duration of progressive shortness of breath. She had two successful vaginal deliveries previously. Labs were unremarkable besides iron deficiency anemia. Imaging showed a large right pleural effusion with right middle/lower lobe collapse and few sub- centimeter lymph nodes. A thoracocentesis yielded 1000cc of bloody fluid. Pleural fluid studies were consistent with an exudative process and cytology showed atypical cells. Given suspicion for malignancy, further abdominopelvic imaging was obtained that showed ascites, mixed solid/cystic mass (6.7 x 2.5 cm) in the left ovary, and a 1.5cm hepatic lobe mass with lymph nodes in the mesentery and right groin. CA- 125 was five times the upper limit of normal. She was referred to a gynecological oncologist after discharge who did a diagnostic laparoscopy that revealed endometriosis with a multicystic pelvic mass adhered to the sigmoid colon. Pre-operative PET/CT and colonoscopy were both normal. She subsequently underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, appendectomy, bilateral ureterolysis
with tumor debulking. Pathology was negative for malignancy. Post-surgery, she was readmitted for right hemothorax and apical pneumothorax with concern for lung entrapment. She underwent a right robotic-assisted pleurectomy, lysis of apical adhesions, mediastinal lymph node dissection. Pathology revealed endometrial tissue without malignant findings. Pathology re-reviewed her initial pleural cytology and found immunohistochemical patterns consistent with endometriosis but without any evidence of malignancy. Discussion: The diagnosis in this patient posed a dilemma as there was initial suspicion for ovarian cancer and Meig’s syndrome which can have similar presentations. The pathogenesis of thoracic endometriosis is not fully understood and different theories such as retrograde menstruation, lymphatic dissemination and pleural mesothelial metaplasia have been proposed. Surgical intervention is often necessary and postoperative hormonal suppression can prevent relapse.
SWITCHING TO LONG-ACTING INJECTABLES IN THOSE WITH HEPATITIS B AND HIV CO-INFECTION: GOOD INTENTIONS GONE WRONG Jamie Tran MD, Nikki Seraji BS, Keionne Green BS, Alexander Fixler MD, Lauren Nunez MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: For patients with HIV, there has been increased interest in transitioning from traditional daily anti-retroviral therapy (ART) to long-acting injectable medications which can be administered in 4-8 week intervals. Studies have shown that those that achieved viral suppression can safely transition to Cabenuva (cabotegravir and rilpivirine) with few side effects and maintain effective HIV suppression for at least 48 weeks. However, compared to ART, Cabenuva lacks an agent that targets Hepatitis B (HBV). Case: A 49 year-old female with HIV (diagnosed in 1990), hepatocellular carcinoma status post microwave ablation (diagnosed in 2015), and chronic hepatitis B (diagnosed in 2001) presented with chest pain and dyspnea for three weeks. Cardiac work up was unremarkable. Her CD4 count was 467 cells/ mm3 and she had an undetectable viral load. There was an incidental finding of severe elevation in her AST (2565 U/L) and ALT (1577 U/L). Alcohol levels and autoimmune workup was negative. Hepatitis-A IgM, Hepatitis-B surface antigen, Hepatitis-B IgM, Hepatitis-C antibody, and Hepatitis-D antibody
were also negative. Computed tomography of the abdomen and pelvis additionally had no significant findings. The patient denied taking any new medications besides Cabenuva which was recently switched from Symtuza (darunavir, cobicistat, emtricitabine, and tenofovir) 3 months prior. The gastrointestinal and infectious disease teams were in agreement that despite the negative hepatitis panel, confirmatory viral hepatitis labs should be obtained, and empiric HBV therapy should be initiated to treat a potential HBV flare given patient’s history and recent switch to a medication without an agent against HBV. AST and ALT down trended after initiation of Tenofovir so the patient was discharged with plans to transition back to Symtuza. The Hepatitis-B DNA PCR resulted a week later with a level of 4.7 million IU/mL confirming our suspicions.
Discussion: There are about 8-10% of people co-infected with HIV and HBV globally. HBV reactivation and hepatic failure are potential negative outcomes when switched to a regimen without activity against HBV. As a result, it is not 11
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