Abstract: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has increasingly been performed for the diagnosis and staging of thoracic malignancies. Findings of a necrotic lymph node raise concern for infectious process and malignancy. A hypoechoic area on ultrasound/EBUS within a lymph node without blood flow is suggestive of pathologies like infections or malignancy. Inspection of the fluid could suggest a diagnosis; clear aspirates usually suggest bronchogenic or mediastinal cysts and purulent material suggests abscesses or necrotic lymph nodes. Growing tumor cells require a blood supply; if the vascular stroma is insufficient due to rapidly growing malignant tumors this could lead to large central areas of ischemic necrosis. Necrotic aspiration of lymph nodes is not always of infectious etiology. Aspiration of fluid in EBUS-TBNA is a rare occurrence, and malignancy should be considered when purulent fluid material is obtained. We present an elderly woman who underwent bronchoscopy with EBUS-TBNA for evaluation of upper lung nodule and mediastinal lymphadenopathy. Pus-like material was obtained on needle aspiration and endobronchial biopsy and mediastinal core biopsy revealed squamous cell carcinoma. PubDate: Thu, 19 Oct 2017 07:04:32 +000
Abstract: The purpose of this article is to report a case of hemoptysis occurring in combination with secondary spontaneous pneumothorax following chemical pleurodesis by talc. A Japanese male with cancer of renal pelvis was found with the left pneumothorax and multiple lung metastases. A computed-tomography scan revealed severe emphysema throughout the lungs. Talc pleurodesis was employed to arrest air leakage. The patient developed hemoptysis 45 minutes after talc injection into the thorax. This is the first report of hemoptysis following talc pleurodesis. The agent could induce severe inflammation in capillary vessels of the lung following visceral pleura infiltration. PubDate: Mon, 16 Oct 2017 00:00:00 +000
Abstract: Dyspnea accounts for more than one-fourth of the hospital admissions from Emergency Department. Chronic conditions such as Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Asthma are being common etiologies. Less common etiologies include conditions such as valvular heart disease, pulmonary embolism, and right-to-left shunt (RLS) from patent foramen ovale (PFO). PFO is present in estimated 20–30% of the population, mostly a benign condition. RLS via PFO usually occurs when right atrium pressure exceeds left atrium pressure. RLS can also occur in absence of higher right atrium pressure. We report one such case that highlights the importance of high clinical suspicion, thorough evaluation, and percutaneous closure of the PFO leading to significant improvement in the symptoms. PubDate: Mon, 16 Oct 2017 00:00:00 +000
Abstract: Granular cell tumor (GCT) is a neoplasm of Schwann cell origin. Its presence in the aerodigestive tract is uncommon and becomes a diagnostic challenge on initial presentation. Our case is of a 59-year-old woman who presented to the emergency department with a history of productive cough and dyspnea associated with fever and chest pain. An initial chest X-ray (CXR) showed a right middle lobe consolidation with follow-up Computed Tomography (CT) scan showing a mass in the right bronchus. Bronchoscopy revealed a polypoid, sessile granular mass in the right bronchus intermedius with multiple white lesions in trachea, left main bronchus, and right upper bronchi. Histology revealed a benign GCT. Bronchoalveolar lavage from the right middle lobe grew Streptococcus pneumoniae. Patient was treated with intravenous levofloxacin during hospital stay and discharged on a 7-day course of oral antibiotics to be followed as outpatient but was lost to follow-up. GCT can present as a polypoid tumor causing recurrent postobstructive pneumonia. Surgical resection is the most successful treatment option. The tumor is more common in third and fourth decade of life and our patient is the oldest patient, according to our knowledge, to have a GCT. PubDate: Sun, 15 Oct 2017 00:00:00 +000
Abstract: Hereditary hemorrhagic telangiectasia is a rare autosomal-dominant condition affecting visceral blood vessel development. Cerebral and most commonly pulmonary arteriovenous malformations are found in the majority of symptomatic patients. The most common complications include embolic strokes and cerebral abscesses, which have been attributed to abnormal vessel communications. Platypnea orthodeoxia is a rare condition that presents dyspnea and oxygen desaturation when adopting an upright position and is relieved on decubitus. The association between hereditary hemorrhagic telangiectasia, pulmonary arteriovenous malformations, and platypnea orthodeoxia has been described in medical literature; however, orthodeoxia as a single entity without platypnea has not been described yet, especially associated with complications of this hereditary condition. We present the case of a 38-year-old male with persistent headaches, in whom a cerebral lesion was detected. Orthostatic tachycardia and severe orthodeoxia without platypnea were evidenced during physical examination. The patient was subsequently diagnosed with hereditary hemorrhagic telangiectasia and underwent cerebral abscess drainage as well as transcatheter endovascular closure of multiple pulmonary arteriovenous malformations. For this reason, the concept of platypnea orthodeoxia syndrome needs further revision. Patients presenting refractory hypoxemia should warn physicians to initially evaluate their oxygen saturation measurements during standing and decubitus position, even though platypnea may not be present. PubDate: Thu, 12 Oct 2017 00:00:00 +000
Abstract: Pulmonary embolus (PE) and deep vein thrombosis are diagnoses that are commonly made in the emergency department. Well known risk factors for thromboembolic events include immobility, malignancy, pregnancy, surgery, and acquired or inherited thrombophilias, obesity, cigarette smoking, and hypertension. We present a case of a 59-year-old female who watched TV and developed leg swelling and was found to have PE and DVT. PubDate: Tue, 03 Oct 2017 07:19:59 +000
Abstract: Plastic bronchitis is a rare disorder characterized by formation of large, branching bronchial casts, which are often expectorated. We present an interesting case of a 35-year-old woman who presented for evaluation of a chronic cough productive of voluminous secretions. Clinical and radiological examination confirmed a total left lung atelectasis without any pathological mediastinal node. Flexible bronchoscopy demonstrated tenacious, thick, and sticky whitish secretions blocking the left stem bronchus. This material was extracted, and inspection demonstrated a bronchial cast, whose pathological analysis revealed necrotic epithelial cells, some eosinophils, and Charcot-Leyden crystals. Two days after bronchoscopy, the patient rejected more bronchial casts, and dyspnea improved. Control of chest x-ray revealed complete left lung aeration and the diagnosis of idiopathic plastic bronchitis was obtained. This article shows the interest in clinical practice to evoke the diagnosis of plastic bronchitis in front of a productive chronic cough. Our case illustrates a rare clinical presentation represented by an atelectasis of an entire lung. PubDate: Mon, 02 Oct 2017 00:00:00 +000
Abstract: Background. Partial anomalous pulmonary venous connection is a rare congenital vascular disorder that may be asymptomatic. Left-sided connections with the innominate vein are discovered infrequently and those without an atrial septal defect are extremely rare. Case. A 66-year-old male was found to have an anomalous left pulmonary vein when a central venous catheter was inserted for management of hypoxemia. In addition to the connection with the left innominate vein an echocardiogram revealed no atrial septal defect. Computed tomography arteriography was used to define the anomaly. Conclusion. Left superior vein partial anomalous pulmonary venous connection with the left innominate vein was discovered incidentally on insertion of central venous catheter. The otherwise innocuous anomaly can become a significant variable when treating critical cardiopulmonary collapse. PubDate: Wed, 13 Sep 2017 00:00:00 +000
Abstract: A 35-year-old female was started on hydralazine 10 mg orally three times a day for treatment of postpartum hypertension. Three months later, after multiple unsuccessful courses of prednisone and antibiotics for presumed pneumonia and asthma exacerbations, her respiratory symptoms progressed in severity and she developed resting hypoxia. Previous diagnostic work-up included spirometry with a restrictive pattern, chest CT showing bilateral basilar consolidation, negative BAL, and nonspecific findings on lung biopsy of mild inflammatory cells. Review of systems was positive for arthralgia, lymphadenopathy, paresthesia, and fatigue that began four weeks after starting hydralazine. A clinical diagnosis of hydralazine-induced lupus (HIL) with pneumonitis was made. Antihistone antibodies were positive supporting a diagnosis of HIL. Management included cessation of hydralazine and a prolonged steroid taper. Within days, patient began improving symptomatically. Six weeks later, CT chest showed complete resolution of infiltrates. Genetic testing revealed she was heterozygous for N-acetyltransferase 2 (intermediate acetylator). Drug-induced lupus should be considered in patients with lupus-like symptoms taking medications with a known association. While the majority of HIL cases occur with high doses and prolonged treatment, cases of low-dose HIL have been reported in patients who are slow acetylators. PubDate: Tue, 08 Aug 2017 06:32:53 +000
Abstract: Primary Pulmonary Diffuse Large B Cell Lymphoma (PPDLBCL) is an extremely rare entity, which exhibits an aggressive behavior by compressing local blood vessels. It represents only 0.04% of all lymphoma cases and is extremely rare in young age. We present a case of a primary pulmonary lymphoma with superior vena cava syndrome (SVCS) in a young female. 27-year-old African American female presented with fever, cough, and facial puffiness for 2 weeks and unintentional weight loss. Chest examination showed decreased breath sounds and dullness on percussion on right side. Labs were normal except for mild leukocytosis, high lactate, and lactate dehydrogenase. Chest X-ray showed a large right side infiltrate with pleural effusion but chest CT showed 10 × 14 × 16 cm mass in the right lung without hilar and mediastinal lymphadenopathy. CT guided biopsy of the right lung mass was done and large B cell lymphoma was diagnosed. She received “involved field radiation” because of the bulky tumor size and superior vena cava involvement prior to R-CHOP to which she responded well. PPDLBCL should be considered as one of the differentials in a young patient with a large lung mass, which needs timely diagnosis and management. PubDate: Tue, 08 Aug 2017 00:00:00 +000
Abstract: Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. TOS may be classified as either neurogenic TOS (NTOS) or vascular TOS: venous TOS (VTOS) or arterial TOS (ATOS), depending on the specific structure being affected. The basis for the surgical treatment of TOS is resection of the first rib, and it may be combined with scalenectomy or cervical rib resection. Herein, we describe a case of arterial thoracic outlet syndrome which was successfully treated with totally endoscopic video-assisted thoracoscopic surgery (VATS) first rib resection. PubDate: Sun, 06 Aug 2017 00:00:00 +000
Abstract: Hemothorax is a rare but potentially fatal postthoracentesis complication. Early clinical signs may be nonspecific resulting in diagnostic delay. A high index of suspicion is vital for early diagnosis and intervention to avoid further bleeding. Following procedure, early bedside ultrasound findings can be vital for early detection. We report a case of massive hemothorax in a 63-year-old male following therapeutic thoracentesis. Diagnosis was made following highly suggestive sonographic findings prompting thoracotomy and lacerated intercostal artery cauterization. PubDate: Wed, 02 Aug 2017 06:53:49 +000
Abstract: We represent an unfortunate case of postinfluenza streptococcal endocarditis in a 34-year-old healthy male. He presented with hypoxic respiratory failure and was found to have mitral and aortic valve vegetation. Hospital course was complicated by the presence of an aortoatrial fistula from an aortic root abscess, persistent septic shock, and multiorgan failure. PubDate: Wed, 05 Jul 2017 00:00:00 +000
Abstract: Congenital lobar emphysema is an uncommon bronchopulmonary malformation characterized by lobar overinflation and accompanying alveolar septum damage that leads to compression atelectasis of the lung parenchyma and displacement of mediastinal structures, with the resultant ventilation-perfusion mismatch. We present a case of a 33-year-old lady with progressive exertional dyspnea. Chest radiograph findings lead to the suspicion of congenital lobar emphysema, which was then confirmed by a computed tomography (CT) scan. This condition is most commonly identified in newborns, with very few cases being reported in adults. Lobectomy remains the treatment of choice and in general has good outcome. PubDate: Mon, 24 Apr 2017 08:53:14 +000
Abstract: Bronchus Associated Lymphoid Tissue Lymphoma (BALTOMA) is a rare subgroup of pulmonary non-Hodgkin’s lymphomas (NHLs) comprising less than 1% of all cases. It constitutes 3.6% of all extranodal lymphomas and only 0.5–1% of primary pulmonary malignancies. They are usually low grade B-cell lymphomas and are considered to originate from the mucosa associated lymphoid tissue (MALT) of the bronchi. Here, we represent a rare case of BALTOMA presenting with immunodeficiency and multiple pulmonary nodules. PubDate: Mon, 13 Mar 2017 06:57:53 +000
Abstract: Postextubation stridor is associated with significant morbidity. It commonly results in extubation failure after established medical treatment fails, such as nebulized epinephrine and/or intravenous steroids. The role of heliox (i.e., combination of helium and oxygen) in managing patients with postextubation stridor has not been fully established. We report two cases of postextubation stridor successfully treated with heliox delivered with bilevel positive airway pressure (BiPAP) after failure of standard medical therapy. PubDate: Wed, 08 Mar 2017 07:03:26 +000
Abstract: Pulmonary nocardiosis is a severe and uncommon opportunistic infection caused by Nocardia species. We present a patient with cryptogenic organizing pneumonia who was receiving long-term immunosuppressive therapy, whose treatment course was complicated by cutaneous and pulmonary nocardiosis. Tissue cultures confirmed Nocardia brasiliensis. Nocardiosis should be a diagnostic consideration for patients treated with long-term immunosuppression who have worsening pulmonary symptoms and relapsing pustular skin lesions. PubDate: Tue, 28 Feb 2017 09:44:01 +000
Abstract: Sarcoidosis is a multisystem granulomatous syndrome of unknown etiology with noncaseating epithelioid granulomas being the pathognomonic pathological finding. Sarcoidosis most commonly involves the lungs and involvement of the gastrointestinal (GI) tract is uncommon. Pancreatic sarcoidosis is very rare, especially when it is the presenting feature of sarcoidosis and can masquerade as pancreatic cancer. Tissue infiltration in pancreatic sarcoidosis can lead to either a diffuse nodular appearance or a mass-like lesion. We present an interesting case of a 47-year-old woman with a 10-pack-year history of smoking who presented with sharp epigastric pain, weight loss, and elevated lipase level. CT and MRI imaging showed a 4 cm × 5 cm heterogeneous pancreatic mass with a dilated pancreatic duct and peripancreatic lymphadenopathy. Endoscopic ultrasound guided FNA revealed noncaseating granulomas with no evidence of malignancy or atypical infection. CT of the chest revealed bilateral mediastinal and hilar adenopathy with calcification, without any parenchymal abnormalities, and her angiotensin-converting enzyme level was elevated at 170 U/L. The clinical picture pointed to the diagnosis of pancreatic sarcoidosis. Given the severity of gastrointestinal symptoms related to pancreatic sarcoidosis, prednisone therapy at 0.5 mg/kg/day was initiated with complete resolution of symptoms at 8 weeks. PubDate: Tue, 21 Feb 2017 00:00:00 +000
Abstract: We are reporting a case of solitary endobronchial papilloma located in posterior segment of the left upper lobe of the lung with malignant transformation and negative human papilloma virus (HPV) strains in a 40-year-old Saudi nonsmoker man. The patient had a concomitant tuberculosis (TB) infection. The patient received appropriate treatment in the form of anti-TB medication and surgical resection of the squamous cell carcinoma followed by chemotherapy. There was no evidence of tumor recurrence, resulting in a complete cure. We are reporting the case as well as a literature review related to the topic. PubDate: Wed, 08 Feb 2017 00:00:00 +000
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