The Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) Technique in Assessment of Mediastinal Lymph Nodes

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) technique provides a complementary assessment of the areas of mediastinal lymph node involvement, and allows sampling of suspected lymph nodes. But, the usefulness of EBUS-TBNA in assessing all areas of mediastinal lymph nodes is little known and it seems that such assess is dependent to various factors related to the patient's condition and especially the characteristics of local lymph nodes. We aimed to evaluate the utility of EBUS-TBNA in assessing mediastinal lymph nodes and the factors associated with this utility.Methods: This cross-sectional study was performed on 40 patients suspected to mediastinal lymphadenopathy scheduled for assessment by EBUS-TBNA and mediastinoscopy. The diagnostic yield of EBUS-TBNA to mediastinal lymph nodes was evaluated and non diagnostic cases evaluated by mediastinoscopy .Results: In evaluation with EBUS-TBNA, the diagnostic yield of EBUS in assess to mediastinal lymph nodes including 34 out of 40 cases was equal to 85%. The size of lymph node (lower than 10mm), the area of sample (left and right upper paratracheal), and the nature of the lymph node sample (benign type) were associated with lower diagnostic yield for EBUS-TBNA.Conclusion: The diagnostic yield of EBUS in assessing mediastinal lymph nodes for sampling and diagnosis is 85%. This benefit is expected in the case of lesions larger than 10 mm, lesions of a malignant nature, as well as lesions in the inferior paratracheal and subcarinal stations.

Treatment-induced sarcoidosis in a patient with metastatic clear cell ovarian cancer

Sarcoidosis is a granulomatous disease that commonly presents with lung or lymphatic system manifestations. Diagnosis is often delayed due to variable clinical presentation. This is a case of a patient with metastatic clear cell ovarian cancer who developed disease reoccurence after definitive treatment with surgery and adjuvant chemotherapy. She was treated with multiple lines of therapy, including investigational agents. During this time, she developed mediastinal lymphadenopathy and hypercalcaemia. Due to suspicion that her presentation was not a manifestation of her malignancy, she underwent two lymph node biopsies revealing granulomatous disease. She was initiated on prednisone for management of sarcoidosis, which led to radiologic, laboratory and symptomatic improvement. Although the precipitating factor for this patient’s sarcoidosis cannot be definitively determined, nivolumab is a possible culprit. This case highlights the importance of a broad differential diagnosis when a patient undergoing antineoplastic treatment develops mediastinal lymphadenopathy or hypercalcaemia.

High-titer rheumatoid factor seropositivity predicts mediastinal lymphadenopathy and mortality in rheumatoid arthritis-related interstitial lung disease

Rheumatoid arthritis-related interstitial lung disease (RA-ILD) is a common connective tissue disease-related ILD (CTD-ILD) associated with high morbidity and mortality. Although rheumatoid factor (RF) seropositivity is a risk factor for developing RA-ILD, the relationship between RF seropositivity, mediastinal lymph node (MLN) features, and disease progression is unknown. We aimed to determine if high-titer RF seropositivity predicted MLN features, lung function impairment, and mortality in RA-ILD. In this retrospective cohort study, we identified patients in the University of Chicago ILD registry with RA-ILD. We compared demographic characteristics, serologic data, MLN size, count and location, and pulmonary function over 36 months among patients who had high-titer RF seropositivity (≥ 60 IU/ml) and those who did not. Survival analysis was performed using Cox regression modeling. Amongst 294 patients with CTD-ILD, available chest computed tomography (CT) imaging and serologic data, we identified 70 patients with RA-ILD. Compared to RA-ILD patients with low-titer RF, RA-ILD patients with high-titer RF had lower baseline forced vital capacity (71% vs. 63%; P = 0.045), elevated anti-cyclic citrullinated peptide titer (122 vs. 201; P = 0.001), CT honeycombing (50% vs. 80%; P = 0.008), and higher number of MLN ≥ 10 mm (36% vs. 76%; P = 0.005). Lung function decline over 36 months did not differ between groups. Primary outcomes of death or lung transplant occurred more frequently in the high-titer RF group (HR 2.8; 95% CI 1.1–6.8; P = 0.028). High-titer RF seropositivity was associated with MLN enlargement, CT honeycombing, and decreased transplant-free survival. RF titer may be a useful prognostic marker for stratifying patients by pulmonary disease activity and mortality risk.

Performances of Clinical Characteristics and Radiological Findings in Identifying COVID- 19 From Suspected Cases

Background: To identify effective factors and establish a model to distinguish COVID-19 patients from suspected cases.Methods: The clinical characteristics, laboratory results and initial chest CT findings of suspected COVID-19 patients in 3 institutions were retrospectively reviewed. Univariate and multivariate logistic regression were performed to identify significant features. A nomogram was constructed, with calibration validated internally and externally.Results: 239 patients from 2 institutions were enrolled in the primary cohort including 157 COVID-19 and 82 non-COVID-19 patients. 11 features were included for multivariate logistic regression analysis after LASSO selection. We found that the COVID-19 group are more likely to have fever (OR, 4.22), contact history (OR, 284.73), lower WBC count (OR, 0.63), left lower lobe involvement (OR, 9.42), multifocal lesions (OR, 8.98), pleual thickening (OR, 5.59), peripheral distribution (OR, 0.09), and less mediastinal lymphadenopathy (OR, 0.037). The nomogram developed accordingly for clinical practice showed satisfactory internal and external validation. Conclusions: In conclusion, fever, contact history, decreased WBC count, left lower lobe involvement, pleural thickening, multifocal lesions, peripheral distribution and absence of mediastinal lymphadenopathy are able to distinguish COVID-19 patients from other suspected patients. The corresponding nomogram is a useful tool in clinical practice.

Abstract 16926: Outside The Box But All Squeezed In: A 23-year-old Man With Progressive Dyspnea After Overseas Travel

Case Presentation: A 23-year-old previously healthy man presented with progressive dyspnea. Physical examination revealed jugular venous distension and lower extremity edema. Laboratory testing demonstrated elevated B-type natriuretic peptide (193 pg/mL) and normal high sensitivity troponin. Echocardiogram revealed small pericardial effusion, respiratory variation in diastolic flow across the mitral valve, diastolic septal bounce, and annulus reversus ( Figure ). The differential diagnosis for constrictive pericarditis was broadly considered in the context of a recent febrile illness and frequent travel to Hawaii and Vietnam; we included infectious, autoimmune, and malignant etiologies. Cardiac magnetic resonance imaging revealed thickening and diffuse enhancement in the pericardium as well as ventricular interdependence. Chest CT identified hilar and anterior mediastinal lymphadenopathy. Laboratory testing was positive for QuantiFERON gold and negative for COVID-19, HIV, and ANA. Transbronchial biopsy demonstrated non-necrotizing granulomas with negative acid-fast bacilli smear, culture, and polymerase chain reaction for mycobacterial DNA. Re-examination identified a red-brown plaque on the patient’s thigh; biopsy showed granulomatous inflammation and rod-shaped organism with positive FITE staining. A presumed unifying diagnosis was made of extrapulmonary tuberculosis (TB) complicated by constrictive pericarditis. Discussion: Despite being a primarily pulmonary disease, systemic involvement can occur with TB with the heart being one of the most common extrapulmonary sites. This case highlights 1) the utility of extra-cardiac diagnostic testing (e.g., dermatologic biopsy) in the diagnosis of constrictive pericarditis, and 2) the diagnostic challenge associated with extrapulmonary TB, particularly paucibacillary disease that requires a detailed social history with “out-of-the-box” thinking.