Section on chest disease. (Abstracts of Scientific Posters).

CH1-A. BOOP IN A PATIENT WITH POLYMYOSITIS. Sundar Venkatesh, MD, MSHS, Jayaram Bharadwaj, and Vijay Das, MD. Department of Medicine, Unity Health System, Rochester, NY

Bronchiolitis obliterans with organizing pneumonia (BOOP) is known to be associated with connective tissue disorders. We present the case of a young man who initially presented with arthralgia, and exertional dyspnea. A 43-year-old white man initially presented to his primary care doctor with an 8-week history of arthralgia of his ankles and wrists. He was treated with NSAIDs with partial relief. Test for rheumatoid factor was positive, and a rheumatology consult was requested. 3 weeks before admission to the hospital, he also began to have exertional dyspnea that was progressively getting worse. He had a dry cough, but no chest pain or fever. He was again seen in his primary care doctor's office, found to be hypoxic, and was sent to the hospital for further work-up. Initial examination showed that he had bilateral ankle and wrist tenderness, bilateral tender axillary lymphadenopathy, and bilateral basal crackles on lung examination. His WBC count was normal, chest x-ray film revealed bilateral lower lobe str eaky infiltrates. CT scan of the chest revealed mediastinal and axillary lymphadenopathy, and bilateral air-space disease. Lymph node biopsy showed reactive changes. Fiberoptic bronchoscopy was done and biopsies were taken. This revealed BOOP. Further investigations were negative for an infective cause, but CK level was elevated at 5370 U/L. Muscle biopsy was done, and this was consistent with polymyositis. Steroid therapy was begun. Symptoms improved, and the patient was discharged home. Further investigations done as an outpatient revealed that his CK level had normalized. BOOP has been described to be caused by and associated with a number of infective and noninfective causes. When a patient presents with atypical symptoms and has extensive findings on chest x-ray film, further investigations have to be done to establish the nature of the disease. Once a diagnosis of BOOP is made, further investigations to find any associated disorder are necessary.

CH2-A. CHRONIC EOSINOPHILIC PNEUMONIA IN A 64-YEAR-OLD FEMALE PATIENT. Francisco A. Puentes, MD. Medical College of Georgia, Augusta, GA.

Chronic easinophilic pneumonia (CEP) is a serious disease characterized by an abnormal accumulation of eosinophils in the lung. The most common symptoms include cough, fever, dyspnea, weight loss, and night sweats of several weeks' to months' duration. Hemoptysis and chest pain are rare. A 64-year-old white woman presented to the ED complaining of right-sided pleuritic chest pain and dyspnea of 1 day's duration. She had had fever, cough, night sweats, and fatigue for 1 month, and was treated 2 weeks before with Azithromycin, without improvement. Chest x-ray films showed bilateral lower lobe and peripheral right upper lobe alveolar infiltrates. Chest CT scan showed bilateral pneumonia with hilar and mediastinal nodal disease. BAL showed 24% eosinophils, and was KOH- and AFB-negative. Results of transbronchial biopsy were consistent with chronic eosinophilic pneumonia with focal bronchiolitis obliterans. Treatment with prednisone, 60 mg qd, was started, and his symptoms improved within a few days. CEP is a diso rder that requires specific treatment. Fewer than 10% of patients with CEP spontaneously recover or improve, and occasionally, CEP leads to important and irreversible fibrosis. Early diagnosis and treatment is mandatory in CEP. Although death from CEP is unusual, some fatal cases have been reported. Treatment with corticosteroids will produce dramatic resolution of symptoms and x-ray film abnormalities.

CH3-A. VERTEBRAL ARTERY DISSECTION: AN UNUSUAL CAUSE OF RESPIRATORY FAILURE IN THE ELDERLY Halim Aboufaycal, MD. Johnson City, TN.

An 86-year-old white man with a history of atherosclerotic cardiovascular disease and hypertension, complained of a severe occipital headache that radiated into his neck. He had suffered no recent head trauma. The headache was associated with nausea, vomiting, and a near-syncopal episode. While being evaluated in the emergency department he suffered a respiratory arrest necessitating endotracheal intubation and support with positive pressure mechanical ventilation. His blood pressure was 159/78 mm Hg, heart rate 78 beats/min, and temperature 97[degrees]F. Physical examination revealed a holosystloic murmur (2/6) heard best at the apex, with radiation to the axilla. His Babinski reflex was upgoing on the left side. Serum electrolytes, cardiac isoenzymes, and an EKG were unrevealing. Computerized tomography of the patient's head demonstrated no evidence of an acute ischemic event or bleed. Analysis of his cerebral spinal fluid was normal. Magnetic resonance imaging/angiogram (MRI/A) documented dissection of the right vertebral artery. The patient was treated with aspirin and was subsequently successfully extubated. Therapy at the time of his discharge to home included aspirin and blood pressure control. Vertebral artery dissection (VAD) typically afflicts patients in the 4th or 5th decade of life. There is no sex predilection, but females present at a younger age. VAD is responsible for up to 22% of strokes in patients younger than 30 years of age. VAD is categorized as either spontaneous or traumatic. Spontaneous VAD is associated with arteriopathy, Marfan's syndrome, vasculitis, cystic medial necrosis, homocystinuria, and fibromuscular dysplasia. Hypertension is a strong risk factor for VAD. An ipsilateral occipital headache and neck pain are the presenting symptoms in 60% to 80% of cases. Ischemic neurologic symptoms depend on the arteries or branches affected by the VAD. VAD may also present as a subarachnoid hemorrhage. MRI/A is a very useful for diagnostic tool; however, angiography may be required at times t o confirm the diagnosis. Ischemic VAD cases typically have a good prognosis. Ninety percent of ischemic VAD patients make a full recovery and return to their previous lifestyle. Treatment with heparin followed with warfarin therapy has been recommended for patients with VAD unless there is a contraindication. Surgery is not indicated in patients with ischemic neurologic injury due to VAD; however, subarachnoid hemorrhage due to VAD may require surgical intervention. This report serves as a reminder to the clinician that, while unusual, VAD can occur in the elderly, and should alert physicians to consider this diagnosis in patients who present with headaches and respiratory failure.

CH4-A. IMPACT OF LIFE-THREATENING RESPIRATORY EVENTS ON SMOKING CESSATION: STAGES-OF-CHANGE ANALYSIS. Zakari Y Aliyu, MD, MPH, and Anthony Martinez, MD. Department of Internal Medicine St. Agnes Hopital, Baltimore, MD.

Tobacco-related respiratory complications are frequent causes of medical intensive care unit (ICU) admissions; however, research on smoking cessation after episodes of respiratory failure and ICU stay is limited. Forty-eight patients with a history of extensive tobacco use (mean, 25.4 pack-years) and chronic obstructive pulmonary disease (COPD) admitted to the medical ICU with first episode of acute respiratory failure from COPD exacerbation were identified. These patients were administered a structured questionnaire to determine their stage with regard to smoking cessation process (stages of change) before hospitalization, during hospital stay, and thirty days after discharge. During the pre-admission period, 26 (54%) of patients were in the precontemplative stage, 14 (29%) were in the contemplative stage, while 8 (17%) were in the stage of readiness for action. During hospitalization, 4 (8%) were in precontemplative stage, 21 (44%) in contemplative stage, and 23 (48%) in readiness for action stage. At [grea ter than or equal to] 30 days after discharge, 4 (8%) remained in the precontemplative stage, 30 (62%) contemplative, and 10 (21%) readiness for action. Only 4 patients (8%) were in the action/maintenance stage thirty days after discharge. Life-threatening respiratory complications are important stimuli for beginning and advancing in the smoking-cessation process. A high transient tobacco-cessation rate occurs in the immediate post-ICU phase. Regrettably, these initial gains are lost at [greater than or equal to] 30 days from discharge, implying the need for sustained counseling and pharmacotherapy.