Lung Markings Research Articles

Congenital lobar emphysema mis-interpreted as tension pneumothorax: a case report and literature review

Introduction and importance: Congenital lobar emphysema (CLE) is a rare developmental lung anomaly that occasionally remains asymptomatic until adulthood. The right diagnosis is very crucial in its management. Case presentation: The authors report the case of a 29-year-old otherwise healthy, nonsmoker male. Referred after management of a presumptuous diagnosis of tension pneumothorax. His symptoms at initial presentation were a chronic cough and progressive exertional dyspnea. His chest radiography revealed absent lung markings in the right lung field with a trachea deviation to the left, interpreted as a tension pneumothorax. However, chest tube insertion worsened his dyspnea. A computed tomography scan, though initially interpreted as pneumothorax, showed findings consistent with CLE. Discussion: Adult CLE is a very rare presentation. A computed tomography scan is the imaging of choice. Even though watchful waiting is reasonable in selected patients, lobectomy remains the standard of care, preferably via video-assisted thoracic surgery. Conclusion: Failure to recognize CLE or other cystic lung lesions can lead to harmful procedures.

INTERSTITIAL LUNG DISEASE IN A TODDLER WITH ANTI-MDA5 JUVENILE DERMATOMYOSITIS THAT IMPROVED WITH AGGRESSIVE, EARLY TREATMENT WITH STEROIDS AND MULTIPLE IMMUNOSUPPRESSANTS

INTERSTITIAL LUNG DISEASE IN A TODDLER WITH ANTI-MDA5 JUVENILE DERMATOMYOSITIS THAT IMPROVED WITH AGGRESSIVE, EARLY TREATMENT WITH STEROIDS AND MULTIPLE IMMUNOSUPPRESSANTS

Ground truth generalizability affects performance of the artificial intelligence model in automated vertebral fracture detection on plain lateral radiographs of the spine

BACKGROUND CONTEXTComputer-aided diagnosis with artificial intelligence (AI) has been used clinically, and ground truth generalizability is important for AI performance in medical image analyses. The AI model was trained on one specific group of older adults (aged≧60) has not yet been shown to work equally well in a younger adult group (aged 18–59). PURPOSETo compare the performance of the developed AI model with ensemble method trained with the ground truth for those aged 60 years or older in identifying vertebral fractures (VFs) on plain lateral radiographs of spine (PLRS) between younger and older adult populations. STUDY DESIGN/SETTINGRetrospective analysis of PLRS in a single medical institution. OUTCOME MEASURESAccuracy, sensitivity, specificity, and interobserver reliability (kappa value) were used to compare diagnostic performance of the AI model and subspecialists’ consensus between the two groups. METHODSBetween January 2016 and December 2018, the ground truth of 941 patients (one PLRS per person) aged 60 years and older with 1101 VFs and 6358 normal vertebrae was used to set up the AI model. The framework of the developed AI model includes: object detection with You Only Look Once Version 3 (YOLOv3) at T0-L5 levels in the PLRS, data pre-preprocessing with image-size and quality processing, and AI ensemble model (ResNet34, DenseNet121, and DenseNet201) for identifying or grading VFs. The reported overall accuracy, sensitivity and specificity were 92%, 91% and 93%, respectively, and external validation was also performed. Thereafter, patients diagnosed as VFs and treated in our institution during October 2019 to August 2020 were the study group regardless of age. In total, 258 patients (339 VFs and 1725 normal vertebrae) in the older adult population (mean age 78±10.4; range, 60–106) were enrolled. In the younger adult population (mean age 36±9.43; range, 20–49), 106 patients (120 VFs and 728 normal vertebrae) were enrolled. After identification and grading of VFs based on the Genant method with consensus between two subspecialists’, VFs in each PLRS with human labels were defined as the testing dataset. The corresponding CT or MRI scan was used for labeling in the PLRS. The bootstrap method was applied to the testing dataset. RESULTSThe model for clinical application, Digital Imaging and Communications in Medicine (DICOM) format, is uploaded directly (available at: http://140.113.114.104/vght_demo/svf-model (grading) and http://140.113.114.104/vght demo/svf-model2 (labeling). Overall accuracy, sensitivity and specificity in the older adult population were 93.36% (95% CI 93.34%–93.38%), 88.97% (95% CI 88.59%–88.99%) and 94.26% (95% CI 94.23%–94.29%), respectively. Overall accuracy, sensitivity and specificity in the younger adult population were 93.75% (95% CI 93.7%–93.8%), 65.00% (95% CI 64.33%–65.67%) and 98.49% (95% CI 98.45%–98.52%), respectively. Accuracy reached 100% in VFs grading once the VFs were labeled accurately. The unique pattern of limbus-like VFs, 43 (35.8%) were investigated only in the younger adult population. If limbus-like VFs from the dataset were not included, the accuracy increased from 93.75% (95% CI 93.70%–93.80%) to 95.78% (95% CI 95.73%–95.82%), sensitivity increased from 65.00% (95% CI 64.33%–65.67%) to 70.13% (95% CI 68.98%–71.27%) and specificity remained unchanged at 98.49% (95% CI 98.45%–98.52%), respectively. The main causes of false negative results in older adults were patients’ lung markings, diaphragm or bowel airs (37%, n=14) followed by type I fracture (29%, n=11). The main causes of false negatives in younger adults were limbus-like VFs (45%, n=19), followed by type I fracture (26%, n=11). The overall kappa between AI discrimination and subspecialists’ consensus in the older and younger adult populations were 0.77 (95% CI, 0.733–0.805) and 0.72 (95% CI, 0.6524–0.80), respectively. CONCLUSIONSThe developed VF-identifying AI ensemble model based on ground truth of older adults achieved better performance in identifying VFs in older adults and non-fractured thoracic and lumbar vertebrae in the younger adults. Different age distribution may have potential disease diversity and implicate the effect of ground truth generalizability on the AI model performance.

P02.01 CT Integrated Bronchoscopy Manual Spraying Pigment Labeling to Localize of Small Pulmonary Nodules

Popularization of High Resolution Computed Tomography (HRCT) has greatly improved the detection rate of pulmonary nodules. Video Assistant Thoracic Surgery (VATS) lobectomy (sublobar lung resection in selected patients) has been the standard surgical treatment for these early stage non-small cell lung cancer. Uniportal VATS, a widely used innovative technique in minimally invasive thoracic surgery, makes less incision and also demands more precise intraoperative palpation/localization which is often challenging for small nodules. Various strategies such as the hookwire method, CT fluoroscopy-guided bronchoscopic dye marking, contrast median injection, radiotracer localization and a virtual assisted lung mapping technology (VAL-MAP). While they provide new options of nodule location for thoracic surgeons, all of these strategies require expensive hardware or software and additional two or three more doctors which are often not affordable for centers with limited resources. The purpose of this study is to develop a practically cheap method of pigment labeling for bronchoscope with no additional need of medical equipment and medical human resources. This is an ethic committee approved clinical trial. Medically operable patients with the HRCT detected small nodules were eligible. This nodule localization method involved a manual drawing the route by the surgeon/bronchoscopist, through a series of bronchial opening sketches and marking the leading bronchus at every bifurcation point based on the HRCT. Two to four appropriate bronchial pathways were selected for each lesion. A metal-tip catheter was inserted into a selected bronchus and advanced to the pleura. The location of the catheter tip was fluoroscopically confirmed, and 1 mL of diluted methylene blue was injected for each marking. All these procedures were completed by one doctor and one nurse. Then low dose CT scan was used to visualize the localization of the multiple markings, which were used as references in the subsequent operation. Success rate and procedure related complication are reported. From April 2019 to July 2020, 18 lesions in 17 patients were enrolled. All surgical procedures were performed using uniportal VATS. The lesions ranged in size from 3 to 23mm, 15 (83%) were nodules of Ground Glass Opacity (GGO). The depth ranged from 0 to 19 mm. A total of 57 lung markings were planned. 54 of them (95%) were completed. Of the 3 failed markings, the target bronchus could not be accessed under the bronchoscopy because of improper angle. Fifty-two (91%) were visible during the operations. The 3 unidentified markings were in the same patient, who had been a coal miner and had a severe carbon deposition on his lung and pleura. There was no adverse event associated with this manual marking procedures. All lesions were successfully resected. In 3 patients failed multiple markings, alternative localization was used successfully. This HRCT guided manual drawing method of lesion localization is safe and effective for small nodule localization for lung cancer surgery. Results of this study appears to be better than conventional percutaneous techniques in clinically evident complications. Because it does not need special equipment, it is more suitable for developing countries with limited equipment and human resources.

Pseudopneumothorax: diagnostic pitfalls

Evidence of pneumothorax on radiograph of the chest without accompanying major respiratory signs is rare. Various artefacts including skin fold, shirt fold, bed sheet fold and medial border of scapula...

Imaging characteristics of coronavirus disease 2019 (COVID-19) in pediatric cases: a systematic review and meta-analysis.

BackgroundThe confirmed coronavirus disease 2019 (COVID-19) cases, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have exceeded 21 million (with more than 775,000 fatalities), and the number of children with COVID-19 is also increasing. This study aimed to summarize the chest imaging characteristics of pediatric COVID-19 cases and provide a reference for the diagnosis and control of pediatric COVID-19.MethodsThe study protocol was registered in PROSPERO, number CRD42020177391. Studies related to pediatric COVID-19 imaging manifestations were accessed from PubMed, Web of Science, and the Cochrane library databases, without language limitations. The publication date was limited to April 1, 2020, and it was updated on May 1 and May 27, 2020. Data normalization was determined with the Freeman-Tukey double arcsine transformation. Summarized incidences with 95% confidence intervals of various imaging manifestations were assessed by random-effects models. Heterogeneity was assessed with meta-regression and subgroup analyses, robustness with sensitivity analyses; and publication biases with Egger’s test.ResultsTwenty-three with 517 cases were included in this study. The summarized incidence of chest computed tomography abnormalities in pediatric COVID-19 cases was 70%, which was lower than what has been seen in adults. The incidence of halo signs in pediatric COVID-19 cases was 26%, which is rarely seen in adult COVID-19 cases. The incidences of ground-glass opacities (GGOs), GGOs and consolidations, consolidations, reverse halo signs, crazy paving signs, pleural effusion, bronchopneumonia-like signs, air bronchograms, and increased lung markings were 40%, 25%, 10%, 2%, 4%, 1%, 15%, 12%, and 31%, respectively. Pericardial effusions were found in the computed tomography images of adult COVID-19 cases but were scarcely seen in the computed tomography images of pediatric COVID-19 cases. The incidences of bilateral lesions, unilateral lesions, and peripheral lesions were 35%, 22%, and 26%, respectively.ConclusionsChest computed tomography imaging of pediatric COVID-19 cases resulted in various abnormalities that were milder than those of adults. This study will hopefully provide a reference to help identify pediatric COVID-19 cases.

Neonatal COVID-19 exposures and infections: a systematic review of modes of transmission, manifestations and management

Background Since the emergence of the novel coronavirus disease (COVID-19) in December 2019, several publications have emerged describing the manifestations of the disease in different age groups. Reports from the newborn group have however been sparse. This review summarizes the mode of transmission, clinical presentations as well as treatment and outcomes of COVID-19 in neonates. Methods A systematic search for literature was conducted in April and in August 2020. The databases searched include PUBMED, Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar. The search terms used included COVID-19, SARS-CoV-2, Corona virus, Newborn, Neonate, exposure, vertical transmission, breastfeeding, droplet infection. We included primary studies that were carried out globally either in hospitals or in the communities such as case reports, case series, cross-sectional studies and other qualitative or quantitative studies and published in English language, between January and August 2020. Results Fifty six studies were included in this review. Studies were conducted in China, Iran, South Korea, Peru, USA, Spain, Belgium, France, and Australia. A total of 416 neonates were examined between few hours old and 28 days of age. A total of 38 neonates had PCR-confirmed COVID-19 disease following testing. Fourteen (36.8%) out of the 38 neonates that tested positive had no symptoms. Clinical features reported were mild and include systemic features such as fever (4.1%), respiratory features such as tachypnoea (5.1%), cardiovascular, gastrointestinal, and dermatological features. Radiological features reported include pneumonia (1%), ground glass opacity (2.9%), consolidation (0.7%), increased lung markings (0.3%). Person to person transmission was more common. Treatment was generally supportive. Conclusions There is little evidence of vertical transmission in neonates. Neonatal survival following COVID-19 infection is very high perhaps due to mild nature of the disease in this age group. More research using higher quality study designs and methodologies is recommended.

Right lung agenesis in a one-year-old Chihuahua

A one-year-old neutered male Chihuahua was referred for further investigations of spontaneous pneumothorax. Before referral, thoracocentesis and chest drain placement was performed. On presentation, the dog was dull and dyspnoeic...

An Observational Study of Intrauterine Vertical Transmission of SARS-CoV-2 in 20 Neonates

Background: Coronavirus Disease 2019 (COVID-19) has become a global pandemic. Neonates have the risk of contracting COVID-19 through intrauterine vertical transmission, which is one of the most serious consequences of infectious diseases. Methods: We enrolled neonates and their mother, who was suffered from COVID-19 during the last trimester. We investigated the presence of SARS-CoV-2, as well as IgG and IgM against the virus in a longitudinal analysis from the labor period to one month after birth. Findings: From February 2 to March 31, 2020, of 20 neonates, 10 neonates and eight neonates had pneumonia and increased lung markings, respectively. At birth, three neonates had positive RT-PCR results of throat swabs, 16 neonates had increased IgG and/or IgM. The mean concentrations of IgG and IgM were mean [SD] 77.7 [28.4] and 11.1 [12.8] ng/mL, respectively. Among nine neonates whose antibody was measured more than once after delivery, one displayed rapidly increased IgM from 1.0 ng/mL at birth to 21.8 ng/mL at 7 days after birth, and 15 showed steadily decreasing IgM. For IgG levels, seven neonates exhibited a slowly decreasing trend after birth and two exhibited a steadily high level. At the birth time, eight neonates were at the acute phase of infection, including five with high or increased IgM and three with positive RT-PCR results. The remaining 12 neonates who had low IgM levels and negative RT-PCR were at the recovery phase. Conclusions: The study identified the presence of intrauterine vertical transmission of SARS-CoV-2, which led to various phases of infection in the neonates at birth time. Funding Statement: This study was supported by the General Program of Health and Family Planning Commission of Hubei Province of China (Grant No. WJ2017M194), the General Program of Natural Science Foundation of Hubei Province of China (Grant No. 2017CFB709), and Natural Science Foundation of Ningbo (2017A610273). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This observational study was reviewed and approved by the Ethics Committee of Wuhan Women and Children's Hospital and followed the Declaration of Helsinki. Written consent was acquired from the guardians of the patients.

Chest CT imaging characteristics of COVID-19 pneumonia in preschool children: a retrospective study

BackgroundRecently, the World Health Organization has declared the coronavirus disease 2019 (COVID-19) outbreak a public health emergency of international concern. So far, however, limited data are available for children. Therefore, we aimed to investigate the clinical and chest CT imaging characteristics of COVID-19 in preschool children.MethodsFrom January 26, 2020 to February 20, 2020, the clinical and initial chest CT imaging data of eight preschool children with laboratory-confirmed COVID-19 from two hospitals were retrospectively collected. The chest CT imaging characteristics, including the distribution, shape, and density of lesions, and the pleural effusion, pleural changes, and enlarged lymph nodes were evaluated.ResultsTwo cases (25%) were classified as mild type, and they showed no obvious abnormal CT findings or minimal pleural thickening on the right side. Five cases (62.5%) were classified as moderate type. Among these patients, one case showed consolidation located in the subpleural region of the right upper lobe, with thickening in the adjacent pleura; one case showed multiple consolidation and ground-glass opacities with blurry margins; one case displayed bronchial pneumonia-like changes in the left upper lobe; and two cases displayed asthmatic bronchitis-like changes. One case (12.5%) was classified as critical type and showed bronchial pneumonia-like changes in the bilateral lungs, presenting blurred and messy bilateral lung markings and multiple patchy shadows scattered along the lung markings with blurry margins.ConclusionsThe chest CT findings of COVID-19 in preschool children are atypical and various. Accurate diagnosis requires a comprehensive evaluation of epidemiological, clinical, laboratory and CT imaging data.

SUN-500 Viral-Induced Autoimmune Hyperthyroidism in an Adult Patient Without Established Thyroid Disease

Introduction: Subacute thyroiditis is a self-limited inflammation of the thyroid associated with recent upper respiratory tract viral infection. Graves’ disease has also been associated with viral illness. Clinical Case:A 55-year-old female presented to the emergency department complaining of sore throat, cough, and shortness of breath. She also had fatigue, dyspnea on exertion, palpitations, and a family member who recently had bronchitis. She denied chest pain, weight changes, temperature intolerance, constipation, or diarrhea. She had never had similar symptoms before.On initial evaluation, the patient was febrile at 101.2 °F, tachycardic at 156 beats per minute (bpm), and tachypneic at 33 breaths per minute. She was thin and her thyroid gland was tender upon palpation. She had eyelid lag, her skin was warm, and she was diaphoretic. Chest x-ray showed increased interstitial lung markings bilaterally. CBC showed anemia with hemoglobin of 9.7 g/dL (n<12 g/dL). Lactic acid was elevated to 2.00 mmol/L (n<1.9 mmol/L). D-dimer was 3020 ng/mL (n<230 ng/mL) and BNP was 961 pg/mL (n<100 pg/mL). An electrocardiogram showed sinus tachycardia at 140 bpm. Blood, sputum, and urine cultures were drawn, as were studies for viral respiratory pathogens. CT angiography of the chest and bilateral lower extremity venous ultrasound were ordered to rule out thromboembolism.A point-of-care echocardiogram showed reduced ejection fraction of 20%. Thyroid function tests revealed TSH < 0.03 mIU/mL (range 0.5-5.0 mIU/L), free T4 of 4.5 ng/dL (n<2.15 ng/dL), and T3 251 ng/dL (n<200 ng/dL). Patient was started on an esmolol drip for heart rate control. CT angiogram of the chest was negative for thromboembolism but revealed a bilaterally enlarged thyroid gland with multiple small nodules. RNA for Respiratory Syncytial Virus (RSV) type A was detected by PCR. A thyroid ultrasound was done and revealed heterogenous echotexture with increased blast flow.Thyroid antibody studies revealed thyrotropin receptor antibody of 26.5 IU/L (n<1.75 IU/L), thyroid-stimulating immunoglobulin 19.40 IU/L (n<0.55 IU/L), thyroglobulin antibody 235.6 IU/mL (n<0.9 IU/mL), and thyroid peroxidase antibody 11 IU/mL (range 0-34 IU/mL). Patient was started on methimazole 30 mg daily. A formal echocardiogram showed preserved ejection fraction of 50-55%. She was transitioned to oral propranolol. Patient’s shortness of breath and cough resolved, and she was discharged on methimazole 10 mg daily. Conclusion:This case emphasizes the importance of measuring thyrotropin receptor antibodies in confirming Graves’ disease in a patient presenting with upper respiratory viral illness and supports the idea of viral-induced autoimmune thyroid disease.

Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19).

Effective treatments for Coronavirus Disease 2019 (COVID-19) outbreak are urgently needed. While anti-viral approaches and vaccines are being considered immediate countermeasures are unavailable. The aim of this article is to outline a perspective on the pathophysiology of COVID-19 in the context of the currently available clinical data published in the literature. This article appreciates clinical data published on COVID-19 in the context of another respiratory illness - high altitude pulmonary edema (HAPE). Both conditions have significant similarities that portend pathophysiologic trajectories. Following this potential treatment options emerge.Both COVID-19 and HAPE exhibit a decreased ratio of arterial oxygen partial pressure to fractional inspired oxygen with concomitant hypoxia and tachypnea. There also appears to be a tendency for low carbon dioxide levels in both as well. Radiologic findings of ground glass opacities are present in up to 86% of patients with COVID-19 in addition to patchy infiltrates. Patients with HAPE also exhibit patchy infiltrates throughout the pulmonary fields, often in an asymmetric pattern and CT findings reveal increased lung markings and ground glass-like changes as well. Widespread ground-glass opacities are most commonly a manifestation of hydrostatic pulmonary edema. Similarly, elevated fibrinogen levels in both conditions are likely an epiphenomenon of edema formation rather than coagulation activation. Autopsy results of a COVID-19 fatality revealed bilateral diffuse alveolar damage associated with pulmonary edema, pro-inflammatory concentrates, and indications of early-phase acute respiratory distress syndrome (ARDS). HAPE itself is initially caused by an increase in pulmonary capillary pressure and induces altered alveolar-capillary permeability via high pulmonary artery hydrostatic pressures that lead to a protein-rich and mildly hemorrhagic edema. It appears that COVID-19 and HAPE both discretely converge on ARDS. In light of this, a countermeasure that has been shown to be effective in the analogous condition of HAPE is Acetazolamide. Acetazolamide has a myriad of effects on different organ systems, potently reduces hypoxic pulmonary vasoconstriction, improves minute ventilation and expired vital capacity. Other therapeutics to consider that are also directed towards decreased pulmonary pressure include Nifedipine and Phosphodiesterase inhibitors.This review describes COVID-19 in parallel to HAPE. Deranged respiratory parameters that are present in both conditions are highlighted. The utilization of medications found to be effective in HAPE, for the treatment of COVID-19, is proposed. Given the medical emergency of a growing contagion and the thousands of lives at stake, expedient attempts to improve survival are needed. Acetazolamide, Nifedipine and Phosphodiesterase inhibitors may be potential countermeasures.

Precise sublobar lung resection for small pulmonary nodules: localization and beyond.

Early-stage primary lung cancer is increasingly detected by computed tomographic (CT) screening and the radicality of sublobar lung resection (wedge resection and segmentectomy) has been suggested. However, identification of a tumor intraoperatively becomes more difficult, the earlier a nodule is detected. A solution to this challenge is localization techniques. There are many techniques to localize small pulmonary nodules, including that replacing surgeon's tactile sensation, visualizing the tumor using ultrasound, and various types of lung markings that are placed percutaneously under CT guidance or bronchoscopically. The most commonly used technique is CT-guided placement of a hookwire, but there are concerns about potentially fatal air embolism. Bronchoscopic localization, especially using electromagnetic navigation bronchoscopy with or without intraoperative cone-beam CT imaging, has been increasingly reported. Beyond localization, the concept of lung "mapping" is emerging. In sublobar lung resection, in addition to localization of the targeted tumor, acquisition of sufficient resection margins is critical to prevent local recurrence. Virtual-assisted lung mapping (VAL-MAP) has evolved from bronchoscopic dye localization, but by placing multiple dye marks, it provides two-dimensional geometric information on the lung. Moreover, to ensure deep resection margins, the newly developed technique of VAL-MAP2.0 combining dye marks and intrabronchial placement of a microcoil enables three-dimensional lung mapping. This allows for intraoperative navigation of lung resection under a fluoroscope. Development of this field, such as using a new technology of augmented reality, will further enhance the accuracy and convenience of lung resection in the near future.

Tricuspid valve infective endocarditis complicated with multiple lung abscesses and thoracic empyema as different pathogens: a case report

BackgroundOnly 4.1% of tricuspid valve IE cases require surgical intervention. The complication after tricuspid valve IE with lung abscess and empyema is rare.Case presentationWe report the case of a 38-year-old male (an intravenous drug abuser) diagnosed with tricuspid valve IE who underwent tricuspid valve replacement. The case was complicated by multiple lung abscesses and thoracic empyema. The pathogens causing the lung abscesses and empyema were Acinetobacter baumannii complex and Candida albicans, which were different from those causing the endocarditis.After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle.ConclusionThe pathogen causing the lung abscess is not always compatible with that causing the endocarditis. Thoracoscopic incision of the abscess with 4 to 6 weeks of broad-spectrum antibiotic treatment is effective and safe.

Analysis of risk factors for postoperative respiratory and circulatory complications in elderly patients with hip fracture

Objective To investigate the risk factors for postoperative cardiorespiratory complications within one month after operative treatment of hip fracture in the elderly. Methods Data of clinical examination, samples test, CT or MRI images were collected in 665 hip fracture patients aged 60 years and over who were admitted to our hospital from January 2010 to December 2014.Risk factors for postoperative cardiorespiratory complications within one month after operation were analyzed by correlation analysis and multiple regression analysis. Results The incidence of postoperative complications in cardiovascular system was 4.5%(30/665)in all patients.The risk factors for postoperative circulatory complications included gender, high white blood cell(WBC)counts before operation, hypoalbuminemia, a low hemoglobin level(<35 g/L), renal insufficiency, hyponatremia, pulmonary arterial hypertension, segmental ventricular wall abnormal motion, abnormal ST segment changes.The incidence of postoperative complications in respiratory system was 6.9%(46/665)in all patients.The risk factors for postoperative respiratory complications included high WBC counts before operation, hypoalbuminemia, chronic obstructive pulmonary disease(COPD), bronchiectasis and emphysema, history of respiratory failure and abnormal lung markings(P<0.05 or P<0.01). Conclusions The elderly hip fracture patients have high incidence of postoperative respiratory and circulatory complications, and risk factors for these complications include accompanying diseases, hypoalbuminemia, abnormal echocardiography and electrocardiogram and hyponatremia. Key words: Hip fracture; Cardiovascular diseases; Respiratory system; Risk factor

UPPER-LOBE PREDOMINANT NITROFURANTOIN-INDUCED PULMONARY INJURY: A CASE REPORT

SESSION TITLE: Imaging SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Nitrofurantoin is an antibacterial agent frequently used in treatment and prophylaxis of patients with recurrent urinary tract infections (UTI’s). Pulmonary toxicity due to nitrofurantoin has two main presentations: an acute onset after a short course of therapy and a chronic onset developing after several months or years of nitrofurantoin therapy. The most often reported computed tomography (CT) chest finding of nitrofurantoin-induced lung disease is bilateral areas of ground-glass attenuation with no dominant pattern of zonal distribution. Upper-lobe predominant pattern has been seldom reported. CASE PRESENTATION: A 79-yr-old female with past history of recurrent UTI’s in the past 12 months; treated with multiple courses of antibiotics including nitrofurantoin, presented with complaints of progressively worsening dyspnea on exertion associated with a dry cough for 3-4 months. In ED, the patient was tachycardic, tachypneic and hypoxic with SpO2 of 80% on ambient air. Physical examination revealed few scattered rhonchi bilaterally. She was noted to have leukocytosis and elevated serum globulin levels. Pro-B-type natriuretic peptide and procalcitonin levels were within normal range. Chest x-ray showed prominent upper lobe coarse lung markings. CT chest showed lobular upper lobe ground glass infiltrates with interlobular septal thickening. Echocardiogram showed mild concentric left ventricular hypertrophy with normal systolic function. Following exclusion of infection and heart failure; chronic nitrofurantoin-induced lung disease was diagnosed. Nitrofurantoin was discontinued and the patient was treated with oral glucocorticoids. Patient’s symptoms improved and she was discharged on a tapering dose of steroids. Upon outpatient follow-up at 6 weeks; patient reported significantly improved dyspnea on exertion and CT chest showed interval resolution of upper lobe ground-glass opacities and septal thickening. DISCUSSION: Nitrofurantoin-induced pulmonary injury is an underdiagnosed cause of chronic dyspnea and discontinuation of nitrofurantoin is the cornerstone of therapy. Regression of symptoms and radiographic abnormalities may take weeks to months following discontinuation. Oral glucocorticoids may expedite recovery and benefit patients with severe respiratory impairment. The principal chronic alterations associated with nitrofurantoin are usually found in the lung bases. In the case in question, the findings were predominantly in the upper lobes. The favorable clinical evolution after discontinuation of nitrofurantoin, resolution of CT chest findings and the absence of recurrence after discontinuation of glucocorticoids established a causal relationship. CONCLUSIONS: Patients on long-term nitrofurantoin therapy should be regularly monitored for pulmonary adverse effects. Clinicians should be cognizant of the varied clinical and radiographic patterns of nitrofurantoin-induced lung disease. Reference #1: https://www.ncbi.nlm.nih.gov/pubmed/18392467/ DISCLOSURES: No relevant relationships by Asif Abdul Hameed, source=Web Response No relevant relationships by Adeeba Afrah, source=Web Response Speaker/Speaker's Bureau relationship with Sunovion Please note: $1001 - $5000 Added 02/28/2018 by Michael Korman, source=Web Response, value=Honoraria

The Role of Chest X-Ray and Bedside Ultrasound in Diagnosing Pulmonary Bleb versus Pneumothorax

History of present illness: A 48-year-old male with chronic obstructive pulmonary disease (COPD) presented to the emergency department with stabbing chest pain to the right lower rib region along the axillary line. On examination, patient had no visible trauma, but was in mild respiratory distress with absent breath sounds on the right side. The patient's oxygen saturation ranged in the 90s on room air during his encounter, but otherwise had unremarkable vital signs. Significant findings: The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb. A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax. Discussion: Pulmonary blebs are collections of air in the alveolar layer of the pleura formed by a rupture of the alveolar wall.1 They can leak air into chest cavity leading to a high rate of recurrent spontaneous pneumothorax.2 Chest X-rays (CXR) are the current gold standard in diagnosing pneumothorax. A recent study among 192 critically ill patients showed CXR has high diagnostic accuracy and positive predictive value, at 90.6% and 95.0%, respectively.3 Visible visceral pleural lines on CXR seen without distal lung markings is usually diagnostic of pneumothorax.4 In this case however, the patient’s CXR and lung ultrasound findings were similar to standard pneumothorax findings, however chart review demonstrated the patient had a known large pulmonary bleb. The treatment for pneumothorax is chest tube insertion. To avoid unnecessary chest tube placement, emergency physicians must consider pulmonary blebs as a diagnosis in patients with mild respiratory distress who have a large area of absent lung parenchyma and visible visceral pleural lines on CXR. If a clinician is unsure and does not have access to previous imaging, a computed tomography scan of the chest can be used to clarify the diagnosis.5 This patient was conservatively managed with oral prednisone, intravenous morphine sulfate, combination albuterol-ipratropium nebulizer treatment, and later discharged for pulmonology follow up.6 The patient did not require any further imaging during this visit. In recurrent disease or severe dyspnea, bullectomy may be indicated. Topics: Ultrasound, X-ray, pulmonary blebs, pneumothorax.

Term Neonate with Respiratory Distress.

A female infant is born at 39 weeks to a 21-year-old primigravida with an unremarkable antenatal history and good prenatal care. The Apgar scores are 6, 7, and 8 at 1, 5, and 10 minutes, respectively. Physical examination reveals an appropriate-for–gestational age 3.3-kg term infant with grunting, tachypnea, and intercostal retractions. Decreased air entry is noted over the right side of the chest. A grade 2/6 systolic murmur is heard over the left sternal border with normal heart sounds and good peripheral pulses. The rest of the physical examination findings are within normal limits except for a right-sided small ear tag. The neonate requires positive pressure ventilation initially in the delivery room and then is placed on continuous positive airway pressure (CPAP) at 30% fraction of inspired oxygen. Chest radiography shows near-complete opacification of the right thorax with mass effect and normal lung markings on the left (Fig 1). Due to worsening respiratory distress, she undergoes intubation and is transferred to the regional perinatal center for diagnosis and management. Figure 1. Anteroposterior view radiograph of chest and abdomen at birth showing near-complete opacification of the right thorax. Differential diagnoses considered at this point for unilateral lung field opacity with mass effect include right-sided diaphragmatic hernia, congenital pulmonary airway malformation, pulmonary sequestration, or a space-occupying lesion like a tumor. Ultrasonography of the chest shows a large, solid mass in the right thorax with an intact diaphragm, an abnormality consistent with consolidated lung or a tumor (Fig 2 …

Bilateral Lung Transplantation With Interventional Occlusion of an Atrial Septal Defect in a Patient With Eisenmenger Syndrome

On November 28, 2014, the Department of Chest Surgery of Wuxi People's Hospital in China performed the first case of an ECMO assisted bilateral lung transplantation (BLTx) combined with interventional occlusion of an ASD in a patient with Eisenmenger syndrome. The patient was then followed up for 2 years. Thus, we herein reported this case as follows. Patient history: This female patient was 33-year-old with a body weight of 50 kg and height of 162 cm. A cardiac ultrasound examination by other hospital revealed Eisenmenger syndrome, foramen secundum atrial septal defect with right ventricular and atrial enlargement, pulmonary artery broadening and severe pulmonary hypertension (pulmonary artery systolic pressure 120 mmHg). Then, after 3 months, the patient underwent cardiac catheterization and a tentative occlusion of the ASD, but there was no marked drop in pulmonary artery pressure after occlusion, and the patient had a chief complaint of marked chest pain. Thus, the occluder was retrieved, and bosentan was taken orally to reduce pulmonary artery pressure. During treatment, the patient had presented with syncope twice and NYHA class 3–4 symptoms. On October 20, 2014, the patient was admitted to our Hospital to undergo preoperative assessment for lung transplantation. An ECG test showed sinus tachycardia, right axis deviation, T-wave change and right ventricular hypertrophy. Chest X-ray and CT showed increased and disordered lung markings on both sides, and marked prominence of the pulmonary artery segment (Figure 1). A lung function test showed severely obstructive ventilation dysfunction. Blood gas analysis showed the partial pressure of oxygen 50 mmHg, partial pressure of carbon dioxide 35.5 mmHg, and oxygen saturation: 85-90% at rest, 91-93% at 30min after oxygen inhalation, and 60-65% at 3min after walking. A 6-minute walk test (6-MWT) result was 120m and activity was remarkably limited. Cardiac catheterization showed that the pulmonary artery pressure was equal to the systemic blood pressure [110/70 (82) mmHg] and that the pulmonary artery resistance was 19.3Wood units. On November 28, 2014, we performed bilateral cadaveric lung transplantation with interventional closure of the ASD assisted by ECMO. Our experience of successful treatment for this patient indicates that it’s feasible approach to carry out bilateral allogeneic lung transplantation together with heart defect repair for end-stage congenital heart disease. we agree with the article published.

Interstitial lung markings on HRCT Chest

We undertook this study, with the objective of identifying various patterns through which the thickness of interstitium present. 25 patients of interstitial thickness on HRCT were taken. Interstitial thickening was subdivided into three groups. Smooth, Nodular and Irregular. Through this we narrowed the differential diagnosis list and helped the clinician in guiding through the diagnosis. 16 patients had irregular thickening , 5 had nodular thickening.