Bilateral Diffuse Opacities Research Articles

A Case of Pneumocystis jirovecii Pneumonia in an Infant with Ataxia-Pancytopenia Syndrome

BackgroundAtaxia-pancytopenia syndrome (ATXPC), a rare autosomal dominant disorder caused by pathogenic variants in the SAMD9L gene, is characterized by variable onset and severity of cerebellar ataxia, hematologic cytopenias, and immunodeficiency of myeloid, B-, and NK-cells. ATXPC has been associated with viral and bacterial infections, but no cases of opportunistic PJP have been reported. CaseAt 6 weeks of age, the patient was admitted to the hospital for acute hypoxemic respiratory failure due to rhino/enterovirus bronchiolitis, requiring supplemental oxygen. The increased oxygen requirement later led to intubation. A chest x-ray showed diffuse bilateral opacities concerning for pediatric acute respiratory distress syndrome (PARDS). Bronchoalveolar lavage and silver stain revealed organisms morphologically suggestive of Pneumocystis jirovecii pneumonia (PJP), which was confirmed with a positive serum beta-glucan. Based on the diagnosis of PJP, the patient was started on steroids and Bactrim. Immunology was consulted for further evaluation for possible underlying immunodeficiency. The patient had a normal newborn screening. HIV PCR was negative. Repeated TRECs, CD3+, CD8+, CD19+, and immunoglobulin levels (IgG, IgE) were within normal limits, but modest reduction of CD45 RA/RO ratio and IgA were observed. Additionally, natural killer cell function was low. T-cell proliferation to mitogens were normal, but significantly decreased to candida and tetanus antigens. A significant reduction in the expression of HLA-ABC and HLA-DR was observed in the lymphocytes and monocytes of the patient compared to the control. Interestingly, HLA-DR expression on monocytes was particularly affected. A next-generation sequencing of primary immunodeficiency genes identified likely pathogenic, maternally inherited variants: a heterozygous SAMD9L variant (ataxia-pancytopenia syndrome) and NLRP12 variant (familial cold autoinflammatory syndrome 2). DiscussionATXPC has been associated with variable cellular immunodeficiencies. While prior studies have reported recurrent bacterial and viral infections in ATXPC patients, this case is the first to document a PJP opportunistic infection in an infant. It is possible that the NLRP12 variant found in this patient could have also contributed to this clinical presentation. Early diagnosis of ATXPC through clinical recognition and genetic testing may improve prognosis.

TRAFFIC JAM IN THE VASCULATURE: A CASE OF PULMONARY LEUKOSTASIS

TRAFFIC JAM IN THE VASCULATURE: A CASE OF PULMONARY LEUKOSTASIS

ACUTE EOSINOPHILIC PNEUMONIA: COMPLICATIONS OF SMOKE EXPOSURE AND VAPING-ASSOCIATED LUNG INJURY

TOPIC: Occupational and Environmental Lung Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: E-cigarette or vaping product use-associated lung injury (EVALI) encompass a host of pulmonary complications including diffuse alveolar hemorrhage, lipoid pneumonia, hypersensitivity pneumonitis, and rarely, acute eosinophilic pneumonia (AEP) [1]. AEP presents as an acute febrile illness with hypoxemia, diffuse pulmonary infiltrates, and eosinophilia on bronchoalveolar lavage (BAL) without evidence of prior infection or atopic illness [2]. Presented is a young adult patient with a history of continuous vaping and extended exposure to kitchen smoke who developed acute hypoxemic respiratory failure later diagnosed as AEP. CASE PRESENTATION: An 18-year-old male with no significant past medical history presented to the emergency department with acute onset malaise, fever, non-productive cough, and shortness of breath over 12 hours. Social history revealed 3-week workplace exposure to smoke as a barbeque cook and a 5-year history of daily vaping with reported cessation 3 weeks prior. Vitals were notable for hypoxemia which was corrected with administration of 8L of oxygen via nasal cannula. Quickly after admission, he had worsening respiratory status: tachypnea, increased oxygen requirement, use of accessory muscles, and bilaterally diminished breath sounds. He was transferred to the medical intensive care unit for emergent endotracheal intubation. Laboratory testing revealed a neutrophil predominant leukocytosis of 19.3x109/L. COVID-19, rapid influenza A and B, and urine antigens for streptococcus and legionella were negative as were autoimmune serologies. A computed tomography (CT) scan of the chest revealed diffuse bilateral consolidative opacities [Figure 1] with worsening over the next 24 hours [Figure 2]. Further investigation was undertaken with bronchoscopy. A BAL was obtained, and cell count and cultures were sent. BAL cell count was remarkable for 33% eosinophilia. The diagnosis of AEP was made, and the patient was started on systemic glucocorticoids, with significant improvement within 24 hours. DISCUSSION: The modified Philit criteria is used to make the diagnosis of AEP, which the patient satisfied [3]. Although a 5-year vaping history was present, no previous significant respiratory symptoms were reported. Prior studies have demonstrated a relationship between workplace smoke exposure and AEP [3]. Based on the modified Philit criteria, we suspect that the patient had acute respiratory failure from AEP as a result of chronic EVALI acutely exacerbated by workplace smoke exposure. The treatment of AEP treatment involves high-dose intravenous glucocorticoids followed by a prolonged oral steroid taper. CONCLUSIONS: Obtaining occupation history as well as smoke exposure is as important as obtaining vaping history in an otherwise healthy young patient who presents with acute hypoxemic respiratory failure with bilateral diffuse opacities on imaging. REFERENCE #1: Winnicka L, Shenoy MA. EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review. J Gen Intern Med. 2020;35(7):2130-2135. doi:10.1007/s11606-020-05813-2 REFERENCE #2: Allen JN, Pacht ER, Gadek JE, Davis WB. Acute Eosinophilic Pneumonia as a Reversible Cause of Noninfectious Respiratory Failure. N Engl J Med. 1989;321(9):569-574. doi:10.1056/nejm198908313210903 REFERENCE #3: Philit F, Etienne-Mastroïanni B, Parrot A, Guérin C, Robert D, Cordier JF. Idiopathic acute eosinophilic pneumonia: A study of 22 patients. Am J Respir Crit Care Med. 2002;166(9):1235-1239. doi:10.1164/rccm.2112056 DISCLOSURES: No relevant relationships by Nurjahan Khatun, source=Web Response No relevant relationships by Parth Patel, source=Web Response No relevant relationships by Naleen Patel, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response No relevant relationships by Rodger Wilhite, source=Web Response

A novel swine model of the acute respiratory distress syndrome using clinically relevant injury exposures.

To date, existing animal models of the acute respiratory distress syndrome (ARDS) have failed to translate preclinical discoveries into effective pharmacotherapy or diagnostic biomarkers. To address this translational gap, we developed a high‐fidelity swine model of ARDS utilizing clinically relevant lung injury exposures. Fourteen male swine were anesthetized, mechanically ventilated, and surgically instrumented for hemodynamic monitoring, blood, and tissue sampling. Animals were allocated to one of three groups: (1) Indirect lung injury only: animals were inoculated by direct injection of Escherichia coli into the kidney parenchyma, provoking systemic inflammation and distributive shock physiology; (2) Direct lung injury only: animals received volutrauma, hyperoxia, and bronchoscope‐delivered gastric particles; (3) Combined indirect and direct lung injury: animals were administered both above‐described indirect and direct lung injury exposures. Animals were monitored for up to 12 h, with serial collection of physiologic data, blood samples, and radiographic imaging. Lung tissue was acquired postmortem for pathological examination. In contrast to indirect lung injury only and direct lung injury only groups, animals in the combined indirect and direct lung injury group exhibited all of the physiological, radiographic, and histopathologic hallmarks of human ARDS: impaired gas exchange (mean PaO2/FiO2 ratio 124.8 ± 63.8), diffuse bilateral opacities on chest radiographs, and extensive pathologic evidence of diffuse alveolar damage. Our novel porcine model of ARDS, built on clinically relevant lung injury exposures, faithfully recapitulates the physiologic, radiographic, and histopathologic features of human ARDS and fills a crucial gap in the translational study of human lung injury.

HUT LUNG: A CASE OF MIXED DUST PNEUMOCONIOSIS

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumoconioses are a group of interstitial lung diseases (ILD) associated with occupational exposure. Domestically acquired mixed dust pneumoconiosis (MDP) from biomass combustion (Hut lung) is often reported in developing nations but rarely in the US. CASE PRESENTATION: A 76-year-old Hispanic female, non-smoker, who immigrated from Mexico 15 years ago, presented with 1 week of worsening dyspnea on exertion, subjective fever and cough productive of whitish sputum. Past history was significant for asthma and idiopathic ILD. Home medications included montelukast and inhaled albuterol and fluticasone. On admission, she was afebrile, hemodynamically stable and oxygen saturation (SpO2) was 65% on room air. CXR showed diffuse bilateral opacities. CT chest showed diffuse interstitial fibrotic changes, superimposed ground glass opacities and bronchiectasis. Supplemental oxygen, ceftriaxone and azithromycin were initiated, later switched to piperacillin-tazobactam and oral steroids. Blood/sputum cultures, respiratory viral panel, bacterial and fungal serology, HIV, autoimmune work-up, hypersensitivity pneumonitis panel were negative. On day 5, she was lethargic, SpO2 78% on high flow nasal cannula and was intubated. Video-assisted thoracoscopic biopsy showed fibrosis preliminarily reported as Usual Interstitial Pneumonia (UIP). She received 2 doses of azathioprine, 5 days of IVIG, 3 days of 1g solumedrol and trimethoprim/sulfamethoxazole for pneumocystis prophylaxis but had no response to treatment which is unusual for UIP. She developed shock. Norepinephrine drip was started. Confirmatory pathology from Cleveland Clinic showed chronic fibrosing interstitial process with honeycombing, interstitial and peri-bronchovascular mixed dust deposition consistent with MDP. Detailed environmental history revealed use of wood/coal-fueled stove in a small, ill-ventilated hut for several years in Mexico and no other occupational exposure. Ventilator requirements increased to 16 PEEP and 100% FiO2. Palliative care was consulted, and her family transitioned her to comfort care. DISCUSSION: Hut lung is a type of MDP characterized by carbon deposition, dust macules and fibrosis, reported primarily in women with chronic exposure to biomass smoke. Clinical presentation is nonspecific with symptoms of dyspnea, cough and respiratory distress. It is seldom considered in the differential diagnosis, as patients are usually women without typical occupational exposures. Duration of exposure correlates with severity of disease. The only effective form of treatment is prevention of further exposure, which makes early diagnosis a crucial step. Management involves avoidance of exposures and treatment of the underlying airway obstruction in line of COPD. CONCLUSIONS: There needs to be a high degree of suspicion for Hut lung (MDP) in women who have immigrated to the USA from countries where firewood is used for cooking. Reference #1: Assad NA, et al. Biomass smoke exposure and chronic lung disease. Curr Opin Pulm Med.2016;22(2):150–157 Reference #2: Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011; 183:788–824. Reference #3: Sandoval J, Sales J, Martinez-Guerra ML, Et al. Pulmonary arterial hypertension and cor pulmonale associated with chronic domestic woodsmoke inhalation. Chest 103:12-20, 1993 DISCLOSURES: No relevant relationships by Eileen Hu-Wang, source=Web Response No relevant relationships by Manojna Nimmagadda, source=Web Response No relevant relationships by Roshan Thapa, source=Web Response No relevant relationships by Dhiran Verghese, source=Web Response

DIFFUSE ALVEOLAR HEMORRHAGE AS CLINICAL PRESENTATION OF GPA

TYPE: Abstract Publication TOPIC: Diffuse Lung Disease PURPOSE: We describe a case of diffuse alveolar hemorrhage (DAH) as a presenting clinical manifestation of ANCA-associated vasculitis (AAV) leading to pulmonary-renal syndrome (PRS), a rare complication with a high mortality rate. METHODS: A 52-yo male presented with a one-week history of malaise and dry cough. Lung examination showed decreased breath sounds. Chest x-ray demonstrated diffuse bilateral opacities. CT showed diffuse alveolar filling. Labs were significant for normocytic anemia 8.1(g/dL), renal failure (Cr 3.14 (mg/dL)) and PaO2 74mm HG on 100% oxygen. Vancomycin, piperacillin/tazobactam, and azithromycin were initiated. Urinalysis showed hematuria and proteinuria. Autoimmune workup revealed CRP 213 mg/L, ESR 56 mm/h, ANCA (+), C-ANCA 1:1280, PR3+ >8. Due to rapidly decreasing hemoglobin and respiratory failure patient was intubated and bronchoscopy confirmed DAH. Patient was treated with pulse steroids for five days, cyclophosphamide, and plasmampharesis. Intermittent hemodialysis initiated for renal failure and anuria. Patient was extubated on day 7 and renal biopsy on day 10 confirmed acute necrotizing glomerulonephritis consistent with AAV. RESULTS: We report a case of GPA with sudden onset of hypoxic respiratory failure progressing to PRS. Severities of presenting symptoms and findings in patients with GPA vary considerably from asymptomatic to acute alveolar hemorrhage with respiratory failure. CONCLUSIONS: Although DAH is a rare manifestation of the disease, occurring only in 5% to 10% of patients, it acts as a precursor of severe vasculitis. CLINICAL IMPLICATIONS: Early detection of GPA is essential since it may lead to rapid clinical deterioration; high of index of suspicion and early management significantly improves morbidity and mortality. DISCLOSURE: No significant relationships. KEYWORDS: Diffuse Alveolar Hemorrhage, ANCA Vasculitis

ACUTE RESPIRATORY DISTRESS SYNDROME UNFOLDING AS ATYPICAL KAWASAKI DISEASE

TYPE: Abstract Publication TOPIC: Pulmonary Manifestations of Systemic Disease PURPOSE: Kawasaki disease (KD) is a medium vessel multisystemic vasculitis and is the leading cause of acquired heart disease among children in developed countries. Pulmonary involvement in KD is uncommon. Here we present a case of atypical KD, with acute respiratory distress syndrome (ARDS) as presenting manifestation. METHODS: A 7-year old, previously healthy boy presented with fever for 5 days, rash since day 2 of illness and difficulty in breathing for 2 days. On examination, severe respiratory distress, desquamating macular rash over face, neck, chest and minimal conjunctival congestion were noted. X-ray chest with findings of diffuse bilateral opacities and oxygenation index of 11 on blood gas analysis were suggestive of ARDS. The child required mechanical ventilation for respiratory failure. RESULTS: Serum electrolytes, hemogram, liver and renal function tests were within normal limits. Blood culture came sterile and workup for tropical fevers came negative. On day 15 of illness, child developed periungual peeling. Repeat investigations showed hemoglobin of 82g/L, total leucocyte count 18.5x109/L, platelets 707x109/L, ESR 55 mm in 1sthour and CRP 27mg/dL. Diagnosis of atypical KD was considered and 2g/kg intravenous immunoglobulin was given. Clinical and laboratory parameters showed a trend towards normalization and child was extubated 60 hours later. No coronary artery abnormality was noted on echocardiography. Child was discharged on low-dose aspirin and is doing well on follow-up. CONCLUSIONS: ARDS is an extremely unusual initial presentation of KD. CLINICAL IMPLICATIONS: A high index of suspicion for KD must be kept in atypical pulmonary presentations to prevent delay in diagnosis and development of sequelae. DISCLOSURE: No significant relationships. KEYWORDS: Kawasaki disease, Acute respiratory distress syndrome, Intravenous immunoglobulin

Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: A single center study of 100 patients in Brescia, Italy.

A hyperinflammatory syndrome (HIS) may cause a life-threatening acute respiratory distress syndrome (ARDS) in patients with COVID-19 pneumonia.A prospective series of 100 consecutive patients admitted to the Spedali Civili University Hospital in Brescia (Italy) between March 9th and March 20th with confirmed COVID-19 pneumonia and ARDS requiring ventilatory support was analyzed to determine whether intravenous administration of tocilizumab (TCZ), a monoclonal antibody that targets the interleukin 6 (IL-6) receptor, was associated with improved outcome. Tocilizumab was administered at a dosage of 8 mg/kg by two consecutive intravenous infusions 12 h apart. A third infusion was optional based on clinical response.The outcome measure was an improvement in acute respiratory failure assessed by means of the Brescia COVID Respiratory Severity Score (BCRSS 0 to 8, with higher scores indicating higher severity) at 24–72 h and 10 days after tocilizumab administration.Out of 100 treated patients (88 M, 12 F; median age: 62 years), 43 received TCZ in the intensive care unit (ICU), while 57 in the general ward as no ICU beds were available. Of these 57 patients, 37 (65%) improved and suspended noninvasive ventilation (NIV) (median BCRSS: 1 [IQR 0–2]), 7 (12%) patients remained stable in NIV, and 13 (23%) patients worsened (10 died, 3 were admitted to ICU). Of the 43 patients treated in the ICU, 32 (74%) improved (17 of them were taken off the ventilator and were discharged to the ward), 1 (2%) remained stable (BCRSS: 5) and 10 (24%) died (all of them had BCRSS≥7 before TCZ). Overall at 10 days, the respiratory condition was improved or stabilized in 77 (77%) patients, of whom 61 showed a significant clearing of diffuse bilateral opacities on chest x-ray and 15 were discharged from the hospital. Respiratory condition worsened in 23 (23%) patients, of whom 20 (20%) died.All the patients presented with lymphopenia and high levels of C-reactive protein (CRP), fibrinogen, ferritin and IL-6 indicating a HIS. During the 10-day follow-up, three cases of severe adverse events were recorded: two patients developed septic shock and died, one had gastrointestinal perforation requiring urgent surgery and was alive at day 10.In conclusion, our series showed that COVID-19 pneumonia with ARDS was characterized by HIS. The response to TCZ was rapid, sustained, and associated with significant clinical improvement.

A CLAW TO THE LUNG: A PULMONARY MANIFESTATION OF DISSEMINATED BARTONELLA HENSELAE

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Infection from Bartonella henselae typically produces a localized cutaneous lymphadenitis. However, disseminated disease may occur and can be life-threatening. Pulmonary manifestations of Bartonella range from solitary nodules to pneumonia and ARDS. CASE PRESENTATION: A 44-year-old man with type 2 diabetes presented with 3 weeks of fever, weight loss, and nonproductive cough. He was otherwise healthy, used no illicit substances, had not traveled recently, but he owned several cats. On arrival, he was afebrile, hypotensive, and mildly hypoxic on room air. His lung exam revealed diffuse fine inspiratory crackles and diminished breath sounds at the bases. His spleen was enlarged and there were no skin lesions. Notable labs included white blood count 2,700/mm3, hemoglobin 9 g/dl, platelets 50,000 /mm3. Chest X-ray showed diffuse bilateral opacities and effusions and testing for HIV was negative. CT chest/abdomen further demonstrated marked splenomegaly, 2.7 cm splenic lesion, a 1.9 cm left upper lobe pulmonary nodule, and prominent mesenteric, mediastinal, and hilar lymph nodes. Bone marrow biopsy revealed normocellular marrow with erythroid hyperplasia, no abnormal B-cell clones or blasts. Subsequently, wedge resection of the pulmonary nodule and sampling of the mediastinal lymph nodes was performed via video assisted thoracoscopic surgery. Post-operatively, despite Vancomycin, Meropenem, Doxycycline, and Rifampin, fevers persisted, and he developed ARDS, ultimately necessitating veno-venous ECMO. Despite these measures, he died one week after admission. All cultures remained negative, however serologies returned positive for Bartonella henselae IgG at a titer >1:1024 and IgM of 1:128. The mediastinal lymph node biopsy demonstrated microorganisms on Warthin-Starry stain consistent with Bartonella. DISCUSSION: Bartonella henselae is a fastidious and fragile organism, thus very difficult to isolate in cultures. Patients are typically diagnosed with disseminated bartonellosis based on serologies or special stains in the context of typical clinical features such as our patient’s lymphadenopathy, splenic lesions, pancytopenia, and cat exposure. Most reports of disseminated bartonellosis occur in those immunocompromised after solid organ transplant or with advanced HIV, in whom mortality rates are 10-40% even with appropriate anti-microbials. Disseminated disease in immunocompetent hosts occurs rarely and does not commonly involve the lungs. Of 16 cases of Bartonella infections with pulmonary manifestations, 80% occurred in immunocompromised adults in whom nodules were more common manifestations than pneumonia or effusions, and only one individual developed ARDS (1). CONCLUSIONS: Because of its rarity, there are no previous reports describing ECMO to treat Bartonella-associated ARDS, emphasizing the importance of further studies. Reference #1: 1. Bandyopadhyay, Anuja, et al. “Pulmonary Nodules in an Immunocompetent Child with Cat Scratch Disease.” The Pediatric Infectious Disease Journal, U.S. National Library of Medicine, Dec. 2013, www.ncbi.nlm.nih.gov/pubmed/24030347. DISCLOSURES: No relevant relationships by Thomas Baudendistel, source=Web Response No relevant relationships by Tess Knudson-Fitzpatrick, source=Web Response

How to Diagnose Early 5-Azacytidine-Induced Pneumonitis: A Case Report.

Interstitial pneumonitis is a classical complication of many drugs. Pulmonary toxicity due to 5-azacytidine, a deoxyribonucleic acid methyltransferase inhibitor and cytotoxic drug, has rarely been reported. We report a 67-year-old female myelodysplastic syndrome patient treated with 5-azacytidine at the conventional dosage of 75 mg/m2 for 7 days. One week after starting she developed moderate fever along with dry cough and subsequently her temperature rose to 39.5 °C. She was placed under broad-spectrum antibiotics based on the protocol for febrile neutropenia, including ciprofloxacin 750 mg twice daily, ceftazidime 1 g three times daily (tid), and sulfamethoxazole/trimethoprim 400 mg/80 mg tid. High-resolution computed tomography of the chest disclosed diffuse bilateral opacities with ground-glass shadowing and pleural effusion bilaterally. Mediastinal and hilar lymph nodes were moderately enlarged. polymerase chain reaction for Mycobacterium tuberculosis, Pneumocystis jiroveci, and cytomegalovirus were negative. Cultures including viral and fungal were all negative. A diagnosis of drug-induced pneumonitis was considered and, given the negative bronchoalveolar lavage in terms of an infection, corticosteroid therapy was given at a dose of 1 mg/kg body weight. Within 4 weeks, the patient became afebrile and was discharged from hospital. Development of symptoms with respect to drug administration, unexplained fever, negative workup for an infection, and marked response to corticosteroid therapy were found in our case. An explanation could be a delayed type of hypersensitivity (type IV) with activation of CD8 T cell which could possibly explain most of the symptoms. We have developed a decision algorithm in order to anticipate timely diagnosis of 5-azacitidine-induced pneumonitis, and with the aim to limit antibiotics abuse and to set up emergency treatment.

Chest radiographic and CT findings in hyperleukocytic acute myeloid leukemia: A retrospective cohort study of 73 patients.

Hyperleukocytic acute myeloid leukemia (AML) is associated with pulmonary complications and high early mortality rate, but given its rarity, data on chest radiographic presentation are scarce.We retrospectively reviewed the charts of 73 AML patients admitted with white blood cell count >100 × 109/L between 2003 and 2014 in order to describe the chest radiographic and computed tomography (CT) findings and to correlate them with AML subtype and respiratory symptoms.Forty-two of the 73 patients (58%) overall and 36 of the 54 patients (67%) with clinical signs of pulmonary leukostasis had abnormal radiographs on admission. The presence of radiographic abnormalities was significantly associated with dyspnea and oxygen/ventilatory support requirements (P < 0.01) and with day 28 mortality (45% vs 13%, P = 0.005) but not with monocytic subtype of AML. Sixteen patients had isolated focal basilar airspace opacities, unilateral (n = 13) or bilateral (n = 3), while 16 patients had bilateral diffuse opacities, interstitial (n = 12) or airspace and interstitial (n = 4). Two patients had isolated pleural effusion, 2 patients had unilateral midlung airspace opacities, and 6 patients had a combination of focal airspace and diffuse interstitial opacities. Overall, 2 patterns accounted for 75% of abnormal findings: bilateral diffuse opacities tended to be associated with monocytic AML, whereas basilar focal airspace opacities were more frequent in nonmonocytic AML (P < 0.05). Eighteen patients had CT scans, revealing interlobular septal thickening (n = 12), airspace (n = 11) and ground-glass (n = 9) opacities, pleural effusions (n = 12), and acute pulmonary embolism (n = 2).Hyperleukocytic AML is frequently associated with abnormal chest radiographs, involving mostly focal basilar airspace opacities (more frequent in nonmonocytic AML) or diffuse bilateral opacities. CT scan should be considered broadly due to the suboptimal resolution of radiographs for detecting signs of leukostasis.

Hydrocodone Snorting Leading to Hypersensitivity Pneumonitis

We present a case of hypersensitivity pneumonitis caused by intranasal abuse of the prescription narcotic hydrocodone. The patient's clinical course was complicated by acute respiratory failure. A chest radiograph showed diffuse bilateral opacities. The patient was treated with noninvasive ventilation, a high dose of intravenous steroids, and bronchodilators, resulting in improvement of symptoms and radiographic appearance.

Post-mortem computed tomography findings of the lungs: Retrospective review and comparison with autopsy results of 30 infant cases

ObjectivesInfant cases frequently show a diffuse increase in the concentration of lung fields on post-mortem computed tomography (PMCT). However, the lungs often show simply atelectasis at autopsy in the absence of any other abnormal changes. Thus, we retrospectively reviewed the PMCT findings of lungs following sudden infant death and correlated them with the autopsy results. Materials and methodsWe retrospectively reviewed infant cases (0 year) who had undergone PMCT and a forensic autopsy at our institution between May 2009 and June 2013. Lung opacities were classified according to their type; consolidation, ground-glass opacity and mixed, as well as distribution; bilateral diffuse and areas of sparing. Statistical analysis was performed to assess the relationships among lung opacities, causes of death and resuscitation attempt. ResultsThirty infant cases were selected, which included 22 sudden and unexplained deaths and 8 other causes of death. Resuscitation was attempted in 22 of 30 cases. Bilateral diffuse opacities were observed in 21 of the 30 cases. Of the 21 cases, 18 were sudden and unexplained deaths. Areas of sparing were observed in 4 sudden and unexplained deaths and 5 other causes of death. Distribution of opacities was not significantly associated with causes of death or resuscitation attempt. The 21 cases with bilateral diffuse opacities included 6 consolidations (4 sudden and unexplained deaths, 2 other causes of death), 4 ground-glass opacities (3 sudden and unexplained deaths and 1 other) and 11 mixed (11 sudden and unexplained deaths). Types of opacities were not significantly associated with causes of death or resuscitation attempt. ConclusionAtelectasis is very common in sudden and unexplained death of infants. Bilateral diffuse mixed opacity was observed only in sudden and unexplained deaths. Bilateral diffuse pure consolidation or ground-glass opacity was also observed in other causes of death.

Acute Respiratory Distress following Intravenous Injection of an Oil-Steroid Solution

A case of acute respiratory distress and hypoxemia following accidental intravenous injection of an oil-steroid solution in a body builder is presented. Chest roentography at the time of presentation showed diffuse bilateral opacities, and computed tomography revealed predominantly peripheral ground-glass opacifications. The patient's symptoms gradually improved over 48 h and imaging of the chest was unremarkable one week later. The pathophysiology, diagnosis and treatment of this rare but potentially lifethreatening complication of intravenous oil injection are discussed.

Case Scenario: Acute Postoperative Negative Pressure Pulmonary Edema

A 25-yr-old man (weight, 68 kg; height, 183 cm) presentedto the surgery center for excision of back and thigh schwan-nomas on the same day. The patient’s medical history wassignificant only for his history of multiple schwannoma re-sections and a history of smoking one pack of cigarettes perweek for the past 5 yr. He denied previous problems withgeneral anesthesia, and his baseline peripheral oxygen satu-ration was 99% on ambient air.Thepatientwaspremedicatedwith2mgmidazolam,andanesthesia was induced with 250 mg fentanyl, 500 mg thio-pental, and 8 mg vecuronium given for facilitation of tra-cheal intubation. He was atraumatically intubated with a7-mm ID endotracheal tube using a no. 3 Macintosh laryn-goscope (Teleflex Medical, Research Triangle Park, NC) onthe first attempt with direct visualization of the vocal cords.The patient was turned prone, bilateral breath sounds werereconfirmed, and schwannoma excisions were performed ontheleftthighandtheleftflank.Atotalof0.5mghydromor-phone was administered for analgesia. The intraoperativecoursewasunremarkable.Thepatientwashemodynamicallystable with minimal blood loss and was easily ventilated andoxygenated. A total of 500 ml lactated Ringer’s solution wasadministeredduringthe65-minsurgicalprocedure.Thepa-

Index of Suspicion

Index of Suspicion

Bronchopulmonary dysplasia: prevention, management and long-term outlook

Despite major advances in neonatology over the last few years, neonatal intensive care units continue to care for a number of infants with ventilator and oxygen dependency or bronchopulmonary dysplasia (BPD). In 1967 Northway first described a chronic lung disease which developed after recovery from respiratory distress syndrome (RDS). 1 The original description was of a progressive illness culminating at 30 days in severe lung disease with oxygen dependency and a characteristic chest X-ray. The definition of BPD has evolved to the criteria currently used in Table 1. 36 weeks gestation is a more useful cut off when considering extremely preterm babies and is more predictive of final outcome than respiratory status at 28 days of life. The typical chest X-ray of BPD is seen in Figure 1. There are two variants which are sometimes seen in clinical practice. In the first the clinical criteria are similar but the lung appearance on chest radiograph is relatively normal or shows minor bilateral diffuse opacities. In the second the nonventilated preterm infant develops a persistent oxygen requirement commencing in the second week of life or later (Wilson Mikity syndrome). The prognosis in these two groups is better than in classical BPD. Although definitions of BPD are useful for statistics and comparisons, they are less useful clinically. BPD is more of a continuum of lung insult, injury and repair from birth. The absence of a diuresis classically present in the recovery phase of RDS, the development of pulmonary interstitial emphysema or pneumothoraces on the chest radiograph and the inability to wean the infant from the ventilator by day 7 of life are all early signs that chronic lung disease is likely to be established and the infant will continue to require respiratory support. The incidence of BPD from published studies varies considerably and is partly dependent on the definition. It varies from 3 0 4 0 % in mechanically ventilated newborns. 2~ Over the last 3 years a reduction in the number of babies with BPD on our Unit has been noted with an incidence of 15% in infants under 1500 g in 1995. Other units in the UK are reporting an increase. Good epidemiological studies are required to explain these differences.