Middle Lobe Research Articles

LIPOID PNEUMONIA DUE TO PHARYNGOESOPHAGEAL DYSPHAGIA CAUSING PARAFFIN BRONCHOASPIRATION

TYPE: Case Report TOPIC: Occupational and Environmental Lung Diseases INTRODUCTION: We present a case of exogenous lipoid pneumonia caused by paraffin broncoaspiration due to pharyngoesophageal motor dysphagia. CASE PRESENTATION: A 57 year old female consulted for diarrhea. She had a previous history of ischemic stroke related to hypercoagulability syndrome, causing oropharyngeal dysphagia due to pharyngo-esophageal motor incoordination. Owing to possible neurogenic dysfunction she also presented megadolichocolon with chronic diarrhea-constipation syndrome. Due to the epidemiological situation caused by SARS-COV2, a chest X-ray was performed showing increased density of the right middle lobe. The control X-ray exhibited a persistence of this alteration, therefore a thoracic tomographic study was performed (findings included in image), as well as a bronchoalveolar lavage. The bronchoalveolar lavage fluid was initially turbid white which, posterior to resting, revealed a superficial layer of fat, supporting the diagnosis of lipoid pneumonia. The patient was subsequently interrogated. She associated the consumption of oily materials from herbalists and paraffin in order to palliate her constipation symptoms, which in relation to her esophageal motor-pharyngeal incoordination produced bronchoaspiration of the referred oily material. DISCUSSION: Oily substance ingestion was suspended. Subsequently she underwent a corticosteroid treatment and is currently under clinical control. CONCLUSIONS: The ground glass pattern is a finding that causes a wide differential diagnosis in the radiological study, therefore it is of great importance to take an adequate clinical history and to take into account the motor dysfunctions related to swallowing, due to the high consumption of herbalist products that contain oily materials that can cause exogenous lipoid pneumonia. DISCLOSURE: Nothing to declare. KEYWORD: Exogenous_Lipoid_Pneumonia

A QUEST TO FIND AN AETIOLOGY FOR A PULMONARY CONSOLIDATION BEYOND INFECTIVE AND MALIGNANT CAUSES

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: We present a rare inflammatory cause of radiological consolidation found in a 67-year-old lady with unresolved pneumonia. CASE PRESENTATION: A 67-year-old lady was referred to the chest clinic with a persisting right middle lobe opacity on subsequent chest radiography 6 week's after the initial presentation with pneumonia. She had completed a course of co-amoxiclav with clarithromycin. A contrast-enhanced CT Chest demonstrated consolidation in the medial aspect of right middle lobe. Spirometry was consistent with mild restrictive defect. Blood tests showed raised IgG and IgA levels. Serum electrophoresis revealed polyclonal increase in γ-globulins. Her bronchoalveolar lavage was unremarkable. This prompted to investigate her with CT-guided biopsy which showed fibro-inflammatory cells. Alas IgG4-related lung disease was confirmed. She showed clinico-radiological improvement with a course of steroid. Figure: CXR and CT chest showing RML consolidation DISCUSSION: IgG4-related lung disease can be associated with a rare pneumonic presentation. It is an idiopathic multi system disorder characterised by presence of IgG4-positive lymphoplasmacytic infiltrates and storiform fibrosis along with raised serum IgG4. It's presentation is organ specific and its pulmonary presentation ranges from consolidation to interstitial disease, and lymph node enlargement. Among the five radiologic subtypes, alveolar consolidative and solid nodular type remain most common. It is typically steroid responsive. CONCLUSIONS: Although very rare but this case depicts importance of considering inflammatory pneumonia such as IgG4 related lung disease as a differential in unresolved pneumonia. Reference 1: Kamisawa T. IgG4-related disease. Lancet 2015; 385: 1460. Refernece 2: Kang, J. Long-term clinical course and outcomes of immunoglobulin G4-related lung disease. https://doi.org/10.1186/s12931-020-01542-6 DISCLOSURE: Nothing to declare.

Mature mediastinal teratoma with tumor rupture into airway

A previously healthy 16-year-old girl presented with hemoptysis in the setting of a persistent cough for two months. Imaging identified a large mediastinal mass with cystic and solid components, calcifications and fat suggestive of a germ cell tumor. There was associated right middle lobe consolidation with an air-fluid level concerning for a necrotizing pneumonia, right upper lobe bronchiectasis, hilar lymphadenopathy, and right upper lobe and right pleural-based nodules concerning for disseminated disease. Histologic analysis of a percutaneous biopsy revealed skeletal muscle, fibroadipose tissue, skin, and keratinous debris consistent with a mature germ cell tumor. Rigid and flexible bronchoscopy were performed and identified inspissated, purulent, and fibrinous material in the right upper and middle lobe bronchi. Microbial cultures grew Staphylococcus aureus. After 3 weeks of antibiotics, complete surgical resection was performed. No malignant components were identified. Her post-operative course was uncomplicated, and she remains without evidence of disease 6 months after resection. While mediastinal teratomas are common, rupture is uncommon with fewer than 60 reported cases in the literature. Rupture can be associated with inflammation and/or infection, resulting in diagnostic and treatment challenges.

TRACHEAL BRONCHUS OR BRONCHUS SUIS AND ITS IMPORTANCE IN LUNG TRANSPLANT

TYPE: Late Breaking Abstract TOPIC: Imaging INTRODUCTION: Tracheal bronchus (TB) is an aberrant bronchus arising from within 2cm of right lateral wall of supracarinal trachea. The term, bronchus suis, is given when the entire right upper lobe (RUL) is supplied by this bronchus. CASE PRESENTATION: Incidence is estimated at ∼1% (0.1-5%). TB can be classified into supernumerary - usual bronchial supply to affected lung segment is present or displaced - usual bronchial supply to affected lung segment is absent. It is usually an incidental finding, and most patients are asymptomatic. Occasionally patients may have recurrent RUL pneumonia due to focal emphysema or mucus impaction. Improvisation of airway anastomotic technique is required during lung transplantation (LT). DISCUSSION: 5 cases of donor, and 1 case of recipient TB have been reported in literature. Possible options for the airway anastomosis are en-bloc double LT with a tracheal anastomosis, left single LT alone, bilateral LT with left lung and right middle and lower lobe (following donor lung RUL lobectomy), and bilateral LT with a modified right tracheobronchial anastomosis. En-bloc double LT has higher airway anastomotic complication rate compared to bilateral sequential LT. Length of bronchial stump is made as short as possible in the donor lung to maximize the benefit of pulmonary-to-bronchial collateral blood supply. The neo-upper lobe bronchus created by suturing the apical TB and the RUL bronchus of the donor is anastomosed to the RUL bronchus of the recipient in a double-barrel fashion. CONCLUSIONS: Early identification of TB allows for appropriate recipient selection and advanced surgical planning for successful single or bilateral LT. DISCLOSURE: No significant relationships. KEYWORD: tracheal bronchus, bronchus suis, lung transplant

Application of 3D Simulation Software in Chemotherapy and Hepatoblastoma Surgery in Children.

PurposeThis study aims to explore the clinical value of a computer-assisted surgery system (Hisense CAS) in hepatoblastoma (HB) surgery in children after neoadjuvant chemotherapy.Patients and MethodsThe clinical medical records of children with HB treated after neoadjuvant chemotherapy at the Affiliated Hospital of Qingdao University from January 2016 to January 2019 were analyzed retrospectively.ResultsA total of 21 children were enrolled in this study, including 13 boys and 8 girls. All cases successfully underwent three-dimensional (3D) reconstruction of the liver and tumor using Hisense CAS, simulated hepatectomy, and hepatectomy according to the preoperative operation plan. There were twelve cases of right hemihepatectomy, four cases of right trefoil hepatectomy, one case of left lobe hepatectomy, and three cases of middle lobe hepatectomy, and one case of V and VI segment hepatectomy. All children recovered well after the operation. The follow-up ranged from 5 months to 3 years. One child died of systemic metastasis 8 months after the operation. One child received one course of chemotherapy after the operation. Due to the serious reaction to the chemotherapy, the family refused further treatment and follow-up. The remaining 19 children had no complications or recurrence.ConclusionHisense CAS can clearly and intuitively display the position and shape of the HB before and after chemotherapy and its relationship with the intrahepatic pipeline system and accurately evaluate the changes in tumor volume and the distance between important blood vessels, which is conducive to the operator selecting the best operation opportunity, timely formulating the best operation plan and implementing individualized and accurate liver tumor resection.

DISSEMINATED HISTOPLASMOSIS MISDIAGNOSED AS SARCOID FLARE: THE IMPORTANCE OF ACCURATE DIAGNOSIS AND TREATMENT

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Histoplasmosis infection is common, but disseminated histoplasmosis is rare, affecting 1 in 2000 infected people, usually immunosuppressed individuals. Granulomas are a pathological hallmark of histoplasmosis, but can be seen in other conditions, including sarcoidosis. Similarities between these two conditions can result in delayed diagnosis and treatment of disseminated histoplasmosis. CASE PRESENTATION: A 43 year old female with sarcoidosis on methotrexate was admitted with vomiting, sweats, and weight loss. Her temperature was 103F, spO2 85%, and BP was 85/60. Pancytopenia was present, (WBC 2.7, hemoglobin 7.2, and platelets 109) though a CBC was normal four months prior. Computed tomography revealed right middle lobe consolidation, hilar lymphadenopathy, and hepatosplenomegaly. Broad spectrum antibiotics for pneumonia and intravenous methylprednisolone for suspected sarcoid flare were started, but she worsened clinically. On day 7, urine histoplasma antigen and a bone marrow biopsy were obtained. Non-necrotizing granulomas consistent with sarcoidosis were noted, but 2 days later, the final biopsy results reported histoplasma. Histoplasma urine antigen returned positive the subsequent day. Amphotericin B was started with resultant clinical improvement. DISCUSSION: An association of sarcoidosis and histoplasmosis infection is postulated to occur secondary to immunosuppression from sarcoid disease and therapy, and to shared pathophysiology of granuloma formation. Progression from limited to disseminated histoplasmosis is reported in patients with sarcoidosis who receive intravenous steroids. Due to turn-around time of urinary antigen results, consider histoplasmosis testing at admission for patients with sarcoidosis and infectious symptoms. CONCLUSIONS: Swift diagnosis of histoplasmosis is necessary to ensure appropriate therapy and improve morbidity and mortality. DISCLOSURE: Nothing to declare. KEYWORD: histoplasmosis

Recurrent pneumothorax in a human immunodeficiency virus-positive patient with multidrug-resistant tuberculosis: a rare case of bronchopleural fistula: a case report

BackgroundHuman immunodeficiency virus/tuberculosis coinfections have amplified the multidrug-resistant tuberculosis pandemic in many countries in Sub-Saharan Africa, and multidrug-resistant tuberculosis has become a major public health threat. There is a paucity of data on severe complications of multidrug-resistant tuberculosis in the context of human immunodeficiency virus coinfection despite the increasing prevalence of multidrug-resistant tuberculosis/human immunodeficiency virus coinfection and the complexity of multidrug-resistant tuberculosis treatment. This report describes a rare case of complicated multidrug-resistant tuberculosis in a human immunodeficiency virus-positive individual.Case presentationA 39-year-old human immunodeficiency virus-positive Ugandan male on anti-retroviral therapy for 6 years, who had recently completed treatment for drug-susceptible tuberculosis from a public hospital, presented to the tuberculosis ward of Mulago National Referral Hospital with worsening respiratory symptoms including persistent cough with purulent sputum, fever, right chest pain, and shortness of breath. On admission, a diagnosis of drug-resistant tuberculosis was made following a positive sputum Xpert MTB/Rif test with rifampicin resistance. Culture-based tuberculosis tests and line probe assay confirmed multidrug-resistant tuberculosis. The patient was given multidrug-resistant tuberculosis treatment that included bedaquiline, isoniazid, prothionamide, clofazimine, ethambutol, levofloxacin, and pyrazinamide and switched to second-line anti-retroviral therapy that included tenofovir/lamivudine/lopinavir/ritonavir. Chest X-ray revealed a hydro-pneumothorax, following which a chest tube was inserted. With persistent bubbling from the chest tube weeks later and a check chest X-ray that showed increasing pleural airspace (pneumothorax) and appearance of a new air–fluid level, chest computed tomography scan was performed, revealing a bronchopleural fistula in the right hemithorax. The computed tomography scan also revealed a pyo-pneumothorax and lung collapse involving the right middle and lower lobes as well as a thick-walled cavity in the right upper lobe. With the pulmonary complications, particularly the recurrent pneumothorax, bronchopleural fistula, and empyema thoracis, cardiothoracic surgeons were involved, who managed the patient conservatively and maintained the chest tube. The patient continued to be ill with recurrent pneumothorax despite the chest tube, until relatives opted for discharge against medical advice.ConclusionsComplicated human immunodeficiency virus-related multidrug-resistant tuberculosis is not uncommon in settings of high human immunodeficiency virus/tuberculosis prevalence and is often associated with significant morbidity and mortality. Early diagnosis and treatment of multidrug-resistant tuberculosis, with rigorous monitoring for human immunodeficiency virus-positive individuals, is necessary to prevent debilitating complications.

Atrial invasion from primary lung adenocarcinoma extension via the pulmonary vein.

Intravascular extension of lung adenocarcinoma is one of the four defined routes of metastasis to the heart but is rarely described in the literature. This is a rare case of primary lung adenocarcinoma with intravenous extension to the left atrium via the pulmonary vein. A 56-year-old female presented to the hospital with chest tightness and dyspnea. Chest computed tomography revealed a right hilar mass extending through the right superior pulmonary vein into the left atrium. Transthoracic echocardiography revealed a large, partially mobile left atrial mass occupying the entire atrial cavity and affecting mitral valve closure. Endobronchial ultrasound with transbronchial biopsy of the right middle lobe of the lung histologically showed a poorly differentiated adenocarcinoma compatible with the primary lung cancer. The patient was deemed a poor surgical candidate by cardiothoracic surgery due to the extent of metastasis and was started on chemoradiation. The patient's left atrial tumor mass started shrinking in size after starting the treatment. This unique case displaying intravascular extension of lung cancer to the left atrium has rarely been described in the literature.

Disseminated Nocardia infection in a patient with systemic lupus erythematosis

28 year old female who was under treatment for systemic lupus erythematosus with oral prednisolone for 4 months presented with history of fever with chills, productive sputum, pleuritic chest pain, exertional breathlessness, anorexia and was found to have signs of pneumonia clinically on the right side. She also gave history of gradual painful diminution of vision in her left eye and two episodes of generalized tonic clonic seizures just prior to admission. Despite empirical treatment with antibiotics, her condition gradually deteriorated. A computer tomography – thorax (HRCT), showed linear and nodular opacities in right middle lobe segments and right medial basal segment along with homogenous opacity with multiple cavitations noted in the lower lobe of right lung with air bronchogram. MRI- brain showed multiple conglomerate foci of ring enhancing lesions with moderate surrounding edema seen in bilateral cerebral hemispheres, irregular thickening of choroid seen in left eye with hyperintense vitreous cavity showing blooming. CSF did not show any abnormality. Nocardia farcinica was isolated from the vitreous. Diagnosis of Disseminated nocardiosis involving lungs, brain and left eye was made.

Acute Pneumonitis after instillation of Povidone iodine for Chemical Pleurodesis in Secondary Spontaneous Pneumothorax: A case report

Secondary spontaneous pneumothorax is common in adult and is often life threatening. Surgical intervention is preferred, however chemical pleurodesis is also widely recommended in the treatment of recurrent pneumothorax of different etiologies. Variety of agents such as erythromycin, tetracycline, autologous blood and talc slurry are available for chemical pleurodesis among which povidone iodine is cheap, easily available, effective and safe. In this paper, we report the case of acute pneumonitis after pleurodesis using povidone iodine in a 33 years old female with a known case of lymphangioleiomyomatosis with a history of recurrent pneumothorax.
 Chemical pleurodesis was performed using povidone iodine after complete expansion of lung and absence of persistent air leak which was confirmed clinically and radiologically. Post procedure, the patient complained of right sided chest pain and cough. Fever, sputum production and shortness of breath was absent. Chest X-ray revealed new consolidation and infiltrations in the right middle zone. Subsequent CT chest showed extensive parenchymal consolidation and ground glass opacities in the right middle lobe, representing pneumonia with acute lung injury.
 The acute pneumonitis spontaneously resolved with supportive care and the patient was discharged after seven days. Though drug induced pneumonitis is not a usual complication of povidone iodine, it is a possibility and has to be considered.

Diabetic Ketoacidosis Precipitated by COVID-19: A Case Report

Introduction: Diabetic emergencies such as diabetic ketoacidosis (DKA) are life-threatening complications, often precipitated by infections or illnesses such as COVID-19. Case presentation: A 55-year-old African American female presented to their primary care physician, complaining of fatigue, dehydration, decreased appetite, hypersomnia, and sudden weight loss, and a past medical history of Type 2 diabetes. They had a glucose level of >15 mmol/L and ketone level of >16 mmol/L; they were immediately sent to the emergency department for assessment of DKA. There, the patient tested positive for COVID-19. They had a glucose level of 361 mg/dL, a pH of 7.11, a bicarbonate level of 10 mEq/L, a sodium level of 125 mEq/L, a potassium level of 3.9 mEq/L, a chloride level of 95 mEq/L, an anion gap of 20, and a positive ketone level. Over the next few days, the patient’s condition got worse; their chest CT scan showed ground-glass opacities with consolidations in the middle and inferior lobes of the lungs bilaterally, along with interlobular septal thickening, which are consistent with an atypical infection, respiratory distress, and pneumonia. The patient was on intravenous fluids, insulin therapy and empirical antibiotics for the next few weeks, and eventually recovered. Discussion: Factors precipitating DKA in patients with diabetes in the setting of COVID-19are: the increased secretions of stress hormones that counter the effects of insulin and increase blood glucose levels, and the ways in which severe acute respiratory syndrome coronavirus 2 interacts with human cells, leading to pancreatic islet cell damage. Conclusion: Diabetes and COVID-19 intensify each other’s complications in patients diagnosed with both.

Altered Spontaneous Brain Activity Patterns of Meibomian Gland Dysfunction in Severely Obese Population Measured Using the Fractional Amplitude of Low-Frequency Fluctuations.

ObjectiveUtilizing the fractional amplitude of low-frequency fluctuations (fALFF) technique, this study sought to correlate spontaneous cerebral abnormalities with the clinical manifestations of meibomian gland dysfunction (MGD) in severely obese (SO) population.Subjects and MethodsTwelve MGD patients in SO population (PATs) (4 males and 8 females) and twelve healthy controls (HCs) (6 males and 6 females) matched by gender and age were enrolled. Every participant underwent resting-state functional magnetic resonance imaging (rs-MRI) scanning. Spontaneous cerebral activity alterations were examined using the fALFF method. Receiver operating characteristic (ROC) curves were utilized to classify the medial fALFF values of the PATs and HCs. PATs were also asked to complete anxiety and depression score forms, permitting a correlation analysis.ResultsIn contrast with HCs, PATs had prominently increased fALFF values in the left lingual gyrus, the right globus pallidus, the right anterior cingulate and paracingulate gyri and the left middle occipital lobe (P < 0.05), and decreased fALFF values in the right cerebellum, the left fusiform gyrus, the right medial orbitofrontal gyrus, the left triangle inferior frontal gyrus and the left inferior parietal gyrus (P < 0.05). The results of the ROC curve indicated that changes in regional fALFF values might help diagnose MGD in SO population. Moreover, fALFF values in the right cerebellum of PATs were positively correlated with hospital anxiety and depression scores (HADS) (r = 0.723, P = 0.008). The fALFF values in the left triangle inferior frontal gyrus of PAT were negatively correlated with HADS (r = −0.651, P = 0.022).ConclusionsAberrant spontaneous activity was observed in multiple regions of the cerebrum, offering helpful information about the pathology of MGD in SO population. Aberrant fALFF values in these regions likely relates to the latent pathologic mechanisms of anomalous cerebral activities in PATs.

Endobronchial Chondroma: A Rare Case of Benign Tumor With Atypical High Standardized Uptake Value

Chondroma is a rare benign tumor of the cartilage and occurs in the tracheobronchial tree, either isolated or as part of the Carney triad. It has been sparsely described in the literature, and some were mislabeled as hamartomas. We herein report a case of a 63-year-old female who was initially treated for community-acquired right middle lobe pneumonia. However, the patient's symptoms persisted warranting further workup, which confirmed the diagnosis of post-obstructive pneumonia. Whole-body positron emission tomography (PET) scan showed a hypermetabolic soft tissue lesion within the middle lobe bronchus, with a standardized uptake value (SUV) of 5.4, which is highly concerning for a primary or a secondary lesion. Since no distant lesions were identified, the patient underwent bronchial sleeve lobectomy of the right middle lobe under the assumption of localized disease. Pathology revealed chondroma, which had an unexpectedly high SUV on the PET scan; follow-up imaging denied any recurrence. Our case presents a rare entity of bronchial tumors with high SUV that presented with post-obstructive pneumonia. The patient's consent for writing this report was obtained.

Acute haemothorax and pleuropulmonary blastoma: Two extremely rare complications of extralobar pulmonary sequestration

Extralobar bronchopulmonary sequestration (eBPS) is a congenital lung malformation characterized by non-functional lung tissue with no connection with the bronchial tree, receiving systemic blood supply and covered by its own visceral pleura. It is mostly asymptomatic, however it can rarely get complicated with infections and neoplastic degeneration. Its management is still debated: many authors suggest observation for asymptomatic cases and intervention only in case of symptoms, others advocate surgery even in asymptomatic patients. Pleuropulmonary blastoma (PPB) is a rare malignant sarcomatous neoplasm, representing the most common primary lung malignancy in children. Typically, PPB is associated with congenital pulmonary airway malformation (CPAM). eBPS is rarely associated with PPB. We report a case of a previously healthy three-year-old boy presented to our emergency room with massive hemothorax after a low-energy chest trauma. Imaging revealed active thoracic bleeding by an anomalous artery arising from the celiac tripod, and an irregular mass in the lower right hemithorax. After performing biopsy, pathologic examination revealed a PPB. The patient underwent four cycles of chemotherapy before surgery. The operative findings revealed a right supradiaphragmatic extralobar mass, with no communication with the bronchial tree, strictly adherent to the right middle lobe. After mass excision, histological analysis confirmed the diagnosis of PPB type 2. The patient underwent postoperative chemotherapy. No recurrence nor metastasis were noted during the current follow-up. DICER-1 research revealed biallelic mutation on the tumor and on the surrounding normal tissue. We reviewed the literature concerning PPB and BPS. Based on these data, we would recommend intervention even in case of asymptomatic eBPS.

Pathology Encountered During Cadaver Dissection Provides an Opportunity for Case‐based Learning

Dissection based anatomy education engages medical students in building several skills, including professionalism, problem solving, and critical thinking. During the first semester of medical school at Oakland University William Beaumont (OUWB) School of Medicine, students spend a significant amount of time dissecting and learning anatomy regionally. In addition to viewing typical structures throughout the body, cadaveric dissection also allows for the opportunity to discover and learn from pathology that may be encountered. In this case, students observed a malignant tumor (adenocarcinoma) in the right lung, accompanied by severe fibrosis of the right diaphragmatic parietal pleura. The superior, middle, and inferior lobes of the right lung were significantly reduced in size within the thoracic cavity compared with the left lung. Additionally, several gross malformations in the pulmonary tissue and cavity were observed, likely due to the malignancy. As part of this analysis, histopathology and radiology for the malignant lung tumor will be compared and reviewed against normal lung tissue and mechanisms for adenocarcinoma will be discussed. These will be used to develop a case study to facilitate peer teaching. This case provides a valuable opportunity for medical students at OUWB to connect basic anatomy to clinical presentation and develop a deeper understanding of pathophysiology of disease prior to clinical rotations.

Hypogenetic Right Lung with Partial Anomalous Pulmonary Venous Return (PAPVR) Without the Typical Features of “Scimitar” Sign

The partial anomalous pulmonary venous return (PAPVR) aka partial anomalous pulmonary venous connection (PAPVC), is a rare congenital cardiovascular condition in which some of the pulmonary veins, drain into the systemic circulation (Halasz, 1956). While congenital, there is no known cause was attributed for these conditions and may possibly be multifactorial in origin. Scimitar syndrome, first described by Raoul Chassinat in 1836, is a variant of the PAPVR and PAPVC characterized by an abnormal pulmonary venous return of the right lung into the inferior vena cava or right atrium via the superior vena cava (SVC), thus a left‐to‐right shunt. Hypoplasia of the pulmonary arteries and abnormal bronchial branching accompany this syndrome and the abnormal venous drainage involves the right side.This report is based on the cadaveric dissection of a 71‐year old Caucasian male donor who died of chronic obstructive pulmonary disease/hypertension. We noted a faint incisional scar on the thorax, there was an incision extending from the parasternal region at the 4th intercostal level to the midaxillary line. Considering the straight‐line incision followed the ribs and the faintness of the scar was faint, we believe the surgery was done when the donor was young. We also observed numerous surgical interventions of the heart, lungs and vasculature to correct various defects.The morphology of the heart was normal, but was shifted more to the right side. An atrial septal defect (ASD) was closed with sutures. The right superior pulmonary vein that drained into the SVC was ligated close to the SVC. We noticed a dilated coronary sinus entering the right atrium adjacent to the ASD and the ostium of the coronary sinus noticeably lacked the normal valve like structure. We initially thought the right lung was a “horseshoe” lung but realized that it was a “hypogenetic” lung with PAPVR and an accessory diaphragm. The right secondary bronchi were much narrower compared to the left and branched uncharacteristically as seen in hypogenetic lung syndrome. The inferior lobe was highly disorganized, severely hypoplastic and exhibited uncharacteristic morphology. The superior bronchopulmonary segment was markedly hypoplastic. The medial basal segment was not only hypoplastic and slender but extended like a tail to the left pulmonary cavity behind the heart/pericardium and in front of esophagus and aorta. The right lung though hypoplastic, demonstrated patent bronchi and the lobes were inflatable. The superior pulmonary vein from the right upper and middle lobes drained directly into the SVC and the inferior right pulmonary vein from the lower lobe drained into the left atrium. The left superior and inferior pulmonary veins drain directly into the left atrium.The poster will illustrate numerous images as described in our results, discuss the embryology of pulmonary veins, hypogenetic lung, “scimitar” syndrome and accessory diaphragm. To sustain life, all the defects were corrected in childhood which allowed the donor to live for 71 years.

Cysteinyl–leukotriene and prostaglandin pathways in bronchial versus alveolar lavage in allergic asthmatics

Cysteinyl–leukotriene and prostaglandin pathways in bronchial versus alveolar lavage in allergic asthmatics

Prognosis of lung cancer with simple brain metastasis patients and establishment of survival prediction models: a study based on real events

ObjectivesThe aim of this study was to explore risk factors for the prognosis of lung cancer with simple brain metastasis (LCSBM) patients and to establish a prognostic predictive nomogram for LCSBM patients.Materials and methodsThree thousand eight hundred and six cases of LCSBM were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 using SEER Stat 8.3.5. Lung cancer patients only had brain metastasis with no other organ metastasis were defined as LCSBM patients. Prognostic factors of LCSBM were analyzed with log-rank method and Cox proportional hazards model. Independent risk and protective prognostic factors were used to construct nomogram with accelerated failure time model. C-index was used to evaluate the prediction effect of nomogram.Results and conclusionThe younger patients (18–65 years old) accounted for 54.41%, while patients aged over 65 accounted for 45.59%.The ratio of male: female was 1:1. Lung cancer in the main bronchus, upper lobe, middle lobe and lower lobe were accounted for 4.91%, 62.80%, 4.47% and 27.82% respectively; and adenocarcinoma accounted for 57.83% of all lung cancer types. The overall median survival time was 12.2 months. Survival rates for 1-, 3- and 5-years were 28.2%, 8.7% and 4.7% respectively. We found female (HR = 0.81, 95% CI 0.75–0.87), the married (HR = 0.80; 95% CI 0.75–0.86), the White (HR = 0.90, 95% CI 0.84–0.95) and primary site (HR = 0.45, 95% CI 0.39–0.52) were independent protective factors while higher age (HR = 1.51, 95% CI 1.40–1.62), advanced grade (HR = 1.19, 95% CI 1.12–1.25) and advanced T stage (HR = 1.09, 95% CI 1.05–1.13) were independent risk prognostic factors affecting the survival of LCSBM patients. We constructed the nomogram with above independent factors, and the C-index value was 0.634 (95% CI 0.622–0.646). We developed a nomogram with seven significant LCSBM independent prognostic factors to provide prognosis prediction.

Aberrant mediastinal mediobasal segmental pulmonary artery in a patient with lung cancer undergoing right lower lobectomy: a case report

BackgroundA mediastinal mediobasal segmental pulmonary artery (A7) from the right main pulmonary artery is extremely rare.Case presentationWe report the case of a 71-year-old woman with an aberrant mediastinal A7 who underwent right lower lobectomy for lung cancer (cT1bN0M0, stage IA2). Preoperative three-dimensional computed tomography (CT) angiography revealed an aberrant mediastinal A7 in the right main pulmonary artery. Right lower lobectomy and mediastinal lymph node dissection were performed. Intraoperatively, A7 was observed between the superior and inferior pulmonary veins and in the front of the lower bronchus near the anterior hilum. The artery was carefully dissected from the caudal side after inferior pulmonary vein dissection. The lung parenchyma, which was within the fissure due to poor lobulation between the middle and lower lobes, was safely divided.ConclusionsThoracic surgeons need to carefully evaluate CT angiography or enhanced multidetector CT findings at preoperative conferences and always keep this anomaly in mind.

The deadliest lung lobe in COVID-19: a retrospective cohort study of elderly patients hospitalized for COVID-19

Introduction The relationship between which lung lobe is affected on the chest X-ray (CXR) performed at the Emergency Department (ED) and mortality from COVID-19 has not been studied. With this in mind, the present study aimed to discern which lung lobe was the one with the highest associated mortality rate in the elderly population. Methods Information was collected from the 2020 hospital admissions records of our hospital. Our cohort consists of 300 admissions. Results The presence of the left lower lobe (RR = 1.6; 95% CI: 1.1-2.4) and right middle lobe involvement (RR =1.8; 95% CI: 1.2-2.7) on CXR at the ED were both predictive factors of in-hospital mortality. Right middle lobe involvement on CXR at the ED was the risk factor with the highest relative risk value (RR = 1.8). Furthermore, right middle lobe involvement on CXR at ED was a predictor for persistent organ failure (RR = 1.7; 95% CI: 1.2-2.3), respiratory failure (RR = 1.7; 95% CI: 1.2-2.4) and acute kidney injury (RR = 1.5; 95% CI: 1.2-2). The isolated right middle lobe involvement on CXR at ED was a risk factor for in-hospital mortality (RR = 2.6; 95% CI = 1.8 - 3.7). However, the affected right middle lobe along with another/other lobe/s was a null factor. Conclusion Right middle lobe involvement was an independent predictor of in-hospital mortality.