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• W4387253449 abstract "SESSION TITLE: Chest Infections in Immunocompromised Individuals SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: A pulmonary nodule is a focal rounded or irregular opacity measuring less than 30 mm surrounded by lung parenchyma. It can be benign (including infections, granuloma etc.) or malignant (primary or metastatic). To establish etiology for multiple pulmonary nodules, tissue diagnosis is mostly required. This can be challenging in patients with aplastic anemia with low platelet counts making invasive interventions high risk procedures. We present a challenging case of an immunosuppressed patient with aplastic anemia with low platelet count found to have pulmonary nodules. CASE PRESENTATION: Our patient is a 42-year-old female with history of aplastic anemia on cyclosporine, eltrombopag and horse anti-thymocyte globulin and morbid obesity. She presented with severe fatigue and bleeding from vagina. She was hemodynamically unstable with blood pressure 76/44 mmHg, temperature 101.6 F and heart rate 131. She had hemoglobin of 5.1 g/dl, platelet count of 2000/ul and white cell count of 430/uL. She was treated for septic and hemorrhagic shock with vasopressors, blood products and broad-spectrum antibiotics. Her blood cultures were found to be positive for gram negative rods and she started gradually recovering with treatment. She was also found to have elevated total bilirubin of 4 mg/dl most likely due to cyclosporine. Magnetic resonance cholangiopancreatography (MRCP) was done for hyperbilirubinemia which showed hepatic hemosiderosis and left sided pleural effusion concerning for empyema. Pleural effusion was drained and was found to be spontaneous hemothorax in setting of low platelet count. Patient was requiring almost daily platelets and PRBC transfusions. CT chest was done which was suggestive of 4 nodular opacities in right upper and lower lobes. Transthoracic echo (TTE) was done which was not suggestive of infective endocarditis. Repeat blood cultures were negative however beta glucan was elevated to 280 pg/ml (n<80pg/ml). Confirmatory tissue diagnosis was required to differentiate between fungal or malignant cause of pulmonary nodules which was very challenging due to persistently low platelet count around 10,000/ul and patient requiring transfusions daily. Patient was given multiple transfusions to increase platelet count to 50,000/ul and interventional radiology was able to perform CT guided core biopsies of pulmonary nodules. This established tissue diagnosis of aspergillosis and patient was initially treated with voriconazole which was switched to isavuconazole. Patient still requires three times weekly transfusions and is awaiting bone marrow transplant. DISCUSSION: This case highlights challenging diagnosis of multiple pulmonary nodules in immunosuppressed patients with aplastic anemia with profound cytopenia. Confirmatory tissue diagnosis is very difficult to obtain in these patients due to low platelet count and high risk associated with procedures. Sputum cultures and serum-based biomarkers have limitations to diagnose fungal infections. These sampling techniques have long wait time and are more prone to give inconclusive results. As a result, invasive confirmatory tissue sampling is required to establish diagnosis. Serum-based metagenomic next generation sequencing techniques can overcome these barriers as they have rapid turn over and donot require invasive procedures. CONCLUSIONS: The need of hour is to develop more efficient sampling techniques which are faster, more reliable and avoid invasive interventions especially for patients with aplastic anemia. REFERENCE #1: Gu W, Miller S, Chiu CY. Clinical Metagenomic Next-Generation Sequencing for Pathogen Detection. Annu Rev Pathol. 2019;14:319. doi:10.1146/ANNUREV-PATHMECHDIS-012418-012751 DISCLOSURES: No relevant relationships by Hafsa Yasin Rana No relevant relationships by Jamie Sturgill No relevant relationships by Usama Talib No relevant relationships by Haris Zia" @default.
• W4387253449 created "2023-10-03" @default.
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• W4387253449 date "2023-10-01" @default.
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• W4387253449 title "A CHALLENGING DIAGNOSIS OF MULTIPLE PULMONARY NODULES IN AN IMMUNOSUPPRESSED PATIENT WITH APLASTIC ANEMIA WITH CYTOPENIAS: A CASE REPORT" @default.
• W4387253449 doi "https://doi.org/10.1016/j.chest.2023.07.751" @default.
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