Left Lung Field Research Articles

Congenital Lobar Emphysema in a 17-Day-Old Male Neonate: The Plain Radiographic Features and a Case Report

Congenital lobar emphysema (CLE) is a rare respiratory disorder which allows air to enter the lungs but can’t escape causing over-inflation of the lobes of the lung. This condition (CLE) is commonly detected in the newborn or young infants but some cases are diagnosed in adulthood. Congenital lobar emphysema is a rare congenital malformation with a prevalence of 1 in 20,000 to 1 in 30, 000, and more prevalent in males, with a male to female ratio of about 3:1. This is a 17 day old male neonate that presented with respiratory difficulty and .had a supine chest radiograph that showed an overinflated left lung field more on the upper and middle zones with flattening of the left hemi diaphragm, marked shift of the heart and mediastinum to the right with some degree of loss of volume involving the right lung. We report the radiographic findings of this case due the rare nature of congenital lobar emphysema.

Exploring Optimality of Piecewise Polynomial Interpolation Functions for Lung Field Modeling in 2D Chest X-Ray Images

In this paper, a landmark based approach, using five different interpolating polynomials (linear, cubic convolution, cubic spline, PCHIP, and Makima) for modeling of lung field region in 2D chest X-ray images have been presented. Japanese Society of Radiological Technology (JSRT) database which is publicly available has been used for evaluation of the proposed method. Selected radiographs are anatomically landmarked using 17 and 16 anatomical landmark points to represent left and right lung field regions, respectively. Local, piecewise polynomial interpolation is then employed to create additional semilandmark points to form the lung contour. Jaccard similarity coefficients and Dice coefficients have been used to find accuracy of the modeled shape through comparison with the prepared ground truth. With the optimality condition of three intermediate semilandmark points, PCHIP interpolation method with an execution time of 5.04873 s is found to be the most promising candidate for lung field modeling with an average Dice coefficient (DC) of 98.20 and 98.54% (for the left and right lung field, respectively) and with the average Jaccard similarity coefficient (JSC) of 96.47 and 97.13% for these two lung field regions. While performance of Makima and cubic convolution is close to the PCHIP with the same optimality condition, i.e., three intermediate semilandmark points, the optimality condition for the cubic spline method is of at least seven intermediate semilandmark points which, however, does not result in better performance in terms of accuracy or execution time.

A Woman with Fever, Cough, and Dyspnea

A 57-year-old woman with a prior minor ischemic stroke visited the emergency department because of cough with left lower chest pain and progressive dyspnea for a few days. Upon presentation, she was fully conscious with a blood pressure of 157/75 mm Hg, a pulse rate of 102 beats/min, a temperature of 39.1 °C (102.4 °F), and a room air saturation of 95%. On examination, her breath sounds were coarse, whereas her abdomen was soft and nontender. Chest radiograph revealed left lower lung field opacity (Figure 1).

UNILATERAL CRYSTAL METHAMPHETAMINE LUNG

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Methamphetamine is a drug manufactured from ephedrine and pseudoephedrine mixed with ingredients such as ammonia, lithium, iodine, and phosphorous but adulterants such as alcohol, acetone, and energy drinks have also been used. Smoking is the most common form of abuse with complications such as eosinophilic pneumonia, alveolar hemorrhage, acute interstitial pneumonia, and pulmonary fibrosis. We present an atypical methamphetamine-induced lung injury. CASE PRESENTATION: A 57-year-old female with a 40-pack year smoking history and polysubstance abuse presented with acute onset shortness of breath. On admission, she was hypoxic requiring 25 liters of high flow oxygen. On examination, the patient was afebrile with normal blood pressure. Chest auscultation revealed wheezing, most prominent in the left lung fields, while the rest of the systemic examination was unremarkable. Laboratories showed leukocytosis, normal liver, and renal function test. Sputum culture had no bacterial growth and Covid-19 PCR negative. Urine toxicology was positive for methamphetamine. Contrast CT chest showed diffuse interstitial thickening and ground-glass opacities throughout the right lung but normal left lung parenchyma with narrowing of the distal left mainstem bronchus by an endobronchial mass. The patient's hypoxemia improved with Methylprednisolone. Bronchoscopy showed a left mainstem lesion with near-complete obstruction of the left upper and lower lobes with biopsy revealing squamous cell carcinoma. There was normal airway mucosa on the right lung segments and scant inflammation without malignant cells on biopsy. The patient underwent successful tumor debulking with follow-up PET CT demonstrating decreased but persistence of alveolar septal thickening on the right lung with FDG positive mediastinal lymph nodes. The patient was weaned off supplemental oxygen 4 weeks later. DISCUSSION: Diagnosis of Methamphetamine-induced lung injury depends on the history of recent use, ground-glass opacities on imaging, and exclusion of other infections which was fulfilled by our patient but with the question of left lung sparing. Crystalline particles range in size from less than 250 nm-10 μm, with clusters as large as 80 μm where the obstructing mass may have prevented the flow of the drug vapor. Methamphetamine has also been postulated to release early response cytokines including TNF-alpha and IL-6 leading to recruitment of neutrophils and free radicals release causing acute lung injury. The management is mainly supportive with empiric steroids with improvement via impeding this inflammatory cascade. CONCLUSIONS: Our case demonstrates multiple learning points including particle size factor in passage through an obstructed airway, response to steroids supporting in settings of acute inflammation, and the persistence of residual lung disease on imaging in contrast to clinical improvement 4 weeks post-exposure. REFERENCE #1: Javed A, Nasrullah A, Malik K (February 08, 2021) A Rare Case of Methamphetamine-Induced Lung Injury During the Ongoing COVID-19 Pandemic. Cureus 13(2): e13215. doi:10.7759/cureus.13215 REFERENCE #2: Kinner SA, Degenhardt L. Crystal methamphetamine smoking among regular ecstasy users in Australia: increases in use and associations with harm. Drug Alcohol Rev. 2008 May;27(3):292-300. doi: 10.1080/09595230801919452. PMID: 18368611. REFERENCE #3: Lin SS, Chen YC, Chang YL, Yeh DY, Lin CC. Crystal amphetamine smoking-induced acute eosinophilic pneumonia and diffuse alveolar damage: a case report and literature review. Chin J Physiol. 2014 Oct 31;57(5):295-8. doi: 10.4077/CJP.2014.BAC201. PMID: 25241990. DISCLOSURES: No relevant relationships by Uchit Thapa, source=Web Response

P36.01 Primary Acinic Cell Carcinoma of Bronchial Ground Origin: A Case Report

Primary acinic cell carcinoma of the lung is an extremely rare disease. Also known as Fechner’s tumor, this condition was first reported by Fechner et al. in 1972. The accurate diagnosis of primary pulmonary acinic cell carcinoma is difficult and relies on comprehensive evaluation of clinical, histological and immunohistochemical features. A 49-year-old male patient was referred to our hospital because of an abnormal infiltration shadow in the left lower lung field detected on a chest radiograph during a medical check-up. Chest computed tomography revealed a nodal mass shadow 10mm in size, in segment 8 of the left lower lobe. Bronchoscopic examination revealed a polypoid tumor at B8. Transbronchial biopsy was performed and the tumor was diagnosed as a bronchial gland adenoma. The patient underwent video-assisted thoracic segmentectomy to achieve complete resection of the tumor. Macroscopically, the tumor was a solitary mass measuring 14×10×8 mm in size with substantial cut surface and showed no intraparenchimal growth. Histopathological examination revealed a polypoid projection in the bronchial space. Adeno-type cancer cells with monomorphous nuclei invade the bronchial wall tissue in association with tubule or acinus-like space formation. The cytoplasm of the tumor cells is plump and eosinophilic with granularity or clear. No direct invasion into the lung parenchyma was observed. Immunohistochemical staining revealed that the tumor cells were positive for PAS, lactoferrin, and HMG-45MI. The features are consistent with acinic cell carcinoma of bronchial gland origin. Electron microscopy showed that the acinus-forming tumor cell possess well-developed mitochondria and round-surfaced endoplasmic reticulum, in association with active luminal secretion. Rounded, electron-dense secretory exocrine granules, ranging from 150 to 340 nm in size, are noted mainly in the apical cytoplasm. Fat vacuoles are noted in some tumor cells. Microvillous intracytoplasmic lumina are occasionally noted. Bundles of intermediate filaments and desmosomal attachments are also seen. These features are consistent with acinar cell nature of the cells. Fourteen years since the surgical resection, no apparent recurrence or metastasis has been detected. We experienced an extremely rare case of primary bronchial acinic cell carcinoma diagnosed based on clinical information, histopathological features, immunogistopathological staining profile, and electron microscopy features. The limited number of reports on this type of tumor have revealed that the outcome after surgical resection is favorable due to its low-grade malignant potential. Likewise in this case, the patient remained free of recurrence for over 14 years after surgery.

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

TIBIAL METASTASIS AS INITIAL PRESENTATION OF SQUAMOUS CELL LUNG CANCER

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung carcinomas are frequently detected at stage IV and pain caused by bone metastasis - usually to the ribs and thoracic vertebrae - is a frequent manifestation. Metastasis to the lower limbs are extremely rare, particularly below the knee and as solitary lesions. CASE PRESENTATION: A 57 years-old white man, former smoker (74 pack-years) with sleep apnea, presented to his physician with 2 weeks of right atraumatic knee pain, worse on exertion. No constitutional symptoms were reported. Knee radiography was normal. Considering a rheumatological disorder, non-steroidal anti-inflammatories drugs and intra-articular steroid injection were prescribed, but without improvement. The patient then underwent knee magnetic resonance imaging, which showed a mass at the proximal tibial epiphysis extending to the tibial cortex and surrounding soft tissues (figure 1). To exclude primary malignancy of the bone, a computed tomography (CT) guided bone biopsy was made. Bone scintigraphy excluded other lesions. Two months later, the patient presented to our emergency department with hemoptysis and weight loss of 22% of his body weight in the previous 3 weeks. Physical examination revealed low-pitched vesicular murmur on the left hemithorax, as well as swelling of the inferior portion of the right knee and upper third of the right tibial and severe pain at palpation with impaired gait. Chest radiograph showed a heterogeneous opacity on the upper left lung field (figure 2), and the thorax CT revealed a large mass in the central area of the upper lobe of the left lung, extending to the hilum with mediastinal adenopathies. Adrenal and hepatic metastasis were also noted (figure 3). Bone biopsy performed (previously at another hospital), revealed a carcinoma with squamous differentiation favouring a metastatic process. Bronchial biopsy by flexible bronchoscopy revealed squamous cell lung tumor, so the diagnosis of stage IV lung cancer was made. He will start palliative bone radiotherapy shortly and, pending the programmed death ligand 1 tumor proportion score, systemic treatment with chemo or immunotherapy. DISCUSSION: Lung cancer's bone metastases are usually found in the axial skeleton. The few cases of below-the-knee metastasis described in the literature are secondary to adenocarcinoma or small cell lung cancer. In this case, the diagnosis of lung cancer was delayed mainly due to the extremely atypical presentation as knee pain without respiratory or systemic symptoms. CONCLUSIONS: Although rarely, pain due to tibial metastasis may be the initial presentation of lung cancer. Therefore, this should be taken in consideration when approaching single bone lesions or localized rheumatologic disorders in order to prevent a delay in diagnosis and treatment of lung cancer, especially in current or past-smokers. REFERENCE #1: Popper HH. Progression and metastasis of lung cancer. Cancer Metastasis Rev 2016;35(1):75-91. REFERENCE #2: Gurrieri L, Longhi A, Braghetti A. Lung cancer presenting as a metastasis to the tibial bones: A case report. Tumori 2015;101(1):e18-20. REFERENCE #3: Kurishima K, Kagohashi K, Mammoto T, Satoh H. Tibia metastasis from small cell lung cancer. Tuberk Toraks 2014;62(1):89-90. DISCLOSURES: No relevant relationships by Carolina Alves, source=Web Response No relevant relationships by José Alves, source=Web Response No relevant relationships by Maria Carolina Carvalho, source=Web Response No relevant relationships by Ana Mendes, source=Web Response No relevant relationships by Ricardo Oliveira, source=Web Response No relevant relationships by Margarida Pereira, source=Web Response

Re-expansion pulmonary edema following a pneumothorax drainage in a patient with COVID-19

BackgroundRe-expansion pulmonary edema is an uncommon complication following drainage of a pneumothorax or pleural effusion. While pneumothorax is noted to complicate COVID-19 patients, no case of COVID-19 developing re-expansion pulmonary edema has been reported.Case representationA man in his early 40 s without a smoking history and underlying pulmonary diseases suddenly complained of left chest pain with dyspnea 1 day after being diagnosed with COVID-19. Chest X-ray revealed pneumothorax in the left lung field, and a chest tube was inserted into the intrathoracic space without negative pressure 9 h after the onset of chest pain, resulting in the disappearance of respiratory symptoms; however, 2 h thereafter, dyspnea recurred with lower oxygenation status. Chest X-ray revealed improvement of collapse but extensive infiltration in the expanded lung. Therefore, the patient was diagnosed with re-expansion pulmonary edema, and his dyspnea and oxygenation status gradually improved without any intervention, such as steroid administration. Abnormal lung images also gradually improved within several days.ConclusionsThis case highlights the rare presentation of re-expansion pulmonary edema following pneumothorax drainage in a patient with COVID-19, which recovered without requiring treatment for viral pneumonia. Differentiating re-expansion pulmonary edema from viral pneumonia is crucial to prevent unnecessary medication for COVID-19 pneumonia and pneumothorax.

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.

Diagnosing Disseminated Nocardiosis in a Patient With COVID-19 Pneumonia

Signs and symptoms of atypical pneumonia include fever, shortness of breath, cough, and chest pain. During the coronavirus disease 2019 (COVID-19) pandemic, identifying other causes of febrile respiratory illness in patients who tested positive for COVID-19 has been very challenging. Concerns over infecting healthcare personnel and other patients can impede further evaluations like bronchial lavage, lung biopsies, and other invasive tests. A very high index of suspicion, perhaps unreasonably so, is required to perform invasive tests to investigate alternative possible causes of the illness. We present the case of a 63-year-old man who presented to the hospital with dyspnea. Chest X-ray demonstrated a consolidation in the left lower lobe lung field with a possible underlying mass, and the patient tested positive for COVID-19. He received the standard treatment for COVID pneumonia at the time in our institution (remdesivir and dexamethasone), empiric antibiotics for community-acquired pneumonia, and was eventually discharged home with supplemental oxygen. Several days later, the patient returned to the hospital again with worsening dyspnea and was readmitted. Persistent illness and worsening imaging prompted bronchoscopy. The bronchoscopy showed narrowing of the airway in the left upper lobe, and Nocardia asteroides was isolated from bronchial aspirate. The isolation of Nocardia prompted an investigation for central nervous system involvement with an magnetic resonance imaging (MRI) of the head. The MRI demonstrated multiple bilateral ring-enhancing lesions in the brain. To our knowledge, this is the first reported case of disseminated nocardiosis superimposed on COVID-19 pneumonia.

Pericardial calcification with plain radiographic features of tuberculosis in a child: incidental finding and a case report

Tuberculous pericarditis is frequently reported as the primary cause of pericardial calcification and occurs in about 1-2% of individuals with pulmonary tuberculosis, this however is a rare finding in the Western world. This is a 12-year-old male child that was referred from a peripheral health care center for plain radiograph of the chest on account of cough, easy fatiguability, night sweats, loss of weight, loss of appetite and dyspnea most times on excersion for more than a month duration. The plain chest radiograph demonstrated normal cardiac size with a cardiothoracic ratio of about 55/120, there is circumferential radio-opacity of calcic density around the peripheral walls of the heart; the pericardial calcification. The vascular pedicle appears slightly widened. The lung fields show extensive streaky opacities with cystic lung changes bilaterally more marked on the left lung field where consolidation, loss of lung volume and pleural effusion are also demonstrated. A two-dimensional echocardiography showed mild-moderate pericardial effusion, thickening of both visceral and parietal pericardium, and echogenic fond-like structures protruding in to the pericardial cavity. A diagnosis of pulmonary tuberculosis with features of tuberculous pericarditis in a 12-year-old male child was established. The patient has been placed on anti-tuberculous drugs, hematinic, and parents advised on good and adequate diet with adequate rehydration and strict drug compliance. Screening of the siblings and members of the family with close contact have also been emphasized. We report the radiographic features of pulmonary tuberculosis and pericardial calcification in a 12-year-old male child due to its peculiar presentation.

48-Year-Old Woman With Dyspnea and Chest Pain

48-Year-Old Woman With Dyspnea and Chest Pain

Pulmonary perfusion by chest digital dynamic radiography: Comparison between breath-holding and deep-breathing acquisition.

PurposePulmonary perfusion is an important factor for gas exchange. Chest digital dynamic radiography (DDR) by the deep‐breathing protocol can evaluate pulmonary perfusion in healthy subjects. However, respiratory artifacts may affect DDR in patients with respiratory diseases. We examined the feasibility of a breath‐holding protocol and compared it with the deep‐breathing protocol to reduce respiratory artifacts.Materials and methodsA total of 42 consecutive patients with respiratory diseases (32 males; age, 68.6 ± 12.3 yr), including 21 patients with chronic obstructive pulmonary disease, underwent chest DDR through the breath‐holding protocol and the deep‐breathing protocol. Imaging success rate and exposure to radiation were compared. The correlation rate of temporal changes in each pixel value between the lung fields and left cardiac ventricles was analyzed.ResultsImaging success rate was higher with the breath‐holding protocol vs the deep‐breathing protocol (97% vs 69%, respectively; P < 0.0001). The entrance surface dose was lower with the breath‐holding protocol (1.09 ± 0.20 vs 1.81 ± 0.08 mGy, respectively; P < 0.0001). The correlation rate was higher with the breath‐holding protocol (right lung field, 41.7 ± 9.3%; left lung field, 44.2 ± 8.9% vs right lung field, 33.4 ± 6.6%; left lung field, 36.0 ± 7.1%, respectively; both lung fields, P < 0.0001). In the lower lung fields, the correlation rate was markedly different (right, 15.3% difference; left, 14.1% difference; both lung fields, P < 0.0001).ConclusionThe breath‐holding protocol resulted in high imaging success rate among patients with respiratory diseases, yielding vivid images of pulmonary perfusion.

Infecciones en el paciente inmunodeprimido, a propósito de un caso de Esclerosis Sistémica

Introducción: La esclerosis es una enfermedad crónica, degenerativa, incapacitante y letal, que afecta a miles de personas. Su presentación clínica variable la ha convertido en un desafío diagnóstico, retrasando el tratamiento oportuno. En Ecuador no se conocen datos estadísticos exactos del número de pacientes con esta patología. El uso de terapias de inmunosupresión para tratar esta enfermedad ha hecho del paciente un blanco fácil para infecciones por patógenos oportunistas que muchas veces pasan desapercibidos. La infección por tuberculosis es de alta preocupación en estos pacientes, sobre todo cuando se administran terapias con corticoides más inmunosupresores por tiempo prolongado.&#x0D; Objetivo: Describir los efectos del uso prolongado de inmunosupresores y la susceptibilidad a infecciones por patógenos oportunistas.&#x0D; Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico de una paciente femenina diagnosticada con esclerosis múltiple con tratamiento inmunosupresor prolongado que es diagnosticada de manera fortuita con tuberculosis.&#x0D; Resultados: Se presenta un caso de una paciente femenina de 46 años, con antecedentes de Esclerosis Sistémica en tratamiento hace 18 años con prednisona 5 y 10 mg, micofenolato mofetil de 500 mg cada día, con antecedentes de cáncer, que es ingresada después de presentar sintomatología variada con tratamiento sin efectividad. Se realiza Tomografía de tórax que evidencia lesión quística cavitada en campo pulmonar izquierdo, con aparente infiltrado, Función renal, electrolitos y gasometría arterial dentro de parámetros normales y BAAR de esputo resultado positivo, por lo cual se inicia tratamiento antifimico.&#x0D; Conclusiones: Es de gran importancia que todos los profesionales de la salud que atienden a este tipo de pacientes tengan el conocimiento de las posibles complicaciones y el riesgo de infección latente propia de la enfermedad o por las terapias de inmunodepresión de manera prolongada. Se debe enfatizar en la realización de estrategias y protocolos para el correcto seguimiento de pacientes dentro del Sistema Nacional de Salud.

BETWEEN A WET STONE AND A HARD PLACE: SEVERE HYPOXIA, RHABDOMYOLYSIS, AND ACUTE RENAL FAILURE IN A CASE OF LEGIONELLA PNEUMOPHILIA PNEUMONIA

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Legionella pneumophilia (LP) is a formidable pathologic organism of the respiratory tract. Fewer than 10% of cases of community-acquired pneumonia (CAP) are caused by LP. Common clinical manifestations include fever, vomiting, diarrhea, shortness of breath, and lab abnormalities including hyponatremia and transaminitis. Chest imaging typically reveals a unilateral or bilateral patchy consolidation. Extrapulmonary manifestations of LP are rare but include meningitis, pyelonephritis, and skin and soft tissue infections. CASE PRESENTATION: A 60-year-old female presented to the emergency department by ambulance after collapsing while leaving work as a home health nurse assistant. Her history was notable for alcohol and tobacco abuse. Symptoms included generalized weakness, intermittent non-productive cough, nausea, and decreased oral intake for the past two days. In the emergency department, she was found to be febrile to 39.6 degrees C, tachypneic, tachycardic, and hypoxic on room air which improved initially on three liters by nasal cannula. Physical exam was notable for bibasilar crackles, wheezing, and decreased breath sounds in the left lung field. Laboratory data were significant for acute renal failure with a creatinine of 3.0mg/dL, leukocytosis to 29,000, and positive legionella urinary antigen. Chest x-ray revealed a large, dense, left-sided consolidation. She was treated with Azithromycin and Ceftriaxone, but later required intubation and mechanical ventilation due to severe hypoxia. Her oxygenation continued to worsen, prompting neuromuscular blockade and prone positioning. Further evaluation of her acute renal failure revealed markedly elevated creatinine kinase, consistent with rhabdomyolysis. Judicious use of maintenance fluids with intermittent dosing of diuretics was initiated in the setting of severe hypoxia with subsequent improvement in her renal function. DISCUSSION: LP can cause severe CAP requiring mechanical ventilation and, in this case, neuromuscular blockade and prone positioning. Rhabdomyolysis causing acute renal failure is a rare extrapulmonary complication of LP that has been described in the literature in fewer than twenty cases. It is unclear if the mechanism of injury is due to endotoxin or exotoxin-mediated release from septicemia or direct pathological invasion of LP into muscular tissue. Over half of the cases who developed rhabdomyolysis due to LP infection required hemodialysis with most patients experiencing complete renal recovery. This case illustrates a classic, severe, unilateral, dense consolidative pneumonia caused by LP with the rare complications of rhabdomyolysis and renal failure and recovery without hemodialysis. CONCLUSIONS: LP can cause myriad extrapulmonary manifestations. This case demonstrates the difficult balance of treating rhabdomyolysis and acute renal failure with concomitant severe hypoxemia, both occurring due to the same etiology. Reference #1: Buzzard JW, Zuzek Z, Alencherry BP, Packer CD. Evaluation and Treatment of Severe Rhabdomyolysis in a Patient with Legionnaires' Disease. Cureus. 2019;11(9):e5773. Published 2019 Sep 26. doi:10.7759/cureus.5773 Reference #2: Laivier C, Bleuze MO, Hantson P, Devos J. Extreme Rhabdomyolysis, Acute Renal Failure, and Protracted Ileus in a Case of Legionella Pneumonia. Case Rep Crit Care. 2019;2019:3472627. Published 2019 Jan 29. doi:10.1155/2019/3472627 Reference #3: McConkey J, Obeius M, Valentini J, Beeson MS. Legionella pneumonia presenting with rhabdomyolysis and acute renal failure: a case report. J Emerg Med. 2006;30(4):389-392. doi:10.1016/j.jemermed.2005.07.016 DISCLOSURES: No relevant relationships by Mohamed Abdalla, source=Web Response No relevant relationships by Angela Birdwell, source=Web Response No relevant relationships by Omar Enriquez, source=Web Response No relevant relationships by Vincent Gould, source=Web Response no disclosure on file for Audrey Haywood

Comparison of chest radiographic findings among HIV positive and negative adults with smear positive Pulmonary Tuberculosis in Dar-es-salaam

Background: Chest X-ray radiography is a widely available and cheap imaging modality used for identification of pulmonary tuberculosis (PTB) in suspected patients. Knowledge of discriminatory features of PTB among HIV infected patient is of utmost importance to improve tuberculosis case detection and consequently reduce morbidity and mortality associated with TB among HIV infected individuals. We aimed to describe chest radiographic findings among PTB patients and their association with HIV co-infection and CD4 levels among HIV positive patients.Methodology: A total of 170 newly diagnosed consented smear positive PTB patients underwent postero-anterior Chest radiographs (PA - CXR) and HIV testing. Determination of CD4 count was performed among HIV positive patients. The radiographs were interpreted using glossary of terms for thoracic radiology by two independent radiologists who were blinded to HIV diagnosis.Results: Study participants included 100 (58.9%) males and 70 (41.1%) females. Among these 54 (31.8%) had HIV/PTB co-infection. The pattern of radiographic findings among patients with PTB/HIV compared to PTB only were: pulmonary cavities 44.4% vs 61.2%, (p=0.04), alveolar consolidation 64.9% vs 81.7%, (p=0.04), upper zone consolidation 40.7% vs 57.8%, (p=0.039), middle zone consolidation 25.9% vs 44.8%, (p=0.019) and typical PTB 40.7% vs 57.8%, (p=0.039), respectively. Therefore, lesions were less likely to be observed among PTB/HIV compared to PTB only and the differences were statistically significant. When compared to PTB patients only HIV/PTB co-infected patients had more nodules on the left lung field 85.2% vs 60.9% (p=0.023); on each left lung zone upper 59.3% vs 34.4% (p=0.028); mid 77.8% vs 54.7% (p-value=0.039); lower 66.7% vs 34.4% (p=0.005) and miliary nodules 44.4% vs 15.6% (p=0.003), respectively. HIV/PTB co-infected patients with CD4 &gt; 200 cells/μL had more mid zone consolidation (42.9% vs 15.2%, p=0.024).Conclusion: The commonest chest radiographic findings in HIV/PTB co-infected patients were pulmonary cavities and alveolar consolidation are associated with HIV negative status. HIV/PTB co-infected patients with severe immunosuppression had mid zone consolidation. Patients with severe immunosuppression showed less chest radiographic findings. HIV/PTB co-infection was highly associated with mid and lower zone pulmonary nodules and miliary nodules.&#x0D; Key words: PTB, HIV, CXR

Primary adenoid cystic carcinoma of the lung in 14-year-old boy

Abstract We report a young adenoid cystic carcinoma (ACC) case of the lung that was treated with thoracoscopic anatomical segmentectomy. The patient was 14-year-old boy who had a history of a nodular lesion in the left middle lung field on the chest x-ray growing in size. Chest computed tomography (CT) demonstrated a solid 24 mm in diameter nodule in the left S5 region. PET-CT was mild positive. Malignancy could not be excluded based on these findings, so thoracoscopic left lingual (S4+5) segmentectomy was done. Histopathological examination showed ACC. On immunohistochemical analysis, these tumor cells were positive for Thyroid Transcription Factor-1 (TTF-1). This tumor was diagnosed primary ACC of the lung and pT1aN0M0 stage 1A. Because of surgical margin was free, it didn't do radiotherapy and chemotherapy. On follow-up examination three-year postoperatively, he was noted to be in excellent health and no signs of recurrence have been identified. Primary ACCs of the lung are extremely rare lesions and are difficult to diagnose before the surgery. The surgery should be the first therapeutic option. Thoracoscopic anatomical segmentectomy may be the ideal oncologic procedure for patients with small lung cancers and effective means of lung parenchymal preservation in pediatric patients.

The First of Congenital Cystic Adenomatoid Lung Malformation in Iraq: A Radiologic and Pathologic Study

Background: Congenital cystic adenomatoid lung malformation is a very rare condition characterized by replacement of normal pulmonary tissue with cysts of variable size and distribution. The condition is usually unilateral. Very few cases of bilateral and congenital cystic adenomatoid malformation with good outcome after resections of the lesions have been reported, and most cases were stillborn or died early during life. Patients and methods: A forty-day male infant presented with progressive respiratory distress since the first week of life observed at the Children Teaching Hospital of Baghdad Medical City was studied. The literature was reviewed with aim of describing the early documentation of the condition in the literature. Results: Clinically, the infant had significant respiratory distress interfering with feeding and evidence of shift of the mediastinum to the right. Chest X ray showed increased translucency of left lung field and mediastinal shit to the right. CT-scan showed large air-filled cyst in the left lung and small air-filled cyst in the right lung. The child was treated successfully by left upper lobecomy. The gross examination of two gray pieces of lung tissue showed on cut section microcysts that were apparent grossly. Microscopical examination showed intercommunicating cysts lined by cuboidal epithelium with gland like appearance confirming the diagnosis of congenital cystic adenomatoid malformation of the lung. Conclusion: A very rare case of bilateral congenital cystic adenomatoid malformation of the lung is reported and the early documentation of the condition in the literature is described.

RARE CASE OF SALMONELLA EMPYEMA IN MULTIPLE, LARGE LOCULATED PLEURAL FLUID COLLECTIONS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Non-typhoidal Salmonella as a cause of empyema is very unusual with approximately 30 cases reported in the literature (1). Salmonella usually causes gastroenteritis while less commonly causing meningitis or osteomyelitis. Here, we present a case of Salmonella empyema due to Salmonella montevideo in an asplenic patient without gastrointestinal symptoms. CASE PRESENTATION: 57 y.o Caucasian male presented with shortness of breath for three weeks that acutely worsened over three days along with pleuritic chest pain and a cough productive of yellow sputum. He denied hemoptysis but reported chills. History also significant for chronic alcoholism and splenectomy at age six. He was noted to be tachycardic and tachypneic on admission along with a WBC of 13.1. He was afebrile. Physical exam was notable for diminished breath sounds over left lung field and presence of digital clubbing along with cachexia. CT chest showed multiple, large, partially loculated fluid collections in the pleural space of the left hemithorax causing almost complete atelectasis of left lung. A left sided chest tube was placed with 550cc output of foul-smelling, frankly purulent fluid; found to be exudative with pH 7.5 and LDH 3,745. Empiric antibiotic coverage was started. Patient did not have any gastrointestinal symptoms. His pleural fluid cultures grew Salmonella montevideo, sensitive to Ampicillin. He was placed on Augmentin for 21 days and discharged with appropriate vaccinations. DISCUSSION: In this case, we showcase the rare presence of Salmonella in a patient with multiple loculated pleural fluid collections. Given his history of chronic alcoholism, it was suspected that he had episodes of micro-aspiration events associated with retching. Our case is unique in comparison to previously documented cases of Salmonella empyema in that our patient presented with left-sided pathology (2). Typically, aspirated contents are most commonly found in the right lung. In the absence of neurological compromise, as well as absence of GI fistulas, the finding of left-sided complicated fluid collections is impressive. We also show unorthodox pleural fluid studies with alkalotic pH levels inconsistent with conventional definitions of empyema (pH less than 7.2) in the setting of frank pus. Of note, all documented cases of Salmonella empyema have also had significantly elevated levels of pleural fluid LDH values in the thousands (3). We pose that there is a possible association between Salmonella metabolism in pleural fluid that influences these unique pleural fluid findings and further research can help elucidate this association. CONCLUSIONS: While the presence of Salmonella in the respiratory tract is unconventional, we recommend a high index of suspicion for this pathogen as as a causative agent in empyemas, particularly in immunocompromised patients. Reference #1: Rodero MR, Martins Immunization for patients with asplenia. Importance and Recommendations. Journal of Blood and Lymph. 2016; 6-149. Reference #2: Shivanshan, Pathmanathan, S. Welagedara, P. Dorrington, S. Sharma. Salmonella empyema: a case report. Pneumonia. 20156:BF03371465. https://doi.org/10.1007/BF03371465 Received: 23 June 2015, Accepted: 4 November 2015, Published: 1 December 2015. BioMedCentral. Reference #3: Kam, Jennifer. Case Report: Pleural Empyema due to Group D Salmonella. Department of Internal Medicine, St. Michael’s Medical Center, School of Graduate Medical Education, Seton Hall University, South Orange, NJ, USA. Copyright © 2012. Case Reports in Gastrointestinal Medicine DISCLOSURES: No relevant relationships by Jared Coe, source=Web Response No relevant relationships by Shashitha Gavini, source=Web Response No relevant relationships by Farheen Shaikh, source=Web Response no disclosure on file for Christopher Wexler

Basal cell adenoma of the lung identified with obstructive pneumonia.

The seromucinous glands of the bronchi can give rise to tumors resembling those of the salivary glands. Basal cell adenoma (BCA) has not been reported in salivary gland-type tumors of the lung. Here, we report a case of an 86-year-old Asian man who suffered from pneumonia in the left upper lung field that may be associated with an endobronchial tumor occluding B1 + 2a + b. The bronchoscopic biopsy of the tumor revealed that the basaloid cells, which constituted a major component of the tumor and were positive for p40/p63 immunohistochemistry, exhibited a cord-like structure. The Ki-67 (MKI67) staining was less than 1% positive. These findings suggest that the endobronchial tumor was BCA of the lung, which caused obstructive pneumonia in the patient.