Multiple Small Pulmonary Nodules Research Articles

De novo thoracic endometriosis in a menopausal women

Endometriosis is very common in reproductive age group. Since it is an estrogen dependent problem it is generally believed that it denotes “active ovarian function” and is “healed” after menopause. Most commonly endometrial tissue is found in ovaries resulting in the formation of chocolate cysts but it can also be found in extrapelvic sites. In this case report we will discuss endometriosis after menopause. Pulmonary endometriosis is a rare form of thoracic endometriosis. We describe a case of a 54-year-old woman with surgical menopause with recurrent episodes of haemoptysis, chest pain and dyspnea. Her Chest CT revealed multiple small pulmonary nodules. Biopsy from left lung lesion suggested endometriosis.

Preoperative electromagnetic navigation bronchoscopy-guided one-stage multiple-dye localization for resection of subsolid nodules: A single-center pilot study.

BackgroundElectromagnetic navigation bronchoscopy (ENB)‐guided transbronchial dye marking and video‐assisted thoracoscopic surgery (VATS) is an emerging technique that enables successful resection of multiple small subsolid pulmonary nodules. The aim of this study was to evaluate the accuracy and safety of preoperative ENB‐guided transbronchial multiple dye localization for VATS resection of subsolid pulmonary nodules.MethodsAs a single‐center pilot study, we recruited patients with at least two small or subsolid pulmonary nodules. Multiple‐dye localization was performed by intraoperative ENB‐guided transbronchial injection of an indigo carmine dye. The patients underwent VATS for sublobar resection immediately after localization. The accuracy of ENB‐guided dye marking was checked.ResultsENB‐guided one‐stage multiple dye localization was conducted for 18 pulmonary nodules in seven patients between September 2018 and December 2019. The mean diameter of the pulmonary nodules was 9.3 mm (range, 4–18) and the mean distance from the pleura to pulmonary nodule was 6 mm (range, 1–17 mm). ENB‐guided transbronchial multiple dye localization was successfully performed in 94.4% (17/18), and the accuracy of ENB‐guided dye marking was 88.2% (15/17). When two nodules were not seen in intraoperative fields, anatomical sublobar resection was performed. There was no conversion to thoracotomy and operative mortalities. Among the seven patients, only one patient showed mild intrabronchial bleeding but stopped spontaneously. The changes in lung function after multiple wedge resections (−1.6% to 24.8%) were tolerable level.ConclusionsENB‐guided one‐stage transbronchial dye localization showed accurate and safe intraoperative identification of multiple subsolid pulmonary nodules. A large scale prospective clinical study is warranted.

TACROLIMUS-INDUCED LUNG INJURY

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Tacrolimus is commonly used for immunosuppression after solid-organ transplant to prevent organ rejection. Tacrolimus has a wide range of adverse effects, including secondary infections, renal failure, hyperglycemia, and weight gain, when used in combination with other immunosuppression medications. However, association with diffuse lung disease is quite rare. We present a case of diffuse lung injury associated with tacrolimus. CASE PRESENTATION: A 56-year-old Caucasian man with a past medical history of hypertension, diabetes, morbid obesity, renal transplant on tacrolimus and mycophenolate, and localized renal cell carcinoma with nephrectomy was transferred to our institution for evaluation of suspected non-small cell lung cancer (NSCLC). A few weeks prior to the current presentation, the patient was diagnosed and treated for community-acquired pneumonia with oral antibiotics. Follow-up imaging, with CT Chest and subsequent PET CT, revealed diffuse interstitial changes with multiple small pulmonary nodules without increased metabolic activity concerning for lymphangitic carcinomatosis or atypical infection. During PET CT, the patient became hypoxic and was admitted. Bronchoscopy with brush biopsy and BAL demonstrated atypical cells concerning for NSCLC, and the patient was transferred to our institution for further evaluation. Due to inconclusive pathology report from prior bronchoscopy, persistent hypoxia, and dyspnea on exertion, the patient underwent repeat bronchoscopy with endobronchial ultrasound-guided biopsy, BAL, and trans-bronchial biopsies, which was negative for malignancy. Extensive microbiologic workup for viral, bacterial, and fungal organisms remained negative. BAL differential showed significant eosinophilia of 15%, and transbronchial biopsy showed acute on chronic inflammation. Drug toxicity secondary to tacrolimus was presumed to be the primary culprit. The patient was started on prednisone therapy and discharged. On outpatient follow-up six weeks later, the patient had resolution of dyspnea, and repeat imaging demonstrated complete resolution of interstitial opacities. Tacrolimus was discontinued indefinitely. DISCUSSION: Tacrolimus is commonly used for immunosuppression after solid organ transplantation to prevent organ rejection. The association of Tacrolimus with interstitial lung disease is quite rare and previously described in a case series of rheumatoid arthritis patients. To the best of our knowledge, this is the first description of tacrolimus-induced interstitial lung disease in renal transplant patients. CONCLUSIONS: Tacrolimus-associated diffuse lung disease, although rare, should be considered in patients presenting with diffuse infiltrates while on this therapy, after appropriate work up to exclude infections. REFERENCE #1: M. Schwaiblmair, W. Behr, T. Haeckel, B. Markl, W. Foerg, and T. Berghaus, "Drug induced instertial lung disease," Open Respiratory Medicine Journal, vol. 6, no. 1, pp. 63-74, 2012 REFERENCE #2: Allen JN, Davis WB, Pacht ER. "Diagnostic significance of increased bronchoalveolar lavage fluid eosinophils." Am Rev Respir Dis. 1990 Sept;142(3):642-7, doi:10.1164/ajrccm/142.3.642. PMID: 2389917. REFERENCE #3: Koike R, Tanaka M, Komano Y, Sakai F, Sugiyama H, Nanki T, Ide H, Jodo S, Katayama K, Matsushima H, Miwa Y. Tacrolimus-induced pulmonary injury in rheumatoid arthritis patients. Pulmonary pharmacology & therapeutics. 2011 Aug 1;24(4):401-6. DISCLOSURES: No relevant relationships by Sarenthia Epps, source=Web Response no disclosure on file for Anand Venkata

Computed tomography-guided cyanoacrylate injection for localization of multiple ipsilateral lung nodules.

To retrospectively assess the clinical effectiveness of CT-guided cyanoacrylate localization for multiple ipsilateral small pulmonary nodules (SPNs) and to determine the independent predictors for pneumothorax. In total, 81 patients with 169 lesions undergoing CT-guided cyanoacrylate localization for multiple ipsilateral SPNs between September 2016 and July 2020 were enrolled (group M). Another 284 patients who received single SPN localization during the same period served as the control group (group S). Propensity score analysis was performed to minimize selection bias. Possible independent predictors for pneumothorax were evaluated using multivariate logistic regression analysis. Multiple ipsilateral SPN localization was successfully performed in all 81 patients. The incidences of successful targeting during localization and surgery were 100% and 98.8%, respectively. Seventy-seven patients (95.1%) underwent the procedure on the day before the surgery. Propensity matching created 81 pairs of patients. There were no significant differences in the incidence of successful targeting during localization and surgery, localization-related pain score, and additional morphine use between the two groups. However, group M was associated with a significant longer localization procedural time (p < 0.001) and a higher incidence of pneumothorax (p < 0.001). In multivariate analysis, position change was significantly associated with a sevenfold increase in the risk for pneumothorax (p = 0.001). CT-guided cyanoacrylate injection for multiple ipsilateral SPN localization was safe and reliable, and allowed a flexible surgical schedule, despite a lengthy procedure and an increased incidence of pneumothorax. Avoiding position change may help to reduce the occurrence of pneumothorax. • Compared to single SPN localization, multiple ipsilateral SPN localization using cyanoacrylate injection achieved comparable safety, reliability, and comfort. • CT-guided cyanoacrylate localization for multiple ipsilateral SPNs allowed a flexible surgical schedule. • Position change was the only independent risk factor for pneumothorax during the multiple ipsilateral SPN localization.

COBBLESTONE PAVEMENT ALONG THE ENTIRE CITY OF SARCOIDVILLE: DIFFUSE ENDOBRONCHIAL INVOLVEMENT OF ALL THE AIRWAYS IN A SARCOIDOSIS PATIENT

SESSION TITLE: Fellows Diffuse Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Sarcoidosis is a multisystem disorder with granulomatous inflammation of the involved tissues. Lung, skin and eyes are the most commonly involved organs. Sarcoidosis can manifest in various presentations in the respiratory system. The most common manifestations are parenchymal involvement from nodules to fibrocystic disease with or without thoracic lymphadenopathy. Endobronchial mucosal irregularities termed as cobblestone pattern is commonly seen but diffuse severe endobronchial involvement is not commonly reported. We present an unusual case of severe cobblestoning mimicking as obstructive lung disease. CASE PRESENTATION: A 26-year-old African American male with no medical history presented with symptoms of wheezing, dyspnea on exertion, productive cough with thick yellowish sputum over the course of three months. He works at a local post office and noticed respiratory symptoms while loading/unloading packages on the delivery truck. He also endorsed symptoms of night sweats and fatigue but denied weight loss, fever, chills or loss of appetite. Chest radiograph was significant for hilar and mediastinal lymphadenopathy. The CT scan of chest confirmed bilateral hilar and mediastinal lymphadenopathy along with multiple small perilymphatic pulmonary nodules with upper lobe predominance. An Endobronchial Ultrasound was performed to sample the lymph nodes for definitive diagnosis. On the initial airway surveillance bronchoscopy, diffuse mucosal irregularity with waxy nodules was noted in the all the large and small airways. Severe mucosal edema was noted with consequential airway luminal narrowing. Endobronchial biopsy and tranbronchial needle aspiration (TBNA) of the bulky thoracic lymph nodes (LN) were performed which revealed non-caseating granulomas in all the specimens. These specimens were also sent for fungal and bacterial (including mycobacteria) cultures, which did not report growth of any microorganisms. Diagnosis of sarcoidosis was confirmed and he was started on oral prednisone. DISCUSSION: Severe endobronchial sarcoidosis is an uncommon manifestation and is present in advanced disease. These endobronchial changes are due to mucosal granulomatous inflammation resulting in waxy nodular appearance which is commonly described as cobblestone pattern in the sarcoidosis literature. The diagnostic yield for sarcoidosis increases when transbronchial biopsy is combined with endobronchial biopsy of the affected mucosal region. Airway narrowing can occur due to mucosal inflammation and swelling in severe cases. In such instances, it may mimic symptoms of an obstructive lung disease. CONCLUSIONS: Our patient’s symptoms were suggestive of obstructive lung disease with dyspnea, cough and wheezing but radiographic findings concerning for sarcoidosis which was confirmed by biopsy of LNs and mucosa. This is in accordance with the famous quote by Dr. Chevalier Jackson, “All that wheezes is not asthma.” Reference #1: Shorr, A. F., Torrington, K. G., & Hnatiuk, W. (2001). Endobronchial biopsy for sarcoidosis: a prospective study. Chest, 120(1), 109-114. Reference #2: Hutson, T. E., Coulter, T. D., & Mehta, A. C. (2001). Endobronchial sarcoidosis. Journal of Bronchology & Interventional Pulmonology, 8(3), 211-212. Reference #3: Bjermer, L., Thunell, M., Rosenhall, L., & Stjernberg, N. (1991). Endobronchial biopsy positive sarcoidosis: relation to bronchoalveolar lavage and course of disease. Respiratory medicine, 85(3), 229-234. DISCLOSURES: No relevant relationships by James Finley, source=Web Response No relevant relationships by Ishan Lalani, source=Web Response No relevant relationships by Omid Savari, source=Web Response

Routine chest CT for staging of gastric cancer.

BackgroundInternational guidelines on clinical staging of gastric cancer recommend the use of chest CT for the detection of pulmonary metastases. This study assessed the clinical value of routine chest CT in the staging of gastric cancer.MethodsThis retrospective study included patients identified from the gastric cancer registry of Chang Gung Memorial Hospital, Linkou, Taiwan. All patients who underwent clinical staging between 2008 and 2014 were included. The pattern, site and number of metastases at initial presentation and after surgery with curative intent were evaluated. Pulmonary metastases were defined as multiple small round pulmonary nodules with a random distribution or of variable size.ResultsSome 1669 patients were included, of whom 478 (28·6 per cent) had metastatic disease at clinical presentation. The majority of metastases were to the peritoneum (75·7 per cent of patients) or liver (30·5 per cent), and only 27 patients (5·6 per cent) had pulmonary metastases at presentation, none of which were isolated to the lung. Of these 27 patients, 11 had primary lesions located at the cardia/fundus. In 19 patients the lung metastases were also detected on the staging chest X‐ray. After surgery there were 196 cancer recurrences. Some 15 patients (7·6 per cent) had lung metastasis and this was not the only site of metastases in any patient. The prevalence of lung metastasis at presentation of the disease and after surgery was 1·6 and 1·5 per cent respectively.ConclusionThis study does not support the routine use of chest CT for staging of gastric cancer as isolated pulmonary metastasis in the absence of other metastatic sites could not be detected.

Preoperative Computed Tomography-guided Microcoil Localization for Multiple Small Lung Nodules before Video-assisted Thoracoscopic Surgery

背景与目的肺内多发小结节微创手术的成功与否有赖于术前定位，然而目前缺乏针对肺内多发小结节术前定位的临床研究。本研究旨在与同期肺内单发小结节定位相比，探讨行电视胸腔镜手术（video-assisted thoracoscopic surgery, VATS）术前电子计算机断层扫描（computed tomography, CT）引导下留置微弹簧圈定位肺内多发小结节的临床价值。方法回顾性分析术前行肺内小结节微弹簧圈定位者235例的临床资料。根据结节是否为单发分为：单发结节组184例（single nodule group），多发结节组51例（multiple nodules group）。单发结节组常规方式CT引导下定位，多发结节组在CT引导下分级、分批次留置微弹簧圈定位，统计分析两组定位成功率、并发症、病理结果及定位操作相关数据等。结果多发结节组定位成功率达90.2%，与同期单发结节组成功率相比无统计学差异（90.2% vs 94.6%, P=0.205），多发结节组气胸发生率与单发结节组亦无统计学差异（21.6% vs 14.1%, P=0.179），然而多发结节组的操作时间明显长于单发结节组的操作时间[(30.6±6.6) min vs (19.9±7.4) min, P=0.000]。两组均无大咯血、空气栓塞及血胸发生等严重并发症。两组均无因术中无法定位结节而中转开胸者；手术方式以亚肺叶切除为主；术后病理以非浸润性病变为主。结论对于需行胸腔镜手术的肺部多发小结节，按照一定策略，术前CT引导下分级、分批次留置微弹簧圈的定位方法安全、有效，值得推广。

Extrapulmonary Small Cell Carcinoma: An Unfortunate Case of Metastatic Disease

Abstract A 48- year-old man presented with weight loss and 3 weeks of right sided lower abdominal pain. Liver ultrasound and contrast-enhanced computed tomographic scan of the chest, abdomen, and pelvis revealed a 6.8 x 4.3 cm mass like thickening of ascending colon, with numerous hepatic lesions, enlarged mesenteric lymph nodes, peritoneal nodularity and multiple small (2-4 mm) pulmonary nodules concerning for widely metastatic disease (Figure A). A colonoscopy revealed an ulcerated right colon mass obliterating the lumen (Figure B). Histologic examination showed highly proliferative round cells with a high nuclear to cytoplasmic ratio with adjacent high grade adenomatous change (Figure C). Immunohistochemical stain was positive for synaptophysin (Figure D). Histologic examination of a liver lesion revealed similar histology. Findings were consistent with high-grade metastatic extrapulmonary small cell carcinoma (EPSCC), a rare neuroendocrine carcinoma. Data from the National Cancer Institute's Surveillance, Epidemiology and End Results program from 1992 to 2010 reflects the rarity of EPSCC of the colon and rectum with an incidence rate of

Gastric Sarcoidosis Presenting as Gastroesophageal Dysmotility

Sarcoidosis is a systemic granulomatous disease that can involve the gastrointestinal (GI) tract in up to 0.9% of cases. We report a case of sarcoidosis presenting with gastroesophageal dysmotility managed with oral (PO) budesonide. A 51-year-old African-American male with history of asthma and gastroesophageal reflux presented with nausea and vomiting. He reported dry cough but denied fever, weight loss, dysphagia, abdominal pain, or bleeding. He denied tobacco, alcohol, and marijuana use. Physical exam was normal. EGD demonstrated a dilated esophagus and hemorrhagic gastritis (Fig. 1). Pathology revealed superficial congestion and chronic gastritis. H. pylori negative. Gastric emptying study showed delayed gastric emptying. Esophageal manometry demonstrated aperistalsis, lower sphincter tone was normal. Ondansetron, erythromycin, metoclopramide, and esomeprazole were started without improvement and thus discontinued. Abdominal/chest CT showed bilateral hilar adenopathy, calcifications, and lung nodules(Fig. 2). Lung biopsy revealed non-necrotizing granulomas. Acid-fast bacilli and fungus stain were negative. Pulmonary sarcoidosis was diagnosed. Prednisone 40 mg PO daily for 4 weeks was started with improvement of GI and pulmonary symptoms. Attempts of dose tapering resulted in recurrence of severe GI symptoms requiring hospitalization for dehydration and renal insufficiency. Pulmonary symptoms were mild and tolerable without steroids. Few months after being on steroids he developed steroid-induced diabetes and Pneumocystis jiroveci pneumonia. Prednisone was tapered off while transitioning to Azathioprine (AZA) 150 mg daily. Mild control of symptoms was achieved but leukopenia and thrombocytopenia ensued. AZA was stopped and budesonide 9 mg PO daily was started. The granules from opened capsules were mixed with juice and swallowed. Nausea and vomiting control was achieved. Follow-up EGD revealed resolution of hemorrhagic gastritis (Fig. 3). He is unable to taper off budesonide and is on stable dose of 6mg daily. To date no adverse effects have been noticed. This case illustrates gastroesophageal dysmotility as the initial manifestation of sarcoidosis andcomplications associated with chronic steroid and AZA intake. We demonstrate the potential role of oral viscous budesonide for symptom control of gastric sarcoidosis, actually decreasing systemic toxicity.Figure: EGD demonstrating segmental hemorrhagic gastritis of the upper body of the stomach.Figure: Non-contrast CT scan showing multiple small pulmonary nodules in a peribronchovascular distribution (arrowhead), and calcified hilar lymph nodes (arrow).Figure: Follow-up EGD demonstrating resolution of hemorrhagic gastritis.

Preoperative computed tomography-guided dye injection to localize multiple lung nodules for video-assisted thoracoscopic surgery.

Preoperative computed tomography (CT)-guided localization of small lung nodules is important for accurate and efficient video-assisted thoracoscopic surgery (VATS). Resection of multiple small pulmonary nodules in one VATS procedure can aid in patient management. The aim of this study was to evaluate the usefulness of CT-guided Patent Blue V (PBV) dye localization in patients with multiple pulmonary nodules who underwent VATS. This retrospective study was conducted from January 2013 to December 2015. One hundred consecutive patients (59.9±10.5 years of age) with 217 nodules who underwent preoperative CT-guided PBV dye localization for multiple (2 to 4) nodules before VATS were enrolled. The mean nodule size was 0.8±0.4 cm, with a mean depth from the pleura or fissure of 0.7±0.7 cm. The mean procedure duration was 50±20 minutes. The mean amount of injected PBV dye was 0.2±0.1 mL per nodule. The overall success rate was 99% by nodule. Failed localization of two nodules in two patients was due to poor dye visualization (n=1) and significant pneumothorax (n=1). Cases of hemorrhage (24%) were mild and asymptomatic, and none of the patients had hemoptysis. None of the cases of pneumothorax (40%) required chest tube placement before VATS. One (1%) patient developed anaphylaxis. The mean post-operative hospital stay was 6.4±4.4 days. CT-guided PBV dye localization for multiple small pulmonary nodules before VATS is a safe, feasible, and accurate method with high success rate. This approach makes it easy to perform multiple nodule resections during one VATS operation.

Pulmonary epithelioid hemangioendothelioma: a clinicopathologic analysis of six cases

To investigate the clinicopathologic characteristics, differential diagnosis and prognosis of pulmonary epithelioid hemangioendotheliomas (PEHs). The clinical symptoms and imaging findings of 6 cases of PEHs were investigated and pathologic analyses including histomorphologic and immunohistochemical studies were performed. Clinical symptoms of the patients were nonspecific and insidious. The typical radiological manifestation was characterized by multiple small pulmonary nodules. The pathological findings were well-demarcated hypocellular hyalinized nodules with more cellularity at the periphery of the nodule. The neoplastic cells showed mild nuclear atypia and prominent eosinophilic cytoplasm with vacuoles, attempting to form primitive vasculature. Immunohistochemically, tumor cells were positive to CD31, CD34 and ERG. Follow-up data from 8 months to 5 years showed no tumor progression, except for the development of bone metastases in one case at 6 months. PEHs are uncommon vascular tumors with low-intermediate malignancy. Using H&E and immunohistochemistry, the final pathological diagnosis can be made and misdiagnosed as a benign fibrotic nodule or other malignant tumors can be avoided. The most effective treatment is surgical resection, if necessary, combined with chemotherapy or radiotherapy.

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia of the Lung (DIPNECH): Current Best Evidence.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is recognized as a preneoplastic condition by the World Health Organization. We reviewed our experience with 30 patients and performed a systematic review of the English literature to collect best evidence on the clinical features and disease course in 169 additional patients. Some patients presented with one or more carcinoid tumors associated with multiple small pulmonary nodules on imaging studies and showed DIPNECH as a somewhat unexpected pathologic finding. Others presented with multiple small pulmonary nodules that raised suspicion of metastatic disease on imaging. A third subset was presented with previously unexplained respiratory symptoms. In most patients, DIPNECH was associated with a good prognosis, with chronological progression into a subsequent carcinoid tumor noted in only one patient and death attributed directly to DIPNECH in only two patients. There is no best evidence to support the use of octreotide, steroids, or bronchodilators in DIPNECH patients.

Localization of Pulmonary Nodules Using Navigation Bronchoscope and a Near-Infrared Fluorescence Thoracoscope

Video-assisted thoracoscopic wedge resection of multiple small, non-visible, and nonpalpable pulmonary nodules is a clinical challenge. We propose an ultra-minimally invasive technique for localization of pulmonary nodules using the electromagnetic navigation bronchoscope (ENB)-guided transbronchial indocyanine green (ICG) injection and intraoperative fluorescence detection with a near-infrared (NIR) fluorescence thoracoscope. Fluorescence properties of ICG topically injected into the lung parenchyma were determined using a resected porcine lung. The combination of ENB-guided ICG injection and NIR fluorescence detection was tested using a live porcine model. An electromagnetic sensor integrated flexible bronchoscope was geometrically registered to the three-dimensional chest computed tomographic image data by way of a real-time electromagnetic tracking system. The ICG mixed with iopamidol was injected into the pulmonary nodules by ENB guidance; ICG fluorescence was visualized by a near-infrared (NIR) thoracoscope. The ICG existing under 24-mm depth of inflated lung was detectable by the NIR fluorescence thoracoscope. The size of the fluorescence spot made by 0.1 mL of ICG was 10.4 ± 2.2 mm. An ICG or iopamidol spot remained at the injected point of the lung for more than 6 hours in vivo. The ICG fluorescence spot injected into the pulmonary nodule with ENB guidance was identified at the pulmonary nodule with the NIR thoracoscope. The ENB-guided transbronchial ICG injection and intraoperative NIR thoracoscopic detection is a feasible method to localize multiple pulmonary nodules.

Imaging appearances of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia

ObjectiveThe objective of the study was to describe the imaging appearances of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) on computed tomography (CT). Materials and methodsElectronic medical records were searched for patients with pathology-proven DIPNECH who had a CT available for review. Eleven patients were included. ResultsThe most common finding on CT was small pulmonary nodules which were present in all patients and were multiple (≥5) in 7/11 patients. Other CT findings included mosaic pattern attenuation and bronchial wall thickening/bronchiectasis. ConclusionDIPNECH should be considered as a diagnostic possibility when multiple small pulmonary nodules are identified on CT, particularly if there is an associated carcinoid tumor.

Pulmonary epithelioid hemangioendothelioma identified by computed tomography scan

The grade of malignancy of rare, vascular pulmonary epithelioid hemangioendothelioma (PEH) is low to intermediate. These tumors can simultaneously or sequentially arise from the lungs, liver, bone and soft tissue, which renders multicentric tumor growth difficult to distinguish from primary lesions with metastasis to other tissues. Most patients with pulmonary epithelioid hemangioendothelioma (PEH) are female (61–80%) and the median age is 36–50 years, which is relatively younger than those with lung cancer. No specific symptoms are associated with PEH, and 50–76% of patients are asymptomatic at the time the condition is detected by chest radiography. Our patient was also asymptomatic. Multiple pulmonary nodules, multiple pulmonary reticulonodular opacities, and diffuse infiltrative pleural thickening have been identified by computed tomography (CT) scan. The most common feature of PEH on chest CT scan is the presence of multiple small discrete pulmonary nodules of up to 2 cm with well-defined margins in both lungs. However, most nodules are less than 1 cm in diameter.

Pulmonary Necrobiotic Nodules in a Patient With UC and Primary Sclerosing Cholangitis: a Rare Extraintestinal Manifestation of IBD: Case Report

The extraintestinal manifestations of inflammatory bowel disease have been described in association with almost every organ system. IBD can be associated with several respiratory disorders. Histologically, the nodules usually show sterile aggregates of neutrophils containing areas of necrosis. We found published reports of 15 cases of pulmonary nodules associated with IBD, as of august 2011, predominantly as a manifestation of Crohn’s disease (CD) A 17- year-old male patient was diagnosed with ulcerative colitis (UC), with extensive colitis, and primary sclerosing cholangitis (PSC) 2 years ago. He had been treated with topical combined with oral mesalazine and ursodeoxycholic acid since the diagnosis of the disease. The patient started on azathioprine 3 months ago. He was current in remission, but increased ESR and CRP still remained. He presented with symptoms of cough, pleuritic chest pain and mild dyspnea. He described no fevers. He was treated with ceftriaxone and azithromycin, azathioprine was stopped, but it appeared to be ineffective. CT of the thorax revealed pleural effusion and multiple small pulmonary nodules in both lungs. Open lung biopsy showed a granuloma with central coagulative and lytic necrosis, neutrophils in the periphery and foamy histiocytes, consistent with necrobiotic nodules, interstitial pneumonia, organizing pneumonia and focal bronchiolitis obliterans. His respiratory symptoms improved with a course of prednisone (1 mg/kg/day). A follow-up CT scan showed resolution of the pleural effusion and a >75% reduction in pulmonary nodules size. Respiratory manifestations can be observed in patients with IBD, but they remain uncommon. The incidence of respiratory involvement is greater in UC than in CD, although the necrobiotic nodules have been reported most frequently in CD. We report a case of UC associated with PSC presenting lung involvement with predominance of necrobiotic nodules and serositis. Unlike other cases, this patient presents at younger age than usual. Of 15 reported patients with the association of IBD and necrobiotic nodules, CD was present in 10 patients and UC in five (aged 20 to 75 years). The respiratory disease can develop at any point during the course of IBD. Most patients have respiratory and constitutional symptoms, but quiescent bowel disease, as occurred in this case. Most cases responded well to steroids, but the exclusion of an infectious cause is mandatory. In most reported cases steroid therapy was prescribed alone, however in some patients there was an association with other drugs such as immunosuppressive drugs and infliximab. Clinical and radiologic spontaneous resolution, although controversial, has been reported, which may raise questions about the optimal therapeutic management for this condition. Pulmonary necrobiotic nodules are a rare manifestation of IBD. Although steroid therapy provides favorable clinical and radiological response, further studies are needed to define the best approach.

A Pleural Effusion with an Unusual Cause

A 35-year-old presented with an incidental finding of a small left pleural effusion on a routine chest radiograph. A diagnostic pleurocentesis revealed a chylous effusion. CT showed a small left pleural effusion, multiple small pulmonary nodules and thickened interstitial lines in the right lung. Video-assisted thoracoscopic biopsy of the right lung revealed features consistent with diffuse pulmonary lymphangiomatosis.

Thromboelastographic profile for a dog with hypocoagulable and hyperfibrinolytic phase of disseminated intravascular coagulopathy

The objective of this study is to report the use of thromboelastography as a diagnostic tool for the hyperfibrinolytic phase of disseminated intravascular coagulopathy in a dog with metastatic haemangiosarcoma. We established a cytological (i.e. fine needle aspirate) and histopathological (i.e. excisional surgical biopsy) diagnosis of haemangiosarcoma in a 10-year-old male castrated Bichon Frise with multiple dark purple dermoepidermal nodules on the ventral abdomen and medial stifle areas, multiple small pulmonary nodules and a solitary liver mass. The dog was treated with chemotherapy (AC protocol). Forty-nine days after completion of four treatment cycles, the dog was presented for recheck. Complete blood count revealed anaemia and mild thrombocytopenia. Chemistry profile showed no significant abnormalities. Analysis of haemostasis consisted of prolonged clotting times (prothrombin time, activated partial thromboplastin time), mild hypofibrinogenaemia and increased D-dimers. A presumptive diagnosis of disseminated intravascular coagulopathy was made. A re-calcified thromboelastography was simultaneously done to confirm the coagulopathy. Thromboelastographic tracings correlated with the plasma-based test results showing hypocoagulability (prolonged clotting times and prolonged thromboelastography clot kinetics; weaker clot with decreased fibrinogen levels, platelet count and lower thromboelastography tracing amplitude) and hyperfibrinolysis (increased D-dimers and increased D-dimers and increased thromboelastography lysis parameters). Based on these results, the dog was considered to be in the hyperfibrinolytic phase of disseminated intravascular coagulopathy. Results of the conventional haemostasis tests supported those obtained on thromboelastography. Humane euthanasia was performed because of poor prognosis and progressive disease, making further follow-up unavailable. As demonstrated in this case report, thromboelastography was found to be a helpful diagnostic tool for the diagnosis and monitoring of the hyperfibrinolytic phases of disseminated intravascular coagulopathy.

Multinodular Goiter as the Initial Presentation of Systemic Sarcoidosis: Limitation of Fine-Needle Biopsy

Sarcoidosis is a chronic systemic disease characterized by noncaseating granulomas. Thyroid involvement is rare, with a prevalence of 1-4% in large series of autopsied patients with systemic sarcoid. We report a case of a 65-year-old woman with a nontoxic multinodular goiter, dyspnea in the supine position, and rightward tracheal deviation as the initial presentation of systemic sarcoidosis. Fine-needle biopsy of the thyroid mass was consistent with benign adenomatoid goiter. A total thyroidectomy was performed because of compression symptoms. Histopathology revealed numerous diffuse noncaseating granulomata typical of thyroid sarcoidosis. Subsequent chest computed tomography showed extensive bulky mediastinal and hilar adenopathy and multiple small pulmonary nodules consistent with sarcoidosis. Transbronchial fine-needle biopsy also revealed noncaseating granulomas. The patient's supine dyspnea resolved quickly after total thyroidectomy. This case report illustrates that in patients with known sarcoidosis, careful thyroid examination is essential and supine dyspnea may be directly related to tracheal compression by a multinodular goiter rather than pulmonary sarcoidosis.

REVIEWS OF CURRENT LITERATURE

REVIEWS OF CURRENT LITERATURE