Löffler endocarditis, a rare form of hypereosinophilic syndrome (HES), is characterized by transient left ventricular endomyocardial thickening, intracardiac thrombi, and eosinophilic infiltration. Its occurrence as a paraneoplastic manifestation of solid tumors, particularly lung adenocarcinoma, is exceedingly rare and underrecognized. A 75-year-old male smoker presented with progressive dyspnea (New York Heart Association Class III) and bilateral leg edema. He had no history of asthma, allergy, or parasitic infection. Physical examination revealed jugular venous distention and bilateral crackles. Laboratory tests showed marked hypereosinophilia (15.29 × 109/L). Transthoracic echocardiography demonstrated endomyocardial thickening, reduced left ventricular compliance, and mobile intracardiac thrombi. Computed tomography angiography revealed a spiculated left upper lobe lung mass with mediastinal lymphadenopathy. Symptoms developed over 4 weeks. Hypereosinophilia and cardiac abnormalities were identified at presentation. The lung mass was detected on initial imaging; histopathology confirmed adenocarcinoma (biopsy-proven). Despite anticoagulation and heart failure therapy, the patient declined corticosteroids and oncologic treatment. Clinical deterioration occurred within 2 weeks, leading to death. The patient received guideline-directed medical therapy for heart failure (beta-blocker, angiotensin-converting enzyme inhibitor, diuretics), anticoagulation (low-molecular-weight heparin), and diagnostic bronchoscopic biopsy. Corticosteroids and chemotherapy were recommended but refused by the family. The patient's condition rapidly worsened due to progressive heart failure and untreated malignancy. This case highlights the importance of considering occult malignancy in unexplained HES with cardiac involvement. It is the first reported case of Löffler endocarditis as a paraneoplastic manifestation of lung adenocarcinoma. Limitations include the lack of postmortem examination and the inability to initiate immunosuppressive or antitumor therapy due to patient refusal.

Abstract Introduction: Domestically Acquired Particulate Lung Disease (DAPLD) is a pneumoconiosis caused by chronic inhalation of biomass combustion products in poorly ventilated homes. Exposure histories are a useful tool in identifying patients at risk for this disease, especially those from countries where biomass fuels are commonly used for domestic needs. We present an unusual case of DAPLD in the form of a lung mass. Case Report: An 83-year-old woman presented to clinic for evaluation of intermittent episodes of progressive shortness of breath and chest pressure for several months. Chest x-ray showed a left upper lobe lung mass which prompted referral to pulmonary clinic. Born and raised in Mexico, she reported using a wood-burning stove for cooking until age 40. Her family also carried embers throughout the home for heating. She denied exposure to airborne occupational exposures. A computed tomography scan of the chest demonstrated a large left upper lobe mass (Figure 1), along with mediastinal adenopathy and scattered pulmonary nodules. Pulmonary function tests were normal. The patient underwent transbronchial lung mass biopsy and endobronchial lymph node aspiration to rule out malignancy. Anthracosis was visually noted in her airways. Biopsy revealed dust-laden histiocytes with hyaline fibrosis and scattered birefringent particles, indicating retained silica/silicates (Figure 1). Bronchoalveolar lavage and bacterial/fungal/mycobacterial cultures were negative. Given the pathology findings and compatible exposure history, a diagnosis of DAPLD with progressive massive fibrosis (PMF) was made. Conclusion: Burning of inefficient biomass fuels including wood, crops, and animal dung, contributes to household air pollution and is a common practice in many low and middle-income countries. Residential particulate matter exposure to carbonaceous and mineral dusts can cause DAPLD, which may be indistinguishable from occupational pneumoconiosis. Chest imaging often shows lymphadenopathy, lung nodularity, and fibrosis. Nodules may coalesce into PMF, the most severe form of pneumoconiosis characterized by severe mass-like lesions greater than one cm in diameter. Pulmonary function tests can be normal or show rapidly progressive impairment. A detailed environmental/occupational history is important in making a diagnosis of DAPLD or other pneumoconioses. Unless biopsy is needed for high concern of malignancy, as was seen in this case, DAPLD can often be diagnosed with a typical exposure history and compatible chest imaging. There are no evidence-based treatments for DAPLD. Management is centered on avoiding further exposures, providing supplemental oxygen if needed, and monitoring for dust-related complications such as superimposed infections.

Abstract Introduction Exposure to coal mine dust or crystalline silica results in pneumoconiosis with progression to pulmonary fibrosis (PMF) Case description A 34-year-old male from Sudan, presented with exertional dyspnea, productive cough, with 10-kilogram weight loss and occupational history of six-year in coal distribution from 2007 with the last exposure was 6 years back, ex-smoker with 2.5 pack-years. Blood work up and autoimmune investigation were unremarkable. Spirometry showed restrictive and severe obstructive ventilatory defect with no bronchodilator response with air trapping. CT chest showed bilateral perihilar upper lung masses with calcified foci, multiple nodules scattered throughout both lungs, largest nodule 1.7 x 2 cm and multiple mediastinal and hilar lymph nodes. EBUS-FNA from 11L showed non-necrotizing granulomatous lymphadenitis and bronchoalveolar lavage 31% lymphocytic, neutrophil 21%, negative for malignant cell and no growth in cultures. CT-guided biopsy of the left upper lobe lung mass showed diffuse, prominent aggregates of histiocytes containing carbon pigment, multiple nodules formed by coalescent zones of fibrosis. No hyaline membrane, acute pneumonia, thrombus or tumor cell are seen. No fungal and mycobacteria microorganism seen on AFB and GMS special stain. No asbestosis bodies are identified. No evidence of pulmonary Langerhans cell histiocytosis (S100 and CD1a are negative). Given the presence of carbon pigment accompanied by silica dust deposits, the overall findings and the history of occupational exposure, the diagnosis of coal worker's pneumoconiosis was made. As there is no specific treatment has proven effective in reversing Coal lung disease, the patient was started on trial of oral prednisolone and azithromycin. Discussion Surveillance in Virginia US of 416 coal miners, the mean mining tenure was 27.9 years, 22.7% reported a tenure of 20 years or less with mean age of 61.8 years. A surveillance in western US on American Indian and Alsaka Native coal miner found those with at least 10 years’ tenure, 3 % had radiographic findings of pneumoconiosis and 0.3% has PMF. Although the patient had discontinued coal mining 6 years before presentation, with six years of exposure, he progressed to PMF.In a study done among former US coal miners from January 2000 and 31 December 2013, radiographic CWP may develop or progress with no further exposure, even with no evidence of radiographic pneumoconiosis after leaving the industry. PMF usually occurs after more than 10 years of exposure, we recommend regular surveillance of coal miners for CWP and PMF regardless of years of exposure.

Pulmonary giant cell carcinoma (PGCC) is a rare subtype of non-small cell lung cancer (NSCLC) characterized by complex pathology, high rates of misdiagnosis or missed diagnosis, an aggressive clinical course, rapid progression, and poor prognosis. This case report describes a 67-year-old Chinese male with a left upper lobe lung mass, diagnosed via CT-guided lung biopsy as PGCC with symptomatic multiple cerebral metastases. The tumor showed strong PD-L1 positivity, and genetic testing revealed a TP53 exon 4 c.313G mutation. Treatment involved first-line therapy with Penpulimab injection combined with Anlotinib and concurrent cranial radiotherapy. Significant reduction in both the pulmonary and cerebral metastatic lesions was observed, with notable efficacy. As of June 2024, there has been no disease progression for 26 months, with the patient currently maintained on Anlotinib monotherapy. This case demonstrates the favorable efficacy of Penpulimab injection combined with Anlotinib in treating advanced PGCC. These findings indicate that this combination therapy may offer a promising new therapeutic option for this rare type of lung cancer.

Abstract Disclosure: B. Malapur: None. M.G. Jakoby: None. V. Williams: None. Introduction: Bilateral adrenal hemorrhage is rare, and most cases occur in the setting of bacterial sepsis, coagulopathies such as antiphospholipid antibody syndrome, treatment with anticoagulants, surgery, or trauma. We present a patient with asynchronous bilateral adrenal hemorrhages that resulted in an eventual diagnosis of poorly differentiated bronchogenic carcinoma. Case: A 65-year-old female smoker was found to have a large right adrenal hematoma on computed tomography (CT) obtained for evaluation of acute onset right flank pain. No hemorrhage or anatomic abnormalities of the left adrenal gland were apparent, and the patient was discharged home after her pain was controlled. Approximately one month later, she returned to hospital with bilateral flank pain, and bilateral adrenal hemorrhages were diagnosed on repeat CT imaging. An 8 cm left upper lobe lung mass was revealed on a chest CT scan, and cytology from a bronchoscopic biopsy confirmed poorly differentiated bronchogenic carcinoma. The patient had no recent surgeries, abdominal trauma, or treatment with anticoagulants, serologic evaluation for coagulopathies and disseminated intravascular coagulation was unremarkable, blood cultures failed to grow bacterial pathogens, and acid-fast staining of lung tissue was negative. The patient was discharged from her second hospital admission on hydrocortisone and fludrocortisone. Discussion: Adrenal hemorrhage in the setting of malignancy is usually a complication of adrenal metastases. The prevalence of adrenal metastases in advanced stage cancer is approximately 3%, with lung and breast cancers and melanoma showing the highest predilection for adrenal metastases. This case is unusual because the patient had no focal masses or disruption of left adrenal contour on CT to indicate adrenal metastases at the time of right adrenal hemorrhage, and she did not have other established risk factors for pathologic bleeding in the setting of malignancy such as thrombocytopenia or treatment with chemotherapy agents, anticoagulants, or nonsteroidal anti-inflammatory drugs. Adrenal hemorrhage is also a rare inciting event resulting in the diagnosis of lung cancer; to date, there are only 29 published cases of spontaneous adrenal hemorrhage as the initial presentation of lung cancer. This case illustrates the importance of careful evaluation for malignancy in patients with spontaneous adrenal hemorrhage and no clear etiology for adrenal bleeding. Presentation: 6/1/2024

AN INCIDENTAL FINDING OF ASYMPTOMATIC PULMONARY MUCORMYCOSIS IN A PATIENT WITH DIABETES

A previously healthy 34-year-old woman from Vancouver, British Columbia was referred for a left upper lobe lung mass. Main differential diagnoses were infection and malignancy. She underwent a bronchoscopy with endobronchial ultrasound-guided biopsy. Analysis of the bronchoscopic specimens revealed Cryptococcus gattii. Further investigations including neuroimaging and lumbar puncture for cerebrospinal fluid analysis excluded central nervous system involvement. Due to the size and proximity of the pulmonary cryptococcoma to the mediastinum, she was treated with Amphotericin and Flucytosine as induction therapy and oral Fluconazole as maintenance therapy. We review the clinical, radiological and pathological features of this disease entity in this report.

Patients with lung cancer may present with respiratory and systemic symptoms. However, cutaneous metastases from primary lung cancer is a rare phenomenon, especially in women, that signifies a poor prognosis. This paper reported a case regarding a 71-year-old woman who was first presented with a cutaneous nodule over the year. Her condition was further progressed to multiple lesions on the back and abdomen, dyspnoea, haemoptysis and weight loss. The results of the skin lesion biopsy exhibited metastatic lung adenocarcinoma with positive immunohistochemistry for thyroid transcription factor 1 (TTF1) and cytokeratin 7 (CK7). Computed tomography (CT) scan was conducted, and it revealed a left upper lobe lung mass. The patient was subsequently scheduled for additional management, but she had succumbed to complications of pulmonary embolism before the necessary interventions could be provided. In this particular case presentation, the biopsy of cutaneous lesions obtained had revealed an undiagnosed primary malignancy.

IS MARIJUANA SAFE? A CASE OF A NON-SMALL CELL LUNG CARCINOMA IN A SOLE MARIJUANA SMOKER

PAINFUL FINGERS AND TOES REVEAL A CASE OF NON-SMALL CELL LUNG CANCER

LEFT ATRIAL EXTENSION OF PRIMARY LUNG SARCOMA VIA THE PULMONARY VEIN

Adenocarcinoma of the Lung Presenting as Thrombotic Thrombocytopenic Purpura

To the Editor: Pneumomediastinum infrequently complicates diagnostic bronchoscopy. Increased airway or alveolar pressure results in air leaks to the mediastinum through existing or induced defects. Excessive cough, recurrent episodes of increased abdominal pressure, vomiting, or sneezing can all induce spontaneous pneumomediastinum. Less commonly it has been documented with lung or neck infections, esophageal or tracheal tears, and rapid increases in altitude such as during plane flights or scuba diving, with mechanical ventilation, substance abuse, and after bronchoscopy. Pneumomediastinum may be, but is not always, associated with pneumothorax. We recently evaluated a 63-year-old male patient with a 2-day history of hemoptysis and a left upper-lobe lung mass with hilar adenopathy and a postobstructive process. Flexible white light bronchoscopy showed a normal airway except for an occluded left upper-lobe bronchus with sparing of the lingula. Multiple forceps biopsies were obtained from the apparent endobronchial lesion. Endobronchial ultrasound (EBUS)-guided lymph node biopsies were obtained from stations 4R, 4L, 7, and 11L. During the procedure there were no complications and no bleeding. The pathology report revealed moderately differentiated squamous cell cancer from only the left upper-lobe endobronchial biopsies. One day after discharge the patient returned to the emergency room with recurrent severe cough and chest and neck pain associated with increasing swelling of the neck. There was no hemodynamic or respiratory compromise. CT scan of the chest and neck (Fig. ​(Fig.1)1) to investigate the neck and chest “swelling” showed pneumomediastinum with extensive subcutaneous emphysema with no apparent pneumothorax. The patient was treated with cough suppressants, analgesics, and stool softeners, along with oxygen supplementation through a nasal cannula. The pneumomediastinum and subcutaneous emphysema resolved without any other intervention. The pneumomediastinum was felt to be iatrogenic and was most likely related to the bronchoscopic procedure. FIGURE 1 CT scan of the chest and neck showing pneumomediastinum and subcutaneous air (arrows). Lung mass in the left upper lobe (asterisk). Bronchoscopy with endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) is considered to be a very safe procedure and is certainly less invasive than mediastinoscopy or percutaneous needle biopsy. It has been increasingly utilized for the diagnosis of sarcoidosis, for unexplained mediastinal adenopathy, and for lung cancer staging. Complications from EBUS-TBNA are rare. Focal tracheal stenosis secondary to intramural hematoma following EBUS-TBNA has been reported.1 Barotrauma after ablation techniques has previously been seen.2 Pneumothorax was reported in 0.03% (2/7345) of procedures in a survey of 455 facilities in Japan.3 There was no pneumomediastinum reported. Hemorrhagic and infectious complications were the most common. A review of the AQuIRE registry for complications revealed no reported cases of pneumomediastinum, with a rate of pneumothorax of 0.2% reported among patients who did not undergo transbronchial biopsies.4 In a comprehensive review of all published articles on endosonography of the mediastinum (EBUS or EUS or their combination) from 1995 to 2012, von Bartheld et al5 did not report any case of pneumomediastinum. Most complications from this procedure were infectious. EUS was the main risk factor for complications, with 18 of 23 serious complications being observed in this group, compared with EBUS. To our knowledge, this is the first case of pneumomediastinum that is associated with EBUS-TBNA. It is unlikely that the positive pressure ventilation used during the procedure caused the pneumomediastinum. The procedure was performed through the LMA utilizing general anesthesia but with spontaneous ventilation and 5 cm water pressure support. In addition, the patient presented with pneumomediastinum >24 hours after the procedure, which makes it less likely to be related to the positive pressure and more likely related to a defect created by the procedure in the bronchial wall and exacerbated by cough. Although the direct cause of the pneumomediastinum cannot be certainly established, whether related to the TBNA or to the endobronchial biopsy, we would like to alert other bronchoscopists of the potential rare complication and stress upon the fact that conservative therapy should be the first line of treatment. Treatment should be aimed at decreasing intrathoracic pressure spikes by reducing coughing and straining. Oxygen therapy might hasten reabsorption of the subcutaneous nitrogen bubble as it does to a pneumothorax.

A 73-year-old man with a history of previous coronary artery bypass surgery (left internal mammary artery [LIMA]–to–first obtuse marginal artery graft, right internal mammary artery–to–left anterior descending artery graft, and venous graft to second obtuse marginal branch) and previously treated melanoma and gastric carcinoma was referred for evaluation of an enlarging lung mass adjacent to a vascular graft on computed tomography (CT). CT coronary angiography confirmed that the suspicious left upper lobe lung mass was encasing the LIMA graft (Figure 1). 18F-fluorodeoxyglucose positron emission tomography/CT study confirmed isolated, intense metabolic activity within the lesion consistent with malignancy (Figure 2). Echocardiography confirmed normal left ventricular systolic function. A decision for surgical resection was made, with the need for further evaluation of the coronary circulation to assess the implications of potential sacrifice of the LIMA graft. At the time of coronary angiography (Figure 3), 76 MBq 99mTc-sestamibi was injected directly into the LIMA graft to establish the area of viable myocardium perfused by this vessel. Single photon emission CT/CT imaging performed 1 hour later (Figure 4) demonstrated that, at most, sacrifice of the LIMA graft would result in only a small infarct of the lateral wall. Subtraction of these images from …

Approximately 10% of all extra-pulmonary small cell carcinoma (EPSCC) arises in the prostate either as de novo mixed adenocarcinoma with small cell components or a pure small cell carcinoma. Extensive disease carries a median survival of about 10 months in retrospective studies. We present a case managed aggressively with concomitant hormonal and chemotherapy, now 36 months without evidence of disease. At a routine physical, a 55 year male was found to have a 5 cm left upper lobe lung mass, invading his 3rd rib. An FNA revealed an adenocarcinoma of unknown primary. His PSA was elevated to 8 ng/mL and a prostate biopsy revealed Gleason 9 adenocarcinoma with neuro-endocrine/SCC components. A bone scan revealed extensive bone metastasis. He was managed aggressively with concomitant cisplatin, etoposide and hormonal therapy and received 73 Gy of radiation to the prostate. PET scans demonstrated marked response to chemotherapy. PSA and chromogrannin levels down trended to normal limits. His most recent PET scan in July 2010 revealed no evidence of disease and is in remission. We present a unique case of metastatic mixed adenocarcinoma/SCC of the prostate, in which the patient survived more than 36 months with complete remission after initiation of aggressive hormonal and chemotherapy. Data on survival in this patient population is limited to case reports, and ordinarily carries a poor prognosis of less than 1 year. In patients with clinical and pathologic features of mixed disease, initiation of early multi-modal therapy is warranted. Additionally, it may be of prognostic significance to biopsy any metastatic lesion.

Abstract Introduction An 88-year-old woman with a history of coronary artery disease, hypertension, and a history of a large left upper lobe lung mass presented to the Emergency Department (ED) from a nursing home with rapidly progressive shortness of breath and chest pain over 1 day with a rapid decline in mental status. Bedside color Doppler ultrasound para-sternal long-axis examination of the heart revealed severe aortic stenosis. Bedside pulsed-wave and continuous-wave Doppler ultrasound in the apical 5-chamber view revealed critical aortic stenosis using the simplified continuity equation. Conclusion Bedside ED cardiac color Doppler, pulsed Doppler evaluation of the left ventricular outflow tract, and continuous-wave Doppler of the aortic valve were used to assist in the diagnosis of critical aortic stenosis.

A 52-year-old man had a positron emission tomography computed tomography (PET-CT) scan for staging of a biopsy proven lung adenocarcinoma. An additional acquisition of the lower extremities was performed as the patient complained of bilateral leg pain. The PET-CT scan showed a 6.5 x 5.0 cm left upper lobe lung mass invading the mediastinum with maximal standardized uptake value of 10.7, compatible with primary lung cancer. The CT portion of the PET-CT of the legs showed extensive irregular bilateral periosteal new bone formation in the long bones. The PET images showed diffuse moderately increased FDG uptake in the periostea of the long bones of the legs, with some focal sites of more intense FDG uptake in the thicker portions of the periosteum. A bone scan showed mild hyperemia surrounding the long bones of the legs and intense Tc-99m MDP uptake in the periostea. The patient was diagnosed with hypertrophic pulmonary osteoarthropathy.

2Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, MA. Case History A 75-year-old man was admitted to the hospital with an acute myocardial infarction. The patient was a former heavy smoker. A chest radiograph revealed a left apical lung mass (Fig. 1). A CT scan showed a cavitary left upper lobe lung mass measuring 3.5 × 4 cm (Fig. 2A) with an additional 3 × 2 cm mass at the left hilum (Fig. 2B). A wholebody PET scan showed the left upper lobe mass and at the left hilum, increased 18F-FDG uptake that was suggestive of lung neoplasm metastatic to the left hilum (Fig. 3). Therefore, a thoracic radiologist was consulted for biopsy of the left upper lobe lung mass. Dr. Titton. It is interesting to note that a PET scan was obtained for this patient. What is the role of 18F-FDG PET in the evaluation of patients with a pulmonary nodule or lung cancer? Dr. Kalra. In the evaluation of patients with a solitary pulmonary nodule, 18F-FDG PET improves characterization of the nodule by estimating the probability of malignancy. The high positive predictive value for malignancy in nodules greater than 1 cm in diameter suggests that those with positive scan results should undergo either percutaneous biopsy or surgical resection. Histologic examination of PET-positive lesions is necessary because false-positive PET findings can be encountered with granulomatous lesions secondary to sarcoidosis, tuberculosis, or infection [1]. False-negative PET findings are seen in patients with small lesions (< 1 cm) and in selected malignancies, such as bronchioalveolar cell carcinoma or well-differentiated adenocarcinoma or carcinoid tumor. For this reason, regardless of PET findings,

Granular cell tumors (GCT) are rare, usually benign neoplasms of Schwann cell origin. Since discovery in 1926, fewer than 80 cases of GCT involving the lung have been reported. This report presents a 45-year-old male who presented with symptoms consistent with chronic pancreatitis associated with night sweats, weight loss, and a chronic productive cough. Chest radiography revealed a 3 x 4 cm left upper lobe lung mass with an unremarkable right lung field. Bronchoscopy revealed mixed mucosal abnormalities in the left upper lobe and a 4-mm polypoidal lesion in the right lower lobe. Bronchial washings stained positive for acid-fast bacilli. The left upper lobe lesion biopsy showed granulomatous inflammation with caseous necrosis consistent with tuberculosis. The right lower lobe lesion was a GCT without evidence of tuberculosis. This report reviews the literature regarding GCT and presents this unusual case of granular cell tumor co-occurring with active tuberculosis.

We report an unexpected difficult ventilation with a double-lumen endotracheal tube in a patient receiving left upper lobe lung mass resection. The manufacturing defect in both limbs of the Opti-Port Right Angle Double Swivel Connector of the double-lumen tube resulted in this problem. This defect is difficult to localize by the usual recommended methods. We discuss a modified algorithm for difficult ventilation with a double-lumen endotracheal tube. Difficult ventilation occurred during general anesthesia as the result of a manufacturing defect in both limbs of the connector of the double-lumen endotracheal tube. The problem was resolved with a careful approach, and there were no serious consequences.