Left Lung Consolidation Research Articles

Abstract PO2-20-08: Metastatic Lung Cancer Masquerading as Metaplastic Breast Cancer

Abstract Background Metaplastic breast carcinoma (MBC) is an unusual malignancy that presents a diagnostic challenge due to the presence of varying cytomorphologies that can be seen in benign and malignant tumors. We posit that metastatic disease to the breast, itself an uncommon entity, should be considered in the differential diagnosis of MBC. We report a unique case of metastatic non-small cell lung cancer (NSCLC) with an actionable driver mutation that presented as a symptomatic breast mass and was initially considered to represent MBC. Report A 74-year-old woman with a 22-pack-year smoking history presented to the breast clinic complaining of a palpable left breast mass that had grown rapidly over the previous month. Ultrasound-guided biopsy of the breast mass revealed high-grade poorly differentiated carcinoma. On immunohistochemical (IHC) evaluation, tumor cells were strongly positive for epithelial markers CAM5.2 and keratin AE1/AE3, weakly positive for breast cancer (BC) marker TRPS1, and negative for BC marker GATA3, squamous cell carcinoma markers p63 and CK5, and melanoma marker SOX10. Metaplastic triple-negative BC was diagnosed. However, concern remained for metastasis from a non-breast primary tumor due to the patient’s constitutional symptoms such as fatigue, night sweats, and 60-pound unintentional weight loss over the previous year, as well as interval development of a suspicious nodular rash on her right upper extremity. An FDG-PET-CT was obtained and demonstrated a hypermetabolic left lung consolidation (maximum SUV 33.3) measuring 7.2 cm, pulmonary nodules, and extensive thoracic lymphadenopathy. Due to rising suspicion for a primary lung tumor, additional IHC staining on the original breast biopsy was requested. Tumor cells were positive for TTF-1, consistent with metastatic lung adenocarcinoma. Tissue next-generation sequencing (NGS) identified a MET exon 14 skipping mutation, making the patient eligible for treatment with capmatinib, a first-line kinase inhibitor targeted therapy for metastatic NSCLC. At the time of this report, the patient has completed a course of palliative stereotactic body radiation therapy to the left lung and started capmatinib 400 mg BID, which she is tolerating well. Her first restaging scans after treatment initiation will be obtained one week after the time of this report. Conclusion In the absence of heightened suspicion for a non-breast primary tumor, our patient had initially received a diagnosis of triple-negative MBC. This diagnosis would have exposed her to increased treatment-related toxicities from cytotoxic chemotherapy and poor prognosis from MBC without survival benefit from targeted therapy for NSCLC. We advocate for the use of supplemental body imaging, expert and comprehensive IHC evaluation, and multidisciplinary discussion in cases of MBC and undifferentiated breast malignancy to facilitate accurate diagnosis and treatment. Citation Format: Tanmayi Pai, Marte Wasserman, Jason Lewis, Miglena Komforti, James Jakub, Augustine Lee, Yanyan Lou, Pooja Advani, Rohit Rao. Metastatic Lung Cancer Masquerading as Metaplastic Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-20-08.

Medical Management of Acute Spinal Cord Injury with Aspiration pneumonia in a Kid

A two-month-old, non-descript female goat kid was brought to the Veterinary Clinical Complex, Veterinary College and Research Institute, Orathanadu, with a history of continuous high-pitched bleating, respiratory distress, and forelimb paresis over the past two days. The animal has appeared lethargic with an abnormal gait. Neurological examination revealed sluggish sensory and motor reflexes in the forelimbs and palpation elicited pain in the thoracic and dorsal spinal areas (C7-T2). Auscultation revealed exaggerated heart sounds and prolonged expiration. Radiographic examination ruled out spinal involvement but revealed left lung consolidation with pulmonary infiltration. Cerebrospinal fluid analysis showed an increase in neuron-specific enolase (NSE). The condition was tentatively diagnosed as acute spinal cord injury with aspiration pneumonia. Inj. Progesterone and intranasal Budesonide were administered along with a Progesterone patch applied to the lateral neck region. Successful medical management led to gradual clinical improvement observed from the seventh day and completely recovered after 15 days of treatment.

Massive Splenic Infarction Abscess in A Teenager with Sickle Cell Disease: A Case Report in Northern Benin

Introduction: Splenic abscess is rare in children. This report discusses a case of splenic abscess complicating an infarction in a teenager at the Teaching Hospital of Borgou/Alibori in Benin Republic. Patient and Observation: The patient was a 14-year-old teenager with hemoglobinopathy (SC), admitted to the pediatric department for generalized abdominal pain associated with fever and a dry cough. On physical examination, he presented with an infectious syndrome, generalized abdominal pain, highly sensitive splenomegaly, left lung consolidation, and severe malnutrition. Abdominal ultrasound and thoraco-abdominal CT-scan revealed a splenic infarction abscess. Following medical treatment, which included broad-spectrum antibiotic therapy and analgesia, a total splenectomy was performed. During surgery, the spleen appeared greyish and contained pus, which, upon cytobacteriological examination, isolated a Klebsiella pneumoniae strain sensitive to the combination of amoxicillin-clavulanic acid. The patient showed favorable evolution under this treatment. Conclusion: Splenic abscess should be suspected in any subject with sickle cell disease presenting with painful and febrile splenomegaly.

925: ACUTE RESPIRATORY FAILURE WITH PNEUMOTHORAX DUE TO ESOPHAGOPLEURAL FISTULA AND ESOPHAGEAL CARCINOMA

Introduction: Esophagopleural (EPF) is a rare but serious condition that may occur secondary to esophageal instrumentation, malignancy, or as a complication following surgical thoracic procedures. The unfamiliarity of this condition, along with non-specific clinical presentations and elusive imaging makes it a diagnostic challenge. We present an interesting case of EPF causing acute respiratory failure. Description: A 58-year-old female with 40-pack-year smoking history was diagnosed with esophageal carcinoma and presented with dysphagia, shortness of breath, and hematemesis. On arrival, the patient was hypoxic and hypercarbic (PCO2 60mmHg) and in frank respiratory distress requiring intubation and admission to the ICU. Chest x-ray showed a large right pneumothorax and left lung consolidation. A right chest tube was placed, and broad-spectrum antibiotics were started. CT chest with oral contrast revealed contrast extravasation into the bilateral mainstem bronchi, and an esophageal bronchial fistulous communication between the esophageal mass and right pleural space. Esophagogastroduodenoscopy was performed with the placement of an esophageal metallic stent. 2 days later, the patient was extubated to nasal cannula and the chest tube was subsequently removed. Discussion: EPF is an uncommon condition despite the proximity of the trachea and esophagus. Anatomically, the esophagus is in direct contact with the pleura for a considerable distance on the right side, whereas on the left side, the aorta lies in between the esophagus and the pleura, except for a short distance just above the diaphragm. Thus, processes in the esophagus can spread more easily into the right side of the pleura rather than the left as in our patient. In patients with esophageal cancer, the incidence of EPF is 5-15%. Radiological signs of EPF depend upon the site, duration, and severity of perforation; and more importantly, the integrity of the pleura. Esophagographic studies may confirm the presence of EPF, although rarely indicated in the era of CT. Therapeutic strategies for EPF include micro-invasive treatment guided by endoscopy, stent implantation and surgery. Stent placement has a high success rate and is the most used modality given the high morbidity and mortality associated with surgery.

HL-367 ASCT for Treatment-Resistant Mediastinal Gray Zone Lymphoma

Gray zone lymphoma (GZL) is a rare type of blood cancer with intermediate characteristics of diffuse large cell B lymphoma (DLCBL) and classical Hodgkin lymphoma (cHL). There is no universal approach to the management of GZL, and resistant cases often remain challenging. To describe a potential treatment for mediastinal GZL (MGZL) resistant to standard chemotherapy regimens based on a clinical case report. A 40-year-old woman was admitted to the hospital with recent onset of generalized itchiness, weakness, fevers, and night sweats. Upon initial standard workup, a CT scan demonstrated a 7 × 4 cm mediastinal mass with irregular borders and several enlarged paraaortic (2 cm), parasternal (4 cm), and aortic bifurcation (2 cm) lymph nodes. The excision biopsy specimen from the mass showed high expressivity of CD30 and moderate expressivity of CD20, CD3, MUM-1, Fascin, and CD79a, with Ki67 detected in 75%-80%. CD15, AE1/3, ALK, PAX-5, CD45, CD19, CD 23, CD68, BOB 1, and PD-1 were negative. The patient was diagnosed with stage IIB MGZL with intermediate features of DLCBL and cHL. Interventions and Main Outcomes: Initial treatment with the R-BEACOPP regimen resulted in some shrinkage in lymph node sizes; however, after the fourth cycle of chemotherapy, a PET-CT scan demonstrated disease progression with Ds5 metabolic activities in the left axillary, mediastinal, and bronchopulmonary nodes, along with left lung consolidation. Salvage therapy with 2 courses of R-DHAP regimen was administered without significant success, as the consequent CT scan demonstrated a tumor size of 9.4 × 5.9 × 7.6 cm with extension to the left lung. This was followed by 3 cycles of BV, resulting in 3-4 months of disease remission. Due to subsequent disease progression, 2 cycles of BvB and 2 cycles of BV-ICE were initiated, followed by autologous stem cell transplantation (ASCT). The procedure resulted in pancytopenia and oral mucositis, both of which were resolved with appropriate treatment. The patient is currently in the third week of follow-up for further management. ASCT may ultimately be a candidate for treatment-resistant MGZL. These findings should be validated in larger studies.

Lemierre’s Syndrome Presenting Section with Pleural Effusion

Lemierre’s syndrome is a condition characterised by septic thrombophlebitis of internal jugular vein following an oropharyngeal infection along with septic embolisation to other organs mainly lungs. This report is about a 14-year-old girl who presented with complaint of high-grade fever, progressive shortness of breath and painful swelling of throat for seven days. Chest radiograph showed left hemithorax homogenous opacity with contralateral mediastinal shift. Complete haemogram and other blood investigations revealed neutrophilic leucocytosis and raised C-reactive protein. Gram stain and aerobic culture of sputum, pleural fluid and blood were inconclusive. As there was no relief of symptoms even after empirical treatment with antibiotics, Contrast Enhanced Computed Tomography (CECT) scan of neck and thorax was done, and it showed bilateral ectatic internal jugular veins with intravascular thrombus and consolidation of left lung with ipsilateral pleural effusion. Ultrasonography of neck confirmed the presence of thrombus in internal jugular vein on both sides. She was started on intravenous clindamycin and subcutaneous anticoagulants. Gradually the symptoms of the patient resolved. To conclude with, despite being called a “forgotten disease”, Lemierre’s syndrome requires strong clinical suspicion and prompt management to prevent mortality.

COVID-19 and Legionella Co-Infection

Introduction Concurrent infections or co-infections in patients diagnosed with Coronavirus Disease-19 (COVID-19) are not uncommon and predict a pejorative prognosis. A co-infection accounts for 1 out of every 5 cases of COVID-19 and increases the likelihood of adverse health outcomes such as mechanical ventilations, ICU admissions, and death. Specifically, Legionella spp. co-infection presents additional challenges in COVID-19 patients because of its rarity, similar clinical presentation to SARS-CoV-2, and poorer outcomes without prompt treatment. Cases Presentation Case 1. A 62-year-old female presented with a 3-day history of subjective fever and worsening shortness of breath. Room air saturation (saO2) was 70% and improved to 100 % on noninvasive positivepressure ventilation (NIPPV). Lung auscultation revealed rales BL. Chest X –Ray (CXR) showed patchy airspace opacities bilaterally (BL), SARS-CoV-2 PCR and urine legionella antigen tests were positive. The diagnosis of hypoxic respiratory failure secondary to COVID-19 and Legionella pneumonia was made. Patient was admitted to intensive care unit (ICU) and managed with decadron, remdesivir, one unit of convalescent plasma for COVID-19 and Azithromycin for Legionella. Patient subsequently developed acute respiratory distress syndrome (ARDS). ARDS protocol was initiated. 13 days after, the patient was compassionately extubated. Case 2. A 41-year-old male presented with 5-day history of fever, worsening shortness of breath, cough and diarrhea. Patient admitted history of ethanol abuse. SaO2 was 88% and improved on oxygen canula. Lung auscultation revealed rhonchi BL. CXR showed extensive left lung consolidation. Urine test for legionella antigen was positive. COVID-19 PCR was negative, but SARS-CoV-2 IgG was reactive. The diagnosis of Legionnaire disease was made. Despite initial treatment with Azithromycin, patient's hypoxia continued to worsen requiring NIPPV, and subsequently mechanical ventilation in the ICU. The adjunction of empiric treatment for COVID-19 with convalescent plasma, remdesivir and steroids improved both clinicals and laboratory findings. Discussion The cases illustrated the practical challenges of managing COVID-19 and legionella coinfection. Legionella spp and SARS-CoV-2 overlapping incubation periods and similar clinical presentations and complications. In the absence of diagnosis and treatment, legionella pneumonia has an intrinsic mortality rate of up to 80%. As some COVID-19 mitigation strategies, such as the closure of businesses, have enhanced the conditions for Legionella spp proliferation, the incidence of Co-infection with COVID-19 may increase. We recommend clinicians to have high-indexed suspicion of COVID-19 and Legionella co-infection in order to obtain complete work up at patient’s initial presentation.

PEDIATRIC PLASTIC BRONCHITIS IN THE SETTING OF SICKLE CELL DISEASE TREATED WITH INHALED TISSUE PLASMINOGEN ACTIVATOR

TOPIC: Pediatrics TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plastic bronchitis is seen in congenital heart disease, cystic fibrosis, asthma, and less commonly sickle cell disease. It has high morbidity and can be difficult to treat. CASE PRESENTATION: We present an 11-year-old African American boy with past medical history of hemoglobin SS disease, acute chest syndrome, pain crises, and obstructive sleep apnea status post tonsillectomy and adenoidectomy who presented with vaso-occlusive pain crisis consisting of chest pain. CXR was clear without consolidation. He was placed on a pain regimen of morphine and ketorolac. Acute chest prophylaxis was initiated with albuterol plus PEP every 4 hours, incentive spirometry, and oxygen saturation maintenance ≥95%. Over the next two days he developed fevers, increased oxygen requirement, and crackles. CXR progressed to consolidation of left lung. He was transferred to the Pediatric ICU for BiPAP and given 2 units pRBCs, 7 days ceftriaxone, and 5 days azithromycin for acute chest treatment. Despite intense respiratory treatments while on BiPAP with albuterol every 4 hours, dornase alfa every 12 hours, CPT every 4 hours, and home mometasone/formoterol every 12 hours, his CXR demonstrated persistent opacification of left lung. Pulmonology was consulted for bronchoscopy which demonstrated large white mucoid material in the left mainstem consistent with plastic bronchitis. The cast was unable to be removed on initial bronchoscopy. He was initiated on inhaled tissue plasminogen activator 4 times daily in addition to above respiratory treatments. Bronchoscopy was repeated two days later and cast was successfully removed. BiPAP and oxygen were weaned as tolerated and he was discharged home on mometasone/formoterol twice daily. DISCUSSION: Plastic bronchitis describes endobronchial plugs of rubber-like casts in the bronchial trees. It is more commonly seen in patients with congenital heart disease after single-ventricle palliation. There have been various treatments trialed including bronchoscopy, chest physiotherapy, inhaled steroids, hypertonic saline, dornase alfa, nebulized heparin, lymphatic embolization, and inhaled tissue plasminogen activator. Studies performed on casts have demonstrated a substantial fibrin component supporting inhaled tissue plasminogen activator as a potentially effective treatment option. CONCLUSIONS: We present a case of pediatric plastic bronchitis in the setting of a patient with sickle cell disease. This case emphasizes that plastic bronchitis must be considered in patients diagnosed with acute chest. Additionally, inhaled tissue plasminogen activator may be considered as a treatment modality in pediatric patients with plastic bronchitis, particularly in patients who are unable to undergo bronchoscopy or when it has been unsuccessful for removal. REFERENCE #1: Feray S, Mora P, Decavele M, Pham T, Hafiani EM, Fartoukh M. Plastic bronchitis: An unusual complication of acute chest syndrome in adult. Respir Med Case Rep. 2017 Apr 7;21:93–5. REFERENCE #2: Li Y, Williams RJ, Dombrowski ND, Watters K, Daly KP, Irace AL, et al. Current evaluation and management of plastic bronchitis in the pediatric population. Int J Pediatr Otorhinolaryngol. 2020 Mar 1;130:109799. REFERENCE #3: Heath L, Ling S, Racz J, Mane G, Schmidt L, Myers JL, et al. Prospective, Longitudinal Study of Plastic Bronchitis Cast Pathology and Responsiveness to Tissue Plasminogen Activator (tPA). Pediatr Cardiol. 2011 Dec;32(8):1182–9. DISCLOSURES: No relevant relationships by Megan Lilley, source=Web Response No relevant relationships by Carla Roberts, source=Web Response No relevant relationships by Heather Staples, source=Web Response

FATAL MYCOBACTERIUM ABSCESSUS INFECTION WITH BRONCHOESOPHAGEAL FISTULA

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Mycobacterium abscessus is known as the most prevalent rapidly growing non-tuberculous mycobacterium (NTM) (1). It is difficult to treat as it has numerous ways to evade the host immune system. Risk factors for infection include immunodeficiencies, smoking, and pulmonary disorders including cystic fibrosis and bronchiectasis. Tigecycline has been recommended as part of a multi-drug regimen therapy. However, the efficacy of multiple regimens is still being evaluated. Some of the novel therapies include b-lactamase inhibitors as well as macrophage therapy (1). CASE PRESENTATION: We present a 69-year-old female with a past medical history of blindness, atrial fibrillation, anemia, breast cancer with metastasis to the lungs and bones who comes in for generalized weakness from her oncologist office. She was noted to have a significantly worsening consolidation of the left lung with cavitation. (Figure 1 and 2). Furthermore, it showed a small area of communication between the left main stem bronchus and esophagus. Bronchoscopy was performed which showed a broncho-esophageal fistula (Figure 3). Cultures were positive for Pseudomonas aeruginosa which was sensitive and treated with cefepime. Due to the severity of the left lung consolidation, the patient was transferred to a tertiary hospital for placement of a bronchial and esophageal stent. Despite placement of stents, she passed of hypoxic respiratory failure after placement of the stents. A postmortum acid fast culture from the sputum and bronchial alveolar lavage grew Mycobacterium abscessus. Further speciation, macrolide, and additional antibiotic sensitivities were not ordered when culture was sent to National Jewish Laboratory in Denver, CO. DISCUSSION: In this case, the cavitary findings and severe lung consolidation appeared to be clinically out of proportion with the patient's community acquired Pseudomonas aeruginosa infection. Furthermore, a broncho-esophageal fistula has not been seen with Pseudomonas infections. So, the late finding of the Mycobacterium abscessus infection clarified why the patient had such a severe infection and fistula. Acquired broncho-esophageal fistulas are rare and there is one case of an esophago-pulmonary fistula reported in the Japanese literature (3). In this patient, we present a fatal case of a Mycobacterium abscessus and Pseudomonas aeruginosa with a broncho-esophageal fistula. Pseudomonas aeruginosa co-infection has been listed as a risk factor, which contributed to the development of the fistula (1). It is important to consider additional testing with severe pulmonary infections with only Pseudomonas aeruginosa. CONCLUSIONS: Broncho-esophageal fistula has been rarely reported in the literature. So, we felt it was important to report this case of Mycobacterium abscessus and Pseudomonas aeruginosa co-infection causing a consolidation, cavitary lesion and a denouveau broncho-esophageal fistula. REFERENCE #1: Johansen, M.D., Herrmann, JL. & Kremer, L. Non-tuberculous mycobacteria and the rise of Mycobacterium abscessus. Nat Rev Microbiol 18, 392–407 (2020). https://doi.org/10.1038/s41579-020-0331-1 REFERENCE #2: Strnad L, Winthrop KL. Treatment of Mycobacterium abscessus Complex. Semin Respir Crit Care Med. 2018 Jun;39(3):362-376. doi: 10.1055/s-0038-1651494. Epub 2018 Aug 2. PMID: 30071551. REFERENCE #3: Kokuho N, Hayashi H, Matsuyama M, Miura Y, Hayashihara K, Saito T. [A case of pulmonary Mycobacterium abscessus disease complicated with esophago-pulmonary fistula causing repeated exacerbation]. Nihon Kokyuki Gakkai Zasshi. 2010 Sep;48(9):696-701. Japanese. PMID: 20954373. DISCLOSURES: No relevant relationships by Justin Ching, source=Web Response

Antibody Mediated Rejection of Unrelated Donor Lung

Introduction Living-donor lobar lung transplantation (LDLLT) arose from the need to transplant patients deemed unlikely to survive the waitlist for a deceased organ donor. Since the initiation of the lung allocation score (LAS), the wait time for cadaveric organs has significantly decreased in the USA as has the need for LDLLT. According to the Organ Procurement and Transplantation Network (OPTN), there have been 253 recipients of LDLLT in the USA. Of these, 95 were children and only 20 of them had a biologically unrelated donor. We present a case of graft dysfunction in a 28-year-old man who underwent bilateral LDLLT at age 9 for pulmonary arterial hypertension. He received a right lower lobe from his mother and a left lower lobe from a family friend. Case Report The patient presented with new onset dyspnea, productive cough, and hypoxemia. He had a significant decline in lung function, new left lung consolidation, and required hospitalization for hypoxemic respiratory failure. Work-up was significant for undetectable immunosuppressant levels and a new DPB1 antibody. Bilateral transbronchial biopsies were negative for acute cellular rejection, however BAL cell count showed significant lymphocytosis and eosinophilia. He was treated with pulse dose IV steroids followed by plasmapheresis, IVIG, and Rituximab. Oxygen requirement decreased and he was discharged home. A lung ventilation-perfusion scan performed a few months later showed marked asymmetric reduction in perfusion to the left lung. Despite persistent volume loss in the left allograft and decreased lung function, he has remained clinically stable on monthly IVIG infusions and is now off supplemental oxygen. Donor HLA typing was not available to us as the transplant occurred in 2001 when DPs were not routinely typed. However, considering the overall presentation and the patient's response to therapy, we presume the DPB1 is a donor specific antibody (DSA). Summary Unilateral chronic lung allograft dysfunction (CLAD) has been described in bilateral LDLLT. The significance of HLA in the immune response of lung transplant recipients has gained recognition in recent years. Data suggest that the development of alloantibodies as a consequence of HLA mismatching has been shown to correlate with development of CLAD. This case illustrated a unique presentation of presumed antibody mediated rejection of unrelated donor lung in the setting of subtherapeutic immunosuppression.

Case report of hepatic abscess with lung consolidation in a neonate: A rare entity

Neonatal liver abscess is an uncommon finding and very few cases have been reported till date. A 36+5 week near term neonate presented with clinical symptoms of sepsis, convulsion on day 3 of life and hepatomegaly with history of birth asphyxia, chorioamnionitis and oligohydrominos. The baby was diagnosed with liver abscess with left lung consolidation by radiological investigations and the abscess was aspirated under Ultrasound-Guided and treated with antibiotics. The liver abscess resolved on follow up and the baby was discharge healthy.

An Unusual Case of Dengue Fever with Necrotising Pneumonia

Concurrent bacteremia in patients with dengue fever is rarely reported. Two and a half-year-old female child with fever, cough and cold for six days presented to Emergency Room (ER) with tachypnea, tachycardia and hepatomegaly. Investigations revealed dengue fever. Respiratory symptoms probed us to investigate the case further. High-Resolution Computed Tomography (HRCT) thorax showed moderate pleural effusion with collapse consolidation of left lung and a thin walled cavity with septations and fluid in left upper lobe. Child was treated with injection meropenem and vancomycin successfully.

Development of Bleeding Gastric Arteriovenous Malformations in a 23-year-old Man 3 Months After Normal Endoscopy

Gastric arteriovenous malformations (AVMs) are extremely rare. AVMs can develop in the stomach, large and small intestine. They are typically seen in elderly patients and are most commonly found in the large intestine. They are a significant cause of lower gastrointestinal bleeding in elderly patients. AVMs are more common in patients with end-stage kidney disease, Von Willebrand disease and have been found to be associated with aortic stenosis. A 23 year-old Caucasian male was brought in to the hospital by his mother after he had an episode of coffee ground emesis associated with fever and a low oxygen saturation level measured at home by his caretaker. He has a past medical history of an anoxic brain injury from a childhood drowning accident at age 4, with a gastrojejunostomy tube for feeding. In the emergency room, he was found to have hypoxia and was admitted to the hospital. His physical exam revealed blood pressure of 73/51 and an oxygen saturation of 85%. Admission labs revealed hemoglobin of 15.3 g/dl, hematocrit of 43.8%, MCV 94.2 and WBC 8,900. A chest x-ray performed during hospitalization revealed a left lung consolidation suspicious for possible aspiration pneumonia. Blood work on the following day showed his hemoglobin had dropped to 7.9 g/dl with a hematocrit of 23% and he continued to have episodes of coffee ground emesis. An endoscopy was performed that revealed several medium-sized angiodysplastic lesions with stigmata of recent bleeding in the gastric body and underneath the g-tube bumper. Hemostasis was achieved with argon laser and the patient did not have any further episodes of hematemesis. The patient had a previous endoscopy that was performed 3 months prior to hospitalization evaluating for reflux esophagitis which had revealed normal gastric and duodenal mucosa. No AVMs were seen at that time. In this case, a young male patient developed gastric AVMs in a span of 3 months that were associated with significant bleeding, leading to aspiration pneumonia. The patient does not have end-stage renal disease, aortic stenosis or Von Willebrand disease. The pathogenesis of AVMs of the gastrointestinal tract is not well understood. In this patient, it is possible that previous hospitalization with significant hypoxia may have led to the increased expression of angiogenic factors which may be the underlying reason for the development of arteriovenous malformations of the stomach in a short period of time.Figure: Endoscopic view of multiple a/v malformations in patient's stomach.Figure: Endoscopy performed 3 months ago.

Bilateral empyema thoracis due to Lactobacillus gasseri. Has anything changed since Hippocrates?

Introduction Lactobacilli are common commensal bacteria found in the gastrointestinal and genitourinary tract. Although they are usually thought to be non-pathogenic, there have been few reported cases that showcase severe infections caused by these microorganisms. This is the first reported case of a bilateral empyema with bacterial cultures growing only Lactobacillus gasseri in the setting of undiagnosed type 2 DM. Case description Previously healthy 49-year-old male, presented to the emergency room with a 3 month history of a productive cough and worsening fatigue that was associated with a 30 pound weight loss and bilateral lower extremity edema. He denied any smoking history, history of recent or recurrent pneumonia or sick contacts. Upon presentation, he was hypoxic and tachycardic. On physical examination patient appeared cachectic, right lung sounds were diminished and lower extremities showed 2 to 3+ pitting edema. Results and conclusions White count was 23.8x10(9)/L, Hemoglobin A1c is 14.7%. HIV test negative. CT-chest showed a large right sided pleural effusion containing pockets of gas consistent with empyema, along with focal airspace disease within the lingual and left lower lobe. Patient underwent a right sided VATS procedure and two chest tubes were placed. Intraoperatively 1300mL of gray foul-smelling material was drained. Repeated CT-chest showed left lung consolidation and effusion and a chest tube was placed on hospital day 8. Cultures were positive for Lactobacillus gasseri from both lungs. Patient was treated with Ampicillin/Sulbactam followed by a course of Amoxicillin/clavulanic acid. Take-home message Lactobacillus gasseri is an unusual cause of empyema. Management requires adequate drainage.

Pulmonary Tuberculosis Presenting As Total Lung Consolidation and Acute Respiratory Failure An Unusual Presentation

Tuberculosis has varied clinical and radiological presentations, ranging from constitutional symptoms with segmental involvement to severe forms with multiple lobar consolidation and high mortality. Though uncommon, respiratory failure can be a presenting feature of tuberculous consolidation of lungs, rarely requiring mechanical ventilation. We report a 27 year female diagnosed as having total left lung consolidation and respiratory failure who showed marked clinical and radiological improvement after taking anti-tubercular drugs. Knowledge of radiological presentations of the pulmonary tuberculosis such as patchy, poorly defined consolidation with/without cavitation, fibrosis, calcification, lung destruction, pleural effusion or miliary lesions can help in timely diagnosis and proper management of these cases. JMS 2016; 19(1):29-31

Pulmonary actinomycosis affecting chest wall: a case report

Thoracic actinomycosis is an uncommon, chronic suppurative bacterial infection caused by Actinomyces species. Thoracic actinomycosis represents about one-fourth of all cases of actinomycosis. We report a case of left sided pleural effusion with hydropneumothorax with collapse and consolidation of left lung with discharging sinus in the left anterior chest wall. Actinomycosis was suspected and confirmed by microscopic identification of “sulfur granules” in the discharge of the sinus tract and also identification of gram-positive filamentous bacteria in the specimen of discharging sinus.Bangladesh Journal of Medical Science Vol.14(4) 2015 p.417-41

Foreign body aspiration pneumonia in an intravenous drug user

Heroin use is associated with several well described respiratory complications, including noncardiogenic pulmonary edema, aspiration pneumonitis, acute respiratory distress syndrome,pneumonia, lung abscess, septic pulmonary emboli, and atelectasis. We describe an interesting case of a young female patient, an intravenous heroin user who presented with progressive dyspnea, hypoxia, and left lung consolidation.

Successful Treatments of Two Human Avian Influenza Chinese Children and Follow-Up

Background and aims: Human H5N1 avian influenza caused worldwide attention in 1997 when the first case was found in Hong Kong, our present study is to summarize the clinical characteristics, diagnostic and therapeutic experiences of the first human case and the youngest case with human H5N1 avian influenza pneumonia Chinese children in mainland of China and further provide effective strategies for the prevention and cure of future such children.Methods: To analyze the clinical data of two pneumonia children and following up data.Results: On October 18, 2005, a 9-year-old boy, fever, dry cough, on day 7 after onset, his body temperature reached 40°, large areas of consolidation on chest X-ray, decreased peripheral blood leukocyte counts and most neutrophilic granulocytes. After therapies with amantadine and glucocorticoid, he was the first human case in mainland of China and successfully treated and discharged. On January 9, 2006, another 6-year-old boy, high fever, cough, polypnea, the left lung consolidation on chest X-ray, less hemogram. After therapies with short-term symmetrel and ribavirin, low-dosage glucocorticoid for 4 weeks and CPAP assistant ventilations, he also was the youngest avian influenza case in China and successfully treated and discharged. At present, two boys are very healthy.Conclusions: It is very important to pay much more attention on epidemiological contact history and clinical characteristics of avian influenza patients, earlier detect and diagnose and therapy as soon as possible. These two cases children treated successfully attributed to timely discovery, promptly diagnosis and effectively treatments.

Development of Oseltamivir Resistance During Oseltamivir Therapy in a Child With Severe 2009 H1N1 Influenza

Development of Oseltamivir Resistance During Oseltamivir Therapy in a Child With Severe 2009 H1N1 Influenza

Pulmonary Pleomorphic Carcinoma Mimicking Bronchopneumonia in an Elderly Man

A 77-year-old male smoker presented with fever, cough, and night sweat of 4 weeks' duration. Imaging of the chest revealed a left lung consolidation and a right cavitary lesion. Further investigation with flexible bronchoscopy supported the diagnosis of an infectious/inflammatory process. The patient clinically improved with antibiotics and was discharged. He was readmitted with a similar presentation 2 weeks later; at this time he had new onset of atrial fibrillation and worsening respiratory symptoms. After his heart rate was controlled, he underwent transthoracic needle aspiration and pleural fluid drainage, which again were nondiagnostic. A surgical biopsy was scheduled, but he expired before surgery. Necropsy revealed pulmonary pleomorphic carcinoma with invasion of both the lungs, lymph nodes, pericardium, and myocardium. Clinicians should keep a high index of suspicion for pleomorphic carcinoma in those patients with unusual presentation or progressive or nonresolving pulmonary infiltrates. Early surgical intervention, either for diagnosis or treatment, is imperative due to the aggressive nature of the tumor and the dismal prognosis.