Middle Lobe Of Lung Research Articles

Suspected spontaneous idiopathic pulmonary pneumo‐haematocele in a dog

AbstractAn 8‐year‐old male neutered Rottweiler was presented to the local veterinary practice for ongoing cough of one‐week duration, intermittent retching and haemoptysis. Medical treatment dispensed by the referring veterinarian achieved mild improvement in the cough and resolution of haemoptysis for approximately six weeks.Referral was arranged eight weeks after onset of clinical signs, due to relapse of haemoptysis. Computed tomography (CT) and ultrasonography of the thoracic cavity revealed a fluid and air‐filled cystic lesion in the right middle lung lobe. Bronchoscopy showed collapse of the right middle bronchus and bronchioles. A right middle lung lobectomy was performed via right intercostal thoracotomy.Postoperatively, the patient recovered well and was discharged from hospital three days afterwards. Long term recovery was excellent, and histology results were consistent with an air‐blood filled bulla, with no evidence of foreign material, abscess or neoplasia. A tentative diagnosis of spontaneous idiopathic pulmonary pneumo‐haematocele was made.

ACTH-Dependent Cushing’s Syndrome in an Elderly Woman with Pituitary, Adrenal, and Intrathoracic Lesions

A 77-year-old female with rheumatoid arthritis on etanercept, depression on venlafaxine, and treated hypothyroidism presented with easy bruising and muscle weakness. She denied any steroid use. She had normal BP and BMI, but appeared mildly Cushingoid with round facies, and increased dorsocervical and supraclavicular fat.Laboratory evaluation showed: ACTH 70.8 pg/mL (< 63.3), cortisol 24.3 ug/dL, 24 h urine free cortisol 223 ug (< 50), salivary cortisol 0.428 ug/dL, DHEA-S 165.7 ug/dL (< 142.8), LH 0.1 mIU/mL, FSH 2.7 mIU/mL, and hgbA1C 6.1 % (< 5.6 %). All other hormonal testing was normal. MRI of the pituitary showed a 4 x 2 x 3 mm hypoenhancing defect of the anterior pituitary. CT of the chest and abdomen showed a 1.1 cm left adrenal nodule, and a 1 cm non-specific right middle lobe lung nodule. Inferior petrosal sinus sampling (IPSS) with CRH did not show a central ACTH step-up. PET/CT with DOTATATE showed mildly increased tracer uptake in the right middle lobe measuring 1 cm with SUV max 3.7, and a 0.6 cm left apical subpleural nodule with SUV max 1.9.The patient underwent a right middle lobectomy and pathology was positive for typical carcinoid. Post-operatively, she needed hydrocortisone replacement for 9 months. ACTH was 19.7 pg/dL, cortisol 9.5 ug/dL, DHEA-S 31.3 ug/dL, LH 61.8 mIU/mL, and FSH 112.4 mIU/mL. Her Cushingoid features and myopathy resolved.This case highlights several challenges in the diagnosis and source localization in patients with ACTH-dependent Cushing’s Syndrome (CS). In this slim, elderly female, the typical features of CS were subtle. In addition, dynamic biochemical testing with high dose dexamethasone does not reliably distinguish eutopic from ectopic ACTH-dependent CS, as the sensitivity and specificity range from 60–80%. Thus, the diagnosis largely depends on sophisticated imaging and IPSS.The patient had pituitary, adrenal, and lung lesions. The pituitary lesion initially pointed towards a central ACTH source, but IPSS was negative. The prevalence of pituitary incidentalomas is high, at 10.6% based on autopsy data, with an increasing proportion being recognized in the elderly. Adrenal incidentalomas are also often noted in older individuals, but that was clearly not the cause of CS in this patient with a non-suppressed DHEA-S and elevated ACTH. PET/CT with DOTATATE has emerged as a sensitive test for the detection of often small tumors producing ectopic ACTH and was positive in the lung lesion. In spite of newer localization techniques, the source of ectopic ACTH often remains unidentified (12.5% in a large retrospective case-record study). False negatives on PET/CT with DOTATATE imaging may be due to cortisol’s suppressive effect on the somatostatin receptor expression in neuroendocrine tumors. Thus, in cases of ACTH-dependent CS with negative IPSS, ectopic ACTH must remain as a likely source, and be re-explored after medical treatment of the hypercortisolism.

A Case of Carney Triad Complicated by Renal Cell Carcinoma and a Germline SDHA Pathogenic Variant

Background: Carney triad is a rare multiple-neoplasia syndrome presenting as an association of paragangliomas (PGL), gastrointestinal stromal tumors (GIST), and pulmonary chondromas (CHO). Succinate dehydrogenase deficiency has been associated with several neoplasias, including Carney triad, renal cell carcinoma (RCC) and those associated with hereditary PGL/ pheochromocytoma (PHEO) syndromes. Clinical Case: A 57-year-old male diagnosed with hypertension at age 49, presented with a gradual increase in blood pressure over a period of 12 months. For seven years following his diagnosis of hypertension, the patient experienced episodic increases in blood pressure, to a systolic pressure greater than 180 mmHg associated with a tight band sensation around his forehead lasting half a day. Abdominal computed tomography (CT) revealed a left adrenal adenoma, a 5.1 cm para-aortic mass, and a right renal superior pole lesion measuring 2.5 cm, which was suspicious for a carcinoma. 123I-metaiodobenzylguanidine (123I-MIBG) and 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) scans were performed, which suggested the para-aortic mass to be consistent with a PGL. Additionally, 18F-FDG uptake was noted in the gastroesophageal region and was suspicious for a GIST. The left adrenal mass was not associated with 123I-MIBG or 18F-FDG activity. Chest CT demonstrated a right middle lobe lung lesion suggestive of a CHO, although no biopsy was performed. A diagnosis of Carney triad was made. The patient underwent surgical resection of the PGL and GIST, as well as a partial right nephrectomy. The PGL and GIST were positive for SDHA and negative for SDHB by immunohistochemical (IHC) staining. Pathology from the renal lesion was consistent with a 2.3 cm conventional clear cell renal carcinoma, with positive staining for SDHA and SDHB by IHC. The patient was found to harbor a germline heterozygous pathogenic variant (c.91 C>T, p.R31X) in SDHA which has been previously reported and results in loss of function of SDHA. SHDC hypermethylation was not detected in the PGL, GIST, or RCC. Additionally, DNA sequencing of the RCC did not indicate loss of heterozygosity at the variant region of interest. Although the SDHA disease-causing variant is responsible for the patients Carney triad phenotype, it is unclear if this variant is causative of the RCC. Conclusion: This is a novel presentation of a germline inactivating SDHA pathogenic variant in a patient with Carney triad complicated by RCC. However, an SDHA disease-causing variant was previously reported in a patient with comorbid GIST and RCC. This case provides further support to the increasing evidence that SDHx pathogenic variants may predispose patients to develop renal neoplasms.

Occlusion with Bronchial Covered Stent in the Management of Bronchial Stump Fistula after Right Middle and Lower Lobectomy: A Case Report and Literature Review

背景与目的支气管胸膜瘘是临床上较为严重且罕见的术后并发症之一，尤其是肺叶/全肺切除术后支气管残端瘘，处理起来较为棘手。常见治疗方案包括内科保守治疗联合外科手术，但由于瘘口迁延不愈导致胸腔持续与外界相通，患者容易合并严重的胸腔感染及呼吸衰竭等合并症，以至于身体状况无法耐受二次手术。而内镜下治疗，为该合并症的治疗提供了新的思路。方法回顾性分析了北京大学肿瘤医院胸外二科2016年6月收治的1例右肺鳞癌患者的诊断、治疗过程，并文献复习。结果患者男性，65岁，因“咳嗽伴痰中带血3月余”入院，胸部计算机断层扫描提示右肺下叶软组织密度肿块影，气管镜提示右肺中叶及下叶基底段开口可见肿物，活检病理证实为鳞癌。诊断考虑：右肺中下叶鳞癌(cT2aN2，IIIa期)。患者接受了吉西他滨+顺铂方案新辅助化疗2个周期，评效为疾病稳定(stable disease, SD)。末次化疗结束4周之后，患者接受了胸腔镜辅助右肺中下叶切除、纵隔淋巴结清扫术。术后第5天患者出现急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)再次气管插管转入重症加强护理病房(intensive care unit, ICU)，并给予激素冲击治疗。术后第7天患者出现右肺中间干支气管残端瘘，但由于合并ARDS，患者身体情况无法耐受二次手术。遂于体外人工膜肺(extracorporeal membrane oxygenation, ECMO)支持下，经硬质支气管镜在中间干支气管残端置入一枚定制的覆膜、可膨胀金属铰链支架，并成功封堵。由于患者的ARDS未见好转，出现不可逆的肺间质纤维化，经过系统的抗感染治疗之后，患者成功接受了双肺移植手术。结论内镜下放置覆膜支架是一种简单、安全、有效的支气管残端瘘闭合术。当患者的临床情况不适合立即手术时，内镜下支架植入可作为一种优选的治疗方法，为后续治疗创造机会。

Gross morphology of the African lion (Pantheraleo) heart

AbstractThe anatomy of the African lion heart is not well documented, and assumptions are made that the anatomy is comparable to that of the domestic cat. The increasing demand for veterinary intervention in the African lion warrants sound anatomical knowledge of the heart. The heart is situated caudal to the thoracic limbs between ribs 4 and 6. It is covered by the left cranial lung lobe, and cranial and middle lobe of the right lung, respectively, with a prominent cardiac incisure present on the right. Two pericardial ligaments are present, the A. coronaria dextra is dominant, and the Atrium dextrum and Auricula dextra possess a vast network of Mm. pectinati. The massive thoracic limbs, adapted to bring down prey, appear to restrict the cranial thoracic cavity, and as a trade‐off, the thoracic viscera are situated more caudally. During intense activity, the heart and lungs compete against each other for space, thus limiting physical activity to short, intense periods. Capacity for sudden increase of cardiac output is facilitated by the extensive Mm. pectinati of the Atrium dextrum. Intracardiac injection is recommended on the right, ventrally in intercostal space 5. The two pericardial ligaments may help to stabilize the heart during intense activity.

Electroacupuncture improves lung function by suppressing mucin-5AC mediated EGFR-p38MAPK signaling and inflammation reaction in chronic obstructive pulmonary disease rats

To observe the effect of electroacupuncture (EA) at "Zusanli"(ST36) on the expression of epidermal growth factor receptor (EGFR), tumor necrosis factor α(TNF-α) transfer growth factor α(TGF-α), interleukin-8(IL-8), p38 mitogen-activated protein kinases (p38MAPK), mucin-5AC (MUC5AC) and other related factors in chronic obstructive pulmonary disease (COPD) rats, so as to reveal its underlying mechanisms in improving COPD. A total of thirty male SD rats were randomly divided into normal control, model and EA groups, with 10 rats in each group. The COPD model was replicated using a combined method of tracheal infusion of lipopolysaccharide (LPS) and forced smoke-inhaling. EA (1-3 mA, 4 Hz/20 Hz) was applied to bilateral ST36 for 30 min, once daily for two consecutive weeks. The lung ventilation activities including the forced vital capacity (FVC) and forced expiratory volume (FEV) at 0.1 and 0.3 s (FEV0.1, FEV0.3) were detected. Histopathological changes of the middle lobe and bronchus of the right lung were observed after H.E. staining. The contents of TGF-α, TNF-α and IL-8 in the serum, bronchoalveolar lavage fluid (BALF) and superior lobe of the right lung were assayed by using ELISA, and the expression levels of EGFR, p38MAPK and MUC5AC proteins (inferior lobe of the left lung) and mRNAs (inferior lobe of the right lung) detected using Western blot, immunohistochemistry (strept avidin-biotin complex, SABC method) and real-time quantitative PCR, respectively. Compared with the normal group, the FVC, FEV0.1, FEV0.3, FEV0.1/FVC and FEV0.3/FVC levels were significantly decreased (P<0.01), while the contents of TNF-α, TGF-α and IL-8 in the serum, BALF and lung tissues, expression levels of EGFR, p38MAPK and MUC5AC mRNAs and proteins, and the immunoactivity of EGFR, p38MAPK and MUC5AC in the lung tissues were significantly increased in the model group (P<0.01). After EA intervention, the decreased levels of the FVC, FEV0.1, FEV0.3, FEV0.1/FVC and FEV0.3/FVC, and the increased levels of the abovementioned genes and proteins were all reversed in the EA group (P<0.01, P<0.05). After modeling, the bronchial walls were thickened, with enlarged alveolar cavities, fractured alveolar walls, obvious inflammatory cell infiltration, and rich mucus secretion in the lumen, which was relatively milder in the EA group. EA of ST36 can improve the ventilation function in COPD rats, which may be associated with its function in down-regulating the levels of TNF-α, TGF-α, IL-8, EGFR, p38MAPK and MUC5AC mRNAs and proteins in the lung tissues, inhibiting EGFR-p38MAPK signaling mediated expression of MUC5AC.

Correlation Between Pulmonary Sclerosing Pneumocytoma Features and MSCT Imaging Manifestations in 34 Patients: Implications for Precision Medicine.

Objective: To identify and analyze the multi-slice computed tomography (MSCT) imaging manifestations and clinicopathological features of PSP to improve the preoperative and intraoperative diagnosis of the disease.Method: This was a retrospective study conducted on the imaging and clinicopathological data of the PSP patients treated in two major hospitals in China from October 2001 to December 2019. The locations of lung lesions, clinical symptoms, surgical complications, MSCT imaging features, and the corresponding relationship with clinicopathological features were assessed. Then, a new diagnostic approach was defined and used to train imaging and pathological doctors (experimental group). Then, the diagnostic accuracy of the experimental group was evaluated in preoperative and intraoperative diagnosis of PSP.Results: Thirty-four PSP cases were analyzed (mean: 51.42; range: 39–69 years old). The peripheral type was more common, while 92% of the lesions located in the middle lobe of the right lung and the lower lobe of bilateral lungs. The shortest lesion edge-pleura distance ranged 0 to 30 mm and 46% of the lesions (16/34) were attached to the pleura, 62% (21/34) located at 0–5 mm, 92% (31/34) within 20 mm from the pleura. Diameters of the lesions ranged 8.58 to 68.41 mm, while most of them were 20-40 mm. All lesions showed enhancement, and 97% (33/34) were unevenly enhanced. PSP volume was negatively correlated with the total degree of enhancement (r = −0.587, p < 0.01), and the volume difference between the obvious enhancement zone and the slight enhancement zone (r = −0.795, p < 0.01). Welt vessel sign was observed in 61.7% (21/34) of cases, and none of welt vessels entered into the lesions. Vascular-like enhancement area inside the lesion showed no significant correlation with the welt vessels outside the lesion, and no case showed entrance of bronchus into the lesion. The trained experimental group showed significantly greater diagnostic accuracy than the control group. In particular, the accuracy rate of intraoperative frozen section diagnosis was 60% higher in the experimental group than the control group.Conclusion: PSP has characteristic imaging manifestations, which can be utilized to improve the preoperative and intraoperative diagnostic coincidence rate of PSP.

Short communication: Diagnostic accuracy of focused lung ultrasonography as a rapid method for the diagnosis of respiratory disease in dairy calves

This study estimates the accuracy of the focused lung ultrasound (FLUS) compared with systematic thoracic ultrasonography (TUS) as the reference test for diagnosing pneumonia in pre- and postweaned dairy calves. One hundred thirty-five Holstein Friesian calves, aged between 1 to 6 mo were enrolled and were kept in the same pen with one or more animals showing signs of bovine respiratory disease complex (BRDC). One operator performed FLUS on each calf, and then a second, blinded operator performed TUS on the same calf. For the FLUS, we only scanned the lung lobes that are most frequently affected during BRDC and are thus easier to detect, such as the caudal aspect of the cranial lobe of the left lung (fifth and fourth left intercostal spaces; ICS), the middle lobe of the right lung (fifth right ICS), and the caudal aspect of the cranial lobe of the right lung (fourth right ICS). Pneumonia was diagnosed when a calf had a minimum of one small lobular lung lesion that was at least 1 cm deep within a normally aerated lobe (TUS score of ≥2). Diagnostic accuracy indexes of the FLUS were calculated using TUS as the gold standard. The McNemar test was performed to evaluate the differences between the 2 techniques. In addition, an intertest agreement was assessed using the weighted kappa test. A total of 76 out of 135 calves had a TUS score of ≥2 and were therefore considered to be affected by BRDC. The FLUS had a sensitivity of 81.6% (95% CI = 71.0-89.5%), specificity = 100% (95% CI = 93.9-100%), positive predictive value was 100%, negative predictive value was 96.6% (95% CI = 94.7---97.9%), and accuracy was 97% (95% CI = 92.6-99.2%). The McNemar test highlighted a difference of 10.3% between the FLUS and TUS. The agreement between the TUS and FLUS was substantial (weighted kappa test 0.78). Although FLUS shows some limitations in diagnosing lung lesions associated with BRDC compared with the systematic approach, this study shows that the focused method could be used as an additional tool for evaluating consolidation, especially when examining a large number of postweaned dairy calves.

Intestinal Tuberculosis or Crohn's Disease: A Diagnostic Challenge Case Report

Background and Aim: Crohn's disease is a chronic idiopathic disease in the category of gastrointestinal tract inflammation without any obvious reason. Clinical signs include abdominal pain, and diarrhea, which may be accompanied by a fistula or intestinal obstruction. Differential diagnosis of Crohn's disease and intestinal tuberculosis is a complex and difficult challenge. Case presentation: The patient was a 70-year-old woman who had been hospitalized due to fistulas with 4 years of discharge in the left inguinal and gluteal area. The patient's vital signs were stable, and she did not report any fever, chills, or gastrointestinal symptoms. Diagnostic tuberculosis procedures were performed for this patient and despite the lack of evidence in favor of intestinal tuberculosis, experimental tuberculosis treatment was started for him. Despite 10 months of anti-tuberculosis treatment, the symptoms and fistulas of the patient did not recover in 2016. On spiral computed tomography scan of the lung and mediastinum without injection, the presence of cardiomegaly, evidence of ground glass was seen along with an increased thickness of the interlobular septa in the middle lobe of the right lung and ground-glass opacities at the base of both lungs. Since the patient had typical intestinal tuberculosis symptoms, discharge cultivation and smear were performed and it did not grow on Mycobacterium tuberculosis bacillus acid staining. The patient underwent biopsy with MR Enterography, and Crohn's diagnosis was confirmed. The patient was treated with Metronidazole, Ciprofloxacin, and a combination of Azathioprine and Infliximab. Conclusion: According to the rare case reported, advanced diagnostic measures should be taken in dealing with patients with intestinal tuberculosis or Crohn disease

Clinicopathological characteristics and survival in lung signet ring cell carcinoma: a population-based study.

ABSTRACTLung signet-ring cell carcinoma (LSRCC) is a very rare type of lung cancer, the clinical characteristics, and prognosis of which remain to be clarified. In order to explore the clinicopathological and survival-related factors associated with LSRCC, we performed a large population-based cohort analysis of data included in the Surveillance, Epidemiology, and End Results (SEER) registry from 2001 to 2015. A total of 752 LSRCC and 7518 lung mucinous adenocarcinoma (LMAC) patients were incorporated into our analysis, with respective mean ages of 63.8 and 67.5 years at the time of diagnosis. LSRCC patients were significantly more likely than LMAC patients to have distant-stage disease (72.1% vs. 45.8%, p < 0.0001), tumors of a high pathological grade (40.6% vs. 10.8%, p < 0.0001), have undergone chemotherapy (62.1% vs. 39.9%, p<0.0001), be male (52.7% vs. 48.5%, p = 0.03), and be < 40 years old (3.3% vs. 1.3%, p = 0.022), whereas they were less likely to have undergone surgical treatment (52.4% vs. 77.0%, p < 0.0001). LSRCC and LMAC patients exhibited median overall survival (OS) duration of 8 and 18 months (p < 0.0001), respectively, although these differences were not significant after adjusting for confounding variables. Independent factors associated with a favorable patient prognosis included a primary site in the middle or lower lung lobe, underwent surgery, and underwent chemotherapy. However, age ≥80 years, higher grade, distant summary stage disease, and T4 stage disease were linked to poor prognosis. Patient age, tumor grade, primary tumor site, summary stage, T stage, surgery, and chemotherapy were all significantly associated with LSRCC patient prognosis.

Recurrence of a neuroendocrine tumor of adrenal origin: a case report with more than a decade follow-up

BackgroundNeuroendocrine tumor (NET) with adrenocorticotropic hormone (ACTH) secretion are very rare. To our knowledge, no follow-up study is published for ACTH-secreting NET, regardless of the primary site, to show second occurrence of tumor after a long follow-up, following resection of primary tumor.Case presentationHere, we describe a 49-year-old-man with cushingoid feature, drowsiness and quadriparesis came to emergency department at December 2005. Laboratory tests revealed hyperglycemia, metabolic alkalosis, severe hypokalemia, and chemical evidence of an ACTH-dependent hypercortisolism as morning serum cortisol of 57 μg /dL without suppression after 8 mg dexamethasone suppression test, serum ACTH level of 256 pg/mL, and urine free cortisol of > 1000 μg /24 h. Imaging showed only bilateral adrenal hyperplasia, without evidence of pituitary adenoma or ectopic ACTH producing tumors. Importantly, other diagnostic tests for differentiating Cushing disease (CD) from ectopic ACTH producing tumor, such as inferior petrosal sinus sampling (IPSS), corticotropin releasing hormone (CRH) stimulation test, octreotide scan or fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan were not available in our country at that time. Therefore, bilateral adrenalectomy was performed that led to clinical and biochemical remission of hypercortisolism and decreased ACTH level to < 50 pg/mL, findings suggestive of a primary focus of NET in adrenal glands. After 11 years uncomplicated follow up, the ACTH level elevated up to 341 pg/mL and re-evaluation showed a 2 cm nodule in the middle lobe of the right lung. Surgical excision of the pulmonary nodule yielded a carcinoid tumor with positive immunostaining for ACTH; leading to decrease in serum ACTH level to 98 pg/mL. Subsequently after 7 months, serum ACHT levels rose again. More investigation showed multiple lung nodules with metastatic bone lesions accompanied by high serum chromogranin level (2062 ng/mL), and the patient managed as a metastatic NET, with bisphosphonate and somatostatin receptor analogues.ConclusionThis case of surgically-treated NET showing a secondary focus of carcinoid tumor after one decade of disease-free follow-up emphasizes on the importance of long-term follow-up of ACTH-secreting adrenal NET.

&lt;i&gt;Legionella &lt;/i&gt;Causing Lung Abscess in an Immunocompetent Patient

Legionella lung abscess (LLA) is known to develop from pneumonia and Legionnaires’ disease in immunocompromised patients and aspiration. Literature review showed reports of aspiration pneumonia in immunocompetent patients; however, no such was found between LLA and immunocompetency. A 53-year-old male with history of depression and paraumbilical hernia presented for chest pain, which was right sided, started acutely, constant, radiated to the back, and exaggerated with taking deep breaths. The patient denied all other symptoms. Social history was only pertinent for being an active 35 pack-year smoker. The patient was recently admitted one month ago for viral meningitis from Echovirus. On physical exam, the patient was vitally stable, had absent breath sounds in the right middle lobe, and was significantly tender at the right anterior chest. Labs revealed elevated sedimentation rate and C-reactive protein. Imaging demonstrated a right middle lobe lung abscess. Throughout the hospital course, Legionella pneumophila serogroup 1 (LPS1) was found to be positive on urine antigen, sputum polymerase chain reaction, and sputum cultures. The patient was switched to intravenous levofloxacin and ampicillin-sulbactam. Upon symptomatic resolution, the patient was discharged home with recommendations for a follow-up chest computed tomography and diagnostic bronchoscopy. We hypothesize that smoking causes neutrophilic stasis within the lung and the development of the LLA. Treatment includes intravenous long term antibiotics and possibly drainage.

Anomalous drainage of the caudal vena cava into the left atrium and duplication of the posthepatic caudal vena cava in a cat diagnosed with CT

A six‐year and six‐month‐old male neutered British Shorthair cat was referred for investigation of chronic thrombocytopenia and anaemia. On presentation, the cat was dull; however, physical examination was otherwise unremarkable. Complete blood count revealed moderate regenerative anaemia and thrombocytopenia. Serum biochemistry revealed hyperglycaemia. Thoracic radiographs showed two soft tissue opaque masses in the right cranial to mid thorax and in the left caudal lung lobe. CT revealed a multicameral soft tissue attenuating mass in the right cranial and middle lung lobes and an abnormal region of soft tissue attenuation in the left caudal lung lobe. It also revealed anomalous drainage of the caudal vena cava into the left atrium, generalised pulmonary vascular congestion, duplication of the posthepatic caudal vena cava and a suspect gastrophrenic portosystemic shunt.

NOCARDIOSIS PRESENTING LIKE A METASTATIC LUNG CANCER

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Nocardia is a gram-positive, weakly acid-fast, branching rod which is ubiquitous environmental saprophytes that cause localized or disseminated disease in both immunocompetent and immunocompromised patients. We present here a case of a 55-year-old male who was found to have right middle lobe lung abscess as well as right cerebellar abscess secondary to disseminated Nocardiosis from the pulmonary source. CASE PRESENTATION: A 55-year-old male with a past medical history of hypertension, hyperlipidemia, migraines, 30 pack-year smoking history, and emphysematous COPD presented to the hospital with 5 days of cough productive of clear sputum, headache and multiple episodes of emesis. He also reported 30 pounds weight loss over the last 1 year due to poor appetite. On presentation, he was hypoxic and tachypneic requiring 5 liters of oxygen by nasal cannula. Physical examination showed a cachectic male with decreased breath sounds bilaterally and crackles in the right lower lung field. The neurological exam showed nystagmus with right-sided gaze and square wave jerks as well as dysdiadochokinesia. Labs showed elevated WBC count at 17.6*10^3 with Neutrophilic pleocytosis. Chest CT showed right middle lobe lung mass, multiple bilateral pulmonary nodules as well as right lower lobe pneumonia. CT head showed right-sided cerebellar mass. Hence an emergent MRI was obtained to assess the mass which showed a large multiseptated cerebellar mass measuring 4.7 * 5.8 * 3.2 cm with mild vasogenic edema centered in the right cerebellar hemisphere crossing midline and producing severe stenosis of the fourth ventricle and resultant obstructive hydrocephalus. The patient was taken to the Operating room STAT and when the right cerebellum was entered a green-tinged fluid started draining which was sent for a culture that grew Nocardia cyriacigeorgica. The patient also had a bronchoscopic biopsy of the right-sided lung mass a day later which also grew the same organism. The patient was initially treated with Intravenous vancomycin, ceftriaxone and levofloxacin for broad-spectrum coverage for pneumonia and after the cultures grew Nocardia was switched to intravenous trimethoprim-sulfamethoxazole and meropenem after infectious disease consultation. However, he failed to respond to the therapy and was made comfort care and passed away. DISCUSSION: Disseminated disease with Nocardia involving brain and lung has been reported in both immunocompromised and immunocompetent patients. However, most of the cases reported in the literature are of elderly patients or immunocompromised patients. As the population of the United States is aging with many patients on immunomodulators it is imperative to raise awareness about disseminated nocardiosis CONCLUSIONS: Physicians must be aware that disseminated nocardiosis can mimic the presentation of metastatic lung carcinoma: early surgical intervention in brain abscess improves outcomes. Reference #1: Karan M, Vučković N, Vuleković P, Rotim A, Lasica N, Rasulić L. Acta Clin Croat. 2019 Sep;58(3):540-545. doi: 10.20471/acc.2019.58.03.20. Reference #2: Schlaberg R, Huard RC, Della-Latta P. Nocardia cyriacigeorgica, an emerging pathogen in the United States. J Clin Microbiol. 2008. Jan;46(1):265–73. 10.1128/JCM.00937-07 Reference #3: Lee GY, Daniel RT, Brophy BP, Reilly PL. Surgical treatment of nocardial brain abscesses. Neurosurgery. 2002. Sep;51(3):668–71, discussion 671–2. 10.1097/00006123-200209000-00010 DISCLOSURES: No relevant relationships by Fazal Raziq, source=Web Response No relevant relationships by Muhammad Usama, source=Web Response

IT LOOKED BLOODY BUT WASN'T: A CASE OF SALMONELLA EMPYEMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Non-typhi Salmonella was isolated from sample of pleural empyema of an immunocompromised patient. The patient was treated with prolonged antibiotic course, thoracotomy with decortication, and chest tube placement; endured complications including chest tube induced pleural cutaneous fistula, subcutaneous emphysema, pneumomediastinum, and persistent hydropneumothorax with trapped lung. Pulmonary salmonellosis is a rare infection that generally occurs with history of gastrointestinal symptoms or enterocolitis and should be considered in patients with immunodeficiency, sickle cell anemia, and lung cancer. CASE PRESENTATION: 57-year-old man with PMH of RA and recurrent right sided pleural effusion (PE) presented with right sided pleuritic chest pain. The patient was septic with a leukocytosis of 15.8 10E3/uL. CT chest showed moderate sized, loculated PE with adjacent passive atelectasis [Figure 2]. A thoracentesis was performed with 650 cc bloody fluid drained. Pleural fluid was exudative with glucose less than 10, pH 6.83, and LDH 1175. A chest tube was placed and pleurolysis initiated. He subsequently underwent right thoracotomy decortication with findings of extensive adhesions, trapped middle and lower lobe lung, and thick chronic rind with no dissection plane. Fluid culture speciated to Salmonella group D and ABX were narrowed to ceftriaxone. He was successfully treated with a 65-day course. DISCUSSION: Salmonella is a gram-negative non-spore forming anaerobic motile bacilli of the Enterobacteriaceae family. Clinical presentation of a Salmonella infection depends on the serotype and ranges from sepsis to gastroenteritis. Non-typhi salmonella organisms often produce a localized reaction, most commonly intestinal infections.1 There have been rare cases of pleuropulmonary infections, which are abrupt in onset without gastrointestinal symptoms in two-thirds of cases and incidence is highest in immunosuppressed patients.2 Pathogenesis is unclear, however it is suggested that Salmonella may rest dormant in the reticuloendothelial system. Blood spread may be a consequence of reactivation however due to low bacterial load, blood cultures are often negative.3 Due to Salmonella organisms’ propensity for prolonged infection a 4 to 12-week course of ABX should be anticipated and include a third-generation cephalosporin or fluoroquinolone. CONCLUSIONS: In patient with relapsing infections, drainage of empyema is likely necessary, with the possibility of decortication. Patients without known preexisting conditions should also undergo further testing for associated immunodeficiency including HIV and malignancy as well as investigation for focal gastrointestinal tract infections and fistulas.Lastly, in the setting of an immunocompromised patient with exudative pleural effusions or empyema, non-typhi Salmonella should be considered as a causative agent and investigated as early as possible. Reference #1: Abuhasna S, Al Jundi A, et al. Non-typhoidal Salmonella group D bacteremia and urosepsis in a patient diagnosed with HIV Infection. Journal of Global Infectious Diseases. 2012;4(4):218. Reference #2: Pathmanathan, S., Welagedara, S., Dorrington, P. et al. Salmonella empyema: a case report. Pneumonia 6, 120–124 (2015). Reference #3: Saeed N. Salmonella pneumonia complicated with encysted empyema in an immunocompromised youth: Case report and literature Review. The Journal of Infection in Developing Countries. 2016;10(04):437-444. DISCLOSURES: No relevant relationships by Sarah Luber, source=Web Response no disclosure on file for David Sharpe; No relevant relationships by Abigayle Sullivan, source=Web Response

Intractable Bronchopleural Fistula After Lung Resection in Mycobacterial Infection; Surgical and Endoscopic Treatment With Fibrin Glue Application Followed by Latissimus Dorsi Musculocutaneous Flap Coverage: A Case Report

Postoperative bronchopleural fistula (BPF) is a challenging and complicated problem to cope with. Involving with multidisciplinary care team is essential for the best outcome. This report provides our experiences in intractable BPF after lung resection surgery which fail to completely heal after received surgical and endoscopic treatment. A 56-year-old female with no known underlying disease presented with nonmassive hemoptysis, productive cough, low-grade fever, and significant weight loss for 3 years. Her sputum consisted of Mycobacterium abscessus with multidrug resistant. Radiological examination revealed reticulonodular infiltration at middle lobe of the right lung and lingular lobe of the left lung, also a bronchiectatic change of both lungs. After 3 years of medical treatment, neither of her symptoms nor radiological findings improved. Therefore, a video-assisted thoracoscopic surgery (VATS) with middle lung lobectomy and lingulectomy was performed. After that, BPF at lingular stump occurred. Many surgical and endoscopic techniques followed by latissimus dorsi musculocutaneous flap along with vacuum dressing were introduced to encourage the complete healing of the BPF. One month later, the patient’s clinical was improved and endoscopic findings showed nearly complete healing of the BPF. In conclusion, surgical and endoscopic treatments combined with postoperative vacuum dressing encourage patient’s symptoms to be subsided.

Aerosolized pH1N1 influenza infection induces less systemic and local immune activation in the lung than combined intrabronchial, nasal and oral exposure in cynomolgus macaques.

Non-human primates form an important animal model for the evaluation of immunogenicity and efficacy of novel 'universal' vaccine candidates against influenza virus. However, in most studies a combination of intra-tracheal or intra-bronchial, oral and nasal virus inoculation is used with a standard virus dose of between 1 and 10 million tissue culture infective doses, which differs from typical modes of virus exposure in humans. This paper studies the systemic and local inflammatory and immune effects of aerosolized versus combined-route exposure to pandemic H1N1 influenza virus. In agreement with a previous study, both combined-route and aerosol exposure resulted in similar levels of virus replication in nose, throat and lung lavages. However, the acute release of pro-inflammatory cytokines and chemokines, acute monocyte activation in peripheral blood as well as increased cytokine production and T-cell proliferation in the lungs were only observed after combined-route infection and not after aerosol exposure. Longitudinal evaluation by computed tomography demonstrated persistence of lung lesions after resolution of the infection and a tendency for more lesions in the lower lung lobes after combined-route exposure versus upper and middle lung lobes after aerosol exposure. Computed tomography scores were observed to correlate with fever. In conclusion, influenza virus infection by aerosol exposure is accompanied by less immune-activation and inflammation in comparison with direct virus installation, despite similar levels of virus replication and development of lesions in the lungs.

Multifocal neuroendocrine cell hyperplasia accompanied by tumorlet formation and pulmonary sclerosing pneumocytoma: A case report

BACKGROUNDPulmonary tumorlets are nodular hyperplastic neuroendocrine cells (NECs) that extend beyond the basement membrane. They often coexist with other lung diseases such as fibrosis and bronchiectasis, but rarely accompanied by pulmonary sclerosing pneumocytoma (PSP), which has not been reported in the literature.CASE SUMMARYA 54-year-old woman was admitted to the hospital because she had symptoms of bloody sputum for more than 4 mo and hemoptysis for 1 wk. Computed tomography images showed atrophy accompanied by infections in the middle lobe of her right lung. Moreover, numerous nodules were identified in the middle lobe of the right lung. The patient underwent thoracoscopic pneumonectomy of the middle lobe of the right lung, and the resected mass was pathologically confirmed to have bronchiectasis, multifocal NEC hyperplasia accompanied by tumorlet, and PSP.CONCLUSIONOur report presents a rare clinical case of bronchiectasis complicated with multifocal NEC hyperplasia, tumorlet, and PSP.

Morphological and functional reserves of the right middle lobe: Radiological analysis of changes after right lower lobectomy in healthy individuals

ObjectivesRemaining lung tissue after pulmonary resection can expand without decline in structural complexity and compensate for functional loss, showing morphological and functional reserves. However, the distribution of these reserves is unknown. This study examined the heterogeneity of morphological and functional reserves of the remaining lung tissue. MethodsWe retrospectively analyzed 53 donors who underwent right lower lobectomy for living-donor lobar lung transplantation. We examined morphometric changes in computed tomography images from 3 to 12 months after lobectomy. We assessed lung volume and structural complexity expressed as the fractal dimension. We also assessed effective lung volume (the volume of the lung with intermediate density) and volumetric fluctuation during respiration. Changes were compared between the right upper lobe, middle lobe, and left lung. ResultsThe expansion of lung tissue was greater in the middle lobe (130.9% ± 19.7%) than in the upper lobe (109.7% ± 9.2%; P < .001). The fractal dimension declined in the upper lobe (P < .001) but was maintained in the middle lobe (P = .39). The increase in effective lung volume was larger in the middle lobe (97.2 ± 73.5 mL) than in the upper lobe (62.7 ± 87.1 mL; P < .001), but not significantly different from that of the left lung (55.8 ± 186.3 mL; P = .052). A similar pattern was seen in respiratory fluctuation. ConclusionsMorphological and functional changes in lung tissue remaining after pulmonary resection were heterogeneous. The right middle lobe demonstrated morphological and functional reserves after right lower lobectomy.

Pulmonary Herpes Simplex Infection: A Case Report

Pulmonary herpes simplex infection is rarely reported. To date, there is a paucity of literature on this infection. This case study describes a 64-year-old male with a background history of diabetes mellitus and hypertension who was intubated for acute respiratory failure. The managing team had difficulty to wean his oxygenation thus decided for bronchoscopy examination which showed suspicious growth at middle lobe of the right lung. Repeated bronchoscopy by pulmonologist revealed a nodular ‘warty’ appearance lesion at right bronchus intermedius. His biopsy revealed histopathological changes consistent with herpes simplex infection.International Journal of Human and Health Sciences Vol. 05 No. 01 January’21 Page: 112-114