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Erica Turse,1 Majd Aboona,2 Ericka Charley,1 Arnold Forlemu,1 Tessa Bowie,3 Bikash Bhattarai,3 Keng-Yu Chuang,4 Abdul Nadir2,4 1Department of Medicine, Creighton University School of Medicine Program, Phoenix, AZ, USA; 2Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA; 3Department of Research, Valleywise Health Medical Center, Phoenix, AZ, USA; 4Department of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USACorrespondence: Majd Aboona, Email Aboona@email.arizona.eduBackground: With the rising incidence of hepatocellular carcinoma (HCC), ongoing efforts should be focused on providing equitable and state-of-the-art care to patients.Purpose: The aim of this study was to determine the survival of patients with HCC seen at a high-proportion Safety Net Hospital (h-SNH), where loco-regional therapy and hepatology services are available and liver transplantation (LT) is referred to outside facilities.Patients and Methods: A retrospective cohort study was conducted on all patients with HCC seen at Valley Wise Health Center (VWHC) over a ten-year period. Clinical variables, treatment modalities, survival duration, hospice, and LT referrals of 161 patients were collected from the medical records. Survival analysis was used to determine the relationship of clinically relevant variables and survival among patients with HCC. A Log rank test was used to compare univariate variables. A Cox regression analysis was used to compare and control for multiple variables.Results: Of the 161 patients included in the study, 33% were uninsured. The median age was 59 (21 to > 89) years with 47% Hispanic, 31% Caucasian, 15% African American and 7% other races included for the analysis. The median survival for the cohort was 20.1 months. In the multivariate model, insurance status, final MELD, tumor within the Milan criteria and having received treatment for HCC were associated with survival. Surveillance for HCC was associated with HCC in the univariate analysis, but not in the multivariable model. Thirty percent of patients were referred for LT and 1.25% of the entire cohort received it.Conclusion: Despite the availability of treatment modalities available for HCC at VWHC and the option of liver transplantation for appropriate candidates at outside centers, OS was less than reported from programs with on-site liver transplant programs. Reasons for lower survival in centers without liver transplant programs should be further studied.Keywords: liver cancer, cirrhosis, health disparities, health outcomes

TOPIC: Transplantation TYPE: Medical Student/Resident Case Reports INTRODUCTION: Immunosuppressed lung transplant recipients (LTxRs) are predisposed to severe SARS-CoV-2 disease, impaired virus clearance, and increased mortality. Successful recovery from SARS-CoV-2 infection after reduction of immunosuppression (IS) has been reported in kidney and heart transplant recipients [1,2]. We report a case of favorable allograft outcome after reduction of IS in an LTxR with SARS-CoV-2 pneumonia despite prolonged virus shedding. CASE PRESENTATION: A 58-year-old bilateral LTx recipient (July 2020) with blood type A+ was admitted for a positive SARS-CoV-2 RT-PCR result from a nasal wash on July 31, 2020 (day 1). He exhibited fever, increasing shortness of breath, a productive cough, and bilateral radiographic infiltrates, but normal oxygen saturation on room air and stable pulmonary function tests (FVC and FEV1 at 3.17 and 2.65 liters, respectively). Shortly after hospitalization, his dyspnea and oxygen requirement increased (3 LPM) and inflammatory markers were elevated (nadirs of lymphocyte 2.7 thousand/µL and platelet 158 thousand/µL;peaks of D-dimer 260 ng/mL, CRP 75.2 mg/L, ferritin 219 ng/mL, pro-calcitonin 0.22 ng/mL, and LDH 215 U/L). Imaging favored progression of SARS-CoV-2 pneumonia. DSA against DP1 measured 1350 MFI, and immunoglobulin therapy was started. The patient was managed with intravenous corticosteroid pulse, Remdesivir, and convalescent plasma along with appropriate antibiotic therapy due to additional concern for superimposed infection. On day 8 of illness onset, the patient no longer had clinical symptoms, and he was discharged on room air and steroid taper. On outpatient follow-up, the patients' endurance had increased;PFTs improved (FVC and FEV1 at 3.9 and 3.39 L, respectively);DSAs were reassuring;and radiographic changes had resolved by day 42 (Figure 1: serial chest imaging from illness onset to day 42). Of note, the ImmuKnow result at illness onset was 64 ng/mL, and mycophenolate (MMF) was reduced to 500 mg BID, after which the ImmuKnow result increased to 560 ng/mL. Seroconversion for SARS-CoV-2 IgG was mounted on day 26 (index 1.56), and MMF was resumed to baseline dose of 750 mg BID on day 35. Remarkably, prolonged viral shedding in nasal wash was noted with the first negative RT-PCR for SARS-CoV-2 on day 47. DISCUSSION: Our patient had excellent recovery with intact graft function despite prolonged virus persistence. Although an immunosuppressed state may have predisposed our patient to bacterial superinfection, reduction of MMF possibly augmented the antiviral response. Despite reduced IS, seroconversion and virus clearance may have been impacted. CONCLUSIONS: Immunosuppressed LTxRs with SARS-CoV-2 pneumonia may demonstrate prolonged viral shedding. Reduction in IS may facilitate allograft recovery despite delayed PCR conversion. Isolation measures should be considered due to possible prolonged infectivity. REFERENCE #1: Li F, Cai J, Dong N. First cases of COVID-19 in heart transplantation from China. J Heart Lung Transplant. 2020 May;39(5):496-497. REFERENCE #2: Zhu L, Xu X, Ma K, Yang J, Guan H, Chen S, Chen Z, Chen G. Successful recovery of COVID-19 pneumonia in a renal transplant recipient with long-term immunosuppression. Am J Transplant. 2020 Jul;20(7):1859-1863. DISCLOSURES: No relevant relationships by Ashwini Arjuna, source=Web Response No relevant relationships by Ross Bremner, source=Admin input No relevant relationships by Ericka Charley, source=Web Response No relevant relationships by Hesham Mohamed, source=Web Response No relevant relationships by Kristine Nally, source=Web Response No relevant relationships by Ashraf Omar, source=Admin input No relevant relationships by Deepika Razia, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=H noraria Speaker/Speaker's Bureau relationship with Grifols Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Shire Please note: $1001 - $5000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Astellas Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria

Intramedullary tuberculoma (IMT) is a rare form of spinal cord tuberculosis (TB). Unlike Pott’s spine, IMT is without osseous involvement and is indolent. These features may account for why the diagnosis is often overlooked as a cause of compressive myelopathy. Our case is unique in that we discuss an unusual presentation of a patient who presented with gait disturbance as the first symptom of spinal cord TB without foci of TB infection elsewhere. The patient’s neurological symptoms improved with surgery and multidrug-resistant antituberculosis treatment. Although MRI is the preferred modality to characterize IMT, findings may be nonspecific, ultimately requiring biopsy. When IMT is diagnosed and managed appropriately, it carries a good prognosis. An interdisciplinary approach would provide the best outcomes.

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Nocardia is an opportunistic aerobic actinomycete that most frequently affects the lungs, brain, and skin in 0.04% to 3.5%2 patients after solid organ transplant. Natural and synthetic glucocorticoids are at the forefront of anti-inflammatory and immunosuppressive therapies in transplant patients who often succumb to Nocardia infections. Out of the eight species, N. farcinica is potentially more lethal because of its tendency to disseminate and its resistance to antibiotics1. We present a unique patient who developed N. farcinica at the end of a 10-day course of dexamethasone for COVID-19. CASE PRESENTATION: A 61-year-old female with past medical history of non- insulin dependent type II diabetes (hgbA1c 6.3), hypertension, CHF on GDMT, and COVID-19 pneumonia presented with chest pain on the 10th and last day of per oral 4mg dexamethasone course. On admission patient's vitals were stable and labs were notable for leukocytosis, elevated glucose, BNP, and D-dimer prompting a CTA which showed subsegmental PE and a thrombus in SVC extending to the IVC. She was also found to have a right upper lobe 3.3 x 3.2 cm subpleural mass and a left upper lobe 1.9 x 1.5 cm nodule (figure 2). Percutaneous CT-guided coaxial core needle biopsy of right lung mass was done with pathology results notable for branching filamentous organisms consistent with Nocardia further refined by cultures growing Nocardia farcinica. The MRI brain did not show any abscess. She was started on IV Bactrim and meropenem. Eventually, the patient was discharged home on Bactrim and linezolid due to N. farcinica's high resistance rates to Bactrim alone. DISCUSSION: Nocardiosis usually occurs in immunosuppressed states, such as lymphomas, HIV, diabetics, transplant recipients or patients on long term immunosuppressants. Glucocorticoids are widely used as an effective treatment to control inflammatory and autoimmune diseases with more recent prevalent use for covid-19 infections to control immune-mediated damage of lung tissue. We are presenting the first case of N. farcinica infection in a COVID-19 patient after a brief steroid course. The case also highlights N. farcinica infection mimicking a lung mass and demonstrates that pulmonary Nocardia infections can easily be misdiagnosed, highlighting the importance of keeping a broad differential. CONCLUSIONS: steroid use in the management of COVID-19 infection can result in opportunistic infections, including N. farcinica. REFERENCE #1: Margalit I, Goldberg E, Ben Ari Y, Ben-Zvi H, Shostak Y, Krause I, Muhsen K. Clinical correlates of nocardiosis. Sci Rep. 2020 Aug 31;10(1):14272. doi: 10.1038/s41598-020-71214-4. PMID: 32868850;PMCID: PMC7459281 REFERENCE #2: Coussement J, Lebeaux D, van Delden C, Guillot H, Freund R, Marbus S, Melica G, Van Wijngaerden E, Douvry B, Van Laecke S, Vuotto F, Tricot L, Fernandez-Ruiz M, Dantal J, Hirzel C, Jais JP, Rodriguez-Nava V, Lortholary O, Jacobs F;European Study Group for Nocardia in Solid Organ Transplantation. Nocardia Infection in Solid Organ Transplant Recipients: A Multicenter European Case-control Study. Clin Infect Dis. 2016 Aug 1;63(3):338-45. doi: 10.1093/cid/ciw241. Epub 2016 Apr 18. PMID: 27090987. DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by Ericka Charley, source=Web Response No relevant relationships by Jonathan Munoz, source=Web Response No relevant relationships by Hursh Sarma, source=Web Response No relevant relationships by Andrew Talon, source=Web Response