Acute Pleuritic Chest Pain Research Articles

Epipericardial Fat Necrosis and Covid-19.

Epipericardial fat necrosis (EFN) is a rare and self-limiting cause of acute chest pain. We describe a case of EFN in a patient with a recent coronavirus disease (COVID-19). A 55-year-old male presented with a sudden onset of left-sided pleuritic chest pain for the past two days. The patient was diaphoretic, tachypneic, and tachycardic. Acute coronary syndrome was ruled out. A computed tomography (CT) pulmonary angiogram revealed an ovoid encapsulated fatty mass surrounded by dense appearing tissue. Patient symptoms improved remarkably with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). EFN typically presents with a sudden onset of excruciating chest pain. Misdiagnosis, under-diagnosis, and mismanagement are unavoidable. EFN is incidentally diagnosed on CT scan. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects visceral adipose tissue and appears to increase the risk of EFN by promoting inflammatory cytokine production and death of adipocytes. EFN is a rare cause of acute chest pain. SARS-CoV-2 is likely to induce EFN. This rare clinical entity should be considered in the differential of acute chest pain especially in patients with active or recent COVID-19. Epipericardial fat necrosis (EFN) is a rare cause of acute pleuritic chest pain that is often misdiagnosed and mismanaged.SARS-CoV-2 can possibly increase the risk of EFN and this entity should be considered in the differential of chest pain, especially in patients with active or recent coronavirus disease (COVID-19).Clinician awareness of EFN and its potential association with COVID-19, can reduce unnecessary testing and emotional distress.

Epipericardial fat necrosis: a case report of an underdiagnosed disease.

Epipericardial fat necrosis: a case report of an underdiagnosed disease.

Extensive Epipericardial Fat Necrosis in a Case of Metastatic Adenocarcinoma of Lung

Epipericardial fat necrosis is an uncommon benign and self-limiting condition that leads patients to the emergency department owing to the onset of acute pleuritic chest pain. Fat necrosis in adipose tissue can occur at various sites: in the breast and subcutaneous fat after trauma, peripancreatic fat in pancreatitis, and epiploicappendagitis.[1,2] Rarely, it may occur within the epipericardial fat. Since the first description by Jackson et al.,[3] only 35 cases have been published in the English literature, and extensive epipericardial fat necrosis (EFN) is currently described as an extremely rare disease.[4] The aetiology of EFN remains unknown, but some theories have been proposed to explain its origin. Acute torsion of a vascular pedicle is described in some cases, although the presence of a vascular pedicle has been described in only two patients who underwent surgery.[4] Furthermore, increased intrathoracic pressure due to heavy lifting or Valsalva's manoeuvre might trigger rapid changes in capillary pressure, leading to haemorrhagic necrosis, especially if pre-existing structural abnormalities of the adipose tissue, such as lipoma, hamartoma or lipomatosis, are present.[5] Both males and females are affected, and neither age predilections nor pre-disposing factors have been described.[4]

A RARE POST-SURGICAL EMPYEMA AFTER AN APICAL APPROACH TRANSCATHETER AORTIC VALVE REPLACEMENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: First introduced in 2002, the anterograde Transcatheter Aortic Valve Replacement (TAVR) procedure continues to grow in popularity, given its efficacy in patients with high surgical risk suffering from severe aortic stenosis. Although a less invasive procedure than previous techniques, various potential complications can occur causing severe morbidity and death. Post-operative infections occur in for 13-15% of all post TAVR complications. However acute pulmonary complications (APC) after a TAVR procedure only occur in 1.5% of cases. Post TAVR empyema is extremely uncommon. If not emergently diagnosed and treated it may be fatal. CASE PRESENTATION: A 74-year-old male with a past medical history significant for COPD and aortic valve replacement in 2002 underwent a transapical TAVR after presenting with severe aortic insufficiency. 11 days later, the patient developed acute pleuritic chest pain and dyspnea prompting him to return to the emergency department. He was found to be hypoxic requiring 4 liters of nasal cannula and hypotensive requiring Norepinephrine. Initial work-up revealed a leukocytosis of 39.2 K and a large left pleural effusion on CT imaging. A pig-tail catheter was placed with 2 liters of straw-colored fluid removed from the left pleural space. Fluid studies revealed LDH 1163, pH 7.32, glucose of <5, and WBC 2128 suggesting empyema. Fluid cultures were sent and the patient was started on empiric antibiotics. A repeat chest CT found persistent left sided pleural effusion despite pig-tail catheter with concern for complex appearance of residual fluid. Thoracic surgery was consulted who recommended video-assisted thoracoscopic surgery (VATS) with total decortication. During his procedure a large amount of gelatinous and fibrinopurulent debris were found encasing the entire left lung. A sample of pleural peel was obtained and sent for pathology which showed fibrinopurulent exudate and granulation tissue consistent with empyema. After his procedure, the patient's clinical status continued to improve and he remained stable on room air. He was subsequently discharged home. DISCUSSION: Empyema is a rare post-surgical complication following a TAVR procedure, with few reported cases. Patients with underlying pulmonary disease are at increased risk for APCs following a TAVR procedure. APCs are most common from a trans apical approach. Patients suffering an APC following a TAVR procedure have been shown to have poorer outcomes. Because of this, Empyemas are associated with high morbidity and mortality in post TAVR patients. If not urgently treated it may be fatal. CONCLUSIONS: Empyema is an extremely uncommon complication of a trans apical approach TAVR procedure and is associated with high mortality. Physicians must keep empyema on their differential when treating acute hypoxic respiratory failure in patients with a recent TAVR. REFERENCE #1: Baillot, Richard et al. "Surgical site infections following transcatheter apical aortic valve implantation: incidence and management." Journal of cardiothoracic surgery vol. 7 122. 13 Nov. 2012, doi:10.1186/1749-8090-7-122 REFERENCE #2: Mali, Shahriar, and Hasan Haghaninejad. "Pulmonary complications following cardiac surgery." Archives of medical sciences. Atherosclerotic diseases vol. 4 e280-e285. 31 Dec. 2019, doi:10.5114/amsad.2019.91432 REFERENCE #3: Tetsuro Shimura et al. "The incidence, predictive factors and prognosis of acute pulmonary complications after transcatheter aortic valve implantation, Interactive CardioVascular and Thoracic Surgery, Volume 25, Issue 2, August 2017, Pages 191–197, https://doi.org/10.1093/icvts/ivx075 DISCLOSURES: No relevant relationships by Katie Abney, source=Web Response No relevant relationships by Zachary Fyffe, source=Web Response No relevant relationships by Kelly Rodman, source=Web Response No relevant relationships by Jon Simala, source=Web Response

RARE CASE OF A DELAYED HEMOTHORAX AS A COMPLICATION OF EBUS-TBNA

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard of care in staging lung cancer and is regarded as a safe, minimally invasive procedure with low complication rates (0.16-1.44%) as reported in a systematic review of 226 studies of EBUS-TBNA. This case highlights a rare occurrence of a hemothorax secondary to mediastinal hemorrhage post TBNA of mediastinal adenopathy. CASE PRESENTATION: A 66 year-old former smoker with DM, HTN, HLD, and CAD presented for workup of a 6 x 4 cm left lower lobe pulmonary mass. He underwent EBUS-TBNA of hilar and mediastinal lymph nodes and the lung mass. The mass revealed bronchogenic squamous cell carcinoma and TBNA of stations 4R, 4L, 11L and 7 were negative for malignancy. He resumed Rivaroxaban for history of pulmonary embolism (PE) the day after the procedure. Five days after his EBUS, he presented with acute pleuritic right-sided chest pain, dyspnea, and minimal hemoptysis. He had a heart rate of 110, systolic blood pressure of 80 mmHg and required 3L/minute nasal cannula oxygen. Computed tomography of the chest ruled out PE and pneumothorax but revealed interval development of a large right-sided pleural effusion. His hemoglobin dropped to 8 g/dL from 12.4 g/dL five days prior. A 24-French chest tube was placed for a right-sided hemothorax, which drained 1.5L of bloody fluid. The chest tube was maintained until drainage subsided and anticoagulants were held until his follow-up visit. Two weeks later, he presented with recurrent right-sided hemothorax requiring thoracentesis with removal of 1.26L of blood. Pleural studies were negative for malignant and infectious etiologies. He underwent placement of a retrievable inferior vena cava filter while awaiting further therapeutic plans. DISCUSSION: This patient's hemothorax as a hemorrhage-related complication of TBNA is uncommon. One study found that of 7345 patients who had an EBUS-TBNA, 90 patients (1.23%) had a complication, with hemorrhage seen overall in only 50 patients (0.68%) followed by infection (0.19%). A study reviewing 42 cases of hemorrhage-related complications post EBUS-TBNA, noted station 7 in 34 patients (43.0%), followed by 4R in 24 patients (30.4%) as the likely sites. Stations 4R and 7 were sampled in this patient, which likely explain the etiology of his hemothorax. One other case reports mediastinal hematoma as an adverse event of EBUS-TBNA4. This patient was on aspirin though literature suggests that aspirin does not increase risk of bleeding during transbronchial lung biopsy. The patient was not on a P2Y12 inhibitor, a class known to increase bleeding risk. We believe the recurrence of the hemothorax may have been re-accumulation of residual blood. CONCLUSIONS: While the complication rate is low for EBUS-TBNA, this case broadens the bronchoscopist's and patient’s understanding of hemothorax as a potential but rare complication from EBUS-TBNA. Reference #1: Vaidya PJ, Munavvar M, Leuppi JD, Mehta AC and Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: Safe as it sounds. Respirology. 2017; 22: 1093–1101. doi:10.1111/resp.13094. Reference #2: Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013;14:50. doi:10.1186/1465-9921-14-50 Reference #3: Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest. 2002; 122: 1461–1464. DISCLOSURES: No relevant relationships by Venkata Bandi, source=Web Response No relevant relationships by Donald Lazarus, source=Web Response No relevant relationships by Cameron McBride, source=Web Response No relevant relationships by Ritika Singh, source=Web Response

ATYPICAL PRESENTATION OF LEMIERRE'S SYNDROME WITH ISOLATED INVOLVEMENT OF THE EXTERNAL JUGULAR VEIN

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lemierre’s syndrome is a life-threatening complication of pharyngitis leading to internal jugular vein (IJV) thrombophlebitis with pulmonary septic embolisation. Isolated external jugular vein (EJV) thrombophlebitis is rare. CASE PRESENTATION: A 35-year-old woman presented with one day of acute pleuritic chest pain. She had fever, chills, throat pain, dysphagia, malaise, and headache for 2 weeks. On presentation, she had trismus, extensive tender cervical lymphadenopathy with swelling on the left side of the neck, erythematous posterior pharynx and left enlarged erythematous tonsillar pillars without exudates. Blood showed leucocytosis with neutrophil predominance, elevated D-dimer, CRP, elevated bilirubin with normal liver enzymes, low platelets, low albumin, and blood culture revealed Fusobacterium necrophorum. Contrast CT scan soft tissue of the neck showed left tonsillar pillar enlargement with micro-abscesses and extension of inflammation into the left submandibular, parotid, and cervical space with thrombosis of the left EJV. Extension of inflammation into the retro-pharyngeal space was noted. CT Angiogram of Chest revealed bilateral peripheral opacities with cavitation in the right upper lobe and left lower lobe consistent with septic emboli. IJV revealed no thrombosis. A diagnosis of Lemierre’s syndrome was made. The patient improved on antibiotic therapy. DISCUSSION: Lemierre’s syndrome is a rare potentially lethal complication of oropharyngeal infection occurring mainly in young adults characterised by septic thrombophlebitis of the IJV with embolisation to lungs. It is rare (3.6 cases/million/year) with a mortality rate of >15%. 1,2. The common causative organisms are anaerobic gram-negative bacilli from the genus Fusobacterium mainly F. necrophorum.3 The oropharyngeal infection spreads to IJV from local oropharyngeal veins. Lymphatic spread and direct extension of infection also occur. However, in some patients, the venous drainage allows direct propagation of thrombophlebitis into the EJV.3 Patients present with fever, sore throat, neck swelling, pleuritic chest pain with cervical lymphadenopathy. Leucocytosis, elevated ESR, CRP, bilirubin and thrombophilia are seen. CT scan of the soft tissue of the neck and chest with contrast is required for diagnosis. CONCLUSIONS: In patients with severe pharyngitis and pulmonary septic emboli Lemierre’s syndrome must be suspected and the venous system of the neck should be closely visualised for evidence of thrombophlebitis of both IJV and EJV. Reference #1: Nall RW. Sore Throat. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 4e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2715§ionid=228250877. Accessed May 28, 2020.2. Reference #2: Barlam TF, Kasper DL. Approach to the Acutely Ill Infected Febrile Patient. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=183880456. Accessed May 28, 2020 Reference #3: Format:Reicher J, Brooke S, Arnold D, Counter P, Abdelgalil A. An unusual case of cavitating pulmonary nodules: Lemierre's syndrome with isolated involvement of the external jugular vein. BJR Case Rep. 2018;4(3):20170093. Published 2018 Feb 22. doi:10.1259/bjrcr.20170093 DISCLOSURES: No relevant relationships by Anomadarshi Barua, source=Web Response No relevant relationships by padmanabhan krishnan, source=Web Response No relevant relationships by Litty Mathews, source=Web Response No relevant relationships by Qasim Sheikh, source=Web Response No relevant relationships by Sarita Singh, source=Web Response

Spontaneous Pneumothorax: Follow up Treatment Outcome in a Tertiary Care Center of Eastern Nepal

Background Spontaneous pneumothorax is not an uncommon medical emergency in pulmonary practice. Related data are not available in our setting. In emergency departments, clinical presentation is often confused with other cardiopulmonary problems. Follow up outcome is important for better patient care. Objective To study clinical profile and outcome after non surgical intervention in a tertiary care center. Method This was a prospective observational study carried out in Nobel Medical College, Biratnagar over last 3 years. We enrolled consecutive spontaneous pneumothorax patients over 15 years of age. Each data related to individual patients were collected in predefined proforma. To study follow up outcome of management, we used OPD attendance or if not possible took, at least two telephone numbers from the patients. All patients were followed for recurrences. Data was statistically analyzed using SPSS software. Result Over the last 3 years, we enrolled 65 spontaneous pneumothorax patients. Secondary spontaneous pneumothorax was more common (92.3%). Commonest presentations were acute pleuritic chest pain (92.3%), dyspnea (84.62%) and cough (92.3%). COPD (46.14%), PTB sequelae (15.38%), bronchiectasis (23.07%) and bullous lung disease (23.07%) were common risk factors. Tube thoracostomy (95.38%) with pleurodesis with iodopovidone (84.61%) led to lung expansion in 92.3% cases. During follow up, only 4.61% had recurrences of pneumothorax. There was one mortality. Conclusion Spontaneous pneumothorax is a common pulmonary emergency. Meticulous and careful assessment of the patients may help reach the diagnosis even in primary care setting. Tube thoracostomy followed by pleurodesis with iodo-povidone suffices in most circumstances leading lower future recurrences.

Trans-Diaphragmatic Rupture of Liver Hydatid Cyst in to the Pleural Cavity: A Case Report

: Cystic echinococcosis disease is a parasitic and zoonotic disease which is caused by Echinococcosis granulosus, which is endemic in Mediterranean Region and Middle East countries, including Iran. Cyst formation usually occurs in the liver and grows slowly in a spherical shape. The patients are usually asymptomatic until the lesion reaches a significant size or becomes complicated by rupture. Hepatic lesions are usually single. Diagnosis could be made on the basis of imaging studies including computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound study, especially for liver involvement. Serologic studies are usually helpful and antibody detection is more sensitive than antigen. This article introduces a middle aged man who was presented to the emergency department with acute pleuritic chest pain. Further evaluations revealed coexisting liver and chest hydatid cyst with rupture of the liver cyst in to the pleural cavity, following rupture of the diaphragm. Then diagnosis and treatment are discussed.

A CASE OF EMPYEMA SECONDARY TO ACTINOMYCES NEUII

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Actinomyces neuii is a gram-positive organism infrequently recognized and can cause a myriad of infections. To date, no infections have been described in the pleural space. We present a case of empyema secondary to A. neuii. CASE PRESENTATION: 74 year old woman presented with 2 months of dyspnea on exertion, 5 days of acute pleuritic chest pain, fever, and oxygen desaturation to 88% on room air as outpatient prompting hospitalization. She denied weight loss, had a history of hypothyroidism, remote history of removed left breast fibro-adenoma and quit smoking 40 years prior. She received antibiotics for an upper respiratory infection a month prior. She had a neutrophil predominant leukocytosis to 19.4 and elevated liver enzymes. Computed tomography of chest showed right hilar lymphadenopathy and loculated pleural effusion. She was admitted and started on broad spectrum antibiotics. A chest tube was placed yielding purulent drainage and fluid analysis revealed 85% neutrophils with lactate dehydrogenase of 1843 U/L indicating an exudate. She was treated according to the MIST II protocol for empyema. Further workup revealed negative respiratory viral, HIV, immunoglobulin and hepatitis panels. Blood culture grew gram positive rods 84 hours after admission in anaerobic media which speciated 2 weeks after as A. neuii. Pleural fluid cytopathology was negative for malignancy and culture, including acid fast bacilli. CT of her abdomen and pelvis was negative for intra-abdominal source of infection, but revealed fibroid uterus and an intrauterine device (IUD) without evidence of infection. She completed 4 weeks of Ceftriaxone followed by 4.5 months of Amoxicillin with resolution of leukocytosis, lymphadenopathy and complete resolution of pleural space on outpatient interval imaging. DISCUSSION: A. neuii is an aerobic and facultative anaerobic organism that does not produce sulfur granules or branching filaments. It can cause soft tissue abscesses especially surrounding foreign bodies, post intravitreal injection endopthalmitis, and 2 cases of neonatal sepsis that resulted in premature delivery. One mother had emergent placement of cervical cerclage while the other had prolonged use of IUD. A. neuii is susceptible to beta-lactam antibiotics, clindamycin and erythromycin. Fluoroquinolones and trimethoprim-sulfamethoxazole have less in-vitro activity against isolates. Surgical resection is usually indicated for soft tissue infections. Though inconclusive, the preceding respiratory infection or the prolonged use of IUD may have been sources for infection. We suspect A. neuii was the causative organism for the empyema despite the fact that it was only cultured from blood and not from the pleural space. CONCLUSIONS: To date, no cases of empyema due to A. neuii have been reported in literature. We describe a case with successful non-surgical management. Reference #1: 1. Zelyas N, Gee S, Nilsson B, Bennett T, Rennie R. Infections Caused by Actinomyces neuii: A Case Series and Review of an Unusual Bacterim. Can J Infect Dis Med Mircobiol. 2016;2016:6017605 Reference #2: 2. Olson JM, Vary JC Jr. Primary Cutaneous Actinomyces neuii Infection of the Breast Successfully Treated with Doxycycline. Cutis 2013;92(16)E3-4 Reference #3: 5. Alsohime F, Assiri RA, Al-Shahrani F, Bakeet H, Elhazmmi M, Somily AM. Premature labor and neonatal sepsis caused by Actinomyces neuii. J Infect Public Health 2018 S1876-0341(18)30037-6 DISCLOSURES: no disclosure on file for Stella Hahn; no disclosure on file for Gita Lisker; No relevant relationships by Etieno Umobong, source=Web Response

Pneumotoraks spontan primer berulang pada wanita hamil dengan hiperemesis gravidarum: laporan kasus

Background: Spontaneous pneumothorax is a rare case during pregnancy. However, the condition of Hyperemesis Gravidarum during pregnancy is one of the risk factors for recurrent primary spontaneous pneumothorax.Case Description: A 28-year-old woman with G5P3013 gestational age 12-13 weeks with Hyperemesis Gravidarum had complaints of tightness and recurrent acute pleuritic chest pain. After a clinical and supporting examination using ultrasound, patients were diagnosed with recurrent primary spontaneous pneumothorax, and observational and symptomatic treatments were performed. The rupture of the bleb or the subpleura bulla is thought to be a pathological mechanism. Patients given birth vaginally without complications and complete resolution of the pneumothorax occurred.Conclusion: Recurrent pneumothorax in pregnant women with a history of hyperemesis gravidarum is rare. Observational and symptomatic treatment is the initial treatment that can be done.

Epipericardial Fat Pad Necrosis-A Rare Cause of Chest Pain in an Adolescent.

Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain reported in approximately 40 cases. This diagnosis mimics a myocardial infarction, pulmonary embolism, or pericarditis; however, the cardiac enzymes and electrocardiogram are usually normal. We present the first reported case of epipericardial fat necrosis in an adolescent.

Pulmonary nocardiosis mimicking small cell lung cancer in ectopic ACTH syndrome associated with transformation of olfactory neuroblastoma: a case report

BackgroundPulmonary nocardiosis frequently develops as an opportunistic infection in cell-mediated immunosuppressive patients, and sometimes requires differentiation from pulmonary malignancy. Ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) is a neoplastic disorder which leads to impaired cell-mediated immunity, and is commonly associated with small cell lung cancer (SCLC). Because pulmonary infection and causative malignancy can appear as pulmonary lesions with EAS, differentiation of these diseases remains a critical issue for physicians.Case presentationA 52-year-old woman with progressive lower limb paralysis and general fatigue was referred to us. She had been diagnosed with olfactory neuroblastoma (ONB) and treated with surgery and radiation therapy 10 years before the referral and had required stereotactic radiosurgery and chemotherapy 4 years later for a relapse of the ONB. On referral, she presented with Cushing’s syndrome with elevated cortisol and ACTH levels. Potassium supplement improved her symptoms; however, a month later, she was urgently hospitalized due to acute pleuritic chest pain on inspiration. Chest computed tomography revealed left lower lobular consolidations and a contralateral nodule in the right middle lobe. The clinical history and laboratory work-up suggested that her Cushing’s syndrome had most likely arisen from EAS. Additionally, the lungs were suspected as the ACTH source due to high levels of progastrin-releasing peptide and progressive pulmonary consolidation with a contralateral nodule, suggesting SCLC. However, histological examination from bronchoscopy revealed no evidence of malignancy, and Nocardia cyriacigeorgica was isolated from bronchoalveolar lavage fluid. Sulfamethoxazole/trimethoprim improved her pulmonary lesions. Somatostatin receptor scintigraphy revealed strong tracer uptake in the ONB lesions, indicating that the origin of the EAS was the olfactory tumor. However, histological examination of ONB specimens resected 10 years earlier showed no intracytoplasmic immunopositivity for ACTH.ConclusionsWe highlight a rare case of pulmonary nocardiosis, which was associated with EAS mimicking SCLC, and was related to ONB transformation. Nocardiosis has to be considered even though anamnestic, clinical, and radiological aspects suggest the presence of metastasis. Additionally, physicians should carefully monitor patients with ONB for the development of Cushing’s symptoms because the tumor can transform into an ACTH-producing form, even after long-term follow-up.

EVALUATING PULMONARY EMBOLISM IN PATIENTS WITH FONTAN PHYSIOLOGY

Fontan surgery results in complex cardiopulmonary anatomy which complicates interpretation of computed tomography angiography (CTA) when evaluating for pulmonary embolism (PE). A 42-year-old man presented with acute dyspnea and pleuritic chest pain. Medical history included tricuspid atresia status

Xanthogranulomatous pyelonephritis presenting as acute pleuritic chest pain: a case report

BackgroundXanthogranulomatous pyelonephritis is a rare and serious manifestation of chronic kidney inflammation that can be life-threatening if not recognized and treated appropriately, often with antibiotics and surgery. Affected patients are most commonly females in their fifth or sixth decade of life with a background of obstructive uropathy, nephrolithiasis, or recurrent urinary tract infections who present with vague nonspecific symptoms.Case presentationA 43-year-old woman of Russian ethnicity with a history of nephrolithiasis presented to our emergency department with new left-sided pleuritic chest pain amid a 6-week history of constitutional symptoms including fevers, night sweats, and 7 kg of weight loss. Workup for acute coronary syndrome and pulmonary embolism in our emergency department was negative. Given that she was clinically unwell, she was admitted to internal medicine to expedite workup for the cause of her symptoms. A broad differential diagnosis for various infectious, inflammatory/autoimmune, and neoplastic processes was considered. Based on classic radiographic and histopathologic findings, she was ultimately diagnosed with xanthogranulomatous pyelonephritis of her left kidney, which was a direct consequence of chronic inflammation. This inflammation exhibited spread to local tissues and across her left hemidiaphragm, resulting in a unilateral pleural effusion which explained her chest discomfort. She was treated with antibiotics administered intravenously and urgent total nephrectomy with a good functional outcome.ConclusionsOur case illustrates an uncommon but clinically important do-not-miss diagnosis that underlies a common clinical presentation of pleuritic chest pain. The case underscores the importance of maintaining a broad differential diagnosis and organized approach when treating patients with undifferentiated clinical presentations.

Anterior mediastinal masses.

Anterior Mediastinal MassesMaryam Shahrzad1, Thi Som Mai Le1, Mario Silva1, Alexander A. Bankier1 and Ronald L. Eisenberg1Audio Available | Share

Epipericardial fat necrosis: an underdiagnosed condition

Epipericardial fat necrosis (EFN) is an uncommon benign and self-limited condition that leads patients to the emergency department (ED) owing to the onset of acute pleuritic chest pain. The aim of this study was to describe the cases of this disease in our institution and to illustrate the associated clinical and radiological findings. We reviewed 3604 chest scans referred by the ED from November 2011 to July 2013. Patients diagnosed with epipericardial necrosis had their medical records and original tomography reports analysed. Chest pain was the primary complaint in 426 patients; 11 of them had definitive EFN findings characterized by a round soft-tissue attenuation lesion with a varying degree of strands. All patients presented with pleuritic chest pain on the same side as the lesion. Pericardial thickening, pleural effusion and mild atelectasis were the associated tomography findings. Cardiac enzyme and D-dimer tests performed during the episode were normal in all cases. 27% of the cases only were correctly diagnosed with EFN at the time of presentation. EFN is a benign inflammatory condition frequently overlooked in the ED by physicians and radiologists but is an important factor in the differential diagnosis of patients with acute chest pain. The article adds clinically and radiologically useful information about the condition and displays the importance of making the correct diagnosis to avoid unnecessary examinations.

Vanishing Lung Syndrome

Department of Radiology, Bethune First Hospital, Jilin University, Changchun, China Correspondence: Dr Wei Liu, Department of Thoracic Surgery, Bethune First Hospital, Jilin University, No. 71 Xinmin Street, Changchun 130021, China. Telephone 86-431-88782973, fax 86-431-88782733, e-mail davidliuw@hotmail.com A 19-year-old woman was admitted to the emergency room with acute pleuritic chest pain. She had no significant medical history, but was a current smoker. Computed tomography of the chest revealed a giant bulla occupying more than three-quarters of the left hemithorax, compressing the residual lung and displacing the mediastinum toward the opposite side (Figure 1). The images were consistent with vanishing lung syndrome (VLS). At thoracotomy, a giant bulla (at least 20 cm in diameter) was present in the left upper lobe. Bullectomy was performed without incident, allowing re-expansion of the underlying lung (Figure 2). Pathological examination showed an enlarged airspace with paraseptal emphysema on the margin and infiltration of inflammatory cells. images in respiratory medicine

Intra-cardiac erosion of a pectus bar

A 25-year-old man presented with acute pleuritic chest pain and dyspnoea with type I respiratory failure. Past medical history comprised of mild asthma and surgical correction of pectus excavatum 9 years prior by elevation of the sternum and stabilization over a Lorenz Pectus bar. Examination demonstrated tachypnoea, pan-systolic murmur at the left lower sternal edge and giant V-wave jugular venous …

Two Systemic Lupus Erythematosus Patients With Severe Pleurisy: Similar Presentations, Different Causes

History of the present illness. A 25-year-old woman was diagnosed with systemic lupus erythematosus (SLE) 2 years prior to admission, after she presented with fever, malaise, lymphadenopathy, arthritis, myalgias, malar rash, and positive serologies for antinuclear antibody (ANA) and anti–double-stranded DNA (anti-dsDNA). Additional serology tests were negative for anti-Ro/SSA, anti-La/SSB, RNP, and Sm antibodies, as well as antiphospholipid antibodies (aPL). She was treated with intermittent courses of glucocorticoids (GC) for disease flares. Eight months before admission, she had a severe flare that manifested with high fevers, weight loss, delirium, spastic bladder, and non-nephrotic proteinuria. She was ultimately diagnosed with gray matter transverse myelitis of the conus medullaris and lupus nephritis. She was treated aggressively with pulse GC and intravenous (IV) cyclophosphamide (CYC), which led to resolution of all symptoms. After completion of a 6-month course of IV CYC, she was maintained on 20 mg of prednisone. One month prior to admission, she was admitted to another hospital with leftsided pleurisy, dyspnea, and high fever. A chest computed tomography (CT) scan excluded pulmonary embolism, but showed bilateral lung lower lobe consolidations with pleural effusions (left larger than right) and a small fluid collection adjacent to her spleen. Her blood cultures grew Salmonella. Her symptoms improved with cefepime and high-dose GC, and she was discharged home 2 weeks later on 60 mg of daily prednisone and oral levofloxacin for a total of 3 weeks of antibiotics. In addition, she was discharged on trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg 3 times weekly for Pneumocystis jiroveci pneumonia (PCP) prophylaxis. One week before her current admission, she was started on 1,000 mg of mycophenolate mofetil (MMF) daily. She then presented to our hospital with acute left-sided pleuritic chest pain, dyspnea, and arthralgias. She did not have fever or cough.

Imaging Manifestations of Mediastinal Fat Necrosis

Mediastinal fat necrosis (MFN) or epipericardial fat necrosis, as it is commonly referred to in the literature, is a rare self-limiting cause of chest pain of unclear etiology. MFN affects previously healthy individuals who present with acute pleuritic chest pain. Characteristic computed tomography (CT) findings include a fat attenuation lesion with intrinsic and surrounding increased attenuation stranding. There is often associated thickening of the adjacent pericardium and/or pleural effusions. We present two cases of MFN manifesting as ovoid fat attenuation lesions demarcated by a soft tissue attenuation rim with intrinsic and surrounding soft tissue attenuation stranding and review the clinical and pathologic features of these lesions. Knowledge of the clinical presentation of patients with MFN and familiarity with the characteristic imaging findings of these lesions should allow radiologists to prospectively establish the correct diagnosis and suggest conservative management and follow-up.