;very few cases of pneumonitis on the nonirradiated lung have been reported. Immunologically mediated lymphocytic alveolitis has been proposed as a mechanism for contralateral spread of radiation fibrosis. Our patient showed significant clinical improvement with initiation of corticosteroids with the plan for a long, slow outpatient taper based on clinical response.
{"title":"A Case of Bilateral Radiation Pneumonitis and Post Radiation Pulmonary Fibrosis One Month After Unilateral Lung Radiation","authors":"X. Ying, R. Wozniak, H. Swerdloff, R. Kalil, T. Wong","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2151","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2151","url":null,"abstract":"Introduction: Radiation induced pulmonary fibrosis typically develops between 6-12 months after completion of radiation therapy (RT), and typically affects only the irradiated lung. We present a rare case of bilateral radiation induced pulmonary fibrosis occurring only one month after completion of unilateral RT. Case Presentation: A 75-year-old male with pleural mesothelioma treated with five cycles of neoadjuvant carboplatin and pemetrexed followed by thoracotomy, pleurectomy, decortication and six weeks of RT (28 fractions, total 50.4 Grays) (Figure 1A) presented 33 days after completing RT with five days of dyspnea and dry cough. Vitals were notable for oxygen saturation of 86% on room air with improvement to 97% on 4 L/min via nasal cannula. Review of his pre-RT computed tomography (CT) demonstrated left-sided bronchiectasis and basilar ground glass attenuation representing post-inflammatory changes (Figure 1B). Repeat CT 27 days after completion of RT showed new bilateral diffuse ground-glass opacities with left upper and lower lobe fibrosis (Figure 1C);CT upon current presentation revealed increased ground-glass opacities and bilateral fibrosis (Figure 1D). Blood cultures, SARSCoV-2 PCR, respiratory pathogen panel (including influenza A/B and respiratory syncytial virus), cryptococcal antigen, galactomannan and 1,3-beta-d-glucan were all unrevealing. Transthoracic echocardiogram revealed septal E/e' ratio 12.6 and estimated pulmonary artery systolic pressure 30 mmHg, and serum b-type natriuretic peptide level was 48 pg/ml. Detailed reconciliation confirmed he was not taking any new medications, including statins. Hypersensitivity pneumonitis panel was negative. His working diagnosis was radiation induced lung injury with features of both early pneumonitis and late fibrosis. Therapy with short-acting bronchodilators and systemic corticosteroids was initiated with significant clinical improvement;patient was discharged home on hospital day six off oxygen. Discussion: Radiation induced lung injury can generally be divided into acute and late phases. The former is commonly known as radiation pneumonitis and manifests as ground-glass opacities 4-12 weeks after completion of RT, and the latter presents as bronchiectasis and fibrosis 6-12 months later. Ours is a rare case of pneumonitis and fibrosis that developed within one month of completing RT. Additionally, this patient developed pneumonitis and fibrosis of his right lung, which did not receive any radiation;very few cases of pneumonitis on the nonirradiated lung have been reported. Immunologically mediated lymphocytic alveolitis has been proposed as a mechanism for contralateral spread of radiation fibrosis. Our patient showed significant clinical improvement with initiation of corticosteroids with the plan for a long, slow outpatient taper based on clinical response.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"78 2 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83492064","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2117
L. Ramírez, A. Mahgoub, U. Naqvi, A. Thota, J. Meharg
Intro: In patients with advanced melanoma, immune checkpoint inhibitors (ICPIs) have demonstrated a substantial advantage when compared to cytotoxic chemotherapies. By augmenting the immune response with these medications, immune-related adverse effects can occur, and often include dermatological toxicity, hepatotoxicity, endocrinopathies, and much more rarely, pneumonitis. Case Presentation: An 80-year-old with past medical history of bronchial asthma, hypertension, 30 pack year smoking history discontinued over 2 decades ago, and metastatic melanoma (MM) on neoadjuvant nivolumab presented to our hospital in September of 2020 with 5 days of worsening shortness of breath. He denied any fever, cough, chest discomfort, palpitation, nausea, vomiting, epigastric/abdominal pain, leg pain, or palpitations. He had been diagnosed with stage IIIc MM in March of 2020 and underwent surgical resection of his left hallux and had completed 5 cycles of immunotherapy with Nivolumab. On admission, the patient had sinus tachycardia to 115, respiratory rate of 18 bpm, normotensive, oxygen saturation 80% on room air, improved to 94% on 4L nasal cannula. Laboratory studies were remarkable for acute kidney injury with Creatinine 1.7mg/dl (1.1 baseline), procalcitonin less than 0.05 ng/dl, elevated D-Dimer to 2.6mg/L, complete blood count, and comprehensive metabolic panel unremarkable. Viral serologies and sputum cultures resulted negative. Chest x-ray demonstrated extensive multifocal bilateral airspace. CTPA revealed severe diffuse bilateral airspace disease concerning for infectious, versus noninfectious pneumonia or a neoplastic process. He subsequently underwent bronchoscopy with BAL of RLL/LLL and RLL brush biopsy, which was negative for malignancy and infectious etiologies, including COVID-19. The patient was diagnosed with grade 3 nivolumab induced pneumonitis, and treated with high dose steroids, and empiric antibiotics. His condition improved, steroids were tapered, and he was discharged on day 13. Discussion: Pneumonitis is a rare, life-threatening complication in patients being treated with nivolumab. When severe symptoms are present and hospitalization and oxygen supplementation are indicated, treatment includes discontinuation of the immunotherapy agent, high dose steroids, prophylactic antibiotics, and additional immunosuppressive therapy if no response to During the midst of a global pandemic, findings of multifocal pneumonia are presumed to be SARS-CoV-2 until proven otherwise. Despite the burden many physicians have faced amid the COVID-19 pandemic, maintaining a broad differential until the diagnosis is made for accurate treatment.
在晚期黑色素瘤患者中，与细胞毒性化疗相比，免疫检查点抑制剂(icpi)已显示出实质性的优势。通过使用这些药物增强免疫反应，可能会发生与免疫相关的不良反应，通常包括皮肤毒性、肝毒性、内分泌病变，以及更罕见的肺炎。病例介绍:一名80岁的患者，既往有支气管哮喘、高血压病史，20多年前停止吸烟30年，并于2020年9月在新辅助纳沃单抗治疗下出现转移性黑色素瘤(MM)，伴有5天呼吸急促加重。他否认有发热、咳嗽、胸部不适、心悸、恶心、呕吐、上腹痛、腿痛或心悸。他于2020年3月被诊断为IIIc期MM，接受了左拇切除术，并完成了5个周期的尼武单抗免疫治疗。入院时，患者窦性心动过速为115，呼吸频率为18次/分钟，血压正常，室内空气氧饱和度为80%，使用4L鼻插管后改善至94%。实验室研究表明，急性肾损伤的肌酐为1.7mg/dl(1.1基线)，降钙素原低于0.05 ng/dl, d -二聚体升高至2.6mg/L，全血细胞计数和综合代谢组无显著差异。病毒血清学和痰培养结果为阴性。胸部x线显示广泛的双侧多灶空域。CTPA显示严重的弥漫性双侧空域疾病，与感染性肺炎或非感染性肺炎或肿瘤过程有关。随后，他接受了支气管镜检查，检查了RLL/LLL的BAL和RLL刷活检，结果显示恶性肿瘤和感染性病因(包括COVID-19)呈阴性。患者被诊断为3级纳武单抗引起的肺炎，并接受大剂量类固醇和经验性抗生素治疗。他的病情好转，类固醇逐渐减少，并于第13天出院。讨论:肺炎是接受纳武单抗治疗的患者中一种罕见的危及生命的并发症。当出现严重症状并需要住院治疗和补充氧气时，治疗包括停止免疫治疗剂、大剂量类固醇、预防性抗生素和如果对无反应的额外免疫抑制治疗。在全球大流行期间，多灶性肺炎的发现被推定为SARS-CoV-2，除非另有证明。尽管许多医生在COVID-19大流行期间面临着负担，但在做出诊断以进行准确治疗之前，仍要保持广泛的鉴别。
{"title":"Multifocal Pneumonia During a Pandemic","authors":"L. Ramírez, A. Mahgoub, U. Naqvi, A. Thota, J. Meharg","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2117","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2117","url":null,"abstract":"Intro: In patients with advanced melanoma, immune checkpoint inhibitors (ICPIs) have demonstrated a substantial advantage when compared to cytotoxic chemotherapies. By augmenting the immune response with these medications, immune-related adverse effects can occur, and often include dermatological toxicity, hepatotoxicity, endocrinopathies, and much more rarely, pneumonitis. Case Presentation: An 80-year-old with past medical history of bronchial asthma, hypertension, 30 pack year smoking history discontinued over 2 decades ago, and metastatic melanoma (MM) on neoadjuvant nivolumab presented to our hospital in September of 2020 with 5 days of worsening shortness of breath. He denied any fever, cough, chest discomfort, palpitation, nausea, vomiting, epigastric/abdominal pain, leg pain, or palpitations. He had been diagnosed with stage IIIc MM in March of 2020 and underwent surgical resection of his left hallux and had completed 5 cycles of immunotherapy with Nivolumab. On admission, the patient had sinus tachycardia to 115, respiratory rate of 18 bpm, normotensive, oxygen saturation 80% on room air, improved to 94% on 4L nasal cannula. Laboratory studies were remarkable for acute kidney injury with Creatinine 1.7mg/dl (1.1 baseline), procalcitonin less than 0.05 ng/dl, elevated D-Dimer to 2.6mg/L, complete blood count, and comprehensive metabolic panel unremarkable. Viral serologies and sputum cultures resulted negative. Chest x-ray demonstrated extensive multifocal bilateral airspace. CTPA revealed severe diffuse bilateral airspace disease concerning for infectious, versus noninfectious pneumonia or a neoplastic process. He subsequently underwent bronchoscopy with BAL of RLL/LLL and RLL brush biopsy, which was negative for malignancy and infectious etiologies, including COVID-19. The patient was diagnosed with grade 3 nivolumab induced pneumonitis, and treated with high dose steroids, and empiric antibiotics. His condition improved, steroids were tapered, and he was discharged on day 13. Discussion: Pneumonitis is a rare, life-threatening complication in patients being treated with nivolumab. When severe symptoms are present and hospitalization and oxygen supplementation are indicated, treatment includes discontinuation of the immunotherapy agent, high dose steroids, prophylactic antibiotics, and additional immunosuppressive therapy if no response to During the midst of a global pandemic, findings of multifocal pneumonia are presumed to be SARS-CoV-2 until proven otherwise. Despite the burden many physicians have faced amid the COVID-19 pandemic, maintaining a broad differential until the diagnosis is made for accurate treatment.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"43 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80444903","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2115
D. J. Shah, C. Cascio
INTRODUCTION: Pneumonitis is focal or diffuse inflammation of lung parenchyma. With recent advancements in oncology, immunotherapy is an emerging cause of pneumonitis. Atezolizumab is an immune checkpoint inhibitor (ICI) that targets PD-L1 to prevent the interaction with receptors PD-1 and B7-1, thus reversing T-cell suppression and can cause pneumonitis due to the inflammatory response. It has an incidence of up to 10%. Symptoms can include dyspnea (53%), cough (35%), fever (12%), and chest pain (7%). CASE: An 81-year-old male with unresectable hepatocellular carcinoma (HCC) on Atezolizumab-Bevacizumab, intra-lesional hematoma, and portal vein thrombosis presented with one day of dyspnea. In the ED, he was found to be hypoxic to 80% on room air. The examination was unremarkable except for bilateral crackles on auscultation. Laboratory tests including complete blood count, electrolytes, liver function tests, kidney function tests, and arterial blood gas were within normal limits. CT chest revealed bilateral multifocal airspace opacities. Due to the acute hypoxemic respiratory failure, he was transferred to the ICU for care. Blood cultures were sent. Antibiotic therapy with vancomycin, cefepime, and azithromycin was initiated for presumed community-acquired pneumonia. The patient continued to worsen clinically. All initial infectious workup was negative including blood cultures, tuberculosis and fungal workup, and respiratory viral pathogen PCR. COVID-19 and influenza PCR was negative thrice. Of note, the patient completed his second cycle of immunotherapy with Atezolizumab-Bevacizumab, four days prior to admission. He was started on methylprednisolone 2mg/kg/d on hospital day (HD) 5 for likely ICI-induced pneumonitis. Despite steroid therapy, no clinical improvement was noted. He was additionally given a single dose of infliximab 5mg/kg to which he improved clinically initially. However, he later grew Aspergillus in his bronchoalveolar lavage and passed away from multi-organ failure on HD 22. DISCUSSION: We describe a case of HCC with hematoma. Given the risk of bleeding with first-line therapy (Sorafenib), a combination of Atezolizumab-Bevacizumab was used instead. ICI-induced pneumonitis is a diagnosis of exclusion with no specific clinical picture or radiologic findings. Anti-VEGF antibodies like Bevacizumab are more likely to cause pulmonary hemorrhage than pneumonitis. ICI-induced pneumonitis is divided into 4 grades. This patient was categorized as Grade 3. The patient received infliximab as he did not respond to initial therapy consisting of empirical antibiotics and IV methylprednisolone. In patients on ICI, who present with respiratory symptoms, clinicians should have a high degree of suspicion for pneumonitis. Early diagnosis and treatment could potentially reduce mortality.
{"title":"Immunotherapy Induced Pneumonitis","authors":"D. J. Shah, C. Cascio","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2115","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2115","url":null,"abstract":"INTRODUCTION: Pneumonitis is focal or diffuse inflammation of lung parenchyma. With recent advancements in oncology, immunotherapy is an emerging cause of pneumonitis. Atezolizumab is an immune checkpoint inhibitor (ICI) that targets PD-L1 to prevent the interaction with receptors PD-1 and B7-1, thus reversing T-cell suppression and can cause pneumonitis due to the inflammatory response. It has an incidence of up to 10%. Symptoms can include dyspnea (53%), cough (35%), fever (12%), and chest pain (7%). CASE: An 81-year-old male with unresectable hepatocellular carcinoma (HCC) on Atezolizumab-Bevacizumab, intra-lesional hematoma, and portal vein thrombosis presented with one day of dyspnea. In the ED, he was found to be hypoxic to 80% on room air. The examination was unremarkable except for bilateral crackles on auscultation. Laboratory tests including complete blood count, electrolytes, liver function tests, kidney function tests, and arterial blood gas were within normal limits. CT chest revealed bilateral multifocal airspace opacities. Due to the acute hypoxemic respiratory failure, he was transferred to the ICU for care. Blood cultures were sent. Antibiotic therapy with vancomycin, cefepime, and azithromycin was initiated for presumed community-acquired pneumonia. The patient continued to worsen clinically. All initial infectious workup was negative including blood cultures, tuberculosis and fungal workup, and respiratory viral pathogen PCR. COVID-19 and influenza PCR was negative thrice. Of note, the patient completed his second cycle of immunotherapy with Atezolizumab-Bevacizumab, four days prior to admission. He was started on methylprednisolone 2mg/kg/d on hospital day (HD) 5 for likely ICI-induced pneumonitis. Despite steroid therapy, no clinical improvement was noted. He was additionally given a single dose of infliximab 5mg/kg to which he improved clinically initially. However, he later grew Aspergillus in his bronchoalveolar lavage and passed away from multi-organ failure on HD 22. DISCUSSION: We describe a case of HCC with hematoma. Given the risk of bleeding with first-line therapy (Sorafenib), a combination of Atezolizumab-Bevacizumab was used instead. ICI-induced pneumonitis is a diagnosis of exclusion with no specific clinical picture or radiologic findings. Anti-VEGF antibodies like Bevacizumab are more likely to cause pulmonary hemorrhage than pneumonitis. ICI-induced pneumonitis is divided into 4 grades. This patient was categorized as Grade 3. The patient received infliximab as he did not respond to initial therapy consisting of empirical antibiotics and IV methylprednisolone. In patients on ICI, who present with respiratory symptoms, clinicians should have a high degree of suspicion for pneumonitis. Early diagnosis and treatment could potentially reduce mortality.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90848812","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2161
J. Sargi, J. Heaton, O. Adarkwah, G. Parhar, K. Zaman, N. Mesiha, F. Afroza, L. Gerolemou
Introduction:Lipoid pneumonia is a rare condition in which lipid molecules enter the alveoli. This condition usually manifests as hypoxemic respiratory failure after exogenous usage of different consumer products, including Vaseline, Vicks VapoRub and lip gloss, and occupational exposure in lubricant production, machine cleaning, and spray painting. We report a 79-year-old patient who presented with acute hypoxemic respiratory failure secondary to lipoid pneumonia. Case Presentation:A 79-year-old female with PMH of depression, chronic neck and back pain PTSD, HTN, HLD who presented to our institution with a chief complaint of non-productive cough and dyspnea on exertion for greater than a month. CXR showed diffuse bilateral interstitial opacities. CT imaging showed multifocal confluent geographic areas of ground-glass opacities in crazy paving patters, suggestive of alveolar pathology. Connective tissue disorders, respiratory cultures, and multiple COVID-19 tests were negative. BNP was normal. She initially required high flow oxygen with 80% FIO2. Steroids were started without improvement. The patient underwent bronchoscopy with BAL for suspected PAP, HP, and to rule out DAH. BAL showed lipid-laden macrophages on oil red o stain, and periodic acid shift stain was negative. The patient subsequently reported continuous Vicks vapor rub for many years, which was likely the reason for lipoid pneumonia development. Discussion:Lipoid pneumonia is a rare condition in which lipid molecules occupy intraalveolar space and are subsequently found in alveolar macrophages2. The exact mechanism is unknown;however, the pathogenesis and severity are related to the amount of inhaled materials used3. Lipoid pneumonia symptoms typically are chronic cough and progressive dyspnea on exertion. Recently, exogenous lipoid pneumonia has been linked to E-cigarettes usage4. Our case underlines the importance of keeping high clinical suspicion of lipoid pneumonia as a potential cause of dyspnea in patients with crazy paving patterns on CT scan. Taking a detailed history is essential in making the correct diagnosis.Conclusion Lipoid pneumonia is a rare diagnosis caused by inhaling different lipids containing materials. Physicians should be aware of this etiology as a possible differential diagnosis in patients admitted with acute hypoxemic respiratory failure.
{"title":"A Case of Exogenous Lipoid Pneumonia in a Critically Ill Patient","authors":"J. Sargi, J. Heaton, O. Adarkwah, G. Parhar, K. Zaman, N. Mesiha, F. Afroza, L. Gerolemou","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2161","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2161","url":null,"abstract":"Introduction:Lipoid pneumonia is a rare condition in which lipid molecules enter the alveoli. This condition usually manifests as hypoxemic respiratory failure after exogenous usage of different consumer products, including Vaseline, Vicks VapoRub and lip gloss, and occupational exposure in lubricant production, machine cleaning, and spray painting. We report a 79-year-old patient who presented with acute hypoxemic respiratory failure secondary to lipoid pneumonia. Case Presentation:A 79-year-old female with PMH of depression, chronic neck and back pain PTSD, HTN, HLD who presented to our institution with a chief complaint of non-productive cough and dyspnea on exertion for greater than a month. CXR showed diffuse bilateral interstitial opacities. CT imaging showed multifocal confluent geographic areas of ground-glass opacities in crazy paving patters, suggestive of alveolar pathology. Connective tissue disorders, respiratory cultures, and multiple COVID-19 tests were negative. BNP was normal. She initially required high flow oxygen with 80% FIO2. Steroids were started without improvement. The patient underwent bronchoscopy with BAL for suspected PAP, HP, and to rule out DAH. BAL showed lipid-laden macrophages on oil red o stain, and periodic acid shift stain was negative. The patient subsequently reported continuous Vicks vapor rub for many years, which was likely the reason for lipoid pneumonia development. Discussion:Lipoid pneumonia is a rare condition in which lipid molecules occupy intraalveolar space and are subsequently found in alveolar macrophages2. The exact mechanism is unknown;however, the pathogenesis and severity are related to the amount of inhaled materials used3. Lipoid pneumonia symptoms typically are chronic cough and progressive dyspnea on exertion. Recently, exogenous lipoid pneumonia has been linked to E-cigarettes usage4. Our case underlines the importance of keeping high clinical suspicion of lipoid pneumonia as a potential cause of dyspnea in patients with crazy paving patterns on CT scan. Taking a detailed history is essential in making the correct diagnosis.Conclusion Lipoid pneumonia is a rare diagnosis caused by inhaling different lipids containing materials. Physicians should be aware of this etiology as a possible differential diagnosis in patients admitted with acute hypoxemic respiratory failure.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"99 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87344634","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2119
L. Jones, B. Stephens, S. Adams
Introduction:Upadacitinib is a new oral janus kinase (JAK) inhibitor that has been approved to treat rheumatoid arthritis. JAK inhibitors carry a black box warning for their association with severe infections especially when used in combination with other immunosuppressants. Although there is a strong association, there are very few reports of Pneumocystis jirovecii pneumonia (PJP) caused by upadacitinib. We describe a case of PJP due to upadacitinib use in rheumatoid arthritis. Case presentation: A 44-year-old woman with a history of rheumatoid arthritis presented with 2 weeks of dyspnea, dry cough and fever after recently starting upadacitinib. She was noted to be tachypneic, tachycardic and hypoxemic on admission. Initial laboratory tests were within normal limits and lactate dehydrogenase was 304. Respiratory viral panel and reverse transcription-polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 were negative. Computerized tomography of the chest revealed diffuse multi-focal ground glass and consolidative opacities. The patient's respiratory status rapidly deteriorated, requiring admission to medical intensive care unit where she was initiated on invasive mechanical ventilation. A 1,3-beta-D-glucan serology test was positive and PJP polymerase chain reaction in bronchoalveolar lavage was positive. She was started on intravenous trimethoprim-sulfamethoxazole 400mg three times a day and intravenous methylprednisolone 500mg twice a day for three days. Her oxygen requirements rapidly improved and she was extubated on day 4 of admission. The patient was discharged without a supplemental oxygen requirement to complete a course of oral trimethoprim-sulfamethoxazole and prednisone. Discussion:JAK inhibitors are increasingly used for the treatment of rheumatoid arthritis and other autoimmune diseases. Other less selective JAK inhibitors such as tofacitinib and baricitinib have been associated with PJP in rheumatoid arthritis. Upadacitinib is a selective JAK1 inhibitor which is thought to give it an improved side effect profile compared to other less selective JAK inhibitors. This represents one of the first cases of PJP associated with the use of upadacitinib, a selective JAK1 inhibitor. PJP should be included in the differential diagnosis of patients treated with upadacitinib who present with fever, hypoxemia and pulmonary infiltrates. Awareness of this disease and its manifestations are critical to appropriate diagnostic evaluation and timely treatment.
Upadacitinib是一种新的口服janus激酶(JAK)抑制剂，已被批准用于治疗类风湿性关节炎。JAK抑制剂带有与严重感染相关的黑框警告，特别是与其他免疫抑制剂联合使用时。虽然有很强的相关性，但upadacitinib引起的肺囊虫肺炎(PJP)的报道很少。我们描述了一例PJP由于更新他替尼使用在类风湿关节炎。病例介绍:一名44岁女性，有类风湿关节炎病史，最近开始使用更新他替尼后出现2周呼吸困难、干咳和发烧。入院时发现她有呼吸急促、心动过速和低氧血症。初步化验结果在正常范围内，乳酸脱氢酶为304。呼吸道病毒面板和冠状病毒2型逆转录聚合酶链反应阴性。胸部电脑断层显示弥漫性多灶磨玻璃及实变影。病人的呼吸状况迅速恶化，需要送进医疗加护病房，在那里她开始接受有创机械通气。1,3- β - d -葡聚糖血清学试验阳性，支气管肺泡灌洗PJP聚合酶链反应阳性。开始静脉注射甲氧苄氨苄-磺胺甲恶唑400mg，每日3次;静脉注射甲基强的松龙500mg，每日2次，连用3天。她的氧气需求迅速改善，入院第4天拔管。患者出院时无需补充氧气以完成一个疗程的口服甲氧苄氨苄-磺胺甲恶唑和强的松。讨论:JAK抑制剂越来越多地用于类风湿关节炎和其他自身免疫性疾病的治疗。其他选择性较低的JAK抑制剂如托法替尼和巴西替尼与类风湿关节炎的PJP有关。Upadacitinib是一种选择性JAK1抑制剂，与其他选择性较低的JAK1抑制剂相比，Upadacitinib被认为具有更好的副作用。这是与选择性JAK1抑制剂upadacitinib相关的首批PJP病例之一。PJP应包括在upadacitinib治疗的患者的鉴别诊断中，这些患者表现为发热、低氧血症和肺部浸润。认识这种疾病及其表现对于适当的诊断评估和及时治疗至关重要。
{"title":"Upadacitinib Associated Pneumocystis Jirovecii Pneumonia","authors":"L. Jones, B. Stephens, S. Adams","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2119","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2119","url":null,"abstract":"Introduction:Upadacitinib is a new oral janus kinase (JAK) inhibitor that has been approved to treat rheumatoid arthritis. JAK inhibitors carry a black box warning for their association with severe infections especially when used in combination with other immunosuppressants. Although there is a strong association, there are very few reports of Pneumocystis jirovecii pneumonia (PJP) caused by upadacitinib. We describe a case of PJP due to upadacitinib use in rheumatoid arthritis. Case presentation: A 44-year-old woman with a history of rheumatoid arthritis presented with 2 weeks of dyspnea, dry cough and fever after recently starting upadacitinib. She was noted to be tachypneic, tachycardic and hypoxemic on admission. Initial laboratory tests were within normal limits and lactate dehydrogenase was 304. Respiratory viral panel and reverse transcription-polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 were negative. Computerized tomography of the chest revealed diffuse multi-focal ground glass and consolidative opacities. The patient's respiratory status rapidly deteriorated, requiring admission to medical intensive care unit where she was initiated on invasive mechanical ventilation. A 1,3-beta-D-glucan serology test was positive and PJP polymerase chain reaction in bronchoalveolar lavage was positive. She was started on intravenous trimethoprim-sulfamethoxazole 400mg three times a day and intravenous methylprednisolone 500mg twice a day for three days. Her oxygen requirements rapidly improved and she was extubated on day 4 of admission. The patient was discharged without a supplemental oxygen requirement to complete a course of oral trimethoprim-sulfamethoxazole and prednisone. Discussion:JAK inhibitors are increasingly used for the treatment of rheumatoid arthritis and other autoimmune diseases. Other less selective JAK inhibitors such as tofacitinib and baricitinib have been associated with PJP in rheumatoid arthritis. Upadacitinib is a selective JAK1 inhibitor which is thought to give it an improved side effect profile compared to other less selective JAK inhibitors. This represents one of the first cases of PJP associated with the use of upadacitinib, a selective JAK1 inhibitor. PJP should be included in the differential diagnosis of patients treated with upadacitinib who present with fever, hypoxemia and pulmonary infiltrates. Awareness of this disease and its manifestations are critical to appropriate diagnostic evaluation and timely treatment.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"66 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91365437","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2118
R. Kunadharaju, A. Saradna, M. Ahmad, G. Fuhrer
Introduction: In postmenopausal women, Palbociclib is a selective cyclin-dependent kinase CDK4 and CKD6 inhibitor to treat hormone receptor-positive metastatic breast cancer in combination with Letrozole (Aromatase Inhibitor). We describe a case presenting with the rare side effect of Palbociclib induced interstitial pneumonitis. Case report: A 70-year-old Caucasian female was admitted to the hospital with complaints of progressive dyspnea, dry cough, epistaxis, pleuritic chest pain over one month. Her past medical history was significant for stage IIIC (pT3N3) invasive ductal breast cancer (ER-positive/PR-negative/HER2-negative) status post left segmental mastectomy and axillary lymph node dissection 17 years ago. She received adjuvant chemotherapy, followed by Anastrozole, for five years. She had a metastatic recurrence to bones, liver, and lymph nodes, which was ER-positive/PR-negative/HER2-negative, and was started on Palbociclib and Letrozole by the oncology team four months before admission. Upon presentation, she was noted to have hypoxia requiring four liters of oxygen via nasal cannula. On examination, she was in severe respiratory distress and had bilateral crackles on lung auscultation. CT chest with contrast revealed no pulmonary embolism and bilateral patchy interstitial opacities. Her lab work showed neutropenia, lymphopenia, and anemia. She had a thorough evaluation for viral (including COVID-19), bacterial, and fungal infection, heart failure, and autoimmune disorders, which were negative. Although diagnostic bronchoscopy was offered, she declined the procedure. She continued to have worsening hypoxemia and required a high flow nasal cannula (FiO2 70% and 50 liters of flow) for moderate ARDS, which was presumed to be secondary to drug-induced pneumonitis. Given the pattern of lung injury on CT, the subacute nature of her symptoms, and initial non-invasive evaluation, it was felt that infectious pneumonia was unlikely. She was managed conservatively with discontinuation of Palbociclib, and IV steroids were initiated (20 mg dexamethasone daily). Over 14 days during the hospital stay, her hypoxemia largely resolved, and she was successfully discharged to a rehabilitation facility. On the day of discharge, she was discharged on PO Prednisone dose 0.5mg/kg for six weeks along with oral Bactrim full dose three times a week for PJP prophylaxis. Discussion: Palbociclib is commonly associated with neutropenia, anemia, thrombocytopenia, fatigue, infection, and gastrointestinal side effects. Rarely Palbociclib is associated with interstitial pneumonitis (incidence <1%) due to unknown mechanisms. The early identification of this side effect and treatment with immediate cessation of the drug and corticosteroids could be a life-saving measure, as is the case with our patient.
{"title":"Palbociclib (Cyclin-Dependent Kinases CDK4 and CDK6 Selective Inhibitor) Induced Grade 3 Interstitial Pneumonitis","authors":"R. Kunadharaju, A. Saradna, M. Ahmad, G. Fuhrer","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2118","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2118","url":null,"abstract":"Introduction: In postmenopausal women, Palbociclib is a selective cyclin-dependent kinase CDK4 and CKD6 inhibitor to treat hormone receptor-positive metastatic breast cancer in combination with Letrozole (Aromatase Inhibitor). We describe a case presenting with the rare side effect of Palbociclib induced interstitial pneumonitis. Case report: A 70-year-old Caucasian female was admitted to the hospital with complaints of progressive dyspnea, dry cough, epistaxis, pleuritic chest pain over one month. Her past medical history was significant for stage IIIC (pT3N3) invasive ductal breast cancer (ER-positive/PR-negative/HER2-negative) status post left segmental mastectomy and axillary lymph node dissection 17 years ago. She received adjuvant chemotherapy, followed by Anastrozole, for five years. She had a metastatic recurrence to bones, liver, and lymph nodes, which was ER-positive/PR-negative/HER2-negative, and was started on Palbociclib and Letrozole by the oncology team four months before admission. Upon presentation, she was noted to have hypoxia requiring four liters of oxygen via nasal cannula. On examination, she was in severe respiratory distress and had bilateral crackles on lung auscultation. CT chest with contrast revealed no pulmonary embolism and bilateral patchy interstitial opacities. Her lab work showed neutropenia, lymphopenia, and anemia. She had a thorough evaluation for viral (including COVID-19), bacterial, and fungal infection, heart failure, and autoimmune disorders, which were negative. Although diagnostic bronchoscopy was offered, she declined the procedure. She continued to have worsening hypoxemia and required a high flow nasal cannula (FiO2 70% and 50 liters of flow) for moderate ARDS, which was presumed to be secondary to drug-induced pneumonitis. Given the pattern of lung injury on CT, the subacute nature of her symptoms, and initial non-invasive evaluation, it was felt that infectious pneumonia was unlikely. She was managed conservatively with discontinuation of Palbociclib, and IV steroids were initiated (20 mg dexamethasone daily). Over 14 days during the hospital stay, her hypoxemia largely resolved, and she was successfully discharged to a rehabilitation facility. On the day of discharge, she was discharged on PO Prednisone dose 0.5mg/kg for six weeks along with oral Bactrim full dose three times a week for PJP prophylaxis. Discussion: Palbociclib is commonly associated with neutropenia, anemia, thrombocytopenia, fatigue, infection, and gastrointestinal side effects. Rarely Palbociclib is associated with interstitial pneumonitis (incidence <1%) due to unknown mechanisms. The early identification of this side effect and treatment with immediate cessation of the drug and corticosteroids could be a life-saving measure, as is the case with our patient.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"11 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81360565","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2154
A. Mukherjee, K. Sankaramangalam
Introduction-Daptomycin is a unique lipopeptide antibiotic that exerts bactericidal action by cell membrane action potential disruption. It is used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant gram-positive organisms. However, acute eosinophilic pneumonitis (AEP) remains a rare life-threatening adverse effect of daptomycin therapy. Case-A 65-year-old gentleman with a history of diabetes mellitus presented with palpitations, dyspnea, and lethargy for four days. He did not have any fever but noted occasional nonproductive cough. He was discharged a week prior after a two-week hospitalization where he underwent treatment for MRSA septic knee arthritis, which was complicated by MRSA bacteremia and COVID-19 pneumonia. He was discharged on daptomycin and ceftaroline maintenance therapy. He was afebrile, but had tachycardia, tachypnea, and was hypoxic to 88% on room air. Pulmonary examination revealed bibasal decreased breath sounds. Investigations were notable for leukocytosis with peripheral eosinophilia of 27%. COVID-19 testing was negative twice. His chest-Xray revealed patchy bilateral opacities (Fig-1A), similar to his prior admission (Fig-1B). A computed tomography pulmonary angiogram showed bilateral, multifocal, irregular opacities (Fig-1C). Supplemental oxygen was started and daptomycin was promptly discontinued. Intravenous methylprednisolone was also initiated. Over the next two days, the patient improved significantly, was weaned off supplemental oxygen, and peripheral eosinophilia also improved. He was discharged after four days, on a prednisone taper and only ceftaroline was completed for a total of eight weeks. Discussion-Daptomycin induced AEP may present with dyspnea, fever, peripheral eosinophilia and bilateral multifocal pulmonary infiltrates, commonly within two to four weeks of drug exposure. 25% or more eosinophilia on bronchoalveolar lavage specimen is very specific. This adverse effect of daptomycin appears to be more time-dependent than dose-dependent. Daptomycin is inactivated by pulmonary surfactant, and this altered lipid biochemistry may precipitate T-helper-2 cell-mediated interleukin-5 elaboration. This triggers eosinophil recruitment and their pulmonary migration, resulting in the characteristic pulmonary inflammatory response. However, the exact mechanism remains unclear. We considered other differentials, including fungal or parasitic infections, recent COVID-19 pneumonia, and vasculitides;however, considering our patient's compatible presentation, and with a Naranjo algorithm score of six, daptomycin induced AEP was hypothesized to be the probable etiology. Management involves early recognition and discontinuation of daptomycin, with corticosteroids being used often to augment clinical recovery. The rarity of the presentation necessitates awareness and vigilance, as early discontinuation often results in an excellent prognosis and leads to future avoidance of daptomyc
{"title":"A Case of Daptomycin Induced Acute Eosinophilic Pneumonia in a Patient with Septic Arthritis","authors":"A. Mukherjee, K. Sankaramangalam","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2154","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2154","url":null,"abstract":"Introduction-Daptomycin is a unique lipopeptide antibiotic that exerts bactericidal action by cell membrane action potential disruption. It is used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant gram-positive organisms. However, acute eosinophilic pneumonitis (AEP) remains a rare life-threatening adverse effect of daptomycin therapy. Case-A 65-year-old gentleman with a history of diabetes mellitus presented with palpitations, dyspnea, and lethargy for four days. He did not have any fever but noted occasional nonproductive cough. He was discharged a week prior after a two-week hospitalization where he underwent treatment for MRSA septic knee arthritis, which was complicated by MRSA bacteremia and COVID-19 pneumonia. He was discharged on daptomycin and ceftaroline maintenance therapy. He was afebrile, but had tachycardia, tachypnea, and was hypoxic to 88% on room air. Pulmonary examination revealed bibasal decreased breath sounds. Investigations were notable for leukocytosis with peripheral eosinophilia of 27%. COVID-19 testing was negative twice. His chest-Xray revealed patchy bilateral opacities (Fig-1A), similar to his prior admission (Fig-1B). A computed tomography pulmonary angiogram showed bilateral, multifocal, irregular opacities (Fig-1C). Supplemental oxygen was started and daptomycin was promptly discontinued. Intravenous methylprednisolone was also initiated. Over the next two days, the patient improved significantly, was weaned off supplemental oxygen, and peripheral eosinophilia also improved. He was discharged after four days, on a prednisone taper and only ceftaroline was completed for a total of eight weeks. Discussion-Daptomycin induced AEP may present with dyspnea, fever, peripheral eosinophilia and bilateral multifocal pulmonary infiltrates, commonly within two to four weeks of drug exposure. 25% or more eosinophilia on bronchoalveolar lavage specimen is very specific. This adverse effect of daptomycin appears to be more time-dependent than dose-dependent. Daptomycin is inactivated by pulmonary surfactant, and this altered lipid biochemistry may precipitate T-helper-2 cell-mediated interleukin-5 elaboration. This triggers eosinophil recruitment and their pulmonary migration, resulting in the characteristic pulmonary inflammatory response. However, the exact mechanism remains unclear. We considered other differentials, including fungal or parasitic infections, recent COVID-19 pneumonia, and vasculitides;however, considering our patient's compatible presentation, and with a Naranjo algorithm score of six, daptomycin induced AEP was hypothesized to be the probable etiology. Management involves early recognition and discontinuation of daptomycin, with corticosteroids being used often to augment clinical recovery. The rarity of the presentation necessitates awareness and vigilance, as early discontinuation often results in an excellent prognosis and leads to future avoidance of daptomyc","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89051061","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 : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2123
A. Syeda, T. Mohammed, M. Mir
Introduction: Pulmonary toxicity can be a lethal side effect associated with many newer anti-cancer agents especially immune checkpoint inhibitors. In the times of ever-growing patient population on precision oncology therapies, timely identification of drug induced lung injury can be challenging. Here we highlight pulmonary toxicity as an adverse effect of brentuximab vedotin (BV). Case Report: A 70-year-old male, former smoker with a recent diagnosis of advanced stage classic Hodgkin's lymphoma recently started on BV, presented with two days of progressive dyspnea, fever and productive cough. He denied exposure to sick contacts and recent travel. Of note, he was hospitalized ten days earlier for suspected pneumonia and had completed a course of antibiotics. Vital signs were notable for temperature 101.7°F, heart rate 110 beats/minute, respiratory rate 30 breaths/minute and oxygen saturation of 90% on 6L of oxygen. Physical examination was noteworthy for bibasilar rhonchi. Lab workup was unremarkable and COVID-19 test was negative. Imaging studies displayed new bilateral basal infiltrates on CXR and CT scan of the chest demonstrated new alveolar opacities involving the lower lobes, and interval improvement was noted in the upper lobe opacities. He was treated for presumed pneumonia with broad spectrum antibiotics. However, his oxygen requirements continued to increase, necessitating a further infectious and rheumatologic workup which was negative. After thorough diagnostic evaluation, in the absence of other plausible etiology, the patient's symptoms were attributed to pneumonitis secondary to the chemotherapeutic agent BV. Henceforth, intravenous steroids were initiated which resulted in clinical improvement. Further treatment with BV was withheld and he was discharged on a steroid taper. One month later, a subsequent CT scan of the chest demonstrated complete resolution of bilateral alveolar opacities. Discussion: BV is a CD30 directed antibody-drug conjugate used in advanced or refractory classic Hodgkin's lymphoma. It is known to cause a higher rate of pulmonary toxicity when combined with bleomycin containing regimens with a reported incidence of 40%, hence this combination is contraindicated. However, the incidence of pneumonitis is noted to be only 5% in patients receiving BV in combination with non-bleomycin regimens, which was the case in our patient in lieu of his two back-to-back hospitalizations after receiving two cycles of BV. The exact mechanism of action is unclear but is probably due to hypersensitivity pneumonitis. Although it is a diagnosis of exclusion, a high degree of suspicion is crucial for prompt cessation of the drug in order to prevent adverse outcomes.
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Pub Date : 2021-01-01DOI: 10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2160
L.A. Vazquez Zubillaga, A. Rivera-Diaz, O. Cantres
Piperacillin-tazobactam is a Beta-lactam and beta-Lactamase combination antibiotic very commonly used to treat infections, specially in critically ill patients. The most common adverse effects related to its use are mostly gastrointestinal and allergic. Lung infiltration with pulmonary eosinophilia is a very rare event, but when occurs has significant morbidity and mortality. For this reason, physicians should be aware of this possible reaction. This is a case of a 43 year-old woman with medical history of Morbid Obesity who presented to the emergency department complaining of severe stabbing right upper quadrant pain associated with nausea and non-bloody emesis after a heavy meal. Abdominal computed tomography (CT) revealed acute cholecystitis. She was initially treated with piperacillin-tazobactam, intravenous volume expansion and pain medication. The patient underwent cholecystectomy the next day. After surgery, the patient was complained of dyspnea. Arterial blood gases revealed respiratory acidosis and significative hypoxemia. Chest CT revealed bilateral consolidation and ground glass opacities with predominance of upper lobes. Laboratory was unremarkable, without leukocytosis, or eosinophilia, normal procalcitonin, and blood cultures and COVID-19 test were negative. A bronchoscopy was performed to obtain cultures, cell count and cytology analysis. Results showed negative negative microbiology cultures. Cellular differential counts of bronchoalveolar lavage showed a predominance of eosinophils (26% of total cell count. There was no peripheral eosinophilia, and eosinophilia work up, including parasitic infection evaluation was negative. Rheumatologic serologies work-up was also negative. The patient did not received other medications during her short admission, and initial admission X ray was completely normal. Piperacillintazobactam was discontinued and the patient was started in systemic steroids with rapid resolution of hypoxemia after the first 48hrs. Those findings suggested that piperacillin-tazobactam was most likely the cause of Acute Eosinophilic Pneumonia in this patient, after she was started for the treatment for acute cholecystitis. Piperacillin-tazobactam has been rarely associated to acute eosinophilic pneumonia. It may present as an acute hypoxemic respiratory failure as seen in few case reports. Presentation can occur any time during piperacillintazobactam, therapy, usually after days or weeks of therapy. High suspicion of the diagnosis in patients with pneumonia treatment with poor response to antibiotics or multi lobar disease, during therapy with piperacillintazobactam help to identify the diagnosis. Bronchoalveolar lavage with cellular differential > 25% confirm the diagnosis in a patient with no other etiology for pulmonary eosinophilia. Discontinuation of the medication and systemic steroids is the treatment of choice, usually with favorable rapid response.
{"title":"Think It Twice Before You Give Piperacillin-Tazobactam","authors":"L.A. Vazquez Zubillaga, A. Rivera-Diaz, O. Cantres","doi":"10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2160","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a2160","url":null,"abstract":"Piperacillin-tazobactam is a Beta-lactam and beta-Lactamase combination antibiotic very commonly used to treat infections, specially in critically ill patients. The most common adverse effects related to its use are mostly gastrointestinal and allergic. Lung infiltration with pulmonary eosinophilia is a very rare event, but when occurs has significant morbidity and mortality. For this reason, physicians should be aware of this possible reaction. This is a case of a 43 year-old woman with medical history of Morbid Obesity who presented to the emergency department complaining of severe stabbing right upper quadrant pain associated with nausea and non-bloody emesis after a heavy meal. Abdominal computed tomography (CT) revealed acute cholecystitis. She was initially treated with piperacillin-tazobactam, intravenous volume expansion and pain medication. The patient underwent cholecystectomy the next day. After surgery, the patient was complained of dyspnea. Arterial blood gases revealed respiratory acidosis and significative hypoxemia. Chest CT revealed bilateral consolidation and ground glass opacities with predominance of upper lobes. Laboratory was unremarkable, without leukocytosis, or eosinophilia, normal procalcitonin, and blood cultures and COVID-19 test were negative. A bronchoscopy was performed to obtain cultures, cell count and cytology analysis. Results showed negative negative microbiology cultures. Cellular differential counts of bronchoalveolar lavage showed a predominance of eosinophils (26% of total cell count. There was no peripheral eosinophilia, and eosinophilia work up, including parasitic infection evaluation was negative. Rheumatologic serologies work-up was also negative. The patient did not received other medications during her short admission, and initial admission X ray was completely normal. Piperacillintazobactam was discontinued and the patient was started in systemic steroids with rapid resolution of hypoxemia after the first 48hrs. Those findings suggested that piperacillin-tazobactam was most likely the cause of Acute Eosinophilic Pneumonia in this patient, after she was started for the treatment for acute cholecystitis. Piperacillin-tazobactam has been rarely associated to acute eosinophilic pneumonia. It may present as an acute hypoxemic respiratory failure as seen in few case reports. Presentation can occur any time during piperacillintazobactam, therapy, usually after days or weeks of therapy. High suspicion of the diagnosis in patients with pneumonia treatment with poor response to antibiotics or multi lobar disease, during therapy with piperacillintazobactam help to identify the diagnosis. Bronchoalveolar lavage with cellular differential > 25% confirm the diagnosis in a patient with no other etiology for pulmonary eosinophilia. Discontinuation of the medication and systemic steroids is the treatment of choice, usually with favorable rapid response.","PeriodicalId":23339,"journal":{"name":"TP36. TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE","volume":"54 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74948720","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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