INVASIVE ASPERGILLOSIS WITHOUT A KNOWN IMMUNODEFICIENCY Stephany Nguyen, Jessica Bordes, Daniel Holmes; Louisiana State University, New Orleans, LA.
Introduction: Aspergillus is an opportunistic fungus resulting in severe infections with high mortality rates. Because immunocompetent patients typically clear Aspergillus before disease occurs, Aspergillus infections primarily affect the immunocompromised. Case: A 29-year-old male with a history of varicella zoster meningoencephalitis presented with chest pain for two months. Since hospitalization two months prior for pneumonia, he reported pleuritic chest pain with cough productive of green sputum, night sweats, diffuse joint pain, and an unintentional weight loss of 40 pounds over this time period. CT imaging revealed diffuse cavitary lesions throughout the lungs as well as liver and splenic lesions. Sputum fungal smear grew Aspergillosis. Despite positive sputum cultures for Aspergillus niger and positive serum fungitell, his aspergillus galactomannan was negative. Liver biopsy revealed scarred inflammation with focal granulomas, but no fungal organisms
identified on culture. Immunodeficiency workup included: HIV negative, CD4 count of 151 cells/ microL and a CD4% of16.6%, negative for chronic granulomatous disease (CGD). Given his clinical picture and high suspicion for hepatic involvement, he was presumed to have invasive aspergillosis and discharged with posaconazole with plans for close follow up. Because of this patient’s presumed diagnosis of invasive aspergillus in the setting of no known immunosuppression, he was worked up for an underlying immunodeficiency. Although the inpatient workup was unremarkable, there were plans to continue evaluation in the outpatient setting Discussion: In patients with an opportunistic infection, such as invasive aspergillosis, it is important to assess for immune system deficiencies, with no known prior history. This information may be able to guide the use of prophylactic treatment options to prevent future opportunistic infections.
A RARE CASE OF LARGE CELL NEUROENDOCRINE CARCINOMA OF THE LUNGS IN A YOUNG GUY WITH MINIMAL SMOKING HISTORY Ahmad Anbar, Nadjel Opamen, Archa Rajesh, Gregory Ardoin; Louisiana State University, Lafayette, LA.
Introduction: Large Cell Neuroendocrine Carcinoma (LCNEC) is the rarest subtype of neuroendocrine carcinoma (NECs) in the lungs with an incidence of 3% peaking around the 6th decade, LCNEC is associated with heavy smoking. Presenting similarly to other high-grade NECs. It often presents histologically with a mix of Small Cell Lung Cancer “SCLC” and Non-SCLC features. LCNEC has been identified in the gastrointestinal and genitourinary tracts. Case: A 39-year-old with a history of tobacco use and myocardial infarctions presented with scant hemoptysis and melena for 3 days and associated with an unintentional 15-pound weight loss. He had a family history of colon cancer in his father and lung cancer on his maternal side. He reportedly smoked 3.7 pack-years, but daily marijuana for 25 years. The physical exam was remarkable for right supraclavicular lymphadenopathy and digital clubbing. A CT of the chest revealed a large necrotic right upper lobe mass, right hilar and mediastinal
adenopathy, and lymphadenopathy in the right supraclavicular fossa. A frozen section of the latter suggested Squamous Cell Carcinoma, but the final pathology returned LCNEC. Tumor markers were positive for TTF1, CK7, CD56, and negative p40, CK20. Imaging showed adrenal and lytic bone metastasis. The patient was started on palliative chemotherapy with Carboplatin, Etoposide, and Atezolizumab Q21D. Imaging after 4 cycles of treatment showed a marked decrease in the mediastinal and hilar adenopathy, a decrease in the size of the multifocal nodular opacities throughout the lungs and no changes in the distant metastatic lesions. Discussion: Our patient’s young age with minimal smoking history makes this a very unique presentation. Appropriate imaging, confirmatory biopsy, immediate management, and oncology follow-up are essential due to the aggressive nature and poor prognosis. No large studies support a specific treatment for LCNEC. Therapy for early- 37
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