Lower Lobe Of Left Lung Research Articles

The left main bronchus transected incorrectly during video-assisted thoracoscopic lobectomy: a case report

BackgroundSeveral severe intraoperative complications of lung cancer surgery have been reported, but the incorrect transection of the main bronchus is a very rare and serious complication. We report a surgical case of a patient with left lower lobe lung cancer invading the inferior segment of the lingula, with fused interlobar fissure and dense pleural adhesion, in which the left main bronchus was mistaken for the left lower lobe bronchus and was transected.Case presentationA 64-year-old woman with lung adenocarcinoma was referred to our hospital for surgical treatment. Chest computed tomography (CT) scan showed a 30-mm nodule with a clear border and irregular margins in the center of the anterior (S8) segment of the lower lobe of the left lung and another similar 30-mm nodule in the lateral (S9) segment of the same lobe. Metastasis within the same lobe was suspected. A thoracoscopic left lower lobectomy was scheduled for the patient. As the patient had a moderately, fused fissure, dense pleural adhesion, and suspicious tumor invasion from the left S8 segment to the left S5 segment, and the interlobar node tightly adhered to the main PA at the site of basilar artery origin of the LLL, we performed left lower lobectomy and a left S5 segmentectomy using the fissureless fissure-last technique. During surgery, the left main bronchus was mistaken for the left lower lobe bronchus and was transected. After transecting the left main bronchus, we performed a sleeve bronchoplasty to prevent pneumonectomy.ConclusionsWe experienced the rare and serious intraoperative complication of the incorrect transection of the main bronchus. There are few reports of this intraoperative complication, and it should not be overlooked by surgeons.

Mycobacterium Avium Complex Presenting as a Lung Mass, Broncho-pleural Fistula and Empyema in an Immunocompetent Patient-A Case Report and Review of Literature

Mycobacterium avium complex (MAC) is a non-tuberculous mycobacteria (NTM) that causes subacute or chronic nodular bronchiectasis, cavitary or fibro-cavitary pneumonia in patients with chronic structural lung pathology including emphysema, chronic bronchitis, and bronchiectasis. It is also known to cause pulmonary and extrapulmonary infections in patients with impaired cell mediated immunity such as transplant recipients, (Acquired Immune Deficiency Syndrome) AIDS where it can cause disseminated infections. Empyema from MAC has been reported in immunocompromised patients and is a rare phenomenon. Here we report a patient who presented with chronic left pleural effusion and a left lower lobe lung mass that went undiagnosed for 2 years, despite extensive work-up. Later in his course, he presented with a large effusion complicated by a bronchopleural fistula and was diagnosed as MAC empyema. To our knowledge, this is the first case of MAC empyema, that presented as a chronic lung mass, complicated by a bronchopleural fistula. In this article, we present the clinical, laboratory, and radiological features, with emphasis on a combined medical and surgical approach in the management of MAC empyema. We also provide a brief overview of cases of MAC associated pleurisy and empyema that have been reported in literature.

INFLAMMATORY MYOFIBROBLASTIC TUMOR OF PLEURA: A RARE BENIGN TUMOR

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Inflammatory myofibroblastic tumor (also known as plasma cell granuloma, inflammatory pseudotumor, fibrous histiocytoma, fibroxanthoma, xanthogranuloma) is a rare benign neoplasm which can also be locally invasive. The symptoms and radiological findings are mostly non-specific. It is occasionally reported in lungs with incidence of 0.04 - 0.7% of all lung tumors, whereas in pleura, it is rarely reported. CASE PRESENTATION: A 30yr female non-smoker presented with breathlessness, left sided chest pain for 2 months. CXR- large homogenous opacity in the left hemithorax sparing the left upper zone. HRCT chest - a large multiloculated, multiseptated cystic lesion was found in left pleural cavity with collapse of underlying left lung and mild pleural effusion. Thoracotomy was performed and a large fleshy highly vascular mass was noted of size 30cm x 20cm having variegated margins, adherent to lower lobe of left lung, diaphragm and postero-medial aspect of mediastinum. The tumor was resected in-toto weighing around 4.5kg. HPE of the tissue showed features of INFLAMMATORY MYOFIBROBLASTIC TUMOR. IHC analysis showed positive staining for vimentin and smooth muscle actin(SMA) confirming the diagnosis DISCUSSION: IMT was first described in lungs by Brunn in 1939. It is reported in other extrapulmonary sites like orbit, liver, spleen, thyroid, breast, lymph nodes, skull base and rarely in pleura. Pathogenesis of IMT is still unknown. One Hypothesis is that, IMTs are low grade mesenchymal neoplasms with a secondary inflammatory component. It is supported by the presence of a fusion gene ALK gene, a tyrosine kinase oncogene located on chromosome 2p23, initially found to be arranged in anaplastic large cell lymphomas, leading to overexpression of ALK gene. The cytoplasmic expression of ALK gene is found on immunohistochemistry in some cases of IMT. It is found less commonly in pulmonary IMT than in extrapulmonary IMT. The clinical findings and symptoms are largely non-specific. The symptoms may be cough, dyspnea, chest pain, hemoptysis, fever and fatigue. Weight loss and anorexia are rare. Approximately 70 percent of patients are asymptomatic and tumor discovered incidentally on chest x-ray. Approximately 50 percent of the patients have an elevated sedimentation rate, mild anemia and thrombocytosis can also occur. The diagnosis of IMT requires the presence of characteristic pathological features- a background proliferation of spindle cells associated with a variable dense polymorphic infiltrate of mononuclear inflammatory cells CONCLUSIONS: IMT is a rare benign tumor. Clinical and radiological presentation is variable and nonspecific and diagnosis can be made only by histopathological and immunohistochemical studies. Despite being benign, its potential for recurrence and local invasion requires complete surgical resection. 4.5 kg of IMT pleura was never reported in literature till now. Reference #1: R. J. Cerfolio, M. S. Allen, A. G. Nascimento et al., “Inflammatory pseudotumors of the lung,” Annals of Thoracic Surgery, vol. 67, no. 4, pp. 933–936, 1999. Reference #2: J. Loeffler-Ragg, J. Bodner, M. Freund et al., “Diagnostic and therapeutic challenges of a large pleural inflammatory myofibroblastic tumor,” Case Reports in Pulmonology, vol. 2012, Article ID 102196, 5 pages, 2012. Reference #3: C. M. Coffin, A. Patel, S. Perkins, K. S. J. Elenitoba-Johnson, E. Perlman, and C. A. Griffin, “ALK1 and p80 expression and chromosomal rearrangements involving 2p23 in inflammatory myofibroblastic tumor,” Modern Pathology, vol. 14, no. 6, pp. 569–576, 2001. DISCLOSURES: No relevant relationships by PRAPULLA CHANDRA DAVULURI, source=Web Response

AN UNUSUAL CASE OF PULMONARY CAVITARY LESIONS IN AN IMMUNOSUPPRESSED PATIENT

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The differential diagnosis of pulmonary cavitary lesions is broad. They can be categorized in to infectious and non-infectious diseases, including neoplasms. Among malignancies, squamous cell carcinoma is a common cause of lung cavitation (1). Herein, we report a rare case of primary pulmonary diffuse large B-cell lymphoma (DLBCL) in a patient with rheumatoid arthritis that presented with multiple cavitary lesions and hypercalcemia. CASE PRESENTATION: 83-year-old male presented with hemoptysis, dyspnea, confusion, and constipation for several weeks. His past medical history was significant for tobacco abuse and interstitial lung disease from rheumatoid arthritis (RA) treated with methotrexate. CT chest showed bilateral cavitary lung lesions, left-pneumothorax and pneumomediastinum, needing chest-tube placement. Pulmonary function test showed a mild restrictive defect with a severe reduction in diffusion capacity. Labs showed hypercalcemia of 13.7 mg/dl, suppressed parathyroid hormone (PTH), elevated PTH-related peptide (PTHrp), and 1-25(OH) 2 Vitamin-D level. Quantiferon gold, sputum acid-fast bacilli and cultures were negative. Blood cultures (1/4 bottles) grew Actinomyces viscosus that was treated with 6-weeks of piperacillin-tazobactam. Bronchoscopy with lavage was unrevealing; however, due to a suspicion for malignancy with elevated PTHrp level, a CT-guided biopsy of left lower lobe lung mass was performed that confirmed a diagnosis of DLBCL, non-germinal center B-cell type. DISCUSSION: Pulmonary lymphoma is very rare and presents with nonspecific pulmonary symptoms (2). The pathogenesis of primary pulmonary DLBCL remains elusive. Patients with autoimmune disorders and recurrent bacterial infections are at a higher risk for developing DLBCL. Chest imaging may show nodular lesions, consolidation or interstitial /mixed alveolar infiltrates (2). DLBCL presenting with multiple cavitary lesions, is rarely reported. In our patient hypercalcemia was mediated by elevation of both PTHrp and 1-25(OH)2 Vitamin-D, which is unusual. Most primary pulmonary lymphomas (PPL) are low-grade mucosa-associated lymphoid tissue (MALT)-type, compared to more aggressive pulmonary diffuse large B-cell lymphoma (DLBCL), which is very uncommon (3). Most likely, our patient's autoimmune disorder (RA) and chronic methotrexate use contributed in the development of his DLBCL. CONCLUSIONS: We report a rare case of primary pulmonary DLBCL that manifested with multiple cavitary lesions and hypercalcemia. DLBCL must be considered in the differential diagnosis of cavitary lung lesions particularly in immunosuppressed patients. Reference #1: Chaudhuri MR. Primary pulmonary cavitating carcinomas. Thorax. 1973;28:354-366 Reference #2: Fujita N, Ando M, Goto A, Sakata M, Ogata M, Usagawa Y, et al. Diffuse large B-Cell lymphoma arising from the lesion of chronic lobar atelectasis. Tohoku J Exp Med. 2020;250(2):129–35. Reference #3: Brown S, Horton J, Rosario D, Dorsey DA, Hetz S, King CS. High-grade primary pulmonary B cell lymphoma presenting as a Necrotic mass. Respir Care. 2011 Jun 1;56(6):871–3. DISCLOSURES: No relevant relationships by Haytham Adada, source=Web Response no disclosure on file for Mahmoud Amarna; No relevant relationships by Pavan Annamaraju, source=Web Response No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Nino Nemsadze, source=Web Response No relevant relationships by Sana Yakoob, source=Web Response

INDEPENDENT PERITONEAL CANCER, NEARLY MISSED AS A METASTASIS FROM LUNG CANCER

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung carcinoma is the leading cause of cancer-related mortality and nearly 50% of cases exhibit distal metastasis at the time of diagnosis. The most common sites of metastasis are brain, spine, nerve, adrenal gland, bone, liver, pleura, but rarely involves the peritoneum.[1] Peritoneal involvement in lung cancer is assumed to be due to metastasis from primary lung cancer. The occurrence of primary peritoneal adenocarcinoma and lung cancer together in one person is uncommon and difficult to distinguish from the metastatic spread. [2] CASE PRESENTATION: A 73-year-old female, smoker of 30 pack-year, presented with symptoms of abdominal bloating, distension, and loss of appetite. Computed tomography(CT) chest, abdomen, and pelvis showed moderate abdominal ascites consistent with peritoneal carcinomatosis, along with a 4.3 cm mass in the left lower lobe of the lung and 1.1 cm left-sided mediastinal lymph node. Paracentesis with ascitic fluid analysis was positive for adenocarcinoma. [Picture 1] She underwent endobronchial ultrasound with biopsy with immunohistochemistry staining which showed poorly differentiated squamous cell carcinoma [Picture 2]. Metastatic workup with a magnetic resonance imaging(MRI) of the brain was negative. Positron emission tomography-computed tomography scan showed a Fluorodeoxyglucose avid left lower lobe lung lesion with hilar and subcarinal adenopathy, consistent with primary lung malignancy. Pelvic ultrasound showed enlarged uterus secondary to multiple intramural fibroids. Labs showed Carcinoembryonic antigen level 1.2 and Alpha-fetoprotein 1.6. Oncology planned to start on carboplatin and paclitaxel along with pembrolizumab every 3 weeks for 4 cycles, followed by maintenance therapy with pembrolizumab every 3 weeks. She reported improvement in the abdominal bloating with the removal of 2-3 liter of peritoneal fluid weekly and symptomatic treatment. The patient continued to feel excessively tired and deteriorated within a few weeks. Unfortunately, the patient passed away before the start of the treatment. DISCUSSION: Peritoneal metastasis of primary lung carcinoma is very rare, only present in 2.7–16% of all lung cancer patients.[3] Advanced stage IV non-small cell lung cancer (NSCLC) and peritoneal adenocarcinoma can present in the same patient together, like in our case, which can be easily missed assuming it as metastatic cancer. Management of two separate cancers requires individualized treatment plans dissimilar to standard practices in the setting of a single tumor. A 1-year survival rate after cytotoxic chemotherapy is only 29% in patients with advanced NSCLC hence priority must be given to the treatment regimen that improves symptoms and prolongs survival. CONCLUSIONS: Therefore, one should always be suspicious and more effort should be made to improve the diagnostic approach and management to rule out any other underlying malignancy. Reference #1: McNeill PM, Wagman LD, Neifeld JP. Small bowel metastases from primary carcinoma of the lung. Cancer. 1987;59:1486–1489. Reference #2: MARÍA SERENO,1. Lung cancer and peritoneal carcinomatosis. Oncol Lett. 2013 Sep; 6(3): 705–708 Reference #3: Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer. 1950;3:74–85. DISCLOSURES: No relevant relationships by Mary Grace Bethala, source=Web Response No relevant relationships by Apurwa Karki, source=Web Response No relevant relationships by Salman Khan, source=Web Response No relevant relationships by Shobha Mandal, source=Web Response

A rare clinical entity of asymptomatic adult bochdalek hernia

Bochdalek hernia (BH) is the commonest congenital diaphragmatic hernia, caused by the failure of the posterolateral diaphragmatic foramina to fuse properly. It is extremely rare in adults and accounts for 5-10%. Presenting a case of 48 years female with complaints of dry cough and left chest pain for 1 week. Diminished breath sounds and abnormal gurgling sounds heard on auscultation of left chest wall. X-ray chest showed elevated left hemi diaphragm and gastric bubble. Computed tomography (CT) chest revealed left diaphragmatic hernia with splenic flexure, transverse colon, mesocolon, spleen and upper pole of left kidney as content and atelectasis of left lung lower lobe. Patient underwent laparoscopic repair of hernia with mesh plasty. Intraoperatively, the contents were reduced into the abdominal cavity and left lung expansion noted. The defect of size 6×10 cm in the left diaphragm was sutured and composite mesh placed. Post-operative chest x-ray showed expanded left lung. On follow up of patient after 2 weeks and 1 month, patient was asymptomatic. BH in adults is an uncommon. The contents can be reduced via thoracic or abdominal approach, with abdominal approach having easier access. With the advent of minimal access techniques, delineating clear anatomy, more working space, early recovery, and early return to home and work is possible. Thus, laparoscopic repair of adult diaphragmatic hernia is a safe and effective modality of surgical treatment.

A RARE AND INTERESTING PRESENTATION OF LUNG TUMOUR

A 72 year old male presented with a chief complaint of groin swelling and was clinically diagnosed as direct inguinal hernia and was planned for hernioplasty. Patient had no respiratory symptoms like cough or haemoptysis. Incidentally it was found that patient was having mass lesion on the left side in chest x ray and was referred to CTVS department. The patient however had no complaints pertaining to the mass. He underwent CECT and was found to have ?peripheral bronchogenic tumour in left posterior mediastinum. Later left posterolateral thoracotomy was done and intra operatively mass was found originating from left lower lobe of lung and left lower lobectomy was done. Mass was around 10x15x10 cms, stony hard in consistency within the left lower lobe. The entire specimen was sent for HPE. Post operatively the patient was stable and regularly followed up. HPE of the mass was pulmonary hamartoma.

SAT-127 Localization and Treatment of the Ectopic ACTH Syndrome Using Somatostatin Analogues

Ectopic ACTH syndrome (EAS) is a rare disorder with a high morbidity and mortality due to the sequelae of severe hypercortisolism and possible underlying carcinoma. It is caused by various tumors, some originating from neuroendocrine cells. Optimal management includes localization and removal of the ectopic ACTH source. About 80% of these tumors have somatostatin (SS) receptors, so that SS analogues may be useful in the localization and treatment. This case demonstrates the use of SS analogues in localization and treatment of EAS.A 49-year-old female presented with 7 months of worsening Cushingoid features including rounded plethoric face, full supraclavicular fat pads, facial hair growth, multiple bruises, violaceous abdominal striae, kyphoscoliosis, 4+ peripheral edema, weight gain, hypertension (190/110 mmHg) and thoracic compression fractures. AM plasma ACTH concentration was 333 pg/mL (nl = 6 - 58 pg/mL); serum concentration cortisol was 71.4 mcg/dL (nl = 7 - 23 mcg/dL) and serum potassium concentration was 1.2 mmol/L (nl = 3.6 - 5.1 mmol/L). A 24-hour urine cortisol could not accurately be obtained. High dose 8 mg overnight dexamethasone testing demonstrated suppression of serum cortisol concentration from 71.4 to 6.3 mcg/dL, suggesting pituitary Cushing disease. Pituitary MRI scan revealed a 2.5 mm disc shaped cystic focus suggesting a Rathke’s cleft cyst. No central-to-peripheral ACTH gradient was present on bilateral inferior petrosal sinus sampling suggesting an ectopic ACTH source. There was a 1.2 x 1.0 cm nodule in the left lower lung lobe on CT chest. A gallium-68 dotatate PET/CT scan demonstrated enhancement of this same lung lesion and mild uptake in the left inferior hilum, suggesting a neuroendocrine lung tumor with possible metastases to lymph nodes. Biopsy and resection of the lesion was deferred until after control of her hypercortisolism. 30mg of Sandostatin LAR was started every 4 weeks to control the ectopic ACTH secretion and to confirm that the SS analogue positive lung lesion was the cause of the EAS. Sandsostatin LAR therapy over the next 12 weeks resulted in a steady clinical and biochemical improvement with a decrease in serum cortisol to 9.7 mcg/dL, control of hypertension (108/64 mmHg), weight loss of 6 pounds, and resolution of supraclavicular fat pads, hypokalemia, and peripheral edema. This confirmed our impression that the neuroendocrine lung tumor was the ACTH source.In summary, this patient with EAS had severe clinical manifestations of hypercortisolism and could not safely undergo surgical intervention. This case demonstrates the value of SS analogues (gallium-68 dotatate PET/CT and Sandostatin LAR) in localizing and confirming the source of ectopic ACTH production and markedly improving the clinical and biochemical features of the EAS.

Rasmussen's Aneurysm Associate With Pulmonary Artery Vascular Malformation Presented With Haemoptysis

Rasmussen's aneurysm is an inflammatory pseudo-aneurysmal dilatation of a branch of pulmonary artery associated with a cavitary lung lesion. Like any aneurysm, a Rasmussen's aneurysm is at increased risk of rupture and bleeding into the lungs. A 52 years old male presented with low-grade fever and haemoptysis, chest x-ray revealed a well margined nodular shadow with calcifications in mid zone of left lung associated with ipsilateral upper zone fibrosis and bronchiectasis. The patient had past history of pulmonary tuberculosis eight years back. For characterization of left pulmonary nodule the patient was referred to radiology and Imaging department and contrast CT scan of chest was done. Contrast CT scan of chest with reformat MIP pulmonary angiogram revealed a small pulmonary artery vascular malformation in lateral basal segment of lower lobe of left lung associated with left upper lobar cavitating lesion with fibrosis, traction bronchiectasis and Rasmussen's aneurysm arising from upper lobar apical segmental pulmonary artery. Early surgical or angiographic interventions with endovascular embolization are recommended once it be clearly diagnosed.
 KYAMC Journal Vol. 10, No.-3, October 2019, Page 168-170

Pulmonary hydatid disease

Pulmonary hydatid disease - JDPO- Print ISSN No: - 2581-3714 Online ISSN No:- 2581-3706 Article DOI No:- 10.18231/j.jdpo.2019.069, IP Journal of Diagnostic Pathology and Oncology-IP J Diagn Pathol Oncol

INTRAPULMONARY SEQUESTRATION IN AN ADULT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: An intrapulmonary sequestration is defined as nonfunctioning lung tissue that is not in normal continuity with the tracheobronchial tree and derives its blood supply from systemic vessels[1]. Pulmonary sequestration is considered a childhood disease; however, the condition can continue into adolescence and sometimes adulthood[2]. Here, we present a middle-aged female presenting with pneumonia, found to have intrapulmonary sequestration and underwent lobectomy. CASE PRESENTATION: 43-year-old female with past surgical history of diaphragmatic hernia repair in childhood presented with persistent cough of two weeks duration with clear rhinorrhea and sharp left lower chest pain. Chest radiography revealed a left lower lobe consolidation suspicious for pneumonia. Patient was admitted for suspected pneumonia, and initial vital signs showed temperature 99F, heart rate 134, respiratory rate 25, blood pressure 97/75, and oxygen saturation of 99% on room air. Laboratory studies were significant for WBC count of 9.60, Hgb 10.5, and platelet count 69,000, with a d-dimer of 722. A CT angiogram to rule out a pulmonary embolism displayed a complete collapse of the left lower lobe with abnormal systemic arterial branch extending to the left lower lobe consistent with sequestration. Subsequently, patient underwent bronchoscopy that was noted to be normal with negative cultures and washings. The patient signed out against medical advice after the procedure, but returned to the hospital five days later with non-resolution of her cough and left sided chest pain. Chest radiograph and CT angiography performed showed unchanged findings of left lower lung infiltrate and suspected sequestration. Cardiothoracic surgery was consulted and patient was taken for a left lower lobectomy. The procedure and pathology confirmed the diagnosis of intrapulmonary sequestration. The patients’ symptoms resolved after surgery and she was discharged home in stable condition. DISCUSSION: Pulmonary sequestration, a disease of childhood, most commonly presents as pneumonia but may also present with chest pain, cough, shortness of breath and hemoptysis [3,4]. The condition may also be found incidentally in asymptomatic adults. Most pulmonary sequestrations arise in the left lung with two-thirds arising in the lower left lung lobe with the blood supply coming from systemic circulation, usually the thoracic or abdominal aorta. The treatment for a pulmonary sequestration involves surgical resection of the effected lung lobe to avoid infection and damage to the lung parenchyma. Our case is made unique by the advanced age of our patient with no prior history of recurrent infections or underlying respiratory symptoms prior to this presentation[5]. CONCLUSIONS: Pulmonary sequestration should be in the differential even in advanced age without prior history of underlying respiratory symptoms or recurrent infections. Reference #1: 1. "Congenital Malformations and Genetic Disorders of the Respiratory Tract.” American Review of Respiratory Disease, 120(1), pp. 151–185 Reference #2: 2. Petty, L., Joseph, A., & Sanchez, J. (2018). Case report: Pulmonary sequestration in an adult. Radiology Case Reports,13(1), 21-23. https://doi.org/10.1016/j.radcr.2017.09.029 Reference #3: 3. Frazier, A. A., Christenson, M. L., Stocker, J. T., & Templeton, P. A. (1997). Intralobar sequestration: Radiologic-pathologic correlation. RadioGraphics, 17(3), 725-745. https://doi.org/10.1148/radiographics.17.3.9153708 4. Hertzenberg, Casey & Daon, Emmanuel & Kramer, Jeffrey. (2012). Intralobar pulmonary sequestration in adults: Three case reports. Journal of thoracic disease. 4. 516-9. 10.3978/j.issn.2072-1439.2012.06.07. 5. Alsumrain, M., & Ryu, J. H. (2018). Pulmonary sequestration in adults: A retrospective review of resected and unresected cases. BMC Pulmonary Medicine, 18(1) DISCLOSURES: No relevant relationships by Anas Al-khateeb, source=Web Response No relevant relationships by Sharath Bellary, source=Web Response No relevant relationships by Michael Ellis, source=Web Response No relevant relationships by Muqueet Kadri, source=Web Response No relevant relationships by William Meng, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Hari Sharma, source=Web Response No relevant relationships by Euclid St.Hill, source=Web Response

Pleural fluid secondary to pulmonary cryptococcal infection: a case report and review of the literature

BackgroundPulmonary Cryptococcosis (PC) is diagnosed with increasing incidence in recent years, but it does not commonly involve the pleural space. Here, we report a HIV-negative case with advanced stage IIIB non-small cell lung cancer (NSCLC) treated with radiation therapy presented with dyspnea, a new PET-positive lung mass and bilateral pleural effusion suspecting progressive cancer. However, the patient has been diagnosed as pulmonary cryptococcal infection and successfully treated with oral fluconazole therapy.Case presentationA 77-year-old male with advanced stage non-small cell lung cancer treated with combined chemo-radiation therapy who presented with progressive dyspnea, a new PET-positive left lower lobe lung mass and bilateral pleural effusions. Initial diagnostic thoracentesis and bronchoscopy yielded no cancer, but instead found yeast forms consistent with cryptococcal organisms in the transbronchial biopsies of the left lower lobe lung mass. Subsequent to this, the previously collected pleural fluid culture showed growth of Cryptococcus neoformans. The same sample of pleural effusion was tested and was found to be positive for crytococcal antigen (CrAg) by a lateral flow assay (LFA). The patient has been treated with oral fluconazole therapy resulting in gradual resolution of the nodular infiltrates.ConclusionPC should be considered in immunosuppressed cancer patients. Additionally, concomitant pleural involvement in pulmonary cryptococcal infections may occur. The incidence of false positive 18FDG-PET scans in granulomatous infections and the use of CrAg testing in pleural fluid to aid in diagnosis are reviewed.

Chest wall implantation of lung cancer following percutaneous transthoracic biopsy

A 75-year-old man had an incidental finding of a 1.7 cm spiculated lung nodule over the left lower lobe on thoracic CT scan (figure 1). He underwent CT-guided percutaneous thoracic...

Young Immunocompetent Individual Positive for Histoplasma Capsulatum on Bronchoalveolar Lavage Fluid Cytology

Primary pulmonary histoplasmosis is a lung disease caused by dimorphic fungus Histoplasma Capsulatum. Bronchoalveolar fluid cytology is routinely performed as an inexpensive test even in under equipped laboratories. A 26 year old female, presented with persistent cough, evening rise of temperature and generalised weakness since 3 months and streaky hemoptysis since 3 weeks. CT showed consolidation in lower lobe of left lung and multiple mediastinal nodes in perivascular (aortic arch ) region and in sub carinal region. Bronchoscopy showed purulent exudates in lower lobe (6th segment of left lung). Bronchoalveolar lavage fluid was obtained and subjected to cytological evaluation and microbiological examination for Acid Fast bacillus. Cytosmears revealed macrophages with engulfed clusters of single walled yeast cells. The suspicion of Histoplasma was raised and the fluid was sent for fungal culture and Antigen testing was performed. Histoplasma Capsulatum can present in immunocompetent individuals and a strong suspicion must be made in patients with history of travel to endemic areas. Pathologist needs to look for the yeast cells even in immunocompetent individuals while routine screening of the BAL fluid cytosmears. Special staining may be resorted to, in individuals with high suspicion and positive history. Confirmation may be done by fungal cultures and antigen testing.

Comparison of the effects of sevoflurane and propofol anesthesia on pulmonary function, MMP-9 and postoperative cognition in patients receiving lung cancer resection.

Effects of sevoflurane and propofol anesthesia on pulmonary function, matrix metalloproteinase-9 (MMP-9) and postoperative cognition were compared in patients undergoing simple resection of lower lobe of left lung. Retrospective method was used to analyze 58 cases of lung cancer patients treated by simple resection of lower lobe of left lung in the Second Hospital of Dalian Medical University from October 2016 to October 2017, and they were divided into two groups: Sevoflurane group (n=32) with sevoflurane anesthesia and propofol group (n=26) with propofol anesthesia. In the present study, the moment before induction of anesthesia (T1), before the start of one-lung ventilation (T2), before the end of one-lung ventilation (T3), after closed chest surgery (T4), 24 h after surgery (T5), calculate alveolar-arterial oxygen difference (A-aDO2), respiratory index (RI) and intrapulmonary shunt ratio (Qs/Qt), were compared between the two groups. The serum MMP-9 concentration at T1, T4 and T5 were detected by enzyme linked immunosorbent assay. The cognitive function of two groups was assessed by Mini-Mental State Examination (MMSE) 1 day before surgery and 1 and 10 days after surgery. The A-aDO2 level at T4 in sevoflurane group was significantly higher than that in propofol group (P<0.05). The RI level at T3, T4, the Qs/Qt and the MMP-9 level at T4 in the sevoflurane group was significantly higher than that in the propofol group (P<0.05). The MMSE score in sevoflurane group was significantly lower than that in propofol group 1 and 10 days after surgery (P<0.05). Propofol has little effect on pulmonary function and can decrease inflammatory factor MMP-9. Both sevoflurane and propofol have an effect on cognitive function after lung cancer resection, but propofol can reduce cognitive impairment in patients with lung cancer.

Dramatic and early complete resolution of lobar collapse in young patient of bronchial asthma: a case report from radiologist perspective

To A 30 year old female with known history of bronchial asthma since five years presented to emergency depart­ment with acute shortness of breath and left sided pleuritic chest pain since one day. Imaging with initial chest x-ray reveal left lower lobe lung collapse with ipsilateral tracheo-mediastinal shift. On CT scan complete cutoff of the left lower lobe bronchus was seen. With conservative management including inhaled bronchodilators and intravenous corticosteroids and physiotherapy treatment; dramatic and complete resolution of lobar collapse seen within period of 4 days without any residual changes. Such dramatic changes have never been perceived in our radiology experience and literature review, which we report as interesting case.

Breast cancer and synchronous multiple primary lung adenocarcinomas with heterogeneous mutations: a case report

BackgroundMultiple primary malignant tumors (MPMT) refers to the presence of two or more primary cancers of different organs in the same patient. MPMT is a sparse disease in the past, but there has been a gradual increase in the morbidity. Since multiple primary malignant tumors treatment methods differ, it is essential for clinicians to be able to distinguish between separate primary lesions and metastasis.Case presentationWe present the case of a 57-year-old woman with MPMT presenting with cancer in the left breast and synchronous double primary lung adenocarcinomas. We used IHC and epidermal growth factor receptor(EGFR)mutation to analyze genomic alteration profiles in the patient to validate the difference among the pathological assessments and the clinical differences between double primary lesions of lung and breast. EGFR gene analysis of breast cancer lesion revealed no mutations. The left and right lower lobe lung adenocarcinomas contained EGFR gene mutations: an L858R point mutation in exon 21 in the left lesion and a deletion mutation in exon 19 in the right lesion. The breast cancer and both lung adenocarcinomas were surgically resected. To date, the patient has remained disease-free.ConclusionsBoth pathological and molecular assessment adapted in the current study appeared necessary. Mutational analysis of the EGFR gene provided important information not only in the diagnosis and but also in the treatment of MPMT.

Partial Sleeve Lobectomy Preserving the Upper Lobe Bronchial Artery in Left Lower Lobe Lung Cancer

Bronchial sleeve resections are performed in lung malignancies involving major airways. Key to smooth healing of the anastomosis is an optimal vascularization. Many techniques have been proposed for anastomosis protection and revascularization; the preservation of the bronchial artery has not been considered, however. We present a modification of a partial sleeve left lower lobe resection in which we preserve the left upper bronchus artery by leaving the dorsal wall between the main and the left upper lobe bronchus intact, thus maintaining a physiologic vascularization to the anastomosis.

\u201cPulmonary Actinomycosis attributable to Actinomyces meyeri presenting as cardiac tamponade: a case report\u201d

BackgroundRecently, it is reported that Actinomyces meyeri is the most common species causing actinomycosis. However, to our knowledge, there was no report about pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade.Case presentationHereby we describe a case of pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. At first, the patient was diagnosed with bacterial pericarditis with lung abscess in the left lower lung lobe and underwent pericardial drainage. Three days after the removal of the drainage tube, atrial fibrillation followed by cardiac arrest with asystole occurred and immediate cardiopulmonary resuscitation restored his circulation. Thereafter, he underwent pneumocentesis of the lung abscess and the culture grew A. meyeri. He was successfully treated with penicillin G.ConclusionThis is the first case of pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. We believe that an increased awareness of the disease is necessary to expedite diagnosis therefore minimizing morbidity and mortality.

Pulmonary Actinomycosis attributable to Actinomyces meyeri presenting as cardiac tamponade: a case report

Background: Recently, it is reported that Actinomyces meyeri is the most common species causing actinomycosis. However, to our knowledge, there was no report about pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. Case presentation: Hereby we describe a case of pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. At first, the patient was diagnosed with bacterial pericarditis with lung abscess in the left lower lung lobe and underwent pericardial drainage. Three days after the removal of the drainage tube, atrial fibrillation followed by cardiac arrest with asystole occurred and immediate cardiopulmonary resuscitation restored his circulation. Thereafter, he underwent pneumocentesis of the lung abscess and the culture grew A. meyeri. He was successfully treated with penicillin G. Conclusion: This is the first case of pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. We believe that an increased awareness of the disease is necessary to expedite diagnosis therefore minimizing morbidity and mortality.