INTRODUCTION: Pneumopericardium, or air in the pericardial space, most often results from associated trauma. Less commonly, it is associated with disease processes in contiguous organs. Rare cases of tension pyopneumopericardium have been described (1). CASE PRESENTATION:A 57-year-old female with a history of an enlarging cavitary lung lesion of unknown etiology for one year, complicated by recurrent P. Aeruginosa pneumonia presented to the emergency room with acute on chronic chest pain and shortness of breath. On admission, she was toxic appearing with decreased breath sounds over the left lung field and tachycardic. Initial laboratory evaluation showed a WBC of 19K with 87% neutrophils and lactic acidosis of 2.6. A CT scan noted the previously described cavitary mass in left hemithorax measuring 10 x 7 x 9 cm and a pericardial effusion measuring up to 2.9 cm. Blood cultures grew MDR P. Aeruginosa for which she was started on appropriate antibiotics. On hospital day 2, she developed atrial fibrillation and was transferred to the cardiac intensive care unit. While undergoing an urgent pericardiocentesis which demonstrated frank pus, she experienced massive hemoptysis with subsequent cardiac arrest requiring mechanical ventilation. Pericardial fluid also grew MDR P. Aeruginosa. On hospital day 8, air was noted in the pericardial drain requiring frequent emptying. The patient subsequently developed tamponade physiology with increasing vasopressor requirements with accumulation of air in the pericardial drain. Review of the CT scan noted a fistulous tract from the cavitary lesion to the pericardium. Given the patient's poor prognosis, family elected to withdraw care. Pathology from a chest wall biopsy yielded poorly differentiated squamous cell carcinoma.DISCUSSION: A limited number of cases of pyopneumopericardium as a cause of tension pneumopericardium have been described. To our knowledge, there have been no cases of tension pneumopericardium associated with squamous cell carcinoma and P. Aeruginosa pericarditis. Tension pneumopericardium is an emergent condition. Prompt recognition, surgical intervention and antimicrobial therapy is important in patients with pyopneumopericardium, though unfortunately the majority of documented cases have resulted in mortality (2). In the above-described patient, she developed tension pneumopericardium following pericardiocentesis and mechanical ventilation leading to rapid clinical deterioration. Given her advanced disease state, therapeutic interventions were limited at the time of diagnosis. These complications are often unavoidable in the acute clinical setting when patients require urgent or emergent procedures and interventions.CONCLUSIONS: This case illustrates the poor clinical outcomes associated with pyopneumopericardium and the difficult task of early recognition in a patient with multiple acute medical conditions.

Background The CDC recommends testing for SARS-CoV-2 in patients who present with symptoms consistent with COVID-19 and to cohort hospitalized patients diagnosed with COVID-19. Up to 35% of persons infected with SARS-CoV-2 are asymptomatic; however, no recommendations exist for universal testing in hospitalized patients. We assessed the point prevalence of SARS-CoV-2 infection amongst hospitalized patients at a tertiary care center during a time when there was a regional surge of cases. Methods Nasopharyngeal SARS-CoV-2 PCR testing was performed on inpatients at Georgetown University Hospital on 4/27/20, excluding those who were SARS-CoV-2 positive, tested within 72 hours or admitted to pediatric, psychiatric, labor & delivery or ICUs. Patients within the hospital were not cohorted based on COVID-19 status. Patient demographics and comorbidities were obtained from the EMR and analyzed for significance based on SARS-CoV-2 status. Results Hospital census on the testing date was 297; 204/297(68.7%) met inclusion criteria; 78/297(26.3%) were known COVID-19 patients. Within the study group 78/204 (38.2%) had known COVID-19, 21/204 (10.3%) were PUIs (4 of whom tested positive), 31/204 (15.1%) tested negative for COVID-19 within 72 hours and 74/204 (36.3%) met criteria for testing. The median age was 62 years (IQR, 53 to 70), 59%(n=122) were male, 56%(n= 115) were Black, and 90%(n=185) had at least one co-morbidity. 0/74 of those tested on 4/27/20 were positive for SARS-CoV-2, and none were diagnosed with COVID-19 within 28 days. In adjusted analyses, patients who were hospitalized for COVID-19 were more likely to be Black(OR=10.53 95% CI 3.02, 36.68, p=0.0002); male(OR=3.27 95% CI 1.26, 8.47, p=0.0143); reside in group/nursing homes(OR= 11.78 95%CI 3.03, 45.76, p=0.0004); have a history of prior stroke(OR= 6.25 95%CI 1.49, 26.12, p=0.012); but less likely to smoke(OR=0.10 95%CI 0.02, 0.48, p=0.0039), or have active malignancy (OR= 0.11 95%CI 0.01, 0.73, p=0.0223). Conclusion The use of CDC testing criteria for PUIs were successful in identifying COVID-19 patients and limiting the need for routine testing in all hospitalized patients during a time when access to testing was limited. Nosocomial transmission did not occur in our institution despite a lack of cohorting. Disclosures Princy Kumar, MD, Gilead Sciences Inc. (Scientific Research Study Investigator)