Left Lower Lung Field Research Articles

6724 A Broken Heart Due to Excess Thyroid

Abstract Disclosure: R. Subramani: None. R. Subramani: None. V. Zeykan: None. Introduction: Tachycardia-induced cardiomyopathy related to thyrotoxicosis is an uncommon yet serious complication affecting fewer than 1% of individuals with hyperthyroidism. Restoring a euthyroid state can potentially reverse the abnormal cardiac structure and function. Here we report a case of tachycardia-induced cardiomyopathy secondary to thyrotoxicosis Case Summary: A 52-year-old woman with a history of hypertension presented with recent-onset exertional dyspnea, a nonproductive cough, and paroxysmal nocturnal dyspnea. On examination, she exhibited tachycardia (heart rate: 150/min), tachypnea, hypertension, and was afebrile. Physical findings included a mildly enlarged, firm, non-tender thyroid gland bilaterally, without exophthalmos or tremors. Auscultation revealed bilateral crackles in the left lower lung fields. Laboratory analysis revealed undetectable TSH (<0.02 uIU/mL), elevated free T4 (5.3 ng/dL), free T3 (16.30 pg/mL), thyroid stimulating immunoglobulin (TSI) at 216%, and NT proBNP at 8528 pg/mL. Neck ultrasound and CT confirmed diffuse enlargement of the thyroid gland. Transthoracic echocardiography (TTE) displayed severely depressed left ventricular systolic function, estimating an ejection fraction (EF) of 25-30%. Initial management involved intravenous beta-blockers for heart rate control, IV Lasix, and IV hydrocortisone. Subsequently, the patient received propylthiouracil, propranolol, and prednisone, resulting in symptomatic improvement. A follow-up TTE after 6 months revealed an improved EF of 50%. Discussion: The pathophysiologic mechanisms underlying thyrotoxic cardiomyopathy encompass several factors, including tachycardia-induced cardiomyopathy, direct myopathic effects induced by the T3 hormone, and concurrent autoimmune myocarditis associated with Graves' disease. Thyroid hormone exerts a comprehensive impact on nearly all tissue and organ systems, heightening basal metabolic rate and subsequently increasing preload, myocardial contractility, and cardiac output. While thyrotoxicosis-related congestive heart failure (CHF) is relatively uncommon among patients hospitalized for acute CHF, addressing hyperthyroidism and CHF through definitive treatment yields a more favorable prognosis compared to cases of acute CHF stemming from other etiologies. The intricate interplay of these mechanisms highlights the importance of a comprehensive approach in managing thyrotoxic cardiomyopathy, emphasizing the need for targeted interventions to address both the underlying thyroid dysfunction and associated cardiac manifestations. Presentation: 6/3/2024

Enlarging pulmonary cyst: a rare form of alveolar adenoma

BackgroundAlveolar adenoma is a rare benign tumour, usually presenting as a peripherally located solid mass, sometimes mimicking malignancy.Case presentationA 37-year-old woman presented with chronic intermittent vague chest discomfort. The chest x-ray showed a simple cyst in the left lower lung field, and serial computed tomography (CT) over the following 2-year period showed rapid growth of the cyst, from 3.5 to 9.0 cm in diameter. The CT scan suggested bronchiolar communication, which was suspected to be the cause of growth, via check-valve mechanism. Thoracoscopic surgery was performed, and we found a thin-walled cyst in the lingular segment. Wedge resection was performed and the pathology was an unexpected alveolar adenoma which had grown on the terminal bronchiole, causing the alveolus to rupture and the cyst to grow. In 48 months of follow-up, there was no evidence of recurrence and the patient’s symptoms resolved.ConclusionsRapidly growing pulmonary cysts can lead to complications including rupture with pneumothorax and haemothorax, and surgery is always indicated. Abnormally rapid growth may indicate an underlying pathology such as alveolar adenoma. Surgical resection is the treatment of choice and there have been no reported cases of recurrence. Here we present a rare form of alveolar adenoma, which was a form of rapidly growing pulmonary cyst.

Primary pancreatic Ewing sarcoma with metastases on FDG PET/CT

BackgroundEwing sarcoma (ES) is a highly aggressive malignant tumor most commonly affecting long bones. Extraskeletal Ewing sarcoma (EES) is a malignant tumor with aggressive behavior carrying bad prognosis with pancreas being an extremely rare primary site. We present a case of histopathologically proven EES of the pancreas in a young female who presented with abdominal pain. 18F-fluorodeoxyglucose positron emission tomography (18F FDG PET/CT) is a useful modality for detecting distant metastases in EES. It helps in diagnosis, localizing the primary, its extension, optimal treatment planning and evaluation of response to standard treatments available.Case presentationAn 18-year-old female presented with complaints of progressive abdominal pain and distention since 6 weeks. Physical examination was suggestive of a solid large mass in the upper left abdomen and decreased breath sounds with dullness in the left lower lung fields. On Contrast enhanced computed tomography (CECT) imaging, a large heterogeneously enhancing mass was seen arising from pancreas along with retroperitoneal lymphadenopathy. A moderate sized left sided pleural effusion with atelectasis of lower lobe of left lung was also noted. Histopathological analysis was suggestive of pancreatic ES following which the patient underwent five cycles of chemotherapy. Following this, she underwent 18F FDG PET/CT which showed hypermetabolic large mass arising from body and tail of pancreas with areas of internal necrosis along with left adrenal metastasis, retroperitoneal lymphadenopathy, a massive left pleural effusion and compressive atelectasis of left lower lobe. The patient expired within a week following PET/CT.ConclusionsEES most often presents in the late stage of the disease with vague symptoms. Timely diagnosis and initiation of treatment is of utmost importance considering the aggressiveness of the tumor. Establishing a diagnosis of Ewing sarcoma is especially difficult when the mass is arising from the pancreas. Imaging, histopathology and immunohistochemistry (IHC) play a key role in accurate diagnosis of such masses. 18F FDG PET/CT can be useful for detecting local and distant spread, operability, treatment planning and evaluation of response to chemotherapy.

CAVITARY PNEUMONIA: THE CLOT THICKENS

CAVITARY PNEUMONIA: THE CLOT THICKENS

A Rare Cause of Peri-esophageal Cystic Lesion

A Rare Cause of Peri-esophageal Cystic Lesion

Pulmonary sequestration: a rare cause of false-positive uptake in Iodine-131 whole-body scan

BackgroundHigh-dose radioactive iodine-131 (I-131) is generally used post-total or subtotal thyroidectomy in differentiated thyroid cancer (DTC) patients. I-131 whole-body scan (WBS) is performed to localize I-131 accumulation in the body and for restaging after therapy. Nonetheless, there are numerous causes of false-positive uptake in I-131 WBS in the absence of residual thyroid tissue or thyroid cancer metastasis.Case presentationWe present a case of 51-year-old lady with false-positive uptake in I-131 WBS mimicking lung metastasis. Patient underwent total thyroidectomy, and histopathological examination showed well-differentiated papillary thyroid microcarcinoma. Diagnostic I-131 WBS followed by two subsequent high-dose radioiodine ablation showed persistent I-131 uptake in the left lower lung field. However, the serum thyroglobulin (Tg) is incessantly undetectable (< 0.04 μg/ml) with negative anti-thyroglobulin antibody (anti-TgAb). Three serial CT scans over the course of treatment coupled with MRI of the thoracolumbar region revealed stable lung lesion in the posterior segment of left lower lobe which signifies pulmonary sequestration. Based on the clinical assessment, imaging findings and blood investigations, patient was no longer subjected to I-131 therapy and is maintained on TSH suppression with L-thyroxine. After due consideration of the pros and cons of surgical intervention, the patient opted against surgical removal of the pulmonary sequestration.ConclusionsMeticulous assessment of patient with suspected disease recurrence or metastasis in thyroid carcinoma is essential to avoid unnecessary I-131 ablation or surgical intervention. In this case, the positive I-131 imaging is associated with undetectable serum Tg (with negative anti-TgAb). Albeit uncommon, pulmonary sequestration should be taken into consideration as one of the differentials in false-positive findings of an I-131 WBS.

A TICKING TIMEBOMB: FLOATING AORTIC ARCH THROMBUS IN A PATIENT WITH METASTATIC SQUAMOUS CELL CARCINOMA OF THE LUNG

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thoracic aortic mural thrombi are a rare clinical entity and most patients are asymptomatic before significant embolic events occur(1). There are only a few reported cases and are mostly in patients who presented with complications of peripheral thromboembolism. We report the case of a patient who presented with symptoms of congestive heart failure and was found to have a large floating thoracic aortic thrombus. CASE PRESENTATION: The patient is a 61-year-old female with no prior medical history who presented with shortness of breath on exertion and dry cough of three weeks duration. The patient has an extensive 40 pack-year smoking history. On evaluation, the patient was tachypneic, hypertensive, and was saturating well on room air. Crackles could be heard at the bases of the lungs and there was pitting edema of bilateral lower extremities. Laboratory studies showed a b-type natriuretic peptide level of 1741 pg/mL. A chest X-ray revealed pulmonary edema and bilateral pleural effusions. With a diagnosis of heart failure, gentle diuresis with intravenous furosemide was initiated. An echocardiogram showed global hypokinesis of the left ventricle with a reduced ejection fraction of 25-30%. CT scan of the chest revealed a large 6 x 7 cm necrotic mass in the left lower lung field with mediastinal adenopathy. There was a pulmonary embolus in the posterior basal segment of the left pulmonary artery, originating from the location of the mass. The CT was also significant for an intraluminal polypoid filling defect in the aortic arch with multiple small splenic and left renal infarcts, suggestive of a peripherally embolizing aortic thrombus. The patient was started on anticoagulation with low molecular weight heparin and was recommended to have an aortic arch stent placed to prevent further embolization of the thrombus. However, the patient decided against the procedure. Further biopsy and staging workup of the left lung mass revealed metastatic squamous cell carcinoma. The patient decided against palliative chemotherapy and opted for hospice care. DISCUSSION: Thoracic aortic mural thrombus is the result of disturbances in the Virchow's triad, ie, stasis, hypercoagulability, and endothelial dysfunction. The patient's smoking history, extensive atherosclerosis, malignancy, and left ventricular dysfunction were likely contributing factors. Aortic thrombi are prone to peripheral embolization to sites such as the spleen, kidneys, small bowel, and lower extremities(2). Early diagnosis and prompt management with anticoagulation are key. Endovascular repair with endograft stents is a novel modality of treatment with higher safety, patient acceptability, and a lower rate of peripheral embolization(3). CONCLUSIONS: Thoracic aortic thrombi are an initially silent rare disease condition with potentially fatal complications. Prompt management with anticoagulation and possible endovascular treatment is warranted. REFERENCE #1: Yang P, Li Y, Huang Y, Lu C, Liang W, Hu J. A giant floating thrombus in the ascending aorta: a case report. BMC Surg. 2020 Dec 9;20(1):321 REFERENCE #2: Bukharovich IF, Wever-Pinzon O, Shah A, Todd G, Chaudhry FA, Sherrid MV. Arterial Embolism Caused by Large Mobile Aortic Thrombus in the Absence of Atherosclerosis, Associated with Iron Deficiency Anemia. Echocardiogr Mt Kisco N. 2012 Mar;29(3):369–72. REFERENCE #3: Jamjoom R, Zagzoog MM, Sait S. Outcome of Endovascular Approach for Management of Thoracic Aortic Thrombus. Ann Vasc Surg. 2019 Aug 1;59:307.e7-307.e12. DISCLOSURES: No relevant relationships by Amjad Basheer, source=Web Response No relevant relationships by Rana Prathap Padappayil, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response No relevant relationships by vinit singh, source=Web Response No relevant relationships by Raghu Tiperneni, source=Web Response

Deep Learning for Detection of Pulmonary Metastasis on Chest Radiographs.

Background A computer-aided detection (CAD) system may help surveillance for pulmonary metastasis at chest radiography in situations where there is limited access to CT. Purpose To evaluate whether a deep learning (DL)-based CAD system can improve diagnostic yield for newly visible lung metastasis on chest radiographs in patients with cancer. Materials and Methods A regulatory-approved CAD system for lung nodules was implemented to interpret chest radiographs from patients referred by the medical oncology department in clinical practice. In this retrospective diagnostic cohort study, chest radiographs interpreted with assistance from a CAD system after the implementation (January to April 2019, CAD-assisted interpretation group) and those interpreted before the implementation (September to December 2018, conventional interpretation group) of the CAD system were consecutively included. The diagnostic yield (frequency of true-positive detections) and false-referral rate (frequency of false-positive detections) of formal reports of chest radiographs for newly visible lung metastasis were compared between the two groups using generalized estimating equations. Propensity score matching was performed between the two groups for age, sex, and primary cancer. Results A total of 2916 chest radiographs from 1521 patients (1546 men, 1370 women; mean age, 62 years) and 5681 chest radiographs from 3456 patients (2941 men, 2740 women; mean age, 62 years) were analyzed in the CAD-assisted interpretation and conventional interpretation groups, respectively. The diagnostic yield for newly visible metastasis was higher in the CAD-assisted interpretation group (0.86%, 25 of 2916 [95% CI: 0.58, 1.3] vs 0.32%, 18 of 568 [95% CI: 0.20, 0.50%]; P = .004). The false-referral rate in the CAD-assisted interpretation group (0.34%, 10 of 2916 [95% CI: 0.19, 0.64]) was not inferior to that in the conventional interpretation group (0.25%, 14 of 5681 [95% CI: 0.15, 0.42]) at the noninferiority margin of 0.5% (95% CI of difference: -0.15, 0.35). Conclusion A deep learning-based computer-aided detection system improved the diagnostic yield for newly visible metastasis on chest radiographs in patients with cancer with a similar false-referral rate. © RSNA, 2021 Online supplemental material is available for this article.

AN EXUDATIVE PLEURAL EFFUSION ASSOCIATED WITH GRAVES DISEASE

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Graves’ disease is an autoimmune disease associated with hyperthyroidism and antithyroid autoantibodies. Ocular and dermatologic findings are well described extrathyroid manifestations of Graves’ disease. Here we present a case of pleural effusion as an extrathyroid manifestation of Graves’ disease. CASE PRESENTATION: A 42-year-old African American male with a history of traumatic pneumothorax presented with five days of dyspnea and cough with scant hemoptysis. He reported associated subjective fever, chills, left sided pleuritic chest pain, recent sick contacts and a twenty pound weight loss over the last year. Tachycardia and tachypnea as well as decreased breath sounds over right lower lung fields and rhonchi over left lower lung fields were present on exam. Computed tomography angiography was performed in the emergency department and revealed patchy left sided infiltrates, marked thyromegaly, cardiomegaly and a moderate right sided effusion. He received ceftriaxone and azithromycin as treatment for community acquired pneumonia. Laboratory evaluation was notable for TSH 0.01 mcIU/mL and Free T4 >7.7 ng/dL consistent with hyperthyroidism. Thyrotropin receptor antibody was also significantly elevated raising concern for Graves’ disease. Transthoracic echocardiogram revealed dilated cardiomyopathy with moderately reduced ejection fraction (35%). Thoracentesis of right pleural effusion was performed on hospital day two and returned 1200cc amber colored fluid. Fluid studies were consistent with an exudative effusion (pleural/serum protein ratio 0.58) and cell count was lymphocyte predominant (77%). Gram stain and fluid cultures revealed no growth. Adenosine deaminase was not elevated, and cytology was unremarkable. Prior to discharge, the patient was started on methimazole as management of his Graves’ disease. Repeat chest x-ray three months later revealed persistent resolution of the pleural effusion. DISCUSSION: Pleural effusion is a rare but reported manifestation of Graves’ disease. Effusions are exudative and thus other common causes of exudates should also be ruled out. The pathophysiology is thought to be an autoimmune mediated epiphenomenon similar to pretibial myxedema and ophthalmopathy associated with Graves’ disease. CONCLUSIONS: In patients with uncontrolled hyperthyroidism and an exudative pleural effusion, Graves’ disease should be considered as a potential etiology. Reference #1: Fatourechi, V. (2015). Thyroid dermopathy and acropachy. In Graves' Disease (pp. 195-212). Springer, New York, NY. Reference #2: Kapur, S., & Olarewaju, A. (2014). Pleural Effusion in the Setting of Graves’ Disease and Congestive Heart Failure: A Case Report. Chest, 145(3), 257A. Reference #3: Khalid, Y., Sulaiman, R., Zahir, R., Baskar, V., & Buch, H. N. (2011). An unusual complication in a patient with Graves’ disease. Clinical Correspondence. DISCLOSURES: No relevant relationships by William Denney, source=Web Response no disclosure on file for Jessie Harvey

Unusual synchronous double primary treatment-na\xefve lung adenocarcinoma harboring T790M and L858R mutations in early-stage lung cancer

BackgroundConcurrent mutations of synchronous multiple primary non-small cell lung cancer (SMPNSCLC) is rare, and only a few cases have been reported. Herein, we present a case of early-stage SMPNSCLC with T790M and L858R mutations.Case presentationA 68-year-old male patient presented to the Thoracic Surgery Department due to a tumor in the right lower lung. The tumor was detected more than 5 years previously during a health examination; however, the patient ignored the problem because the clinician at that time stated that the lesion was highly likely to be benign. Chest computed topography (CT) was ordered and the images showed a well-defined tumor in the right lower lung and a faint nodular lesion over the left lower lung field. A CT-guided biopsy results showed the presence of atypical cells and positive staining of TTF-1 and CK7. Surgical intervention was performed. The right- and left-sided tumors disclosed micropapillary predominant adenocarcinoma and acinar-predominant adenocarcinoma, respectively. Both tumors were positive for TTF-1 but negative for ALK and p40. Real-time PCR analysis showed that the right-sided tumor had an epidermal growth factor receptor (EGFR) mutation presenting as point mutation T790M in exon 20, while the left-sided tumor had a point mutation L858R in exon 21 of EGFR.ConclusionsOur patient’s case suggests that tumors resembling a benign pattern with central calcification may be misdiagnosed. Thus, early screening for lung cancer is important, and intensive efforts to make a diagnosis through surgical resection or biopsies to allow for tailored optimal treatment may be preferential for the best patient outcomes.

Lung abscess by Actinomyces odontolyticus and Parvimonas micra co-infection presenting as acute respiratory failure

Rationale:Actinomyces odontolyticus and Parvimonas micra are very rare causative organisms of lung abscess and acute respiratory failure.Patient concerns:A 49-year-old male patient visited the emergency room with a complaint of sudden onset of shortness of breath, and he developed acute respiratory failure rapidly.Diagnosis:An abscess in the left lower lung field was diagnosed on the computed tomography scan of chest.Interventions:Immediate treatment with intravenous antibiotics was initiated along with a pigtail catheter insertion for pus drainage.Outcomes:A odontolyticus was cultured on the drained pus and P micra was identified by a blood culture. The patient was successfully weaned from the mechanical ventilator and the lung abscess was completely resolved.Lessons:To the best of our knowledge, this is the first case report of mixed infection with A odontolyticus and P micra, which caused acute respiratory failure in an immune-competent patient. Therefore, physicians should consider the possibility of these organisms as causative pathogens of a fulminant pulmonary infection even in an immune-competent patient.

Recurrent intestinal ischemia following surgery for gastric and duodenal perforations: a case report

BackgroundExtremely low birth weight (ELBW) is a risk factor for various gastrointestinal complications. In the recent decades, advances in medicine have increased the survival of ELBW infants with necrotizing enterocolitis (NEC). To our knowledge, there have been no reports of neonates or infants developing simultaneous gastric and duodenal perforations and later developing NEC. We report a case of an extremely low birth weight infant (ELBWI) who developed both gastric and duodenal perforations at the same time and developed NEC after operation for gastric and duodenal perforations.Case presentationThe patient was a female infant with ELBW who developed both gastric and duodenal perforations at the same time and developed NEC after operation for gastric and duodenal perforations. After birth, endotracheal intubation was performed. However, barotrauma occurred during positive pressure ventilation, resulting in a large area of emphysema in the left lower lung field, leading to collapse of the left lung. This giant bulla may have compressed the pulmonary vein, possibly resulting in pulmonary venous thrombosis (PVT). This episode could have triggered simultaneous gastric and duodenal perforations. In addition, we hypothesized that PVT caused acute arterial ischemia, leading to the development of NEC. The infant was started on heparin for anticoagulation. Later, the infant developed non-immunoglobulin E (IgE)-mediated gastrointestinal food allergies (non-IgE-GI-FAs). The giant bulla associated with barotrauma might have caused PVT, resulting in arterial emboli and multiple simultaneous gastrointestinal perforations.ConclusionsAnticoagulation therapy with heparin for acute arterial thrombosis is effective for preventing the development of short bowel syndrome. Duodenal and intestinal surgery probably acted as risk factors for the subsequent development of non-IgE-GI-FAs. The infant had been stabilized at the time of writing this report.

SUN-397 A Rare Case of Ectopic Adrenocorticotropic Hormone (ACTH) Syndrome Due to Thymic Large Cell Neuroendocrine Carcinoma Presenting as Severe Hypokalemia in a Taiwanese Man

Background Ectopic ACTH syndrome (EAS) represented 5% of Cushing syndrome. EAS is rapid onset, severe, associated with hypercortisolism related life-threatening infections and hypokalemia. In 60% of cases, the tumor is located in intrathoracic organ (lung, bronchus and thymus). Large cell neuroendocrine tumor of thymus secreting ACTH is a high grade, aggressive, poor prognosis and only few case reports in literature. Here we report a case of thymic LCNEC related EAS, which presented as severe hypokalemia, metabolic alkalosis and muscle weakness. Clinical Case A 71-year-old man presented with 12-kg weight loss, progressive generalized weakness and bilateral legs edema for two months.He has medical histories of hypertension and diabetes mellitus. Physical examination revealed generalized weakness without Cushingoid appearance. Laboratory examination showed metabolic alkalosis and severe hypokalemia (1.7 mmol/L, range 3.4-4.7).Hypokalemia work-up showed high morning ACTH 497 pg/mL (normal <46.0), cortisol 87.8 μg/dL (range 3.7-19.4), and normal limits of other pituitary hormones. Cushing syndrome survey showed lack of ACTH/cortisol circadian rhythm, markedly increased 24h urinary free cortisol excretion on two consecutive days ( 21429, 17061 μg). Low-dose and high-dose dexamethasone suppression tests showed non-suppressible. Ovine corticotrophin-releasing hormone stimulation test and desmopressin (DDAVP) test showed ectopic ACTH source. Pituitary MRI revealed negative findings. Bilateral inferior petrosal sinus sampling showed no central-to-peripheral ACTH gradient. Ectopic ACTH syndrome was impressed. Etomidate continuous infusion was prescribed.Fournier gangrene of left scrotum occurred during hospitalization and antibiotic and surgical treatment were given. Chest CT scan revealed tiny lobulated nodule in left lower lung field and soft tissue nodule in prevascular of mediastium. In-111 Octreoscan revealed several nodular lesions with increased In-111 uptake in the paraortic and prevascular region considering neuroendocrine tumor. Anterior mediastinal tumor excision was performed and histopathological report showed large cell neuroendocrine carcinoma of thymus with mitotic count 13/10 HPF and positive immunohistochemical stain for synaptophysin, chromogranin, DD-56, SSTR2 and ACTH. Sandostain LAR injection was administered afterward. Unfortunately, tumor progression with hypercortisolemia occurred after 6 months . External radiation and systemic chemotherapy were performed later. Clinical Lessons Although rare, Cushing syndrome must be considered in differential diagnosis of hypokalemia like our case, a challenging case of EAS. Early diagnosis and treatment was important to avoid life-threatening infections and metabolic complications. Moreover recurrence free survival with Sandostain LAR alone was only 6 months for LCNEC.

Huge carcinosarcoma of lung presenting as an intra-abdominal mass

We report a case of huge carcinosarcoma of lung initially presenting as an intra-abdominal mass: treatment with enucleation of the firm sarcomatous component followed by pulmonary resection. A 65-year-old man with mild mental retardation who smoked one pack of cigarettes per day until 1-month before he was admitted to our hospital complaining of a progressively poorer appetite, vomiting and an abdominal mass at the left upper quadrant region. Physical examination revealed a palpable mass over the left upper abdomen with percussion dullness of the lower hemithorax. Chest radiograph revealed a homogeneous mass lesion in the left lower lung field with obliteration of the costophrenic angle. Computed tomography scans of the chest disclosed a huge mass over the left lower thorax and upper abdomen with compression of the heart and shift of the esophagus and descending aorta to the midline. Sono-guided aspiration biopsy cytology revealed squamous cell carcinoma. Surgical intervention with enucleation of the very firm sarcomatous component with fragmentation followed by radical lobectomy. Chemotherapy was planned as adjuvant therapy in the postoperative period, but the patient's family declined it. The patient is currently survived without tumor recurrence 14 months after surgery. Our case revealed a huge tumor not only mediastinal compression but also initial presenting abdominal symptoms. Initially, from the symptoms and nonbiopsy study, we were unable to determine exactly if it was an intrathoracic tumor or an intra-abdominal tumor. This case highlights the importance of remaining clinically vigilant to differentiate an unusual tumor mass, and preoperative tissue proof is warranted.

Heart failure in dilated cardiomyopathy mimicking asthma triggered by pneumonia

Heart failure is a rare cause of wheezing and may develop into a critical condition in children. Few cases report patients with heart failure, secondary to dilated cardiomyopathy, with high...

Acute pulmonary embolism in a dengue fever patient co-infected with influenza B

Introduction The main pulmonary embolism is a blockage of blood flow to the lungs by a blood clot which is composed of clumped platelets and condensed fibrin lodged into an artery in the lungs. A condition associated with thrombotic events due to loss of endothelium non-thrombogenic protective factors and severe dehydration might occur in the early course of severe dengue, thereby increasing the risk of embolic formation. We report acute pulmonary embolism in a severe dengue patient co-infected with influenza B, which might additionally predispose to an acute embolic event. Case description This 71-year-old diabetic woman with hypertension suffered from the dizziness, episodic fever, and general weakness since September 13, 2015. The data of dengue virus IgM, IgG and NS1 antigen were all positive. The presenting platelet count was 11000/uL. She felt worsening malaise, dizziness, anorexia, and newly developed dyspnea. The brain CT did not indicate obvious lesion except mild atrophy. The chest X-roentgenogram (CXR) revealed the opacity in left lower lung field. Abnormal liver function tests were noted, including S-GOT (AST), 1526 U/L; S-GPT (ALT), 709 U/L; total bilirubin, 2.71 mg/dL and direct bilirubin, 1.84 mg/dL. Under the impression of severe dengue with pneumonia, she was admitted for the further management. Antibiotic therapy with cefuroxime was given. However, the patient had worsening dyspnea and tachycardia 5 days later. Laboratory data showed elevated lactate (4.1 mmole/L), hypoxemia with mild decrease PaO2/FiO2 ratio, and elevated D-dimer (3271 ng/m). CXR showed resolution of pneumonia patch. As suspected pulmonary embolism, chest CT was arranged, which revealed partial thrombosis of right pulmonary artery at superior lobar branch. Therefore, she was admitted to the intensive care unit. In addition, the result of rapid influenza diagnostic test for influenza B antigen was positive. A 5-day course of oseltamivir and antibiotic therapy with levofloxacin were given. After treatment, fever subsided and dyspnea was improved. Follow-up platelet count rose to 91000/uL. Then, she was transferred to ward. After heparin therapy, subsequent daily warfarin was titrated to daily 2.5mg to achieve the desired prothrombin time ratio. As stable condition, she was discharged after 16 days of hospitalization. Conclusion Pulmonary embolism has been reported in association with dengue fever or severe influenza, particularly influenza A(H1N1). Co-existence of severe dengue, influenza B and acute pulmonary embolism was sparsely reported before. Awareness for these complications should be recommended to all practitioners who treat patients with severe dengue fever, particularly co-infected with influenza.

Round pneumonia with Pseudomonas luteola and Escherichia vulneris bacteremia

A 40-year-old man with a past medical history of alcohol abuse presented with altered mental status. The patient’s wife reported that he had stopped drinking alcohol three days prior, and on the day of presentation had experienced two seizures and fever while at home. Physical examination at the time of admission revealed crackles over the left lower lung fields and a fluctuating mental status without focal neurological deficits or meningeal signs. Patient was febrile with a temperature of 101.4 F. Posteroanterior and lateral chest radiographs revealed a left sided pleural effusion with suspected pneumonia. After drawing blood cultures, he received ceftriaxone 1g IV Figure 1

Diaphragmatic Hernia in an isolated severe head injury patient: An accidental finding

Blunt traumatic rupture of diaphragm is uncommon in an isolated severe head injury patient and usually seen in polytrauma patients. Due to poor neurological status, diagnosis is often difficult and leads to increase in morbidity and mortality. We report a case of diaphragmatic hernia in a 25 year old male having isolated severe head injury sustained in a road traffic accident, diagnosed two days later on routine chest X-ray. Ryle’s tube shadow in left lower lung field that give raise to suspicion of diaphragmatic hernia and CT scan confirms the diagnosis. A high index of suspicion is required for early diagnosis and minimizes the morbidity and mortality associated with it.

Pediatric Round Pneumonia

“Round pneumonia” or “spherical pneumonia” is a well-characterized clinical entity that seems to be less addressed by pediatricians in Taiwan. We herein report the case of a 7-year-old boy who presented with prolonged fever, cough, and chest X-rays showing a well-demarcated round mass measuring 5.9 × 5.6 × 4.3 cm in the left lower lung field, findings which were typical for round pneumonia. The urinary pneumococcal antigen test was positive, and serum anti-Mycoplasma pneumoniae antibody titer measurement using a microparticle agglutination method was 1:160 (+). After oral administration of antibiotics including azithromycin and amoxicillin/clavulanate, which was subsequently replaced by ceftibuten due to moderate diarrhea, the fever subsided 2 days later and the round patch had completely resolved on the 18th day after the diagnosis. Recent evidence suggests treating classical round pneumonia with antibiotics first and waiving unwarranted advanced imaging studies, while alternative etiologies such as abscesses, tuberculosis, nonbacterial infections, congenital malformations, or neoplasms should still be considered in patients with atypical features or poor treatment response.

A minimal invasive surgical alternative to aberrant systemic arterial supply: Coil embolization

We present the case of a 20-year-old man with hemoptysis for 3 years. Chest radiography revealed increased pulmonary vascular opacities in the left lower lung field. Computed tomography showed an anomalous systemic artery arising from descending aorta supplying the basal segments of the left lower lobe. Bronchial tree was normal. Pulmonary artery angiogram revealed a hypoplastic inferior lobar branch of the left pulmonary artery. There was no direct communication between anomalous artery and pulmonary veins. We diagnosed our case as aortopulmonary collateral with normal lung parenchyma. Coil embolization of the anomalous systemic artery was performed. The patient survived well without evidence of hemoptysis for 18 months after coil embolization.