Lower Lobe Consolidation Research Articles

Multiple gingival metastasis of adenocarcinoma of the lung

Metastasis to the gingival soft tissues is an extremely rare phenomenon, and metastasis of multiple lesions (i.e. more than 2 lesions), is even more hard to find. In this study, we have reported a rare case of lung adenocarcinoma, which metastasized to the maxillary (2 lesions) and mandibular gingivae (1 lesion) in a 57 year old male patient. Metastasis was also seen to the vertebrae. The differential diagnosis consisted of acute myelomonocytic leukemia, chronic lymphocytic leukemia, haemangioma, pyogenic granuloma, giant cell granuloma, peripheral fibroma, primary gingival carcinoma and secondary metastasis. Contrast enhanced computed tomography of the lung showed a well-defined mass situated below the right hilum with lower lobe consolidation and pleural effusion on the right side with dorsal spinal metastasis. Excisional biopsy of the lesions was consistent with the diagnosis, and the immunohistochemical analysis was positive for cytokeratin 7, carcinoembryonic antigen (CEA), thyroid transforming factor 1 (TTF1), and negative for vimentin and cytokeratin 20 (CK20).

The efficacy of chest radiographs in detecting parapneumonic effusions

Current guidelines recommend parapneumonic effusions (PPEs) with a thickness of ≥ 10 mm be sampled via thoracentesis. We hypothesized that anteroposterior (AP) CXRs are not as sensitive as posteroanterior (PA) and lateral radiographs in identifying PPEs and should not be routinely used in patients with suspected pneumonia. Sixty-one hospitalized patients with pneumonia and PPE were retrospectively studied, all of whom had a CXR and CT scan within 24 h of each other. The CXRs of these patients were independently read by three pulmonologists for an effusion in each hemithorax, which was correlated with measured pleural fluid thickness on chest CT. Lateral, PA and AP radiographs were equivalent in identifying the presence of PPEs. All three views missed more than 10% of PPEs. The sensitivities of lateral, PA and AP CXRs were 85.7%, 82.1% and 78.4%, respectively (P = 0.749); the specificity was 87.5%, 81.3% and 76.4%, respectively (P = 0.198). The majority of effusions missed in each view were on films with lower lobe consolidation. All three CXR views missed effusions of a size significant enough to warrant thoracentesis. Consideration should be given to obtaining additional imaging at the time patients present with pneumonia, particularly in those with lower lobe consolidation.

PET scan in a patient with pneumococcal sepsis

A 63-year-old man presented to the Otolaryngology department with severe dysphagia. On laryngoscopy, a whitish nodule 3 cm in size exiting from the posterior commissurae of the larynx, and almost obstructing the hypopharyngeal space, was observed. The excision biopsy specimen was diagnosed as moderately differentiated squamous cell carcinoma of the hypopharynx. A staging procedure with positron emission tomography-computer tomography (PET-CT) was recommended. The day before the procedure, the patient experienced chills, and his temperature increased up to 38.9 C. He was evaluated in the emergency department (ED) of our hospital. The plain film of the chest X-ray study revealed a small infiltrate in the right lower lobe (arrows Fig. 1a, b) and the patient was discharged on oral antimicrobial therapy to manage his pneumonia. The patient’s wife had been hospitalized with pneumococcal pneumonia 2 days earlier. The day after his ED visit, the patient underwent the previously arranged ambulatory PET-CT that revealed a significant increase of fluorine-18-fluorodeoxyglucose (F18-FDG) uptake in the hypopharyngeal mass (thick arrow Fig. 1a), diffuse uptake in the bone marrow of the spine, ribs, and pelvis without underlying bone lesions on a computed tomography (CT scan) (black arrows Fig. 2a–c), and an increased uptake in the right lower lobe consolidation consistent with pneumonia (white arrows Fig. 2b, c). The diagnosis of pneumonia was supported by significant

溺水後に <i>Enterococcus faecium </i>による肺炎をきたした 1 例

A 73-year-old man admitted for near drowning was found after 24 hours of mild therapeutic hypothermia to have pneumonia. Blood gas analysis showed metabolic acidosis, hypercapnia, and hyponatremia. Chest X-ray and computed tomography (CT) showed bilateral mainly lower-lobe consolidation. After being treated with 13.5 g of tazobactam/piperacillin and 1.0-1.25 g of vancomycin per day for two weeks, the man recovered from his severe respiratory failure. Enterococcus faecium was isolated twice from sputum and raising the dose of vancomycin was effective, but it took 10 days to wean him from ventilator support. While this case may be rare, therapeutic hypothermia and near drowning together were considered predisposing factors in the severity of the pneumonia caused by E. faecium. The possibility of pneumonia due to vancomycin-resistant Enterococci should thus be considered in similar cases.

Bedside Transthoracic Sonography in Suspected Pulmonary Embolism: A New Tool for Emergency Physicians

Bedside Transthoracic Sonography in Suspected Pulmonary Embolism: A New Tool for Emergency Physicians

Delayed Presentation of a Post-Traumatic Left Ventricular Pseudoaneurysm in a Child

Left ventricular pseudoaneurysms can occur after myocardial infarction or trauma, but are extremely rare in pediatric patients. We present a case of post-traumatic left ventricular pseudoaneurysm, in whom the causative event was some time before the acute clinical deterioration. The 9-year-old boy had repeated presentations for chest pain and lethargy for some months prior to admission. The report describes an effective primary suture repair.

“Black Bronchoscopy”—A Case of Endobronchial Metastases From Melanoma

The presence of black pigmentation in the airways during flexible bronchoscopy is uncommon. We report an unusual case of "black bronchoscopy" as a result of endobronchial metastases in a 77-year-old Chinese man, who presented with hemoptysis and postobstructive pneumonia 3 years after initial excision of a skin melanoma. Chest radiograph showed right lower lobe consolidation and collapse. Bronchoscopy showed narrowed airways with black pigmentation involving the lower trachea and right main bronchus. Biopsy confirmed metastatic melanoma. The patient received palliative radiation and died 6 months later. We review the causes of black airway pigmentation. We also briefly review the prevalence, clinical presentation, and prognosis of endobronchial metastases.

Missed congenital glottic web may mimic subglottic stenosis in a child

Missed congenital glottic web may mimic subglottic stenosis in a child

Thoracic CT findings of novel influenza A (H1N1) infection in immunocompromised patients

The goal of this study is to describe the spectrum of initial and follow-up CT findings of novel influenza A (H1N1) infection in a series of immunocompromised patients. Eight immunocompromised patients with documented novel influenza A (H1N1) had CT imaging at our institution between May 2009 and August 2009. A total of 20 CTs (initial and follow-up) were reviewed for the presence, severity, and distribution of the following: ground glass opacity, consolidation, interlobular septal thickening, mosaic perfusion, airway wall thickening, airway dilatation, nodules, cysts, pleural effusion, pericardial effusion, lymphadenopathy, and air trapping. The most common findings were airway thickening/dilatation, peribronchial ground glass opacity, centrilobular nodules, and tree-in-bud opacities. Peripheral consolidation involving the lower lobes was also a common pattern. Findings frequently involved all lobes and were closely associated with either large or small airways. Two patients presented with atypical CT findings including focal lobar consolidation and patchy lower lobe consolidation with soft tissue centrilobular nodules. Most survivors showed near complete resolution of findings within 35 days. CT scans in immunocompromised patients with novel influenza H1N1 commonly show a strong airway predominance of findings or peripheral areas of consolidation involving the lower lobes. A subset of patients with novel influenza A (H1N1) will show findings not typical of viral infection.

A Rubber-degrading Organism Growing from a Human Body

Introduction: Patients with hematological malignancies are susceptible to unusual infections because of the use of broad-spectrum anti-infective agents and their immunocompromised state. Case: A 17 yr old lady with Undifferentiated Myeloblastic leukemia (AML - M1 type) on Cytarabine and Mitoxantrone, presented to the hospital with 4 days of fever, rhinorrhea and productive cough. One month earlier she developed Rhodococcus equi bacteremia. Examination did not show any source of infection. Laboratory exam, WBC of 300. Chest × ray showed right lower lobe consolidation in the lung which was confirmed on CT scan. She was started on Vancomycin and Ceftazidime. Ambisome was also added for aspergillus coverage. All the cultures remained sterile and an echo done did not show vegetations. Bone marrow aspirate and biopsy done to rule out recurrence of leukemia showed only hypocellular marrow. The cultures continued to be negative until 4 weeks after admission when the blood grew a Gram-positive weakly acid-fast organism identified by Center for Disease Control (CDC) to be Gordonia polyisoprenivorans. Discussion: Gordonia polyisoprenivorans is a ubiquitous environmental aerobic Actinomycetes belonging to the family of Gordoniaceae in the order Actinomycetales. Most of the 21 identified species are typically gram positive, catalase positive, weakly acid fast, thin beaded coccobacilli. G. polyisoprenivorans was first described in 1999 as a rubber-degrading bacteria isolated from stagnant water inside a deteriorated automobile tire. Extensive literature review has only identified 2 case reports of bacteremia due to this unusual organism. The 2 earlier case reports highlighted patients with hematological diseases (one with bone marrow transplant and the other with Osler-Weber-Rendu and myelodysplastic syndrome). Our patient although is free from leukemia, is similar in being neutropenic. We believe that hematologically immunocompromised patients with broad-spectrum antibiotics and long term central catheters select the possibility of infection with G. polyisoprenivorans.

Pericardial cyst: an unusual cause of pneumonia

IntroductionPericardial cysts occur rarely with an incidence rate of 1 per 100,000. They are usually detected by chance and are clinically silent in most cases.Case presentationWe report the case of a 66 year old Irish male, with signs and symptoms of pneumonia. A chest X-Ray confirmed left lower lobe consolidation. Further imaging including a CT thorax identified a large pericardial cyst as the cause of the symptoms.ConclusionAlthough pericardial cysts are usually asymptomatic, they can present with chest pain and symptoms of respiratory tract infection.

A 75-year-old man with chest discomfort and a cough

A 75-year-old man was admitted with a non-productive cough and chest discomfort. He had been admitted 2 months previously with left lower lobe (LLL) consolidation for which he received intravenous...

Amyloidosis kidney with filariasis presenting as nephrotic syndrome: Incidental finding or unusual association?

Background: It is estimated that around 120 million people in tropical and subtropical areas of the world are infected by filariasis. In the Southeast and South Asian regions, Wuchereria bancrofti is the most prevalent parasite,causing filariasis in 99.4% of cases. We report a rare case of amyloidosis kidney with an incidental finding of microfilariae.Case report: An 85 year old male presented with complaints of gradually progressive anasarca and loss of weight for 2 months as well as vomiting and decreased urine output for a week. On clinical examination, aside from mild pallor, there was evidence of bilateral pitting pedal edema and free fluid in the abdomen. Sonography revealed the presence of bilateral renal parenchymal disease and bilateral hydrocele with thickened spermatic cord. Lower lobe consolidation was the only significant finding on the chest skiagram. The patient was rigorously worked up to identify pathology in other systems, but all the data were within normal limits. Histopathological examination of the renal biopsy specimen revealed complete to partial replacement of most of the glomeruli by pink, hyaline eosinophilic material and microfilariae of Wuchereria bancrofti were seen incidentally. Blood vessels showed pink hyaline material in their walls. Tubules and interstitium were unremarkable. The provisional diagnosis of amyloidosis kidney was confirmed by positivity on methyl violet staining.Conclusion: In the present case, the clinical picture did not provide any clue regarding the association of amyloidosis kidney with filariasis except for mild peripheral eosinophilia. However, renal biopsy revealed amyloidosis with microfilariae of Wuchereria Bancrofti. It is presumed that, in this case, microfilariae entered the glomerular capillaries after breaching the blood renal barrier. This is the first case in which renal amyloidosis was shown to be associated with microfilariae of Wuchereria bancrofti. The possibility of the latter condition, resulting in the genesis or development of the former, needs to be further investigated and discussed.

Fire‐eating: Hazards of hydrocarbon aspiration

A 30-year-old male fire eater presented following aspiration of hydrocarbon fuel during a performance. A plain chest radiograph carried out 2 h after aspiration showed left lower lobe consolidation. The patient subsequently developed worsening shortness of breath, haemoptysis, fever and myalgia and a repeat plain chest radiograph showed extensive bilateral pulmonary consolidation with mediastinal and bilateral hilar lymphadenopathy. Computed tomography showed features consistent with necrotizing pneumonia. The clinical course was complicated by the development of large pleural effusions, pneumatocoeles and a spontaneous pneumothorax. Early abnormalities on a plain chest radiograph following suspected hydrocarbon aspiration require close monitoring for the development of further life-threatening complications.

AN ESOPHAGEAL BRONCHUS IN A 9-YEAR-OLD GIRL PREVIOUSLY DIAGNOSED WITH COUGH-VARIANT ASTHMA

The patient coughed up fresh blood whilesitting at school on three occasions in two weeks. A tickle in her throat andmild chest pain preceded the onset of hemoptysis. She had no bleedingelsewhere. She had lost four pounds over two months. There was nohistory of fever, night sweats or TB contact. She had been diagnosed withasthma four years previously, for which she used daily inhaled steroid andprn albuterol twice weekly. Her cough was usually aggravated by runningand eating. On examination, her vital signs were stable. Fine crepitationswere heard in the right lower lung field. Her fingers were clubbed. ChestX-ray revealed ill-defined opacities with patchy infiltration around thehilum and in the superior segment of the right lower lobe. The coagulo-gram, immunology workup and tuberculin skin test were all negative. CTscan of the chest revealed a communication between the lower esophagusand the superior segment of the right lower lobe of 9 mm in diameter.There was right lower lobe consolidation without any abnormal vessels.Oral contrast material freely entered the lung. Bronchoscopy revealed anextra opening in the second order bronchus of the superior segment of theright lower lobe with whitish mucus plugging, but no active bleeding orendobronchial lesion. Gastroscopy revealed a large abnormal connectionto the lung from the distal esophagus, but no esophagitis, gastritis orpeptic ulcer. Bronchoalveolar lavage cultures grew Candida albicans. Alobectomy and esophageal repair were performed without complication.Pneumonia was treated with cefuroxime and clarithromycin. At pathology,there were bronchiectatic changes of the right lower lobe, especially thesuperior segment bronchi, along with bronchopneumonia, lymphocyticbronchiolitis, and intra-alveolar hemorrhage. Thickened irregular islandsof cartilage with respiratory and gastrointestinal epithelium colocalized inthe connection, suggesting a congenital bronchopulmonary foregut mal-formation, most likely esophageal bronchus. Food and Actinomycetesparticles were found in bronchioles and lung parenchyma, suggestingaspiration pneumonia.

Unusual presentation of a complicated community-acquired pneumonia resembling lung cancer

Summary We report a case of an unusual presentation of a complicated community-acquired pneumonia resembling lung cancer in an adult male with a long history of fever and consumption syndrome. Chest X-ray showed a right lower lobe consolidation and CT of the chest confirmed those findings. The bronchoscopy demonstrated a mass obstructing the right lower lobe orifice and narrowing the intermedius and right bronchus. Although the picture resembled a lung cancer, two biopsies were consistent with chronic inflammation and features of squamous metaplasia. He received several courses of empiric antibiotics (moxifloxacin and macrolides) without improvement. Cultures yielded Streptococcus pneumoniae and the antibiogram indicated exhibited resistance to moxifloxacin. We started with Amoxicilin–Clavulanic with a clear clinical and radiological improvement. This is the first case report in USA of a community-acquired pneumonia resistant to moxifloxacin.

Transthoracic ultrasound approach of thoracic aorta in critically ill patients with lung consolidation

Purpose Normally, the aortic arch and the descending aorta are not visible using transthoracic ultrasonography. We hypothesize that lung consolidation of upper and lower lobes, by opening an acoustic window, may allow the ultrasound examination of the thoracic aorta. Methods During a 2-month period, 18 consecutive patients hospitalized in the intensive care unit with consolidation of upper and/or lower lobes diagnosed by lung ultrasound were studied. The ascending and descending aorta and the aortic arch were systematically searched for by positioning the probe on the anterior, lateral, and posterior regions of the chest wall. Results Among the 16 patients with left lower lobe consolidation, the descending aorta was always visible by positioning the probe on lateral and posterior parts of the chest wall. In the 4 patients with consolidation of the left upper lobe, the aortic arch was visible when positioning the probe on anterior and upper parts of the left chest wall. In the patient with right upper lobe consolidation, both the ascending aorta and the aortic arch were visible when positioning the probe on anterior and upper parts of the right chest wall. Conclusions In critically ill patients, the presence of consolidated upper and left lower lobes may allow the ultrasound examination of the different parts of the thoracic aorta.

Multiple organ failure as initial presentation of pheochromytoma

A 50-year-old woman presented to the emergency department complaining of recent cephalalgias with sudden onset of palpitations, abdominal, and thoracic pain followed by nausea and vomiting. She had no medical history, but she reported a case of rhinitis treated for 2 days with a nonsteroidal anti-inflammatory agent. On examination, she was afebrile, with cold peripheries and discreet cyanosis, and abdominal palpation was normal and painless. There were no signs of heart failure, blood pressure was 164/114 mm Hg, and heart rate was 150 beats per minute, but she was oliguric. Electrocardiogram showed a sinusal tachycardia, an ST-segment elevation, Q waves in leads V1 and V2, and an ST-segment depression of more than 2 mm in leads V4 to V6. Chest radiograph showed bilateral interstitial infiltrates with right lower lobe consolidation. Echocardiography showed global alteration of left ventricular systolic function and grade II mitral regurgitation. Troponin Ic on admission was 66.8 lg/L (NR b 0.5); creatine kinase, 634 U/L (NR b 175); and creatine kinase–

Oesophago-bronchial fistula causing cough and recurrent lower respiratory tract infections in a patient with Crohn's disease

A40-year-old non-smoking woman was referred to the outpatient clinic because of an increasing dry cough and recurrent lower respiratory tract infections over a 10-year period. The patient was diagnosed with Crohn's disease in 1979. The disease was initially confined to the large intestine but despite intensive medical treatment she required a total colectomy with ileostomy formation and, 2 years later, she was treated with a proctectomy. In 1996 she developed a problematic nocturnal cough with associated early morning sputum expectoration and intermittent wheeze, which did not respond to a trial of inhaled bronchodilators. In 1998 she was admitted to hospital with a severe left lower lobe pneumonia, which responded well to oral ampicillin and erythromycin. She subsequently complained of coughing during meals but denied any indigestion or heartburn. There was no background of atopy, or history of asthma or rhinitis. Systemic examination was unremarkable. Review of previous chest radiographs revealed recurrent changes of left lower lobe consolidation (Figure 1). Initial investigations including spirometry, biochemical screen, full blood count, immunoglobulin subclasses, aspergillus precipitins and sputum culture for bacteriology and tuberculosis were normal. An initial diagnosis of minor localized bronchiectasis was made and the patient was referred to the physiotherapy department for postural drainage. Because of the persistent nocturnal cough, gastro-oesophageal reflux with aspiration was considered and a barium swallow arranged. The barium swallow (Figure 2) demonstrated a fistula between the oesophagus and the left lower lobe bronchus arising approximately 10 cm from the gastro-oesophageal junction. Multiple ‘rose-thorn’ ulcers were also seen in the mid- and lower oesophagus. The barium, which passed into the left lower bronchial tree, did not demonstrate bronchiectatic changes (Figure 3). This was confirmed with high resolution computer tomography, which revealed some localized fibrosis in the left lower lobe, but did not show any evidence of bronchiectasis. At endoscopy a 4 mm defect was seen at 32 cm, which was biopsied. The histology showed hyperplastic squamous epithelium with inflammatory changes but no features of malignancy. The patient gained considerable relief of her symptoms from the use of antacid suspensions and propping the head of her bed at night. She discontinued the proton pump inhibitor owing to side effects, but has remained relatively symptom free during the last year. She has consistently refused enteral feeding and surgical intervention despite being aware of the potential risks of complications from the oesophago-bronchial fistula.

Disseminated mycobacterium avium complex infection in a patient with complete interferon gamma receptor deficiency

RATIONALE: Host defense against mycobacteria is dependent upon the functional integrity and interaction between mononuclear phagocytes, T cells and effective granuloma formation. Recent progress revealed the importance of IFN gamma (IFN-γ) and IL-12 axis for granuloma forming pathogens. An increased susceptibility to atypical mycobacterium is seen in patients with defects of IFN-γ and IL-12 axis. CASE REPORT: A Hispanic female born to consanguineous parents presented with persistent fever and cough at 12 months of age. A CT scan demonstrated left lower lobe consolidation and prominent mediastinal lymphadenopathy and she had a positive Mantaux test (12 X 12 mm). While she was started on a four drug regimen for tuberculosis, her blood cultures and gastric aspirates grew Mycobacterium avium that disseminated to bone marrow, spleen, liver and central nervous system, in spite of aggressive combination chemotherapy. RESULTS: Conventional immune workup results were unremarkable and given her clinical presentation, defects involving IFN-γ and IL-12 axis were suspected. Further studies revealed elevated IFN-γ production by her peripheral blood mononuclear cells with PHA and Con A, but normal production with IL-12. IL-12 production with these mitogens was low but her cells produced high normal levels of IL-12 with IL-12p70 and IL-18. ELISPOT revealed increase in IFN-γ production as well. With these findings, IFN-γ receptor (IFN-γR) defect was suspected and complete IFN-γR defect was confirmed by flow cytometry (Dr. Holland's laboratory at NIH). CONCLUSION: This case demonstrates an importance of IFN-γ for eradicating atypical mycobacterium and also altered PPD reactivity to Mycobacterium avium in patients with IFN-γR defect.