Left Lower Hemithorax Research Articles

An autopsy case of disseminated Cunninghamella bertholletiae infection in an immunocompetent patient: a case report

BackgroundRecently, deaths due to mucormycosis in immunocompromised hosts have increased; however, the clinical and pathological features of mucormycosis are not fully understood, especially in view of the associated high mortality and rare incidence in immunocompetent patients.Case presentationWe have described a rare autopsy case of a 67-year-old Japanese man with chronic obstructive pulmonary disease who contracted mucormycosis. He had not been on any immunosuppressants, and his immune functions were intact. Since 3 days prior to admission to our hospital, he had experienced progressive dyspnea, productive cough, and fever. Chest computed tomography revealed pleural effusion in the left lower hemithorax and consolidation in the right lung field. Although he was administered with tazobactam-piperacillin hydrate (13.5 g/day), renal dysfunction occurred on the ninth disease day. Therefore, it was switched to cefepime (2 g/day). However, his general condition and lung-field abnormality worsened gradually. Cytological analysis of the sputum sample at admission mainly revealed sporangiophores and unicellular sporangioles, while repeated sputum culture yielded Cunninghamella species. Therefore, he was diagnosed with pulmonary mucormycosis. Liposomal amphotericin B (5 mg/kg/day) was initiated on the 28th disease day. However, chest radiography and electrocardiography detected cardiomegaly and atrial fibrillation, respectively, and he died on the 37th disease day. A postmortem examination revealed clusters of fungal hyphae within the arteries of the right pulmonary cavity wall, the subpericardial artery, intramyocardial capillary blood vessels, and the esophageal subserosa vein. Direct sequencing revealed that all fungal culture samples were positive for Cunninghamella bertholletiae.ConclusionsCunninghamella bertholletiae could rapidly progress from colonizing the bronchi to infecting the surrounding organs via vascular invasion even in immunocompetent patients.

Pneumonia with empyema: rare complication after sea urchin injury

Staphylococcal pneumonias are rare, especially in immunocompetent children. They can represent a complication of tissue infection with hematogeneous dissemination. Sea urchin injuries can result in local reactions, granulomas and, unfrequently, systemic disease. We describe the case of a 16-year-old boy with a four-day fever and left-sided chest pain, with referral to a sea urchin injury five days before admission. Physical examination revealed diminished pulmonary sounds and crackles in the left lower hemithorax. The chest radiograph showed a pleural effusion. Blood tests showed leukocytosis, neutrophilia, and an elevated C-reactive protein. Empyema was diagnosed after performing a thoracentesis. Subsequently he initiated inflammatory signs with fluctuation on his right heel, with purulent drainage. Suspecting on a staphylococcal etiology, he was treated with flucloxacillin, a suspicion that was confirmed by the isolation of Staphylococcus aureus in pleural liquid and abscess material. After antibiotic treatment was established, there was a favorable clinical and radiological evolution. With this case report, we would like to draw attention to the possibility of hematogenous dissemination of a microorganism after local skin infection, even in immunocompetent individuals.

NUTS IN THE LUNGS: AN UNFORTUNATE RIME

TYPE: Abstract Publication TOPIC: Lung Cancer PURPOSE: Nuclear Protein in Testis (NUT) Carcinoma is an extremely rare and undifferentiated malignancy characterized by the rearrangement of NUT gene. Typically affects midline structures in younger individuals. We report a case of a NUT Carcinoma of the Lung. METHODS: A 51-year-old female non-smoker with no significant past medical history was presented to a hospital with fatigue and left anterior pleuritic chest pain for 2-weeks. She was performed a chest radiography which showed a homogeneous opacification with concave upper margin in left lower hemithorax, suggestive of pleural effusion. Computed Tomography (CT) scan confirmed a massive pleural effusion associated with pleural thickening. Diagnostic thoracentesis was performed and was suggestive of exudative effusion with no detection of malignant cells. Blind pleural biopsy showed tumoral cells with high proliferation rate (Ki67 50%). Following surgical pleural biopsy and immunohistochemical analysis identified a NUT Carcinoma. 18F-Fluorodeoxyglucose Positron Emission Tomography scan for staging confirmed a left pleural thickening (SUV: 11.7), revealing also bilateral mediastinal ganglion, left adrenal and multiple lithic bone metastasis. RESULTS: The patient was proposed to clinical trial but died 1 month after the diagnostic, due to rapid progression of the disease, invading left main bronchus, vascular structures and pericardium with large pericardial effusion. CONCLUSIONS: NUT carcinoma is a highly aggressive disease that can also affect non-middle structures. CLINICAL IMPLICATIONS: Due to its rarity and lack of experience it can be un/misdiagnosed. NUT Carcinoma should be included in differential diagnosis of rapid progressive malignancy in children and young adults. DISCLOSURE: No significant relationships. KEYWORD: NUT Carcinoma

Anesthetic management of a case of spontaneous rupture of diaphragm.

Sir, A 58-year-old male patient presented with a history of sudden onset of the left upper quadrant pain and vomiting from 6 days following the lifting of bucket filled with water. He also had a history of the left lower chest pain on inspiration, dyspnea on lying supine, decrease appetite and constipation. Vitals were almost normal at admission. Oxygen saturation was 90%. On auscultation air entry was absent over left lower hemithorax. Routine blood tests were normal. Arterial blood gas showed respiratory alkalosis with mild hypoxemia (pH 7.50, pCO2 30 mmHg and pO2 64 mmHg). Electrocardiogram showed “t” wave inversion in leads V1, V2 and V3. A plain erect chest radiograph showed upward shifting of the left side of hemidiaphragm, air filled shadow of stomach occupying lower half of left hemithorax, compression of the left lung, shifting of the trachea and mediastinal structures to the right side [Figure 1]. In the operating room, standard anesthesia monitors were attached. A rapid sequence induction (RSI) of anesthesia was done with thiopentone, succinylcholine, and fentanyl. Due to nonavailability of double lumen tube trachea was intubated with number 8.0 standard endotracheal tube (ETT) that was intentionally inserted in the right main bronchus and was fixed at 26.0 cm. A pressure controlled mode was initiated. Anesthesia was maintained on oxygen in the air and isoflurane. Laparotomy via midline approach revealed a tear of approximately 5 cm at the lateral side of left hemidiaphragm. Stomach was pulled down through the rent along with gangrenous part of omentum. Gastropexy was done and diaphragm tear was repaired. Gangrenous part of omentum was resected out. ETT was withdrawn to 22 cm at upper incisor and bilateral air entry was confirmed. Chest drain was placed. At the end of surgery, patient was extubated in the operating room with acceptable vital parameters. Figure 1 X-ray chest posteroanterior view showing left diaphragmatic hernia Spontaneous rupture of the diaphragm is extremely rare with limited literature. Spontaneous rupture can be due to violent cough,[1,2] during vaginal delivery[3] physical activity,[2] violent vomiting and defecation.[4] Sudden and violent Valsalva maneuver with increased intraabdominal pressure is main denominator in these cases.[5] Diagnosis is difficult due to nonspecific clinical presentation such as upper quadrant abdominal pain, vomiting, and constipation.[6] This is mostly associated with dyspnea, tachycardia and hypotension. Chest radiograph may help in diagnosis, but has poor sensitivity and specificity. Radiographic finding includes herniation of abdominal viscera into the thoracic cavity, compression of ipsilateral lung and displacement of mediastinum to the opposite side. “Collar sign” is the presence of a large bulla between the abdomen and the chest, with a constriction at the diaphragmatic level is specific of a diaphragmatic defect.[5] Early complications may include strangulation of intestine that can terminate in rupture and gangrene formation. Peritonitis and pleural effusion may be the sequel. Early intervention includes oxygenation, correction of fluid deficit, gastric decompression etc. Emergent surgical intervention is usually required in view of high mortality and morbidity. The causative factor for diaphragm rupture would be the raised intraabdominal pressure during lifting of a heavy object. Other possible etiologies like congenital diaphragmatic hernia or ischemic process was ruled out by intraoperative findings. Anesthetic management of these patients is quite challenging in view of an emergency nature of surgery with inadequate time to patient optimization, unstable hemodynamics, high probability of hypoxemia and rapid desaturation, full stomach, fluid deficit, electrolyte imbalance and need for one lung ventilation. These patients often require the securing of wide bore intravenous access or central venous cannulation, beat to beat blood pressure monitoring if hemodynamically unstable. RSI in these patients may cause rapid desaturation because of already decreased functional residual capacity. During mechanical ventilation, lung protective strategy should be applied with low tidal volume and positive end expiratory pressure. Postoperatively, patient can be extubated in the operating room if vital parameters allow. Grossly ruptured and hemodynamically unstable patient should be allowed to ventilate postoperatively. Adequate analgesia (epidural analgesia) in the postoperative period can help in early recovery. Patient controlled analgesia can be used if epidural was placed.

A Patient with Left Cardiophrenic Angle Mass Presenting with Intermittent Chest Symptoms

A 42-year-old male shopkeeper presented in the out-patient department (OPD), with intermittent cough for the last six months along with occasional compressive symptoms at the centre of chest and mild dyspnea on exertion. Detailed cardiological history was not contributory. Chest on auscultation showed diminished air entry in the left infra-scapular region with occasional crepitations; the right side of the chest and other systemic examinations were within normal limits. Chest X-ray postero-anterior (PA) view revealed a lobular opacity in the left cardio-phrenic angle. (Fig. 1) Figure 1 Chest X-ray PA view showing a lobular opacity at the left cardio-phrenic angle large enough to obscure the left costo-phrenic angle, shown by the arrow. Routine blood investigations and 12-lead electrocardiography (ECG) revealed no abnormality. Two-dimensional echocardiography revealed a large well defined mass having echo-free space measuring 9.0 × 5.6 cm, resting on the postero-lateral side of the left ventricle (LV) without any connection to ventricular cavity (Fig. 2). But due to poor window, the exact morphological and anatomical nature of the mass could not be substantiated. Later contrast enhanced computed tomography (CECT) scan of the chest confirmed (Fig. 3), a large well circumscribed cystic lesion measuring 9.8 cm (antero-posterior) × 6.4 cm (supero-inferior) × 5.5 cm (transverse) in the left lower hemi-thorax, abutting the lateral aspect of the pericardial cavity, not separable from it and indenting the lateral wall of the LV. It had thin barely perceptible wall, homogeneous fluid attenuation content, without any foci of calcification, contrast enhancement, or internal septa. Figure 2 2-D echocardiography showed a large well defined mass having echo-free space near the postero-lateral side of left ventricle (shown by interrogation mark). Figure 3 CECT chest showing a large well circumscribed cystic lesion in left lower hemi-thorax, abutting lateral aspect of pericardial cavity. Question What is the diagnosis?

Fat-forming variant of solitary fibrous tumour of the pleura: CT findings

The fat-forming variant of solitary fibrous tumour (SFT) was previously called lipomatous haemangiopericytoma and is a rare variant of solitary fibrous tumour. It predominantly occurs in the deep soft tissues of the retroperitoneum and thigh. Only a handful of cases involving the perineum, spine, thoracic wall and pelvic cavity have been reported in the radiological literature and the fat-forming variant of SFT involving the pleura has not been previously reported. Herein, we report the CT findings of a case of the fat-forming variant of SFT involving the pleura that was treated by excision. Chest CT showed a large lobulated heterogeneous fatty mass with a multifocal enhancing soft-tissue component in the left lower hemithorax. Although rare, the fat-forming variant of SFT of the pleura should be added to the differential diagnosis of fat-containing pleural soft-tissue tumours.

A Fat Density Mass in the Mediastinum

A 47-year-old female was admitted for an evaluation of a left mediastinal mass. The chest X-ray performed 16 months ago was normal, but the chest X-ray upon admission showed a large mass adjacent to the anterior aspect of the left hemidiaphragm. The CT scan demonstrated a large mass with a fat density in the left lower hemithorax. A focal diaphragmatic defect behind the xiphoid process was suspected. A thoracoscopic examination revealed omental herniation through the diaphragmatic defect. Therefore, a left thoracotomy was performed and the defect was repaired. We believe that a differential diagnosis should be needed to include a diaphragmatic omental hernia when a fat density mass is observed in the mediastinum.