Diminished Breath Sounds Research Articles

A Case of Pleural TB

SESSION TITLE: Other Infections SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Extra-pulmonary Tuberculosis (TB) comprises a quarter of the initial TB presentations but can be challenging to diagnosis. Reactivation of latent TB infection (LTBI) is seen in the immunocompromised population. Initial screening for TB with tuberculosis skin test (TST) can be falsely negative in them. Interferon gamma release assay (IGRA) is now the preferred TB screening test. CASE PRESENTATION: 43-year-old male with history of Crohn’s disease with negative TST on adalimumab and mercaptopurine presented with progressively worsening shortness of breath, fevers, night sweats, productive cough and pleuritic chest pain for three weeks duration. He was seen by his primary care physician and given azithromycin for bronchitis. However, symptoms persisted prompting an ER evaluation. He was found febrile, tachycardic, tachypneic and hypoxic. On exam he had diminished breath sounds and dullness to percussion of the right lung field. Chest x-ray showed large right pleural effusion. Laboratory studies were unremarkable. He was started on antibiotics for pneumonia with parapneumonic effusion. A thoracentesis showed exudative fluid process. The adenosine deaminase (ADA) level was low and bacterial culture was negative. However, his Quantiferon test was positive. He continued to worsen so he underwent video-assisted thoracotomy with pleural biopsy given concern for TB. He was found to have numerous pleural implants. The tissue culture was positive for acid fast bacilli. The pathology of the pleural biopsies showed multiple non-necrotizing epithelioid granulomata with histiocytes and giant cells. He was started on RIPE therapy for extra-pulmonary TB. DISCUSSION: Extrapulmonary TB can present as primary TB or in reactivation of LTBI. Tuberculous pleuritis develops from direct infection of the pleura and lymph nodes as a result of a ruptured sub-pleural caseous area in the lung. A delayed hypersensitivity reaction ensues resulting in the development of a tuberculous pleural effusion. In these cases, TB can be detected by sampling the pleural fluid. The pleural fluid has lymphocyte pre-dominance and elevated ADA level. The reliability of this biomarker in detecting TB depends on the prevalence of TB in the area. ADA levels can be falsely low in the early part of tuberculous pleurisy and in the immunocompromised. CONCLUSIONS: This case highlights the high false negative rate of TST among immunosuppressed individuals due to anergy. Our patient was initially tested for TB with TST while on oral steroids during a Crohn's flare. This test was false negative. He had underlying LTBI that became reactivated while on immunosuppressive therapy. IGRA testing would have been a more sensitive method of detecting LTBI. This case also emphasizes the gold standard of diagnosing extra-pulmonary TB with thoracotomy and pleural biopsy. Reference #1: Vorster M., et al. Tuberculous pleural effusions: advances and controversies. Journal of Thoracic Disease. 2015; 7(6): 981-91. DISCLOSURE: The following authors have nothing to disclose: Rohini Manaktala, Ricardo Perez, Prashant Grover No Product/Research Disclosure Information

Case 1: Persistent Tachypnea in an Infant

1. Daniel Hinds, MD* 2. Matthew Cooper, MD* 3. Ameet Daftary, MD* 1. *Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN A 4-month-old boy presents to the hospital with worsening tachypnea. He was born at 34 weeks' gestation via cesarean delivery to a gravida 1 mother owing to preterm labor and cephalopelvic disproportion. After birth, he was admitted to the NICU for prematurity, feeding difficulty, and hypoxemia. He advanced to full feeds by 7 days after birth; however, by day 23 after birth, he had developed tachypnea, and auscultation of his lungs demonstrated slightly diminished breath sounds in the right upper lobe (RUL) with crackles in the left upper lobe (LUL). A chest radiograph showed RUL atelectasis with mild LUL expansion (Fig 1). Because he did not improve with chest physical therapy, a bronchoscopy with bronchoalveolar lavage was performed on day 39 after birth and did not show any airway …

Pleural Effusions and Pneumothoraces.

1. Katherine Cashen, DO* 2. Tara L. Petersen, MD† 1. *Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI 2. †Division of Critical Care, Department of Pediatrics, The Children’s Hospital of Wisconsin/The Medical College of Wisconsin, Milwaukee, WI * Abbreviations: BTS: : British Thoracic Society CHF: : congestive heart failure CT: : computed tomography VATS: : video-assisted thoracoscopic surgery 1. Clinicians should be aware of the causes and clinical presentation of pleural effusions and pneumothoraces. 2. Clinicians should understand the current role of diagnostic tests, imaging modalities, and timing of minimally invasive treatments. After completing this article, readers should be able to: 1. Describe the pathogenesis of pleural fluid accumulation. 2. Identify the most likely causes of pleural effusion and pneumothorax. 3. Understand the basic clinical presentation, diagnostic tests, and management of pleural effusions and pneumothoraces. 4. Differentiate between transudative and exudative pleural effusions. 5. Understand the natural history of spontaneous pneumothorax. The pleural space is created by the parietal and visceral pleura that line the chest wall and the lung surface, respectively. Normally, only a small amount (0.3 mL/kg) of hypotonic fluid is present within the pleural space due to homeostatic balances in physiologic fluid production and absorption. Various infectious and noninfectious processes can lead to pathologic filling of the pleural space with fluid (effusion) or air (pneumothorax). Such pathologic changes create a true space that can interfere with normal lung mechanics and, in severe cases, cardiac function. Although much less common in pediatric than adult populations, pleural effusions and pneumothoraces in both groups can lead to substantial complications, resulting in significant morbidity and mortality if unrecognized or untreated. Overall, the cause of pleural effusions and pneumothoraces differs in children compared to adults. In adults, congestive heart failure (CHF) and malignancy account for a substantial number of pleural effusions, but these are uncommon causes in children. Infectious pleural effusions in the setting of pneumonia (parapneumonic effusions) remain the most common cause of effusions in both children and adults. Unlike the adult population, children experience spontaneous …

Foreign body aspiration in children and role of flexible bronchoscopy: A 3 year experience

BackgroundFlexible airway bronchoscopy is an accepted and frequently performed procedure in the evaluation of children with known or suspected airway and lung parenchymal disorders. MethodsBetween 2012 and 2015, retrospective analysis of 134 flexible bronchoscopies was done in Children’s Hospital, Cairo University, as regards demographic profile, clinical and radiological presentation and diagnostic indication. The results were analyzed on the basis of bronchoscopy inspection, conclusion and future recommendations. ResultsPatients indicated for flexible bronchoscopy presented clinically with unilateral diminished breath sounds in 24.6%, unilateral bronchial breathing in 17.9%, recurrent lower respiratory tract infection in 11.2%, persistent cough in 4.5% and stridor in 9.7%, others showed radiological findings in the form of unilateral hyperinflation in 9%, bronchiectasis in 3.7% and unilateral wheezes in 1.5%. Out of 134 patients undergoing bronchoscopy, 38% had foreign body (FB) in the airways although only 7.5% of patients had recalled a previous history of FB aspiration (15.6% in the trachea, 52% in the right side and 31.3% in the left side, among those patients 60.8% were males while 39.2% were females), 14.1% had tracheal abnormality, 26.8% had post inflammatory changes, 56.7% had right bronchus abnormality, 55.2% had left bronchus abnormality, bronchoalveolar lavage (BAL) was done in 30.6% of patients, FB was successfully removed in 15.6% of patients and further cardiothoracic intervention was needed in 29.8% of patients. ConclusionThe combination of history, physical examination, and chest X-ray findings are crucial when investigating a child with suspected foreign body aspiration. Flexible bronchoscopy is effective for diagnostic and sometimes therapeutic purpose of problems in the upper and lower respiratory airways in children, with a high success rate as it significantly reduces the rate of negative rigid bronchoscopies and ultimately saves the child from undergoing an unnecessary procedure.

A Rare Cause of Pancreatitis

SESSION TITLE: Student/Resident Case Report Poster - Obstructive Lung Diseases SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Roflumilast, a selective phosphodiesterase-4 inhibitor, is a well tolerated medication in the prevention of chronic obstructive pulmonary disease (COPD) exacerbations in patients with moderate to severe COPD. Roflumilast has infrequently been described as a cause of pancreatitis. We present a patient with Roflumilast induced pancreatitis, which resolved after discontinuation. CASE PRESENTATION: A 59 year old male with GOLD III COPD, started on Roflumilast three weeks earlier, presented to the emergency department with acute onset epigastric pain associated with nausea and vomiting. Exam revealed a diaphoretic male in moderate distress with diminished breath sounds, and epigastric tenderness without rebound, or rigidity. Laboratory values include lipase of 24,289 unit/L with an elevation in amylase and total bilirubin, as well as a normal lipid and hepatitis profile and IgG4 level. Ultrasound noted gallbladder wall edema without stones or sludge. Computed tomography revealed pancreatic enlargement and fat stranding. Roflumilast was discontinued and supportive management, including intravenous fluids, anti-emetics and pain control were provided. Symptoms and elevated lab values resolved within one week of discontinuation. DISCUSSION: Roflumilast has an overall low incidence of adverse events. Compared to placebo, the incidence of severe adverse events was less in both the 500 mcg and 250 mcg treatment groups. With the most common adverse effect being diarrhea, Roflumilast is tolerated well in patients with moderate to severe COPD. However acute pancreatitis has been described in a small subset of patients. In one benefit-harm assessment, acute pancreatitis had an incidence rate of 0.077 per 1000 person-years. In a separate double blind placebo-controlled study, the incidence was equal to that of the placebo. While rare, the FDA does recognize pancreatitis as a possible severe gastrointestinal adverse effect. Of the patients who developed pancreatitis, increased mortality was noted in those receiving treatment doses of 500 mcg, suggesting a possible dose-dependent relationship on mortality from Roflumilast induced pancreatitis. While there is no proven mechanism for the cause, Roflumilast may cause pathology via duct constriction, accumulation of toxic metabolites or hypersensitivity. The associated elevation of cAMP, an intended effect within the lung parenchyma, may play a role in the side-effects experienced elsewhere in the body. CONCLUSIONS: Drug induced pancreatitis, though rare, is a potential fatal side effect of Roflumilast. While the incidence is low, the potential side effect and possible dose-related mortality relationship cannot be ignored. As with all new medications, a meticulous risk-benefit ratio should be analyzed and discussed before starting Roflumilast in all patients. Reference #1: Yu, T. et al. Benefits and Harms of Roflumilast in Moderate to Severe COPD.” Thorax 69.7 (2013):616-22 DISCLOSURE: The following authors have nothing to disclose: Noah Reisman, Lelia Logue, Saleem Shahzad No Product/Research Disclosure Information

A Rare Case of Mycoplasma Pneumoniae Infection Causing Cold-Agglutinin Autoimmune Hemolytic Anemia

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Mycoplasma pneumoniae typically causes upper respiratory infections and atypical pneumonia and hemolysis can be an uncommon extrapulmonary manifestation. We present an unusual case of Mycoplasma pneumoniae pneumonia causing cold-agglutinin autoimmune hemolysis in an immunocompetent patient. CASE PRESENTATION: A 63-year-old Hispanic male with hypertension presented with non-productive cough for two weeks, associated with shortness of breath and fatigue. He was tacchycardic, tacchypneic, saturating 92% on room air, with a temperature of 102.1° Farenheit. Pulmonary exam revealed scattered rhonchi in the right lower lung field and diminished breath sounds in the left base. Laboratory investigations showed leukocytosis. Computed tomography of the chest showed areas of nonspecific groundglass attenuation in the right upper lobe and inferior right middle lobe along with enlarged hilar and subcarinal lymph nodes. IgM titer for Mycoplasma pneumoniae was 5081 units/mL (Ref < 770). Despite treatment with Ceftriaxone and Azithromycin, his hypoxia worsened as he became jaundiced with notable scleral icterus. His hemoglobin level decreased from 13.3 g/dL to 6.6 g/dL. Haptoglobin level was consistently low along with elevations in LDH, total and direct bilirubin. A peripheral blood smear revealed red blood cell agglutination with no evidence of spherocytes. Direct antiglobulin test was 3+ positive for C3d and weakly positive for IgG. Cold-agglutinin antibody titer obtained towards the end of his stay was 1:64, confirming the diagnosis of cold agglutinin autoimmune hemolysis. He finished a 14-day course of Azithromycin, received warmed IV fluids along with strict cold avoidance, leading to an improvement of his symptoms and hemoglobin. Two weeks after discharge, his hemoglobin continued to increase to 12.4g/dL. DISCUSSION: In 50 to 75% of Mycoplasma pneumoniae infections, IgM cold agglutinins are formed against erythrocyte I antigen but only rarely does it lead to hemolysis. The majority of erythrocyte destruction is extravascular as complement coated erythrocytes are phagocytosed by reticuloendothelial cells, especially Kupfer cells in the liver. In this case of autoimmune hemolysis, the patient’s symptoms improved with supportive treatment, cold avoidance, and an extended course of Azithromycin. Severe symptomatic hemolysis can be treated with Rituximab, cytotoxic agents or plasmapheresis. CONCLUSIONS: Mycoplasma pneumoniae is a well recognized cause of pneumonia but its association with cold-agglutin autoimmune hemolysis is rare; very few case reports exist around the world. Early suspicion and detection in the appropriate clinical setting can aid physicians in preventing further erythrocyte destruction in these patients. Reference #1: Han X et al. Mycoplasma pneumonia associated with hemolytic anemia: case report. Chinese J of TB and Resp Diseases. 2011 Nov;34(11):832-6. DISCLOSURE: The following authors have nothing to disclose: Robert Chao, Kayur Shah No Product/Research Disclosure Information

We Sprung a Leak! Pancreaticopleural Fistula: An Uncommon Case of Pancreatic Leak in Chronic Pancreatitis

Internal pancreatic fistula (IPF) is a rare cause of pancreatitis-related pleural effusion. Identification of IPF is essential for appropriate management. We present a case of a pleural effusion secondary to a pancreaticopleural fistula (PPF). Routine imaging did not identify a fistula initially, but transpapillary stent for presumed fistula resulted in resolution of symptoms. A high level of suspicion for PPF is essential when presented with pancreatitis-associated pleural effusion, and treatment should be guided by the overall clinical scenario. A 43- year-old male with alcoholic cirrhosis, chronic pancreatitis, and pancreatic pseudocyst presented to the emergency department with dyspnea. On exam, he had diminished breath sounds at the left mid lung base and epigastric tenderness. Serum lipase was 724 U/L. CT chest with contrast revealed a large simple pleural effusion with near-complete collapse of the left lung, and a pseudocyst at the head of the pancreas. Magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic pseudocyst with the superior margin extending beneath the right diaphragmatic crus. A thoracentesis extracted one liter of fluid, with amylase greater than 30,000 U/L. He underwent three additional thoracenteses due to rapid re-accumulation of effusion. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with placement of a pancreatic duct stent for suspected fistula. After placement, the recurrent pleural effusion resolved. The pancreaticopleural fisutula was not identified on initial imaging nor initial ERCP, a repeat ERCP visualized a fistula, confirming the diagnosis. Pleural effusion due to pancreaticopleural fistula is rare, occurring in 0.4-4.5% of pancreatitis patients. The diagnosis of PPF includes elevated pleural fluid amylase and imaging to confirm disruption of the pancreatic duct. In this case, elevated pleural amylase and high level of suspicion led to accurate treatment despite absent visualization of PPF on initial imaging and ERCP. Conservative management is first indicated for a pancreaticopleural fistula, including thoracentesis, parenteral nutrition, and octreotide. If conservative therapy fails, ERCP with transpapillary stenting is recommended. Differential includes disconnected duct syndrome, which may not respond to endoscopic measures, and often requires surgery. The ability to recognize a pancreaticopleural fistula is essential for proper management of these patients.Figure 1Figure 2

Man With Diminished Breath Sounds on the Right

Man With Diminished Breath Sounds on the Right

Sevelamer crystals in the bronchus: a case report

An 80-year-old woman was admitted with a history of cough and gradually worsening shortness of breath of 3 months duration. Respiratory system examination revealed tracheal shift to the left, together...

Clinical indicators of ineffective airway clearance in children with acute respiratory infection.

The identification of clinical indicators with good predictive ability allows the nurse to minimize the existing variability in clinical situations presented by the patient and to accurately identify the nursing diagnosis, which represents the true clinical condition. The purpose of this study was to analyze the accuracy of NANDA-I clinical indicators of the nursing diagnosis ineffective airway clearance (IAC) in children with acute respiratory infection. This was a prospective cohort study conducted with a group of 136 children and followed for a period of time ranging from 6 to 10 consecutive days. For data analysis, the measures of accuracy were calculated for clinical indicators, which presented statistical significance in a generalized estimated equation model. IAC was present in 91.9% of children in the first assessment. Adventitious breath sounds presented the best measure of accuracy. Ineffective cough presented a high value of sensitivity. Changes in respiratory rate, wide-eyed, diminished breath sounds, and difficulty vocalizing presented high positive predictive values. In conclusion, adventitious breath sounds showed the best predictive ability to diagnose IAC in children with respiratory acute infection.

Chest Injury in a Soccer Player

HISTORY: A 24 year-old female collegiate soccer player presented 3 days after a collision injury. While playing soccer she was struck on the left side of chest by a male soccer player. Witnesses nearby told her they heard a pop at the time of collision. Since the game, she had been wrapping her chest with an ACE wrap and taking Tylenol 1000mg twice daily with mild relief. She denied hemoptysis but had some left sided chest tightness with walking about 100 feet. She complained of pain with deep inspiration and difficulty sleeping. She felt her pain was improving until she lifted her 2 year-old niece 1 day prior to presentation, when it acutely worsened. PHYSICAL EXAM: Examination in the clinic. Vital signs: Pulse 84 Blood pressure 110/80. Oxygen saturation was 98% on room air and with brisk walking. Trachea midline, jugular veins non-distended. Tenderness to palpation over ribs 4–6 in the mid-axillary line without ecchymosis or step-off appreciated. Normal respiratory effort. On auscultation, there were diminished breath sounds at the left apex. Pain noted with deep inspiration. Abdomen without obvious deformity or ecchymosis, nontender, normal bowel sounds, no hepatosplenomegaly. DIFFERENTIAL DIAGNOSIS: 1. Rib fracture 2. Rib contusion 3. Lung contusion 4. Pneumothorax TESTS AND RESULTS: 6/17/15 – CXR – Large left-sided apical pneumothorax measuring 3–3.5 cm (approximately 30-35%). – No rib fractures seen 6/18/15 – CXR status post CT-guided placement of chest tube – Much improved left-sided pneumothorax measuring 5 mm from the apex with small-caliber chest tube overlying 2nd-3rd intercostal space FINAL DIAGNOSIS: 1. Traumatic left-sided apical pneumothorax 2. Non-displaced left-sided rib fracture TREATMENT AND OUTCOMES: 1. CT-guided chest tube placement with removal after 2 hours. 2. Continue ACE wrap for comfort. 3. Rest with return-to-play progression over 5 weeks post chest tube. 4. Patient had return of mild chest pain 10 weeks after chest tube placement but repeat chest x-ray showed no return of pneumothorax. Progressed well back to playing soccer without further complication.

Explosive Pleurisy Related to Group A Streptococcal Infection: A Case Report and Literature Review

Group A Streptococcus (GAS) can cause invasive infections, such as pneumonia. It is rarely associated with a rapidly progressing exudative pleural effusion termed explosive pleurisy, leading to significant morbidity and mortality. A 27-year-old healthy man devel - oped sore throat 1 week prior to admission and then progressively developed fever, chills and shortness of breath. Upon presentation, his vitals were remarkable for an oral temperature of 102.4 F, blood pressure of 89/64, heart rate of 124, respiratory rate of 40 and a pulse oximeter reading of 84%. Examination revealed pharyngeal erythema and exudates, and decreased right chest expansion with diminished breath sounds and dullness to percussion on the right. Labs revealed leukocytosis of 13,000/mcl White Blood Cells (WBC) (Normal 3,500-10,500 cells/mcl). Chest radiographs showed early pneumonia with a small pleural effusion. A CT scan of the chest was performed 4 hours later, revealing the presence of right middle and lower lobe pneumonia and a moderate-sized pleural effusion. A chest tube was placed and drained serosanguinous fluid. Cultures of the pleural fluid grew GAS. The patient was treated with intravenous Penicillin G and Clindamycin. The patient continued to deteriorate, despite antibiotics and the empyema worsened despite presence of a chest tube. Video Assisted Tho- racoscopic Surgery (VATS) with decortication and drainage was performed with significant improvement of the patient's condition. GAS pneumonia can progress rapidly with develop- ment of complicated parapneumonic effusions and empyema, the so-called 'explosive pleu- risy'. Early surgical intervention may result in quicker symptom resolution and may minimize morbidity.

Integrated Therapy for Invasive Pulmonary Aspergillosis in a Patient with Asthma and Chronic Obstructive Pulmonary Disease Overlap Syndrome

Integrated Therapy for Invasive Pulmonary Aspergillosis in a Patient with Asthma and Chronic Obstructive Pulmonary Disease Overlap Syndrome

Predictors of treatment with antibiotics and systemic corticosteroids for acute exacerbations of asthma and chronic obstructive pulmonary disease in primary care.

BackgroundAntibiotic and oral corticosteroid prescribing rate in patients suffering from acute exacerbations of chronic obstructive pulmonary disease (COPD) or asthma in general practice are only sparsely described. Our aim was to identify predictors for such prescribing when results from CRP testing, spirometry, and pulse oximetry are available.MethodsPatients aged 40 years or more diagnosed with asthma, COPD or both, the previous five years from seven general practice offices in Norway, were invited to a baseline examination and asked to visit their GPs during exacerbations the following 12 months. At all visits, symptoms, chest findings, and results from spirometry, pulse oximetry and CRP testing were registered.ResultsOut of the 376 who took part in baseline examination, 95 patients with an exacerbation were included in the analysis. Based on the diagnosis made by GPs, 46 patients (48.4%) were only registered with asthma, and 49 (51.6%) with COPD (or both diagnosis). 11 patients had taken antibiotics and 16 had taken systemic corticosteroids prior to their visit to their GPs. After excluding those already treated, antibiotics were prescribed in 34.9% and systemic corticosteroids in 42.5% of patients diagnosed with COPD compared to 14.6% and 30.8% respectively in patients only diagnosed with asthma (P = 0.02, P = 0.2). In the COPD group, antibiotic prescribing was not significantly associated with purulence or other respiratory symptoms, but increased phlegm was a significant predictor of antibiotic prescribing in the whole sample (P = 0.04). Prolonged expiration, wheezes and diminished breath sounds also predicted the prescribing of both antibiotics and systemic corticosteroids in the whole sample with P values < 0.01. The prescribing rate of antibiotics and systemic corticosteroids also increased with increasing CRP value (P = 0.001 and P = 0.01, respectively) and with decreasing oxygen saturation (P = 0.01 and P = 0.003, respectively). FEV1/FVC < 0.7 at baseline was as significant predictor in patients with COPD and in the whole sample of patients regarding treatment with antibiotics (P = 0.004 and P = 0.001, respectively) and treatment with systemic corticosteroids (P = 0.004 and P = 0.001, respectively).ConclusionChest findings, raised CRP value and decreased oxygen saturation were stronger predictors of prescribing of antibiotics and systemic corticosteroids than were respiratory symptoms. Further evaluation of the importance of these findings to guide treatment of asthma and COPD exacerbations is warranted.

An unusual association of pleural effusion with acute viral hepatitis A infection

An unusual association of pleural effusion with acute viral hepatitis A infection Ajaya Kumar Dhakal Arati Shakya, Devendra Shrestha, Subhash Chandra Shah, Henish Shakya Department of Pediatrics, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal Abstract: Hepatitis A virus infection is a common public health problem in developing countries primarily due to poor hygiene and sanitation. The clinical features of hepatitis A virus are mostly related to the derangement of liver function with occasional extrahepatic complications. Herein, a 2.5-year-old girl presented with abdominal pain and decreased appetite for 4 days, high-colored urine for 3 days, and yellowish discoloration of the eyes for 2 days. On presentation, there was icterus along with hepatomegaly and diminished breath sounds on the right side were noted 1 day after admission. Chest X-ray revealed right sided pleural effusion; however, ultrasonography of chest and abdomen displayed bilateral pleural effusion (right more than left) and minimal ascites with thickened gall bladder wall. Immunoglobulin M anti-hepatitis-A virus serology was positive. The pleural effusion in this child resolved spontaneously in 10 days. We report this case to highlight that hepatitis A infection should be considered in the differential diagnosis of pleural effusion in a patient with features of acute hepatitis. However, other common causes of pleural effusion such as tuberculosis and parapneumonic effusions that may coexist with hepatitis, especially in developing world, need to be excluded. Keywords: hepatitis A, pleural effusion, viral hepatitis

Systematic review and meta-analysis of the accuracy of clinical indicators for ineffective airway clearance.

To report quantitative evidence for the accuracy of the defining characteristics of ineffective airway clearance in different settings and populations. Defining characteristics are tests used by nurses to clinically indicate the presence or absence of a particular nursing diagnosis. A few studies have reported the accuracy of certain defining characteristics of ineffective airway clearance, but these studies address specific populations with particular needs. A systematic review with meta-analysis was conducted to provide a synthesis and critical appraisal of the included studies. The electronic databases CINAHL, PubMed, Scopus and LILACS were searched using a systematic search strategy for studies published in any year. The last search was performed on 31 July 2013. Using the recommendations from Cochrane Collaboration for Systematic Reviews of Diagnostic Test Accuracy and the Standards for Reporting of Diagnostic Accuracy (STARD), a systematic review was conducted using studies investigating the presence of ineffective airway clearance and its defining characteristics. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to evaluate the quality of the studies. Seven papers met the search criteria. The studies were developed in different clinical settings and most of them fulfilled QUADAS criteria. Summary measures indicated the following defining characteristics with higher accuracy values: adventitious breath sounds, changes in respiratory rate, difficult vocalizing, diminished breath sounds, dyspnoea, ineffective cough, orthopnoea and restlessness. This systematic review showed that the variability in clinical indicators of ineffective airway clearance is related to differences in the clinical settings and patients.

Cardiac Sarcoma: Unusual Cause of Intracardiac Contrast Filling Defect

A 28-year-old female was transferred to the emergency department from her physician’s office for further evaluation of tachycardia. She was being seen for a recent illness which included nausea, vomiting, diarrhea and fevers. The patient endorsed fatigue, dyspnea on exertion, and extremity edema. She had no chest pain or cough. Exam revealed a pale, fatigued, mildly ill-appearing female with bilateral lower extremity edema and diminished breath sounds on the right. Chest radiograph revealed a large right pleural effusion (Figure 1). Computed tomographic angiography of the chest was performed (Figure 2).

Case report of tracheobronchopathia osteochondroplastica

Introduction: Tracheobronchopathia osteochondroplastica (TPO) is a rare entity characterized by bony and cartilaginous submucosal nodules which project into the tracheal–bronchial lumen. Nodules sometimes reach to the main bronchus and rarely to larynx. The disorder is more common in men and the diagnosis is usually made in the fourth through sixth decades of life. It's etiology remains unknown, with no relationship to smoking or systemic disorders. The patients are only rarely symptomatic since severe airway obstruction is unusual. Nevertheless the clinic is characterized by cough, dyspnea and recurrent respiratory infections. Even though imaging studies and bronchoscopy may indicate the diagnosis, the diagnosis is histological. There is only symptomatic therapy available. Methods: We report a case of an 81 year old men, with past history of auricular fibrillation, hypertension and heart failure who presented with recurrent respiratory infections treated with different courses of antibiotics. He was hospitalized due to community acquired pneumonia, with fever (37.8 °C), productive cough, yellow sputum, dyspnea and wheezing. He was treated with Ceftriaxone and Clarithromycin, completing 10 days of therapy. No agent was isolated. At the time of discharge we presented only with dry cough. One week after, he was readmitted for the same symptoms. Laboratory tests revealed mild leukocytosis and slight PCR elevation. The chest X-ray revealed right pleural effusion. Blood cultureswere negative. He started broad spectrumantibioticwith Piperacillin–Tazobactam, completing 10 days. Thoracocentesis revealed exudative effusion, with negative cultures. On the control X-ray there was a reduction of the effusion. Two days after, we noticed diminished breath sounds on physical examination, so another X-ray was performed, presenting a large pleural effusion, as we saw at the beginning. Regarding the medical history of the patient, the exudative nature of the effusion we performed bronchoscopy that showed cartilaginous submucosal nodules of the tracheal submucosa, consistent with tracheobronchopathia osteochondroplastica. Conclusions: TPO is a rare entity, characterized by bony and cartilaginous submucosal nodules which project into the tracheal–bronchial lumen, being more frequent in males being in the majority of the cases asymptomatic. In our case, regarding the age of the patient and the medical history, we think that this pathology favors the recurrent respiratory infections.

Fungating Mass as First Presentation of Advanced Breast Cancer

A 52-year-old woman visiting from the nation of Tonga presented to the Emergency Department with shortness of breath and an enlarging right breast mass that she first noticed one year prior to evaluation. Physical examination revealed a pulse of 120 beats/min, a respiratory rate of 40 breaths/min and a necrotic right breast mass, measuring 15 cm × 7.5 cm (Fig. 1). Diminished breath sounds and dullness to percussion were noted at the right posterior chest. Computed tomography of the chest showed one dominant (Fig. 2, X) and multiple smaller lesions in the right breast; a right-sided pleural effusion (Fig. 2, asterisk); nodular pleural thickening (Fig. 2, arrowhead); lung parenchymal nodules (Fig. 2, arrow); and diffuse lymphadenopathy. Biopsy demonstrated infiltrating poorly differentiated ductal adenocarcinoma. While fungating breast masses are considered locally advanced disease (stage III), she was diagnosed with stage IV breast cancer due to the presence of distant metastases.1–3 Globally, breast cancer incidence is increasing.4,5 In developing countries >60 % of women present with later stage cancers (III/IV).4 In one case series, 39 % of 212 patients presented with fungating breast masses.6 This patient was subsequently discharged with palliative care follow-up. Figure 1 Necrotic right breast mass. Figure 2 Computed tomography of the chest showing one dominant (X) and multiple smaller lesions in the right breast; a right-sided pleural effusion (asterisk); nodular pleural thickening (arrowhead); lung parenchymal nodules (arrow); and diffuse lymphadenopathy. ...

Physical Signs in the Chest

Part 1 of a Series of Two Articles This article is a personal one, based on my own practice and techniques. The evidence of the x-ray has taught consultants modesty in the evaluation of physical signs in the chest. In the good old days when the Chief said that there were dullness and diminished breath sounds in some area of the chest, the referee had spoken and there was no appeal. Nowadays he is liable to look rather silly if the x-ray is normal or the abnormality is found on the other side he is likely, therefore, to be less dogmatic. We have also learnt, in the last few years, about “observer error”. We know how differently even skilled observers may interpret the same phenomena and how even a skilled observer may fail to notice something which may be spotted immediately by one of his colleagues, or by himself on another occasion.