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Background : There are limited reports describing critically ill COVID-19 patients in the state of New York. Methods : We conducted a retrospective analysis of 32 adult critically ill patients admitted to a community hospital in upstate New York, between 14 March and 12 April 2020. We collected demographic, laboratory, ventilator and treatment data, which were analyzed and clinical outcomes tabulated. Results : 32 patients admitted to the intensive care unit (ICU) were included, with mean (±SD) follow-up duration 21 ± 7 days. Mean (±SD) age was 62.2 ± 11.2 years, and 62.5% were men. 27 (84.4%) of patients had one or more medical co-morbidities. The mean (±SD) duration of symptoms was 6.6 (±4.4) days before presentation, with cough (81.3%), dyspnea (68.7%), and fever (65.6%) being the most common. 23 (71.9%) patients received invasive mechanical ventilation. 5 (15.6%) died, 11 (34.4%) were discharged home, and 16 (50%) remained hospitalized, 8 (25%) of which were still in ICU. Mean (±SD) length of ICU stay was 10.2 (±7.7) days, and mean (±SD) length of hospital stay was 14.8 (±7.7) days. Conclusion : Majority of patients were of older age and with medical comorbidities. With adequate resource utilization, mortality of critically ill COVID-19 patients may not be as high as previously suggested. Abbreviations : ACE-i: Angiotensin converting enzyme inhibitor; ARB: Angiotensin receptor blocker; ARDS: Acute Respiratory Distress Syndrome; BiPAP: Bilevel positive airway pressure; CABG: Coronary artery bypass graft; CFR: Case fatality rate; COVID-19: Coronavirus disease 19; CPAP: Continuous positive airway pressure; CRP: C – Reactive Protein; CT: Computed tomography; DVT: Deep vein thrombosis; ECMO: Extra Corporeal Membrane Oxygenation; ESICM: European Society of Intensive Care Medicine; FiO2: Fraction of inspired O2; HFNC: High Flow Nasal Cannula; HITF: Hypoxia-Inducible Transcription Factor; IBM: International Business Machines; ICU: Intensive Care Unit; IL: Interleukin; IMV: Invasive Mechanical Ventilation; IQR: Interquartile Range; ISTH: International Society of Thrombosis Hemostasis; NIV: Non Invasive Ventilation; NY: New York; PAI: Plasminogen activator inhibitor; PaO2: partial pressure of arterial oxygen; PCV: Pressure Control Ventilation; PEEP: Positive End Expiratory Pressure; RGH: Rochester General Hospital; RRH: Rochester Regional Health; RT-PCR: Reverse transcriptase polymerase chain reaction; RSV: Respiratory Syncytial virus; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; SD: Standard Deviation; STEMI: ST segment elevation myocardial infarction; TNF: Tumor necrosis factor; USA: USA; VTE: Venous thromboembolism

INTRODUCTION: Extramedullary plasmacytoma (EMP) are rare manifestations of multiple myeloma (MM). We report a case of pulmonary EMP presenting as hilar mass.CASE PRESENTATION: A 51 year old female presented with hearing loss and right facial palsy. Medical history was significant for MM diagnosed 2 years prior, treated with bortezomib-prednisone therapy. 6 months ago, thoracic spine plasmacytoma were found requiring surgical resection and local radiation. Remission was perceived and she was maintained on Thalidomide. MRI brain and spine revealed meningeal enhancement with lytic bony lesions, concerning for metastatic disease. CT chest abdomen pelvis revealed a 4.5 x 5.5 cm right hilar mass with complete right lower lobe (RLL) bronchus occlusion, post-obstructive pneumonia, right pleural effusion, pleural thickening and nodularity. She underwent bronchoscopy with endobronchial biopsy of RLL bronchial nodules and EBUS guided transbronchial needle aspiration of right hilar mass. Pathology was consistent with plasma cell myeloma with plasmablastic features. Given her MM history and absence of EBV, primary plasmablastic lymphoma was less likely. A bone marrow biopsy showed >10% myeloma cells, thus her diagnosis was consistent with relapsed MM with extramedullary plasmacytoma (EMP) rather than primary pulmonary plasmacytoma (PPP). Subsequently she underwent systemic and intrathecal second line chemotherapy, but her course was complicated by rapidly progressive refractory disease and patient chose to pursue hospice care.DISCUSSION: EMP are seen in 7 % patients with MM at the time of diagnosis, whereas another 6% develop it later in the course of illness; these portend poor prognosis. Among them, pulmonary EMP are extremely rare. Other pulmonary complications of multiple myeloma include pneumonia, including organizing pneumonia like consolidation, multiple pulmonary nodules, interstitial infiltrates and pleural thickening and effusion. In contrast, primary solitary extramedullary plasmacytoma is a rare discrete plasma cell neoplasm within soft tissue, without bone marrow involvement or other systemic features of MM. They commonly occur in the aero-digestive tract, of which solitary PPP is a rare type. PPP have better prognosis and longer survival rates compared to EMP associated with MM. Their management also differs, EMP associated with MM are treated aggressively with chemotherapy and local radiation or surgery as needed, whereas solitary PPP are treated with radiation only.CONCLUSIONS: Knowledge of pulmonary EMP and its clinical course is important for physicians, such that the etiology of pulmonary abnormalities in patients with multiple myeloma are evaluated and determined in order to ensure appropriate therapy and patient counseling.

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