Diffuse Ground-glass Opacities Research Articles

Idiopathic Pulmonary Hemosiderosis in an Adult with Unusual Radiologic Features

ABSTRACT Idiopathic pulmonary hemosiderosis is an exceptionally rare cause of diffuse alveolar hemorrhage that occurs primarily in infants and children. Few cases are reported in adults. Patients usually present with recurrent episodes of hemoptysis, fatigue breathlessness and severe anemia with asymptomatic periods in between. Our patient, who was diagnosed with idiopathic pulmonary hemosiderosis demonstrated diffuse ground glass opacity, focal centrilobular emphysema and multiple sub pleural cysts and few parenchymal cysts during acute episode of hemoptysis. Unusual findings in our case were sub pleural cysts, parenchymal cysts and focal centrilobular emphysema which was not documented in any case reports of idiopathic pulmonary hemosiderosis cases to that of our knowledge. How to cite this article Kasilingam SK, Prashanth S, Govindagoudar MB, Devaramani B, Swamygowda CC. Idiopathic Pulmonary Hemosiderosis in an Adult with Unusual Radiologic Features. J Postgrad Med Edu Res 2014;48(4):199-200.

Amyopathic Dermatomyositis with Interstitial Lung Disease: A Rare Type of Dermatomyositis with Accelerated Mortality Rate

Background: It was observed that there have been cases with pathognomonic skin lesions of Dermatomyositis, but without muscle weakness and abnormal skeletal muscle enzymes, hence they did not satisfy the Peter and Bohan criteria, and management became undirected. Until in 1993, Euwer and Sontheimer published the diagnostic criteria for Amyopathic Dermatomyositis, a type of Dermatomyositis, without proximal muscle weakness and elevated skeletal muscle enzymes. Setting: St. Luke’s Medical Center, Quezon City, Philippines. Case: We report here a case of a 59-year old female who was admitted for shortness of breath presenting with hyperpigmented papules over the metacarpophalangeal joints. One week before admission, fever, productive cough, and progressive shortness of breath developed prompting hospital admission. She arrived at the ER tachypneic with oxygen saturation of 55% at room air. She had intercostal retractions and crackles on both lung fields. There were violaceous macular rashes on the metacarpophalangeal, and proximal interphalangeal joints of both hands. Neurological examination was normal. Diagnostics: Chest CT scan revealed diffuse ground glass opacities with interstitial thickening consistent with Interstitial Lung Disease (ILD). The serum Creatine Kinase level and electromyography were normal. Skin biopsy showed perivascular lymphohistiocytic infiltrates, suggestive of dermatomyositis. Conclusion: Dermatomyositis is rare and the Amyopathic type is more uncommon (incidence of 2.08/1,000,000 population). Recognizing it can be a challenge. Amyopathic Dermatomyositis (AMD) patients have 80% survival in less than a year and drops to 60% if ILD develops. Hence, early diagnosis and aggressive management are imperative.

The (H1N1) 2009 Pandemic Influenza Pneumonia among Adult Patients in Japan

The recent H1N1 influenza pandemic involved several cases of influenza pneumonia. Although influenza pneumonia may have occurred more frequently in fatal cases, the clinical characteristics of influenza pneumonia in Japan remain unclear. We conducted a retrospective cohort study of adult patients with influenza pneumonia, for which questionnaires were sent to respiratory physicians working in 2,491 hospitals across Japan. Questionnaires were returned by 994 physicians (39.9%), providing data on 346 influenza pneumonia cases. The case-fatality ratio was 8.2% (27 cases). Pure influenza viral pneumonia was observed in 94 cases, which were most frequently young adults with chief complaints of non-productive cough and dyspnea. Radiological imaging showed diffuse ground-glass opacity. Corticosteroid therapy and mechanical ventilation were more frequently used for pure influenza viral pneumonia, but these modalities were not correlated with poor treatment outcomes. Anti-influenza antiviral drugs were prescribed in 335 cases (96.8%). In the recent pandemic in Japan, several pure influenza viral pneumonia cases were observed, but we found no variances in mortality between the different types of pneumonia. Almost all cases were treated with anti-influenza antiviral drugs, which may have contributed to its relatively low mortality rate.

Pulmonary manifestations of the pre-engraftment syndrome after umbilical cord blood transplantation

Pre-engraftment syndrome (PES) is a condition occurring after umbilical cord blood transplantation (UCBT) characterized by fever and erythematous skin rash prior to neutrophil engraftment. We sought to determine the incidence and characterize the pulmonary manifestations of PES. A retrospective review of patients who underwent UCBT at the University of Kansas Medical Center over a 5-year period was performed. Data collected included patient baseline characteristics, presence of PES, pulmonary findings, treatments, and survival. Forty-four patients underwent UCBT with 22 of those patients developing PES. Full-intensity myeloablative conditioning regimen was found to be a risk factor for development of PES. Of those 22 patients, 13 had resting hypoxemia. The most common radiographic findings included diffuse ground glass opacities with pleural effusions. Fifteen patients with PES received corticosteroids, of which 12 had improvement in fevers and rash. These patients had a trend toward worse mortality than those not receiving corticosteroids. There was a nonsignificant trend toward worse survival in patients with PES and hypoxemia compared to those without hypoxemia. PES is a common complication following cord blood transplantation, with hypoxemia being present in over half of patients with PES. Hypoxemia with PES and treatment with corticosteroids may portend a worse prognosis.

Lymphangitic Carcinomatosis of Unknown Primary: A Case Report

Lymphangitic carcinomatosis is an uncommon manifestation of metastasis to lung. Its presentation can mimic several disorders of the lungs. A case is presented here where patient presented with progressive dyspnoea, dry cough, weight loss and fever. The patient was amenorrheic for the last 2 years. Her physical findings were unremarkable initially other than the weight loss and evidence of pulmonary hypertension. Subsequently her dyspnoea rapidly worsened and the patient became bed bound. Investigations revealed neutrophilic leucocytosis, normal Hb with high ESR. ANA, anti Cetromere and anti Scl 70 was negative. Serum calcium was normal. Liver function test was normal other than raised alkaline phosphatase. Tuberculin test was negative. Chest X-ray revealed increased bilateral symmetrical streaks and reticulation with peripheral and lower distribution which is consistent with pulmonary lymphangitic carcinomatosis. HRCT of Lungs has shown diffuse infiltrations, reticulo-nodular and ground glass opacities, centrilobular emphysema with accentuation of broncho-vascular densities in both lung fields. There were enlarged mediastinal lymph nodes, bilateral pleural effusion. Doppler Echo revealed mild pulmonary hypertension with fair EF. Tumor markers were done. CA125, CA 19.9 and AFP were ten times higher than normal. Fibreoptic nasopharyngoesophagoscopy was normal. Diagnosis of PLC was made on clinical feature, radiological finding and elevated tumor markers. Symptomatic treatment was given during the period of evaluation. Ultimately the patient succumbed to death.DOI: http://dx.doi.org/10.3329/jssmc.v5i2.20769J Shaheed Suhrawardy Med Coll, 2013;5(2):114-116

A 12-year-old boy with renal failure and haemoptysis.

A 12-year-old boy, previously well, presented with increasing pallor, lethargy and intermittent gross haematuria for 1 month. He also had a history of haemoptysis for the previous 5 days. His blood pressure was normal and he had pedal oedema. There was no hepatosplenomegaly, joint swelling or skin rash. Laboratory investigations (Table 1) revealed anaemia, hypoalbuminaemia and elevated serum creatinine (estimated glomerular filtration rate by Schwartz formula: 13 mL/min/1.73 m). His white cell count, platelet count and clotting profile were normal. His urine analysis showed 2+ protein, 3+ blood and coarse granular casts. He had nephrotic-range proteinuria. His chest X-ray showed bilateral nodular infiltrates (Figure 1A) and a CT of the chest revealed bilateral diffuse ground glass opacities consistent with alveolar haemorrhage (Figure 1B). A kidney biopsy was performed for further evaluation.

Transcatheter arterial embolization of anomalous systemic arterial supply to the basal segment of the lung

We describe the case of a 67-year-old woman with an anomalous systemic arterial supply to the basal segment of the lung, which was managed successfully by transcatheter arterial embolization (TAE) with microcoils. Her chest computed tomography (CT) scan showed diffuse ground-glass opacity in the left lower lobe, no bronchial abnormalities, and blood supply from an anomalous artery originating from the descending thoracic aorta, with drainage to the normal pulmonary vein. We successfully performed TAE under balloon occlusion of the anomalous artery, without complications. TAE is a minimally invasive, safe, and valuable method, and could be used as first-line treatment in such cases.

Pneumopathie induite par l’hydroxyurée

Hydroxyurea is an antimetabolite drug used in the treatment of myeloproliferative disorders. Common adverse effects include haematological, gastrointestinal cutaneous manifestations, and fever. Hydroxyurea-induced pneumonitis is unusual. A female patient was treated with hydroxyurea for polycythemia vera. She was admitted 20 days after commencing treatment with a high fever, productive cough, clear sputum and nausea. A chest CT-scan showed diffuse ground-glass opacities. Microbiological investigations were negative. The symptoms disappeared a few days after discontinuation of the drug and rechallenge led to a relapse of symptoms. Our case and 15 earlier cases of hydroxyurea-induced pneumonitis are reviewed. Two patterns of this disease may exist: an acute febrile form occurring within 1 month of introduction of hydroxyurea and a subacute form without fever. Even if uncommon, one should be aware of this complication of hydroxyurea.

Severe eosinophilic pneumonia presenting during gemcitabine adjuvant chemotherapy

Gemcitabine is widely accepted as the standard treatment for pancreatic cancer, but it can cause unpredictable side effects. Acute respiratory distress syndrome is a rare complication with gemcitabine, but is sometimes fatal. We describe a cured case of acute, severe gemcitabine-induced pulmonary toxicity. The patient was a 76-year-old man with pancreatic cancer who was receiving adjuvant gemcitabine chemotherapy after surgery. The patient received gemcitabine 1,000 mg/m2 on days 1, 8, and 15 for three 4-week cycles, with intervals of 1 week. He developed severe general fatigue on day 1 of the third cycle. Computed tomography showed diffuse ground-glass opacity with pleural effusion. There was no increase in β-D-glucan, and cytomegalovirus antigenemia assays were negative. No bacteria or acid-fast bacilli were found. The number of eosinophils in bronchoalveolar lavage fluid was increased. Considering these data, we diagnosed eosinophilic pneumonia induced by gemcitabine. The patient was immediately treated with a steroid and neutrophil elastase inhibitor under respiratory supportive therapy. After 4 weeks, his pulmonary symptoms were markedly improved. Physicians should be cognizant of the possible association of serious pulmonary toxicity with gemcitabine treatment. A delay in diagnosis and treatment could lead to a fatal outcome.

Pneumocystis jirovecii and Cytomegalovirus Co-Infection in AIDS Patients

A case report of a young woman with insidious dyspnea, cough and weight loss that began 3 months before hospitalization. She referred to occasional cough, wheezing, and fever during the last 2 years. Over one year before, she performed a chest CT that showed diffuse ground-glass opacity (GGO) distributed in both lungs with predominance in the upper and middle areas. She immediately received standardized treatment with sulfamethoxazole-trimethoprim (SMZ-TMP), and ELISA and Western Blot tests for AIDS were performed, and both were positive. Pneumocystis Jirovecci (PCJ) staining and PCR from bronchoalveolar lavage were negative. The GGO seen in CT was inconclusive. After 10 days of treatment, she progressed to being respiratory insufficient. A lung biopsy was done and revealed co-infection of cytomegalovirus (CMV) and PCJ. Although first line therapy for both PCJ and CMV was instituted early, s he had an unfavorable outcome. Despite following the recommendations for diagnosis and treatment of community-acquired pneumonia in immunosuppressed patients , the patient died . The use of molecular biomethods for recognizing sulfur resistance is not usually performed in daily practice and an old question regarding the aggressiveness of co-infection of PCJ and CMV returned in this case. doi: http://dx.doi.org/10.4021/jmc1249w

Acute eosinophilic pneumonia with eosinophilic leukemoid reaction: a rare hematologic presentation.

Sir, A 26-year-old man presented to us with chief complaints of fever, cough, and dyspnea since 15 days. There was no history of hemoptysis, chest pain, orthopnea, palpitations, or edema feet. A more detailed history was negative for environmental or medication exposure. Past history was insignificant for any prolonged illness. There was no history of any addiction. On examination, pulse was 100/min, regular. Respiratory rate was 18/min, and the temperature was 38.6 °C. JVP was not raised. Auscultation of the lungs revealed bilateral, diffuse rales. Cardiovascular system examination was normal. Investigations revealed, Hb of 11 g %, Total leucocyte count (TLC) was 52,000, DLC revealed polymorphs of 15 %, eosinophils 78 %, lymphocytes 6 %, monocyte 1 % (Fig. 1). Peripheral smear was devoid of any blasts. Absolute eosinophil count was 38,000/mm3 (normal 52–250 mm3). Platelet count was 250,000/mm3. The bone marrow aspiration revealed eosinophilic proliferation without any blasts (Fig. 2). The blood biochemistry was normal. CXR revealed bilateral haziness. HRCT of thorax revealed bilateral ground glass opacities (GGOs) (Figs. 3, ​,4).4). Two dimensional (2D) echo was normal. ABG revealed partial pressure of oxygen, 68 mmHg; partial pressure of carbon dioxide, 29 mmHg; and pH, 7.50. SpO2 was 84 % while patient was breathing ambient air. Cultures of sputum, blood, and urine were negative for bacteria, mycobacteria, fungi. ESR was 24 mm in first hour. Peripheral smear examination for parasites and microfilaria was negative. Fig. 1 Peripheral smear (Leishman stained ×10 view) showing eosinophilia Fig. 2 Bone marrow slide (Leishman stained ×40 view) showing eosinophilic predominance Fig. 3 Coronal CT image shows bilateral, diffuse and patchy ground glass opacity (arrows) Fig. 4 Axial CT image showing bilateral ground glass opacity Patient was treated with empirical antibiotics, NIPPV, oral corticosteroids (Tab. prednisolone 60 mg/day). Patient’s breathlessness decreased dramatically on the third day. NIPPV was discontinued. He was maintaining O2 saturation of 98 % in ambient air. ABG became normal. A bronchoalveolar lavage was done, which revealed, total cell count of 132 × 103 with 22 % eosinophils. In the first week after treatment TLC came down to 15,000/mm3, with 25 % eosinophils. AEC was 4,000/mm3. Repeat HRCT showed partial clearing of the GGOs. Fever, cough and dyspnea subsided. A diagnosis of acute eosinophilic pneumonia with eosinophilic leukemoid reaction was made. By the end of second week, TLC was 10,000/mm3. DLC revealed 12 % eosinophils. AEC was 1,100/mm3. Patient was discharged with a tapering dose of prednisolone, and was advised follow up after two weeks.

Clinical characteristic analysis of 96 cases of hypersensitivity pneumonitis

To improve understanding of the clinical characteristics and diagnosis of hypersensitivity pneumonitis (HP). We retrospectively analyzed the clinical data, including clinical symptoms, laboratory tests, exposure, pulmonary function tests, chest CT imaging and cytological classification of bronchoalveolar lavage (BAL) of 96 patients with HP from Jan 2001 to Jun 2011 in Peking Union Medical College Hospital. We divided the patients into 2 groups: a pathologically-confirmed group and a clinically-suspected group. There were 58 females and 41 males. The median age at the diagnosis was 53 years. The most common exposures were low-molecular-weight chemicals (42.7%) and animal proteins (37.5%). Common clinical symptoms included dyspnea on exertion (90.6%) and cough (76.0%). Pulmonary function test showed diffusion abnormality (73.5%) and restrictive ventilatory impairment (59.7%). Chest CT scan revealed patchy or diffuse bilateral ground-glass opacities (64.6%), centrilobular nodules (21.9%), and air trapping (15.6%). Reticulation (45.8%), traction bronchiectasis (21.9%) and honeycombing(9.4%) were present in chronic HP. BAL lymphocyte counts > 0.2 and CD4/CD8 < 0.9 were more commonly seen in patients with a disease course of less than 1 year. The pathologically-confirmed group and the clinically-suspected group shared many similar characteristics including age at diagnosis, gender, clinical manifestation, pulmonary function impairments and imaging findings, but significant differences existed in certain parameters. In the pathologically- confirmed group, the duration of disease was longer (24 months vs 6 months, Z = -2.492, P = 0.013) and clubbed fingers were more common (23.4% vs 8.2%, χ(2) = 4.227, P = 0.040). Diffusion abnormality was present in more patients of this group (90.7% vs 44.0%, χ(2) = 35.219, P < 0.01). By CT scan, reticulation, traction bronchiectasis and honeycombing (57.5% vs 26.5%, χ(2) = 9.434, P < 0.01) were more evident as compared to the clinically-suspected group. The value of transbronchial lung biopsy for diagnosing HP was limited, with a positive result of only 8.2%. Surgical lung biopsy was needed in uncertain cases. The diagnosis of HP was difficult. In some cases a clinical diagnosis can be made by combination of history of exposure, CT manifestations and cell classification of BAL. For atypical cases a multi-disciplinary approach including pathologists, radiologists and pulmonologists is needed.

Sunitinib Induced Diffuse Alveolar Hemorrhage: A Case Report

A 68-year-old man with papillary renal cell carcinoma of the transplanted kidney presented with worsening respiratory distress while on treatment with sunitinib. Computerized tomography of chest revealed diffuse ground-glass opacities, and sequentially bloody bronchoalveolar lavage fluid was noted on bronchoscopy. There was marked clinico-radiologic improvement after withdrawal of sunitinib. This is the first case report of diffuse alveolar hemorrhage as an adverse effect of sunitinib in non-metastatic papillary renal cell carcinoma. With the increasing use of sunitinib in treatment of solid tumors, it is important to be aware of this potential adverse effect. Clinicians need to be vigilant for alveolar hemorrhage in patients on sunitinib with or without evidence of lung metastasis. doi: http://dx.doi.org/10.4021/jmc1011w

Role of HRCT in detection and characterization of pulmonary abnormalities in patients with febrile neutropenia

Background:Fever is of grave concern in the management of patients with neutropenia with early detection of a focus of infection being the major goal. As lungs are the most common focus, chest imaging is of vital importance. This Institute Review Board approved prospective study was undertaken to assess the usefulness of high resolution computed tomography (HRCT) in early detection and characterization of pulmonary abnormalities in febrile neutropenia.Materials and Methods:A total of 104 consecutive patients (M:F:75:29, age range 11–66 years) with fever of 38.2°C or more with an absolute neutrophil count <500/μl underwent HRCT chest. HRCT diagnosis was compared with final diagnosis based on ancillary investigations.Results:HRCT could detect pulmonary abnormalities in 93 patients (89.4%) with air space consolidation being the predominant finding (n = 57), followed by ground-glass opacities (Ground glass opacity (GGO), n = 49) and nodules (n = 39). HRCT could correctly characterize the infective lesions in 76 patients (81.7%). Presence of random or pleural-based nodules >10 mm with or without surrounding GGO or cavitations was sensitive (95.23%) and specific (96.7%) for fungal infection, while small (1–4 mm) random or centrilobular nodules with tree-in-bud appearance was sensitive (90%) and highly specific (97.02%) for tuberculosis. Diagnosis of pyogenic infection based on presence of air-space consolidation, pleural effusion, GGO or centrilobular nodules showed a sensitivity of 84.78% and specificity of 93.84%, whereas patchy or diffuse GGO, interstitial thickening and/or air-space consolidation showed high sensitivity (86.7%) and specificity (96.8%) for Pneumocystis jiroveci pneumonia.Conclusion:HRCT chest is an excellent modality in the diagnostic work-up of patients with febrile neutropenia allowing early detection and characterization of pulmonary abnormalities.

A case of sarcoidosis with eosinophilia in peripheral blood and bronchoalveolar lavage fluid

A 70-year-old woman, who has had a diagnosis of sarcoidosis since she was 38 years old, showed newly appearing diffuse ground-glass opacities in the bilateral lung field, and bilateral enlargement of the hilar and mediastinal lymph nodes. Based on findings from bronchoalveolar lavage fluid (BALF) and pathology analysis, eosinophilic pneumonia accompanied by sarcoidosis was suspected. Both disease conditions (sarcoidosis and BALF eosinophilia) worsened and improved simultaneously, and she showed two similar episodes during the follow-up. This case prompted us to conduct a retrospective investigation of eosinophil percentage in peripheral blood and BALF in 178 patients (excluding our patient) who had received a diagnosis of sarcoidosis between 2000 and 2009 in our department. Among the 178 patients, the highest eosinophil percentage in BALF was 2.6%; in contrast, peripheral blood eosinophilia was very common. Thus we concluded that, for subjects with sarcoidosis, marked eosinophilia in BALF, as observed in the case of this 70-year-old woman, was exceptional.

Radiological diagnosis of interstitial lung diseases

Introduction. Interstitial lung diseases include the entities of idiopathic pulmonary fibrosis, nonspecific interstitial pneumonia, cryptogenic organizing pneumonia, acute interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, desquamative interstitial pneumonia, and lymphocytic interstitial pneumonia. Recent introduction of high-resolution computed tomography has made the diagnosis of interstitial lung disease much easier. Usual interstitial pneumonia A predominantly subpleural reticulation and honeycombing at the basal posterior part of the lung with a progression to anterior and superior parts are characteristic of usual interstitial pneumonia/ idiopathic pulmonary fibrosis. Nonspecific interstitial pneumonia Typical findings of nonspecific interstitial pneumonia are bilateral, relatively symmetrical subpleural ground glass opacifications and irregular linear opacities. Desquamative interstitial pneumonia is characterized by diffuse symmetrical ground glass opacifications. Respiratory bronchiolitisassociated interstitial lung disease Centrilobular nodules and irregular ground glass opacifications are present. Cryptogenic organizing pneumonia Subpleural and peribronchial consolidations are prominent findings that are not present in other idiopathic interstitial pneumonias. Acute interstitial pneumonia. Bilateral ground-glass opacifications are present and areas of peripheral consolidations may also be seen in acute interstitial pneumonia. Lymphocytic interstitial pneumonia. Diffuse or patchy areas of ground glass opacification with centrilobular nodules and occasionally well-defined cysts are seen. Conclusion. Imaging plays a crucial role in identifying interstitial lung diseases but precise diagnosis requires a dynamic interdisciplinary approach that correlates clinical, radiological and pathologic features.

Ground-Glass Opacity in Lung Metastasis from Breast Cancer: A Case Report

A 43-year-old woman with breast cancer who was on neoadjuvant chemotherapy presented with cough, sputum and mild fever. High-resolution computed tomography showed diffuse ground glass opacities in bilateral lungs and subpleural patchy consolidations. Initially, she was thought to have pneumonia or interstitial lung diseases such as drug-induced pneumonitis and treated with antibiotics and steroids. She subsequently got breast cancer surgery because of disease progression, and concurrent thoracoscopic lung biopsy revealed metastatic carcinoma of the lung from breast cancer. The diagnosis of suspected interstitial lung disease can be made without lung biopsy, but malignancy should always be considered and lung biopsy should be performed in the absence of a definitive clinical diagnosis.

Pneumonitis Induced by Rifampicin: A Case Report and Literature Review

An 84-year-old woman being treated for miliary tuberculosis (TB) with rifampicin (RFP), isoniazid (INH), ethambutol (EB) and corticosteroids suffered from a persistent fever for five months. While tapering the dose of prednisolone, chest computed tomography (CT) revealed diffuse ground glass opacities (GGO) and bronchoalveolar lavage fluid (BALF) showed an increase in lymphocytes. After the anti-TB drugs were discontinued and the dose of the corticosteroids was increased, the CT findings and fever improved considerably. However, readministration of RFP provoked an inflammatory reaction, leading to a diagnosis of RFP-induced pneumonitis. This condition is very rare. This is the first report of RFP-induced pneumonitis occurring during adjunct steroid therapy.

Pneumocystis jirovecii and Cytomegalovirus Co-Infection in AIDS Patients

A case report of a young woman with insidious dyspnea, cough and weight loss that began 3 months before hospitalization. She referred to occasional cough, wheezing, and fever during the last 2 years. Over one year before, she performed a chest CT that showed diffuse ground-glass opacity (GGO) distributed in both lungs with predominance in the upper and middle areas. She immediately received standardized treatment with sulfamethoxazole-trimethoprim (SMZ-TMP), and ELISA and Western Blot tests for AIDS were performed, and both were positive. Pneumocystis Jirovecci (PCJ) staining and PCR from bronchoalveolar lavage were negative. The GGO seen in CT was inconclusive. After 10 days of treatment, she progressed to being respiratory insufficient. A lung biopsy was done and revealed co-infection of cytomegalovirus (CMV) and PCJ. Although first line therapy for both PCJ and CMV was instituted early, she had an unfavorable outcome. Despite following the recommendations for diagnosis and treatment of community-acquired pneumonia in immunosuppressed patients, the patient died. The use of molecular biomethods for recognizing sulfur resistance is not usually performed in daily practice and an old question regarding the aggressiveness of co-infection of PCJ and CMV returned in this case. J Med Cases. 2013;4(6):402-406 doi: https://doi.org/10.4021/jmc1249w

Sunitinib Induced Diffuse Alveolar Hemorrhage: A Case Report

A 68-year-old man with papillary renal cell carcinoma of the transplanted kidney presented with worsening respiratory distress while on treatment with sunitinib. Computerized tomography of chest revealed diffuse ground-glass opacities, and sequentially bloody bronchoalveolar lavage fluid was noted on bronchoscopy. There was marked clinico-radiologic improvement after withdrawal of sunitinib. This is the first case report of diffuse alveolar hemorrhage as an adverse effect of sunitinib in non-metastatic papillary renal cell carcinoma. With the increasing use of sunitinib in treatment of solid tumors, it is important to be aware of this potential adverse effect. Clinicians need to be vigilant for alveolar hemorrhage in patients on sunitinib with or without evidence of lung metastasis. J Med Cases. 2013;4(3):196-198 doi: https://doi.org/10.4021/jmc1011w