SESSION TITLE: Chest Infections SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: We present a case of pulmonary tuberculosis with intestinal hemorrhage initially thought to be due to tuberculous enteritis. CASE PRESENTATION: A 68 year-old man presented to the emergency department with two months of productive cough, anorexia, and weight loss. His medical history included untreated latent tuberculosis (TB) infection and nasal NK/T-cell lymphoma, which recurred after chemoradiation and required autologous hematopoietic stem cell transplantation 12 years prior to presentation. He took no medications. He was afebrile and hemodynamically stable with oxygen saturation of 97% breathing room air. He was cachectic and weighed 49 kg. Leukocyte count was 5.9 x 10ˆ9/L and hemoglobin 5.0 g/dL. Renal and liver function tests were normal. Computed tomography of the chest revealed extensive consolidations with cavitation and tree-in-bud opacities (Figure 1). Empiric treatment for TB was initiated with isoniazid, rifampin, pyrazinamide and ethambutol. Shortly after, sputum smear for acid-fast bacilli and GeneXpert were positive, and culture grew M. tuberculosis. Over the next two weeks, the patient developed hematochezia with a drop in hemoglobin to 6.1 g/dL. Computed tomography revealed a 40-cm segment of jejunum with wall thickening, mucosal enhancement, and ulceration (Figure 2). Stool cultures grew M. tuberculosis. Endoscopy revealed gastritis and a duodenal ulcer without bleeding and colonic diverticulosis. Pathology revealed acute inflammation without acid-fast bacilli or dysplasia. Several weeks later, he developed recurrent hematochezia with hemorrhagic shock. Repeat endoscopy revealed a new ulcerated mass in the stomach and several smaller ulcers in the jejunum. Pathology of the gastric lesion revealed diffuse large B-cell lymphoma (positive for CD20, BCL6, and CD10; negative for CD3, CD5, CD7, and CD56) while jejunal lesions revealed acute inflammation and large cells with inclusion bodies consistent with CMV enteritis. Smears and cultures for TB were negative. With chemotherapy and valgancyclovir treatment the patient improved, with weight gain and cessation of bleeding. DISCUSSION: Intestinal TB is difficult to diagnose because of non-specific signs and symptoms. In a patient with pulmonary TB, the presence of TB in the stool is not diagnostic because this may occur as a result of swallowed infected sputum. In this case, intestinal inflammation on imaging with pulmonary TB supported a diagnosis of TB enteritis. However, gastrointestinal hemorrhage necessitating transfusion is unusual in intestinal TB and its persistence for several weeks despite treatment suggested an alternative diagnosis. Eventually, two alternative diagnoses were found: CMV enteritis and lymphoma involving the gastrointestinal tract. CONCLUSIONS: This case underlines the importance of considering a broad differential for gastrointestinal signs and symptoms, even in the presence of pulmonary TB. Reference #1: Debi U, et al. Abdominal tuberculosis of the gastrointestinal tract: revisited. World J Gastroenterol. 2014;20(40):14831-40. Reference #2: Rahman SMM, et al. Evaluation of Xpert MTB/RIF assay for detection of Mycobacterium tuberculosis in stool samples of adults with pulmonary tuberculosis. PLoS One. 2018;13(9):e0203063. DISCLOSURES: Consultant relationship with Cohero Health Please note: $1-$1000 Added 03/14/2019 by Caralee Caplan-Shaw, source=Web Response, value=stock My spouse/partner as a Speaker/Speaker's Bureau relationship with Cook Incorporated Please note: $1001 - $5000 Added 08/05/2019 by Caralee Caplan-Shaw, source=Web Response, value=Consulting fee No relevant relationships by Andrew DeMaio, source=Web Response No relevant relationships by Imran Sulaiman, source=Web Response

SESSION TITLE: TB or Not TB: That Is the Question: Better Ways to Diagnose Tuberculosis SESSION TYPE: Original Investigations PRESENTED ON: 10/22/2019 10:45 AM - 11:45 AM PURPOSE: Inpatient evaluation for pulmonary tuberculosis (TB) is expensive and can result in prolonged airborne infection isolation (AII) for patients without active disease. At Bellevue Hospital, a large public hospital in New York City, the protocol for TB evaluation historically included three daily sputum inductions for analysis by microscopy and culture. The Xpert MTB/RIF nucleic acid amplification test (NAAT) was added automatically to smear-positive samples, but run on smear-negative samples only per physician request. Current evidence-based guidelines recommend collection of three sputum samples at eight-hour intervals with NAAT performed on the first two samples. Use of standardized protocols may reduce cost and time in AII. METHODS: As part of a quality improvement initiative called “Think TB,” launched at Bellevue Hospital in November 2018, we updated the inpatient TB evaluation protocol to reflect current guidelines and conducted a hospital-wide educational outreach campaign. As a preliminary assessment of this initiative, we reviewed all completed TB evaluations performed between July and December 2018. Time to completed evaluation was defined as number of hours from first to third sputum collection. RESULTS: During this period, 95 patients completed evaluation for pulmonary TB: nine had a microbiologic diagnosis of TB (seven diagnosed via smear and NAAT, two via NAAT alone), twelve were initiated on empiric treatment, and 74 were deemed sufficiently low-risk for discharge. Average time to completed evaluation was 54 hours pre- (n=47) and 26 hours post-protocol implementation (p < 0.0001). Among low risk patients with negative smears, NAAT, and culture, average length of stay in AII was reduced by 35.3 hours (p < 0.001, 95% CI [14.9, 55.7]). CONCLUSIONS: A preliminary assessment of this evidence-based protocol suggests that it has improved inpatient TB evaluation efficiency and has reduced length of stay in AII among low-risk, culture negative patients. As data collection continues, we will assess the impact of the new protocol on cost and airborne isolation errors. CLINICAL IMPLICATIONS: A standardized protocol for inpatient evaluation for pulmonary TB can expedite costly and time-consuming evaluations for low risk patients. DISCLOSURES: no disclosure on file for Maria Aguero-Rosenfeld; No relevant relationships by Shari Brosnahan, source=Web Response Consultant relationship with Cohero Health Please note: $1-$1000 Added 03/14/2019 by Caralee Caplan-Shaw, source=Web Response, value=stock My spouse/partner as a Speaker/Speaker's Bureau relationship with Cook Incorporated Please note: $1001 - $5000 Added 08/05/2019 by Caralee Caplan-Shaw, source=Web Response, value=Consulting fee No relevant relationships by BASIL HAMILTON, source=Web Response No relevant relationships by Sarah Hochman, source=Web Response No relevant relationships by Lauren McVoy, source=Web Response No relevant relationships by Oscar Mitchell, source=Web Response No relevant relationships by Nathaniel Nelson, source=Web Response No relevant relationships by Scott Statman, source=Web Response

SESSION TITLE: Chest Infections 1 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 03:30 PM - 04:30 PM INTRODUCTION: We present two cases of psoas abscesses diagnosed after initiation of TB and antiretroviral (ARV) treatment. CASE PRESENTATION: Case 1: A 33-year-old man presented with 3 months of abdominal pain, fevers, sweats, weight loss, and cervical adenopathy. HIV test and Quantiferon-Gold were positive. CD4 count was 127. Chest radiograph was normal. Cervical lymph node needle aspiration was smear and culture negative for acid-fast bacilli (AFB). ARVs and empiric isoniazid, rifampin, pyrazinamide, and ethambutol were started. He presented with sweats and painful hip flexion 6 months later. Abdominopelvic computed tomography (CT) demonstrated a small left psoas abscess unamenable to drainage. Worsening left flank pain 6 months later prompted magnetic resonance imaging (MRI) which revealed 2 paravertebral abscesses and osteomyelitis at L4. Abscess drainage was performed; fluid was smear and culture negative for AFB, and GeneXpert positive (rpoB gene mutation negative). The pain recurred 2 months later; repeat MRI demonstrated improved prior abscesses with multiple new psoas microabscesses. TB treatment continued for 12 months total with symptom resolution. Case 2: A 40-year-old man with HIV (CD4 274) on ARVs and prior disseminated pansensitive TB presented 2 years after completing TB treatment with 4 weeks of fever and 1 year of left hip pain treated with non-steroidal anti-inflammatory drugs. Abdominopelvic CT demonstrated osseous destruction at L4 and a large left iliopsoas abscess extending into the thigh. Abscess drainage was performed; fluid was culture positive for Acinetobacter baumannii, smear negative and culture positive for AFB, and GeneXpert positive (rpoB gene mutation positive). Therapy for A. Baumannii and multi-drug resistant TB was initiated, with subsequent narrowing of therapy for rifampin-monoresistant TB. Recurrent pain at the site prompted repeat drainage 4 months later; cultures were negative for AFB. TB treatment continued for total of 12 months and repeat CT scan demonstrated abscess resolution. DISCUSSION: In immunosuppressed patients with disseminated TB, psoas abscesses usually extend from a focus of vertebral infection and may present insidiously, leading to delays in diagnosis. Abscess size may increase on TB treatment after initiation of concurrent antiretroviral therapy as result of immune reconstitution inflammatory syndrome (IRIS). Drainage and microbiologic identification is essential to differentiate between active TB infection with a pansensitive organism, recurrence with acquired resistance, bacterial infection, or a sterile fluid collection in a treated patient. CONCLUSIONS: Diagnosis of TB psoas abscesses requires a high index of suspicion. In the immunosuppressed, worsening abscesses despite appropriate antimicrobial treatment may be due to bacterial infection, delayed treatment response, treatment failure due to acquired resistance, or a manifestation of IRIS. Reference #1: Bottieau, E., Noe, A., Florence, E., Ostyn, B., Colebunders, R. Development of Multiple Abscesses In An HIV/TB Co-Infected Patient After Initiation of Antituberculous and Highly Active Antiretroviral Therapy. Acta Clinica Belgica, 2002; 57-4. Reference #2: Narita, M., Ashkin, D., Hollender, E.S., Pitchenik, A.E. Paradoxical Worsening of Tuberculosis Following Antiretroviral Therapy in Patients with AIDS. Am J Respir Crit Care Med 1998;158:157-161. Reference #3: Lopez, V.N., Ramos, J.M., Mesegeur, V., Arellano, J.L.P., Serrano, R., Ordonez, M.A.G., Peralta, G., Boix, V., Pardo, J., Conde, A., Salgado, F., Gutierrez, F. Microbiology and Outcome of Iliopsoas Abscess in 124 Patients. Medicine 2009;88: 120-130. DISCLOSURES: Scientific Medical Advisor relationship with Cohero Health Please note: $1-$1000 Added 03/05/2018 by Caralee Caplan-Shaw, source=Web Response, value=Ownership interestRemoved 03/05/2018 by Caralee Caplan-Shaw, source=Web Response Scientific Medical Advisor relationship with Cohero Health Please note: $1-$1000 Added 03/05/2018 by Caralee Caplan-Shaw, source=Web Response, value=shares No relevant relationships by Gabriela Magda, source=Web Response

SESSION TITLE: Chest Infections 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTON: The incidence of Mycobacterium Tuberculosis (TB) is significantly higher among solid organ transplant recipients. Diagnosis requires a high level of suspicion, as transplant patients may present atypically or with extrapulmonary disease. Management can be difficult due to interactions between TB medications and immunosuppressive drugs. CASE PRESENTATION: A 66-year old Chinese man with a history of treated latent TB and cadaveric kidney transplant was admitted to the hospital with weakness, fever, blurred vision, and worsening left knee pain and swelling. Over the prior two months, he had presented to multiple urgent care centers with the same joint symptoms, for which he was treated with non-steroidal anti-inflammatory drugs. Knee X-ray had shown mild swelling. Patient’s immunosuppressive regimen included prednisone, mycophenylate mofetil, and tacrolimus. On admission, there was a mild leukocytosis, mildly elevated alkaline phosphatase level, and hypercalcemia. Computerized tomography of the chest (figure 1), abdomen and pelvis revealed diffuse pulmonary micro-nodules, gastric thickening, and a left knee effusion with possible osteomyelitis (figure 2). Magnetic resolution imaging of the brain showed evidence of optic neuritis (figure 3). Synovial fluid contained 12,300 white blood cells, with 87% neutrophils. Cerebrospinal fluid analysis was unremarkable. Smears and cultures for acid fast bacilli (AFB) were positive in samples from synovial fluid, sputum, stool, urine and blood. Treatment with rifabutin, isoniazid, ethambutol, pyrazinamide, and levofloxacin was initiated. Mycophenylate mofetil was discontinued, and treatment with tacrolimus was continued with close monitoring of drug levels. Drug levels for isoniazid and rifabutin were sub-therapeutic, and rifabutin and levofloxacin were then administered intravenously and amikacin added. Fevers resolved, visual acuity returned to normal, knee swelling improved, and tacrolimus levels remained in the therapeutic range. DISCUSSION: TB may present as monoarticular swelling of insidious onset, resulting in prolonged treatment delays. Solid organ transplant recipients with a history of latent TB infection or immigration from TB endemic areas are at increased risk, especially in the first year after transplant. Diagnosis requires prompt arthocentesis, which reveals a neutrophil-predominant effusion and AFB. Monitoring and adjustment of TB and immunosuppressive drug levels are critical. CONCLUSIONS: We present a case of disseminated tuberculosis presenting as monoarticular arthritis in a solid organ transplant patient. A high index of suspicion is essential to avoid treatment delays. Reference #1: Aguado JM, Torre-Cisneros J, Fortun J, Benito N, Meije Y, Doblas A, and Munoz P. Tuberculosis in solid-organ transplant recipients: consensus statement of the group for the study of infection in transplant recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology. Clin Infect Dis. 2009;48(9):1276-84. Reference #2: Sundaram M, Adhikary SD, John GT, Kekre NS. Tuberculosis in renal transplant recipients. Indian J Urol. 2008;24(3):396-400. DISCLOSURES: Scientific Medical Advisor relationship with Cohero Health Please note: $1-$1000 Added 03/05/2018 by Caralee Caplan-Shaw, source=Web Response, value=Ownership interestRemoved 03/05/2018 by Caralee Caplan-Shaw, source=Web Response Scientific Medical Advisor relationship with Cohero Health Please note: $1-$1000 Added 03/05/2018 by Caralee Caplan-Shaw, source=Web Response, value=shares No relevant relationships by Assad Oskuei, source=Web Response

SESSION TITLE: Interstitial Lung Disease Cases II