Peripheral Pulmonary Opacities Research Articles

P019 Covid-19 Infection in a Patient with Crohn's Disease Under Treatment with Ustekinumab - Case Report

CASE: We report a case of a 44-year-old patient with ileocolonic Crohn's disease, infected with SARS-Cov-2 and, on treatment with ustekinumab for six months. The patient has been treated for Crohn's disease since 2002. Ustekinumab was prescribed after the failure of treatment with infliximab and adalimumab six months ago. In May 2020, she presented headache, coryza, general malaise, and a temperature of 37.7oC, which persisted for two days. She sought an emergency room for investigation and presented the following lab tests results: Hb = 14.9g/dl; Ht = 44%; Total leucocytes = 8400/mm3; Lymphocytes = 15% (normal range 20-45%); Platelets count = 357.000/mm3; CPR = 20mg/L (normal value < 500ng/mL), oxygen saturation = 97%. Chest tomography showed ground-glass peripheral pulmonary opacities with impairment of less than 25%. Given Covid-19 suspicious, rt-PCR for SARS-Cov-2 was collected and the result was positive. She was discharged to her home with symptomatic pills and azithromycin 500mg/day for 5 days. In the following days, she presented diarrhea (8x/day), nausea, vomiting, and returned to the emergency room for intravenous medication and hydration. After this treatment, she was discharged again to her home. There was an improvement in symptoms, but diarrhea persisted for 8 days. The next maintenance dose of ustekinumab was suspended for 15 days. After this period, she collected a control rt-PCR for SARS-Cov-2 that resulted negative and, returned to use biologic therapy without presenting any complication. In this case, there was a good recovery of Covid-19 even during the use of ustekinumab. The possibility of performing rt-PCR and monitoring signs and symptoms of the disease, allowed the period of active infection to be properly controlled. Additionally, biological therapy could also be promptly resumed without jeopardizing the treatment of Crohn's disease.

Visceral larval migrans masquerading as metastatic disease in a toddler with Wilms tumor

A 22-month-old girl with a renal mass had multiple small pulmonary nodules on CT at her initial presentation. After biopsy and neoadjuvant chemotherapy, a Wilms tumor was resected and the pulmonary nodules were shown to have regressed on CT. Follow-up imaging 4 months after initial diagnosis demonstrated multiple new liver lesions and new pulmonary nodules with peripheral eosinophilia. Lung biopsy revealed granuloma formation with prominent eosinophils. The serum antibody titers for Toxocara canis were elevated. This case illustrates that toxocariasis should be considered as a rare differential diagnostic possibility for multiple liver lesions and multifocal peripheral pulmonary opacities in young children with Wilms tumor.

Thoracoscopic pulmonary lobectomy: Early operative experience and preliminary clinical results

Thoracoscopic video-assisted lobectomy procedures were performed in 11 patients (7 men, 4 women; age range 40 to 74 years, mean 66 years). Ten patients had peripheral pulmonary opacities: eight of these were bronchogenic carcinomas, one was an atypical carcinoid lesion, and one was a pulmonary infarct. All of these cases had preoperative evaluation by computed tomographic scanning to exclude mediastinal lymphadenopathy. The remaining patient had preoperatively diagnosed lobar bronchiectasis. Surgical access was gained via three stab (1 cm) incisions and one short (7 cm) submammary incision, which was made without rib separation and was used for specimen delivery. Lobes resected were the left upper (n = 4), left lower (n = 2), right upper (n = 2), and right lower (n = 3). All patients survived. Overall mean operative time was 3.3 hours and blood loss 263 ml. For the latter five cases, however, these figures were reduced to 2.3 hours and 100 ml, respectively, indicating improvement with experience. In no cases was ventilatory assistance required. Mean high-dependency unit time was 41 hours. In each case, it was possible to perform a standard dissectional lobectomy with lobar lymph node clearance equal to that obtained at open thoracotomy. Comparison with a series of 33 open lobectomy procedures demonstrated reduced postoperative pain, morphine consumption, and high-dependency unit stay. This preliminary experience supports the development of video-assisted thoracoscopic pulmonary lobectomy for patients with small peripheral opacities or known benign disease.

A prospective randomized comparison of fine needle aspiration biopsy and fibreoptic bronchoscopy in the investigation of peripheral pulmonary opacities

Twenty-nine patients, aged 66(+/- 7) years with a peripheral pulmonary opacity (mean diameter 3.6 +/- 1.8 cm) believed to be a tumor, were randomly allocated to initial investigation by either fibreoptic bronchoscopy or percutaneous fine needle aspiration biopsy, the latter performed under fluoroscopic control. The patients proceeded to the alternative investigation in the event of the first failing to achieve a diagnosis. Malignancy was confirmed by the initial procedure in 14/15 patients randomized to fine needle aspiration biopsy but only in 1/14 patients randomized to fibreoptic bronchoscopy (P less than 0.01). Overall, these figures were 25/28 fine needle aspiration biopsy and 2/15 fibreoptic bronchoscopy (P less than 0.01). These results confirm the clinical suspicion that fine needle aspiration biopsy is far more likely than fibreoptic bronchoscopy to establish the presence of malignancy in peripheral pulmonary opacities.

75Se-sodium selenite as a diagnostic aid in the assessment of peripheral pulmonary opacities.

To establish or exclude the diagnosis of bronchial carcinoma a series of 43 patients with peripheral pulmonary opacities was studied by lung scanning after intravenous injection of 75Se-sodium selenite. A diagnosis was ultimately obtained in all patients. The incidence of both false-positive and false-negative results was high. Selenite was taken up by a range of non-neoplastic processes including inflammatory lesions. The value of the procedure in distinguishing bronchial carcinoma from non-neoplastic conditions of the lung that radiographically mimic carcinoma was not confirmed.

Fluoroscopically controlled transbronchial biopsy of solitary peripheral pulmonary lesions using the fibreoptic bronchoscope

Experience of fluoroscopically controlled transbronchial biopsy using the fibreoptic bronchoscope in 30 patients with solitary lesions in the peripheral lung fields beyond bronchoscopic vision is described. At the time of submitting this paper for publication (30 January 1978) no account of the technique has been reported in the British literature. In 21 patients with a final diagnosis of bronchial carcinoma a positive biopsy diagnosis was obtained in 14 (67%). Five of seven patients (71%) with a final diagnosis of an inflammatory condition showed evidence of acute or chronic inflammation on biopsy. There were no complications. The procedure is indicated when a definitive diagnosis is required for management planning in clinically inoperable patients, or when a tissue diagnosis is particularly desired in an attempt to obviate the need for thoracotomy. The relative safety makes this the biopsy technique of choice for the evaluation of isolated peripheral pulmonary opacities.