BACKGROUND:The use of preoperative magnetic resonance imaging (MRI) for early-stage breast cancer (ESBC) is increasing, but its utility in detecting additional malignancy is unclear and delays surgical management (Jatoi and Benson in Future Oncol 9:347-353, 2013. https://doi.org/10.2217/fon.12.186 , Bleicher et al. J Am Coll Surg 209:180-187, 2009. https://doi.org/10.1016/j.jamcollsurg.2009.04.010 , Borowsky et al. J Surg Res 280:114-122, 2022. https://doi.org/10.1016/j.jss.2022.06.066 ). The present study sought to identify ESBC patients most likely to benefit from preoperative MRI by assessing the positive predictive values (PPVs) of ipsilateral and contralateral biopsies.METHODS:A retrospective cohort study included patients with cTis-T2N0-N1 breast cancer from two institutions during 2016-2021. A "positive" biopsy result was defined as additional cancer (PositiveCancer) or cancer with histology often excised (PositiveSurg). The PPV of MRI biopsies was calculated with respect to age, family history, breast density, and histology. Uni- and multivariate logistic regression determined whether combinations of age younger than 50 years, dense breasts, family history, and pure ductal carcinoma in situ (DCIS) histology led to higher biopsy yield.RESULTS:Of the included patients, 447 received preoperative MRI and 131 underwent 149 MRI-guided biopsies (96 ipsilateral, 53 contralateral [18 bilateral]). PositiveCancer for ipsilateral biopsy was 54.2%, and PositiveCancer for contralateral biopsy was 17.0%. PositiveSurg for ipsilateral biopsy was 62.5%, and PositiveSurg for contralateral biopsy was 24.5%. Among the contralateral MRI biopsies, patients younger than 50 years were less likely to have PositiveSurg (odds ratio, 0.02; 95% confidence interval, 0.00-0.84; p = 0.041). The combinations of age, density, family history, and histology did not lead to a higher biopsy yield.CONCLUSION:Historically accepted factors for recommending preoperative MRI did not appear to confer a higher MRI biopsy yield. To prevent delays to surgical management, MRI should be carefully selected for individual patients most likely to benefit from additional imaging.

INTRODUCTION: Acute pulmonary hypertension caused by pulmonary tumor thrombotic microangiopathy (PTTM) as a result of an underlying cancer is a rare but serious complication that is linked to a high crude mortality rate.Early diagnosis requires clinical acuity and a high index of suspicion, so here we present such a case. CASE PRESENTATION:A 46-year-old Nepalese woman with no medical history presented with exertional shortness of breath and right lower quadrant (RLQ) abdominal pain for two weeks, accompanied by a decrease in appetite and unintentional weight loss.On presentation, he had a temperature of 100.2 degrees F, a heart rate of 110 beats per minute, a respiratory rate of 26 breaths per minute, blood pressure of 150/90 mmHg, and an oxygen saturation of 94% on room air.Physical examination revealed RLQ tenderness.Laboratory tests significant for acute kidney injury and elevated liver enzymes; however, all other results, including the respiratory panel, blood cultures, acute hepatitis panel and immunology, were unremarkable (ANA, ANCA, HIV).Pan-computed tomography showed pulmonary artery dilatation and bilateral ovarian cystic mass with lymphadenopathy.Cardiac catheterization revealed significant severe pulmonary hypertension with normal wedge pressure.In the next few hours, significant pulmonary hypertension caused acute hypoxic respiratory failure, aggravating her right heart failure, congestive hepatopathy, and acute renal failure.She was administered intravenous hydration, dobutamine infusion for her hemodynamic instability, and heparin infusion.For a high level of care she was transferred to a tertiary care center.Unfortunately, she died within the next two days.DISCUSSION: Owing to its rapid course and clinical history, acute pulmonary hypertension (PH) is a life-threatening condition that presents a diagnostic challenge.Pulmonary tumor thrombotic microangiopathy (PTTM) is an uncommon but increasingly recognized consequence of advanced malignancy that frequently manifests as quickly progressing PH or sudden hypoxic respiratory failure.PTTM has an aggressive course, a challenging diagnostic challenge, and few therapeutic options [1].The proposed mechanism is tumor cell adhesion to the vascular endothelium, which produces subintimal proliferation and platelet and fibrin microthrombi deposition, resulting in increased pulmonary vascular resistance and progressive PH [2].Pulmonary angiography can only rule out acute or chronic thromboembolic pulmonary embolism.PTTM caused by an underlying cancer is considerably more difficult to investigate, especially in previously undiagnosed cases like ours.It is usually diagnosed post-mortem based on autopsy, but the patient's family declined.Additionally, therapeutic choices are restricted, but may include pulmonary vasodilators, systemic chemotherapy and tyrosine-kinase inhibitors [3].CONCLUSIONS: PTTM is an uncommon but increasingly recognized consequence of advanced cancer that shows clinically as rapidly worsening pulmonary hypertension or sudden hypoxic respiratory collapse.Its aggressive course, diagnostic difficulties, and limited therapy options necessitate additional research into this area.

Introduction: Myocarditis caused by Ehrlichiosis is a rare manifestation. The following case emphasizes the significance of early detection and its treatment. Description: A previously healthy 77-year-old female presented with a two-day history of generalized weakness and altered mental status. On arrival, she had a fever of 101.5°F, a heart rate of 110 beats per minute, a respiratory rate of 26 breaths per minute, a blood pressure of 80/70 mmHg, and an oxygen saturation of 92% on low-flow nasal cannula oxygen therapy. She was disoriented without a focal neurologic deficit, and the remainder of the examination was unremarkable. Laboratory evaluation revealed leukocytosis at 22000 /mm3, thrombocytopenia at 34000 /mm3, troponins at 6300 ng/mL, creatinine of 3.0 mg/dL, and mild transaminitis. Her hepatitis panel, toxicology screen, urine, and blood cultures were negative. A lumbar puncture was not performed because of thrombocytopenia. Her pan-computed tomography (CT) scans were also unremarkable. Echocardiography revealed severe diffuse hypokinesia with a left ventricle ejection fraction of 20%. Cardiac catheterization was deferred due to renal dysfunction. Her empiric antibiotics regimen was de-escalated to doxycycline after peripheral smear, and a PCR test confirmed Ehrlichiosis. Her symptoms improved, and she was discharged to inpatient rehabilitation. An echocardiogram in 6 months showed an improved ejection fraction of 45%. Discussion: Ehrlichiosis usually manifests with symptoms of fever, myalgias, and malaise mimicking influenza-like illness. However, severe sequelae are more traditionally encountered at extreme ages. Myocarditis is a rare and fatal occurrence. The pathogenic mechanism driving cardiac involvement is still partially understood. It may cause cardiac damage or produce immunosuppression and inflammatory cell dysfunction, leading to nonspecific myocyte damage. We believe our patient had ehrlichiosis-related myocarditis, as evidenced by peripheral smear testing, profoundly raised cardiac enzymes, new-onset congestive heart failure, and recovery of cardiac function after treatment. In endemic locations, especially during the summer, it is prudent to keep suspicion of ehrlichiosis-associated myocarditis.

INTRODUCTION: Persistent COVID-19 RT-PCR positivity is reported in patients with hematological malignancies and immunosuppression up to 70 days after infection.We explore the implications of the test through the case of an elderly male with diffuse large B-cell lymphoma (DLBCL) with a positive test 90 days after infection. CASE PRESENTATION:A 72-year-old male with a past medical history of diabetes, chronic kidney disease (stage 3b), Stage 3 DLBCL (diagnosed 5 months prior) presented with generalized weakness and diarrhea.He had received his fifth cycle of R-CHOP and G-CSF 9 days prior.History was notable for COVID-19 antigen positivity 90 days prior that manifested as sinusitis and was managed conservatively.He had received 2 doses of COVID-19 mRNA vaccine.Physical examination showed tachycardia 110 bpm, tachypnea 20 breaths/min, blood pressure 104/68, hypothermia and cachexia.Laboratory tests revealed WBC 0.50/microL, neutrophils 24%, Hb 8.5 gm/dL, platelets 55k/microL, lactate 4 mmol/L, glucose 72 mg/dL, sodium 127 mmol/L and acute on chronic kidney injury.He tested positive for COVID-19 by PCR with negative antigen testing.He was treated for gram negative bacteremia secondary to proctitis and rectal perforation despite which his condition deteriorated.He was transitioned to comfort care per family wishes. DISCUSSION:The SARS-COV2 RT-PCR test usually returns negative 28 days after infection.Persistent test positivity upto 74 days after the original infection has been seen in patients with hematological malignancies (1).This phenomenon has been associated with increased mortality (2).CDC recommends positive tests after 90 days to be treated as reinfection.It is however unlikely that our patient had a reinfection given the absence of typical symptoms because of which he was not treated for active COVID infection.While asymptomatic reinfection with COVID is a possibility, the patient was notably non-infectious despite being in close contact with family.It is therefore more likely that his active lymphoma and chemotherapy crippled his ability to produce antibodies to surmount his original infection resulting in prolonged viral shedding (3).The use of CD20 inhibitors in Bcell lymphoma has also been associated with lower rates of seroconversion following vaccination with the mRNA vaccines.Despite the viral shedding it is also questionable as to whether these patients are actively transmitting the infection in view of which the need for isolation precautions remains debatable. CONCLUSIONS:A persistent COVID positive test in lymphoma patients must be analyzed carefully while determining treatment and isolation needs.It is especially important to make these distinctions since active COVID infection in lymphoma can have mortality rates as high as 40%.

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Report Posters 10 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: The differential diagnosis of multiple lung nodules larger than 1 cm is broad with over 95% related to infection or metastases. Inflammatory diseases such as granulomatosis with polyangiitis (GPA) are less common causes. We describe a patient with intractable cough and abnormal lung imaging in whom the diagnosis of GPA required a high degree of clinical suspicion. CASE PRESENTATION: A 52-year-old female nonsmoker with presumed cough variant asthma presented with intractable, dry cough for one month. Symptoms had not improved with short-course steroids, step-up in bronchodilator therapy and antibiotics. On presentation, heart rate was 109 bpm, temperature 100.3°F, respiratory rate 13/minute with normal oxygen saturation. She had normal respiratory effort despite a protracted cough with clear lungs. Complete blood count, renal function and viral respiratory panel were normal. Aspergillus antigen was negative. Chest X-Ray suggested right basilar infiltrates and perihilar nodular densities. Chest computed tomography (CT) ruled out pulmonary embolism but revealed multiple, bilateral, pan-lobar nodular densities upto 15 mm in diameter, some airway centric and others peripheral with adjacent ground-glass density and no adenopathy. Echocardiography did not reveal valvular vegetations. Bronchoscopy revealed normal airways with negative bronchoalveolar lavage cultures. Autoimmune antibody (Ab) panel returned positive for c-ANCA and anti-proteinase 3 clinching the diagnosis of GPA. The patient was treated with pulse dose steroids and initiation of cyclophosphamide leading to cough resolution. Repeat chest CT 5 months later revealed near-complete resolution of the nodules. DISCUSSION: The classic triad of upper respiratory, lung and renal involvement is seen in only 13% of the cases of GPA. Upper respiratory involvement occurs in 85-100% of cases and lower respiratory manifestations in 90%. 15-23% may not have renal involvement in the first 2 years of disease onset (1). Lower respiratory tract manifestations commonly include nodular disease (majority peribronchial), bronchiectasis, pleural effusion, pulmonary hemorrhage and lymph node involvement. Lung nodules are typically multiple, bilateral and sized 2-4 cm. Larger nodules may develop a cavitary appearance mimicking abscesses and malignancy. Hemorrhage around the nodules secondary to vasculitis may lead to ground glass opacities resembling aspergillosis and malignancy (2). Analysis reveals that nearly 35% of GPA were misdiagnosed with infections and malignancy (3). The majority of GPA patients have positive Ab to PR3/ c-ANCA which is associated with nodular and central airway disease. 20% have alternative ANCA Ab and 10% are ANCA negative. Combination induction therapy with glucocorticoids and cyclophosphamide or rituximab achieves remission rates upto 88%. CONCLUSIONS: Although relatively rare, vasculitis is an important differential underlying lung nodules. REFERENCE #1: Garlapati P, Qurie A. Granulomatosis with Polyangiitis. StatPearls Publishing; 2022. Accessed March 28, 2023. https://www.ncbi.nlm.nih.gov/books/NBK557827/ REFERENCE #2: Arunsurat I, Reechaipichitkul W, So-Ngern A, et al. Multiple pulmonary nodules in granulomatous polyangiitis: A case series. Respir Med Case Rep. 2020;30:101043. doi:10.1016/j.rmcr.2020.101043 REFERENCE #3: Li J, Li C, Li J. Thoracic manifestation of Wegener's granulomatosis: Computed tomography findings and analysis of misdiagnosis. Exp Ther Med. 2018;16(1):413-419. doi:10.3892/etm.2018.6154 DISCLOSURES: No relevant relationships by Lavleen Kaur No relevant relationships by Sarasija Natarajan No relevant relationships by Pius Ochieng No relevant relationships by Lakshmi Priyanka Pappoppula No relevant relationships by Yamini Patel No relevant relationships by Lekha Yadukumar

INTRODUCTION:The human metapneumovirus (hMPV) is an emerging respiratory pathogen infecting approximately 5-9% of hematopoietic stem cell transplant (HSCT) recipients with potential lethal manifestations.We describe a case of severe respiratory failure secondary to hMPV and diffuse alveolar hemorrhage (DAH) in a HSCT recipient. CASE PRESENTATION:A 72-year-old female with past medical history of rheumatoid arthritis, stage III Hodgkin lymphoma, stage I marginal zone B cell lymphoma, stage IV angioimmunoblastic T cell lymphoma treated with chemoradiation and allogeneic sibling HSCT 3 years prior, complicated by chronic graft versus host disease (GVHD) with bronchiolitis obliterans on chronic immunosuppression with ruxolitinib and belmosudil was admitted after being found unresponsive with agonal breathing.Following emergent intubation, physical examination was significant for bilateral rhonchi.Laboratory testing revealed lactate 3.7 mmol/L, WBC 15k/microL, Hb 11 gm/dL, platelets 135k/microL.Autoimmune panel for lupus and vasculitis was negative.Computed tomography of the chest revealed bilateral, patchy, ground glass opacities.Bronchoscopy was concerning for DAH.Bronchoalveolar lavage (BAL) was positive for hMPV.She was started on broad spectrum antibiotics, solumedrol 1 gm/day for 5 days and IV immunoglobulin therapy despite which oxygen requirements remained persistently high.Her prolonged hospital course was complicated by hemodynamic instability, C.difficile colitis and multiple futile attempts to liberate from the ventilator.She was eventually transitioned to compassionate care.DISCUSSION: Our patient was diagnosed with DAH through bronchoscopy.Underlying differentials for DAH included lupus, vasculitis, malignancy, resistant GVHD, infections and RA.Since her RA was well controlled and the remainder of the workup negative, hMPV infection was deemed to be the precipitator of DAH.hMPV lower respiratory infection is associated with a mortality of 33% and fatality rates as high as 80% in HSCT recipients with BAL positive for hMPV.The virus is a rare yet recognised precipitator of DAH (1).Specific risk factors for infection are yet to be clearly outlined.Symptoms and radiological findings are indistinguishable from that of other respiratory viruses with PCR as the main diagnostic modality (2).Management is primarily supportive care with some literature suggestive of IV immunoglobulin and ribavirin demonstrating prophylactic and therapeutic efficacy in animal models and case series (3).The occurrence of subclinical infections with prolonged viral shedding in immunocompromised patients makes it hard to prevent virus transmission despite appropriate isolation.CONCLUSIONS: Lower respiratory tract infection secondary to hMPV in HSCT recipients is associated with high mortality.

Daptomycin is a bactericidal antibiotic used to treat methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). Eosinophilic pneumonia is an uncommon but significant adverse effect of daptomycin. We present two patients treated with daptomycin who subsequently developed eosinophilic pneumonia (EP).

SESSION TITLE: Emergency Endocrine DisordersSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 10:15 am - 11:10 amINTRODUCTION: Ketoacidosis precipitated by starvation is usually associated with an extremely minimal drop in anion gap and pH. We discuss a case of high anion gap, euglycemic ketoacidosis, and hyperammonemia with starvation for one week.CASE PRESENTATION: A 35-year-old non-diabetic female with a history of cholecystectomy 1 week ago presented with increasing nausea, vomiting, and lethargy since the surgery. She had dry oral mucosa and did not follow commands. BMI 26.2 and HbA1c 5.2. Blood gas analysis with a pH of 7.094. Labs showed bicarbonate 8 mmol/L, anion gap 26 mmol/L, serum osmolality 317 mOsm/kg, urine osmolality 719 mOsm/kg, beta-hydroxybutyrate 10.48 mmol/L, acetone 98 mg/dL, ammonia 265 umol/L, CK 355 U/L, AST 39 U/L, ALT 29 U/L, Lipase 78 U/L. Blood glucose, lactate, D-lactate, BUN, creatinine, ethanol level, acetaminophen level, salicylates level, volatile alcohols, LH, FSH, TSH, B12, and B1 were all within normal limits. Extensive toxicology and infectious workup was negative. Urine showed ketonuria. Testing for amino acid metabolism disorders was negative. CT head, abdomen, and pelvis showed no acute pathology. Treatment included intubation, insulin drip, 5% dextrose-half-normal saline with sodium bicarbonate and lactulose. The patient and family denied drug use and medications elevating ammonia.DISCUSSION: The patient was treated for acute metabolic encephalopathy secondary to high anion gap euglycemic ketoacidosis compounded by hyperammonemia. Euglycemic ketoacidosis is frequently reported in the diabetic population, particularly associated with SGLT2 inhibitors. The most common causes of non-diabetic ketoacidosis are starvation, alcoholism, and pregnancy. High anion gap and euglycemic ketoacidosis in non-diabetics precipitated by short-term fasting are extremely rare with the first case reported with the millennial trend of fasting and low carbohydrate diets for weight loss (1,2). Few cases are associated with acute pancreatic insufficiency and reduced insulin secretion (3,4). Our patient reported a week-long history of vomiting and reduced oral intake which likely led to accelerated hepatic ketone production following the depletion of hepatic glycogen stores. Starvation ketosis responds to the administration of insulin similarly to diabetic ketoacidosis. The interesting finding of hyperammonemia with a normal liver function and absence of cirrhosis. Extremely rare cases of hyperammonemia have been reported in diabetic ketoacidosis and attributed to impaired insulin production/sensitivity leading to increased protein catabolism (5,6). We postulate that impairment in insulin sensitivity can occur with short-term fasting leading to euglycemic nondiabetic ketoacidosis and hyperammonemia.CONCLUSIONS: Short-term fasting can precipitate euglycemic high anion gap ketoacidosis and hyperammonemia in the non-diabetic, non-cirrhotic population possibly stemming from altered insulin homeostasis.Reference #1: Larroumet A, Camoin M, Foussard N, Alexandre L, Mesli S, Redonnet I, et al. Euglycemic ketoacidosis induced by therapeutic fasting in a non-diabetic patient. Nutrition. 2020 Apr 1;72:110668.Reference #2: Chang L-Y, Lim L-M, Chiu Y-W. Euglycemic Ketoacidosis Induced by Low Carbohydrate Diet in a Non-diabetic Patient: A Case Report. Arch Clin Med Case Rep. 2020 Nov 12;4(6):1078–83.Reference #3: Burge MR, Hardy KJ, Schade DS. Short-term fasting is a mechanism for the development of euglycemic ketoacidosis during periods of insulin deficiency. J Clin Endocrinol Metab. 1993 May 1;76(5):1192–8.DISCLOSURES: No relevant relationships by Asim AmjadNo relevant relationships by Abhaya KhatiwadaNo relevant relationships by Sarasija NatarajanNo relevant relationships by Yamini PatelNo relevant relationships by Kristina Tanovic SESSION TITLE: Emergency Endocrine Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Ketoacidosis precipitated by starvation is usually associated with an extremely minimal drop in anion gap and pH. We discuss a case of high anion gap, euglycemic ketoacidosis, and hyperammonemia with starvation for one week. CASE PRESENTATION: A 35-year-old non-diabetic female with a history of cholecystectomy 1 week ago presented with increasing nausea, vomiting, and lethargy since the surgery. She had dry oral mucosa and did not follow commands. BMI 26.2 and HbA1c 5.2. Blood gas analysis with a pH of 7.094. Labs showed bicarbonate 8 mmol/L, anion gap 26 mmol/L, serum osmolality 317 mOsm/kg, urine osmolality 719 mOsm/kg, beta-hydroxybutyrate 10.48 mmol/L, acetone 98 mg/dL, ammonia 265 umol/L, CK 355 U/L, AST 39 U/L, ALT 29 U/L, Lipase 78 U/L. Blood glucose, lactate, D-lactate, BUN, creatinine, ethanol level, acetaminophen level, salicylates level, volatile alcohols, LH, FSH, TSH, B12, and B1 were all within normal limits. Extensive toxicology and infectious workup was negative. Urine showed ketonuria. Testing for amino acid metabolism disorders was negative. CT head, abdomen, and pelvis showed no acute pathology. Treatment included intubation, insulin drip, 5% dextrose-half-normal saline with sodium bicarbonate and lactulose. The patient and family denied drug use and medications elevating ammonia. DISCUSSION: The patient was treated for acute metabolic encephalopathy secondary to high anion gap euglycemic ketoacidosis compounded by hyperammonemia. Euglycemic ketoacidosis is frequently reported in the diabetic population, particularly associated with SGLT2 inhibitors. The most common causes of non-diabetic ketoacidosis are starvation, alcoholism, and pregnancy. High anion gap and euglycemic ketoacidosis in non-diabetics precipitated by short-term fasting are extremely rare with the first case reported with the millennial trend of fasting and low carbohydrate diets for weight loss (1,2). Few cases are associated with acute pancreatic insufficiency and reduced insulin secretion (3,4). Our patient reported a week-long history of vomiting and reduced oral intake which likely led to accelerated hepatic ketone production following the depletion of hepatic glycogen stores. Starvation ketosis responds to the administration of insulin similarly to diabetic ketoacidosis. The interesting finding of hyperammonemia with a normal liver function and absence of cirrhosis. Extremely rare cases of hyperammonemia have been reported in diabetic ketoacidosis and attributed to impaired insulin production/sensitivity leading to increased protein catabolism (5,6). We postulate that impairment in insulin sensitivity can occur with short-term fasting leading to euglycemic nondiabetic ketoacidosis and hyperammonemia. CONCLUSIONS: Short-term fasting can precipitate euglycemic high anion gap ketoacidosis and hyperammonemia in the non-diabetic, non-cirrhotic population possibly stemming from altered insulin homeostasis. Reference #1: Larroumet A, Camoin M, Foussard N, Alexandre L, Mesli S, Redonnet I, et al. Euglycemic ketoacidosis induced by therapeutic fasting in a non-diabetic patient. Nutrition. 2020 Apr 1;72:110668. Reference #2: Chang L-Y, Lim L-M, Chiu Y-W. Euglycemic Ketoacidosis Induced by Low Carbohydrate Diet in a Non-diabetic Patient: A Case Report. Arch Clin Med Case Rep. 2020 Nov 12;4(6):1078–83. Reference #3: Burge MR, Hardy KJ, Schade DS. Short-term fasting is a mechanism for the development of euglycemic ketoacidosis during periods of insulin deficiency. J Clin Endocrinol Metab. 1993 May 1;76(5):1192–8. DISCLOSURES: No relevant relationships by Asim Amjad No relevant relationships by Abhaya Khatiwada No relevant relationships by Sarasija Natarajan No relevant relationships by Yamini Patel No relevant relationships by Kristina Tanovic

SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Pulmonary function testing (PFT) can be varied in neuromuscular weakness. Here, we discuss interesting lung function tests in a patient with neuromuscular weakness.CASE PRESENTATION: A 34-year-old female, non-smoker, with idiopathic intracranial hypertension on high dose topiramate (1200 mg) presented with shortness of breath and progressive generalised weakness with lateralisation to the left. There was associated dry cough. Examination showed lungs bilaterally clear to auscultation and decreased strength and stiffness of extremities and shoulders. Chest radiograph, CT scan of the chest, endoscopy and bronchoscopy, echocardiogram revealed no obvious cause for the shortness of breath. MRI of the head and spine, electromyography and multiple lumbar punctures did not reveal the etiology of neuromuscular weakness. Spirometry was suggestive of new onset airway obstruction (FEV1 1.91/59%, FEV1/FVC 58%) compared to testing 2 years ago (FEV1 2.83/87% and FEV1/FVC 76%). Alpha 1 antitrypsin level and IgE were within normal limits. Despite a 6-week trial of long-acting beta agonist and inhaled corticosteroid therapy, shortness of breath did not improve and repeat PFT showed worsening airway obstruction (FEV1 1.56/58%, FEV1/FVC 52%, TLC 9.38/181%) (MEP 20, MIP -4). A diagnosis of functional neurological disorder was made, but additionally, her topiramate was also stopped. The neuromuscular weakness and shortness of breath resolved within the next month. Follow-up PFT was normal (FEV1 3.32/103%, FEV1/FVC 81%, TLC 4.64/89%).DISCUSSION: Adequate spirometry requires full inspiration, quick attainment of the highest flow, continuous decrease in flow with expiration, smooth, gradual termination and expiration of 3-6 seconds. When these criteria are not fulfilled, there maybe pseudo-obstruction (when the expiration is not forceful) or concealed obstruction (when the graphic record is started late), or pseudo-restriction (from either inadequate inspiration or premature termination of expiration) (1). Our patient likely had both pseudo-obstruction and pseudo-restriction but it was hard not to attempt a trial of bronchodilators in a patient with shortness of breath and obstructive PFT. It is unusual that the symptoms and FEV1/FVC continued to rapidly worsen despite weeks of bronchodilator therapy (2,3) leading us to postulate that the obstruction was pseudological, secondary to neuromuscular weakness.CONCLUSIONS: Neuromuscular weakness can result in different, complex spirometry findings.Reference #1: Lewis BM. Pitfalls of spirometry. J Occup Med Off Publ Ind Med Assoc. 1981 Jan;23(1):35–8.Reference #2: Ward NS, Hill NS. Pulmonary Function Testing in Neuromuscular Disease. Clin Chest Med. 2001 Dec;22(4):769–81.Reference #3: Neder JA, Berton DC, O'Donnell DE. Pitfalls in the interpretation of pulmonary function tests in neuromuscular disease. J Bras Pneumol [Internet]. 2020 Aug 26 [cited 2022 Mar 30];46.DISCLOSURES: No relevant relationships by Asim AmjadNo relevant relationships by Aishwarya KrishnaiahNo relevant relationships by Sarasija NatarajanNo relevant relationships by Pius OchiengNo relevant relationships by Yamini Patel SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary function testing (PFT) can be varied in neuromuscular weakness. Here, we discuss interesting lung function tests in a patient with neuromuscular weakness. CASE PRESENTATION: A 34-year-old female, non-smoker, with idiopathic intracranial hypertension on high dose topiramate (1200 mg) presented with shortness of breath and progressive generalised weakness with lateralisation to the left. There was associated dry cough. Examination showed lungs bilaterally clear to auscultation and decreased strength and stiffness of extremities and shoulders. Chest radiograph, CT scan of the chest, endoscopy and bronchoscopy, echocardiogram revealed no obvious cause for the shortness of breath. MRI of the head and spine, electromyography and multiple lumbar punctures did not reveal the etiology of neuromuscular weakness. Spirometry was suggestive of new onset airway obstruction (FEV1 1.91/59%, FEV1/FVC 58%) compared to testing 2 years ago (FEV1 2.83/87% and FEV1/FVC 76%). Alpha 1 antitrypsin level and IgE were within normal limits. Despite a 6-week trial of long-acting beta agonist and inhaled corticosteroid therapy, shortness of breath did not improve and repeat PFT showed worsening airway obstruction (FEV1 1.56/58%, FEV1/FVC 52%, TLC 9.38/181%) (MEP 20, MIP -4). A diagnosis of functional neurological disorder was made, but additionally, her topiramate was also stopped. The neuromuscular weakness and shortness of breath resolved within the next month. Follow-up PFT was normal (FEV1 3.32/103%, FEV1/FVC 81%, TLC 4.64/89%). DISCUSSION: Adequate spirometry requires full inspiration, quick attainment of the highest flow, continuous decrease in flow with expiration, smooth, gradual termination and expiration of 3-6 seconds. When these criteria are not fulfilled, there maybe pseudo-obstruction (when the expiration is not forceful) or concealed obstruction (when the graphic record is started late), or pseudo-restriction (from either inadequate inspiration or premature termination of expiration) (1). Our patient likely had both pseudo-obstruction and pseudo-restriction but it was hard not to attempt a trial of bronchodilators in a patient with shortness of breath and obstructive PFT. It is unusual that the symptoms and FEV1/FVC continued to rapidly worsen despite weeks of bronchodilator therapy (2,3) leading us to postulate that the obstruction was pseudological, secondary to neuromuscular weakness. CONCLUSIONS: Neuromuscular weakness can result in different, complex spirometry findings. Reference #1: Lewis BM. Pitfalls of spirometry. J Occup Med Off Publ Ind Med Assoc. 1981 Jan;23(1):35–8. Reference #2: Ward NS, Hill NS. Pulmonary Function Testing in Neuromuscular Disease. Clin Chest Med. 2001 Dec;22(4):769–81. Reference #3: Neder JA, Berton DC, O'Donnell DE. Pitfalls in the interpretation of pulmonary function tests in neuromuscular disease. J Bras Pneumol [Internet]. 2020 Aug 26 [cited 2022 Mar 30];46. DISCLOSURES: No relevant relationships by Asim Amjad No relevant relationships by Aishwarya Krishnaiah No relevant relationships by Sarasija Natarajan No relevant relationships by Pius Ochieng No relevant relationships by Yamini Patel

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 375 doi: 10.1097/01.ccm.0000809372.36875.de

All modern vaccines share the risk of neurological adverse effects. Only a few cases of Parsonage-Turner syndrome (PTS), an uncommon peripheral nerve condition associated with coronavirus disease 2019 (COVID-19) immunization, have been reported to date. We describe a case of COVID-19 vaccine-induced PTS and provide a brief literature review. A 78-year-old male non-smoker with a medical history of coronary artery disease presented with non-exertional, constant chest pain for one hour and new onset of bilateral hand weakness for three days. He had no neurological disease or allergies and denied any recent trauma or infection. Three weeks before the onset of the symptoms, the patient received a second dose of the BNT162b2 COVID-19 vaccine, which was administered 21 days after the first dose. Physical examination was significant for weakness in right-hand grip and wrist flexion. There were no other motor deficits, upper motor neuron signs, bulbar weakness, or sensory deficits. Diagnostic workup for the underlying diabetes mellitus, infections, or other autoimmune diseases was negative. Imaging workup revealed no demyelination, fracture deformity, traumatic subluxation, or compressive myelopathy. Nerve conduction studies, including needle electromyography, showed decreased motor unit recruitment in the bilateral first dorsal interosseous and right deltoid, biceps, and triceps muscles confirming PTS. The patient was treated with 40 mg/day of oral prednisone and occupational therapy to maintain range of motion and activities of daily living. PTS is also known as neuralgic amyotrophy, brachial plexus neuritis, brachial plexopathy, and shoulder-girdle syndrome. It is characterized by asymmetrical, chronic, resistant upper extremity neuropathic pain and neurological defects such as paralysis and paresthesia. There are two different types of PTS: non-hereditary and inherited. The etiology and pathophysiology of PTS are not fully understood. Various aspects such as genetic, environmental, and immunological predisposition may play a role in developing the syndrome. Infections, vaccines, and injuries are typical causes of non-hereditary forms. After the COVID-19 epidemic and the commencement of a global immunization effort, similar instances happened. Presently there is no available test that unequivocally confirms or excludes PTS itself. Electrodiagnostic study and imaging modalities help to rule out other differential diagnoses. Also, there is no specific treatment available; however, it may resolve independently of treatment with supportive care.

Background: Lumpectomy with radiation (breast conservation) and mastectomy have equivalent overall survival. However, recent studies suggest that patients undergoing breast conservation have lower rates of recurrence compared to those undergoing mastectomy. A 2013 meta-analysis by Houssami, et al. found that the rate of mastectomy in patients who had preoperative MRI was 16%, twice as high as that in patients who did not have preoperative MRI. A multi-institutional analysis was performed to investigate the possible impact of modern MRI on the surgical management of early-stage breast cancer (ESBC). Methods: A retrospective comparative cohort study included patients with in-situ and invasive breast cancer eligible for breast conservation surgery from two institutions (NY and FL). Patients who received preoperative systemic therapy were excluded. Eligibility for breast conservation was defined as clinical stage Tis-2. Risk factors for the bilateral or multicentric disease were compared between the two groups including breast density, menopausal status, and concerning family history. The rate of ipsilateral mastectomy in lumpectomy-eligible women was compared between patients who did and did not receive preoperative MRI. Chi-square analysis was used to compare rates between groups. P values <0.05 were considered statistically significant. Results: 505 patients diagnosed between 1/2016-4/2019 (NY) and 2/2020-12/2020 (FL) underwent primary surgery for ESBC. 434 did not receive neoadjuvant therapy and were included in the analysis. 292 (67.3%) had preoperative MRI. There was no difference in the proportion of patients who were premenopausal or who met the criteria for genetic testing by family history. The largest dimension on preoperative imaging was similar between the two groups. Patients who had MRI were younger (median age 58 vs. 68, p<0.001) and more likely to have group 3 or 4 breast density (64.5% vs. 27.1%, p<0.001). Patients who underwent preoperative MRI were twice as likely to undergo mastectomy as their first surgery (32.6% vs. 15.3%, p<0.001). The rate of re-excision was similar between the two groups (MRI 13.0% vs. no MRI 10.8% p=0.511). Of note, the final pathologic size of the invasive or in-situ component was similar between the two groups (Table 1). Conclusion: Younger age and greater breast density are associated with preoperative MRI receipt and all three factors likely play a role in choosing mastectomy. Young women with dense breasts represent a unique cohort of patients that may be particularly susceptible to cancer-related worry and anxiety related to additional biopsies, and therefore may be more likely to opt against continued breast imaging. Since approximately 70% of patients with ESBC undergo preoperative MRI, future work should focus on mitigating these challenges to improve shared decision-making. Table 1.Comparison of ESBC Patients Who Did and Did Not Receive MRIMRI (n=292) %, median (IQR)No MRI (n=142)%, median (IQR)p-valueAge58 years (50-65)68 years (60-76)<0.001bPremenopausal27%21%0.108Dense Breasts65%27%<0.001bMeet Criteria for Genetic Testing40%38%0.207Imaging Size13 mm (9-21)12 mm (8-20)0.315Mastectomy as First Surgery33%15%<0.001bPlan for Repeat Surgerya20%24%0.402Re-excision13%11%0.511Pathologic Size (Invasive)13 mm (8-20)13 mm (9-22)0.482Pathologic Size (DCIS)10 mm (5-20)8 mm (3-15)0.093aRepeat surgery includes re-excision, completion mastectomy, and axillary dissectionbDenotes significant p-values. Citation Format: Peter A Borowsky, Seraphina Choi, Orly Morgan, Amy K White, Claudya Morin, Jose Net, Susan Kesmodel, Neha Goel, Yamini Patel, Alexa Griffiths, Joshua A Feinberg, Aaron Kangas-Dick, Charusheela Andaz, Christina Giuliano, Natalie Zelenko, Donna-Marie Manasseh, Patrick Borgen, Kristin E Rojas. The association of preoperative MRI with surgical decision-making in patients with early-stage breast cancer: A multi-institutional analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-03-20.