INTRODUCTION: Pulmonary sequestration (PS) is a rare congenital malformation where a nonfunctional lobe of lung tissue does not appropriately communicate with the tracheobronchial tree. The dysplastic lung tissue can have an anomalous vascular supply. Outside of incidental diagnosis on chest imaging, PS most commonly presents as recurrent localized pneumonia. CASE PRESENTATION:A 74-year-old female with a history of coronary artery disease, tobacco use, and chronic obstructive pulmonary disease was admitted frequently over four years for recurrent dyspnea and cough and repeatedly treated for community acquired pneumonia. The episodes appeared to resolve with antibiotics until she presented with hemoptysis in addition to her usual symptoms. Computed tomography (CT) chest revealed a right lower lobe abscess and bronchoscopy cultures grew Actinomyces Turicensis. She was discharged home on prolonged antibiotics with follow up at infectious disease (ID) and pulmonology. Interval CT chest was preformed to evaluate progression of the abscess with findings consistent with a sixcentimeter congenital PS in the right lower lobe extending into the subcarinal region with a feeding artery arising from the mid aortic arch. She completed the course of antibiotics with improvement in her dyspnea and functional status. Her CT images were reviewed at the multidisciplinary cardiothoracic surgery conference however, she was not an ideal candidate for lobectomy due to osteoporosis and kyphosis. She was medically optimized with trelegy, smoking cessation, and pulmonary rehabilitation and fortunately has had a significant reduction in the frequency of hospital admissions. DISCUSSION: Interestingly, this patient had two rare conditions: PS and pulmonary actinomycosis. As a congenital malformation, PS is usually diagnosed in childhood. It is incredibly rare for a malformation to be discovered in an adult older than 50 years old. The treatment of symptomatic lesions has historically been surgical resection, however transarterial embolization is emerging as a possible therapy. Recurrent pneumonia is a frequent presenting symptom of PS and the most commonly identified agent is Pseudomonas aeruginosa. The incidence of pulmonary actinomycosis is now incredibly rare with the frequent use of antibiotics. Actinomycosis has been noted in immunocompetent patients with structural lung disease, however the literature is limited.CONCLUSIONS: While the incidence of PS is quite rare, it is not unreasonable to include congenital lung malformations in the differential diagnosis of recurrent localized pneumonia or recurrent hemoptysis. Frequent admissions for either warrant additional investigation with advanced imaging or bronchoscopy.

The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology in 2010. The registry collects data from participating sites with the agreement that all bedside and telehealth medical toxicology consultation will be entered. This eleventh annual report summarizes the Registry's 2020 data and activity with its additional 6668 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2020. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. Gender distribution included 50.6% cases in females, 48.4% in males, and 1.0% identifying as transgender. Non-opioid analgesics were the most commonly reported agent class, followed by opioid and antidepressant classes. Acetaminophen was once again the most common agent reported. There were 80 fatalities, comprising 1.2% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe race and ethnicity demographics and exposures in the registry, telemedicine encounters, and cases related to the COVID-19 pandemic.

INTRODUCTION: Amyloidosis is a group of disorders characterized by abnormal deposition of fibrillar proteins into betapleated sheet configuration. Clinical presentation is heterogenous and depends on the organ involvement. Pulmonary manifestation of amyloidosis may be localized to the lungs or may be a part of the systemic disease. Below, we describe a case of pulmonary nodular amyloidosis with eventual development of widespread multi-organ involvement.CASE PRESENTATION: 79-year-old female with a past medical history of Sjögren Syndrome, Discoid Lupus and Ramsay-Hunt syndrome was found to have numerous bilateral pulmonary nodules as incidental findings on chest x-ray and computed tomography (CT) of the chest. She has no history of tobacco use. Initial CT-guided lung biopsy was inconclusive, showing only interstitial fibrosis and chronic inflammation. She subsequently underwent wedge resections and tissue pathology with Congo red stain, which demonstrated apple-green birefringence of the eosinophilic material under polarized microscopy. Serum electrophoresis revealed a spike in the gamma region, consistent with IgG monoclonal gammopathy. Bone marrow biopsy was negative for plasma cell neoplasm and amyloid infiltration. As the patient was asymptomatic with no evidence of systemic involvement, the treatment plan was focused on surveillance with CT/PET scans. A year later, CT chest revealed increased size of bilateral pulmonary nodules. Repeat CT five months later noted enlarging mediastinal lymph node. Patient subsequently underwent transbronchial needle aspiration, which was negative for malignancy. Repeat CT imaging again noted increased size of bilateral pulmonary nodules and patient underwent right lung core needle biopsy to differentiate between AL amyloidosis and AA amyloidosis. Biopsy confirmed pulmonary nodular amyloidosis with mass spectrometry further classifying as AL amyloidosis. Due to rising NT-proBNP suggesting cardiac involvement, patient was started on bortezomib-based chemotherapy for systemic amyloidosis approximately 26 months into diagnosis. Patient has been responding to treatment with reduction in free light chain and NT-proBNP. Additionally, she is undergoing evaluation at Hershey Penn State for autologous stem cell transplant.DISCUSSION: Diagnosis of amyloidosis is challenging as amyloid proteins can infiltrate virtually any organ system and have diverse clinical presentation. Patients who are asymptomatic with localized amyloidosis do not require chemotherapy. However, patients with localized amyloidosis need complete assessments to confirm the absence of systemic amyloidosis and follow with active surveillance to evaluate for progression. Treatment varies based on the type of amyloidosis, therefore testing for amyloid typing is imperative.CONCLUSIONS: Awareness of systemic amyloidosis is essential as these patients benefit from autologous stem cell transplant and chemotherapy.