Pleurisy Research Articles

Incidence of acute pericarditis after pulsed-field ablation for the treatment of atrial fibrillation

Abstract Introduction Pulsed-field ablation (PFA) has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). While traditional thermal ablation modes such as radiofrequency energy or cryoballoon energy showed an acute pericarditis rate of 0.5 – 4%, little is known about the incidence of acute pericarditis after PFA. Purpose To assess the incidence of acute pericarditis using PFA for the treatment of AF. Method Patients undergoing catheter ablation for AF using PFA were consecutively enrolled in a prospective registry in a tertiary referral center between January 2022 and January 2024. After PFA, all patients received a clinical assessment for cardiothoracic symptoms including cardiac auscultation, 12-lead ECG and transthoracic echocardiography. A clinical diagnosis of acute pericarditis was established according to the 2015 European Society of Cardiology (ESC) guidelines by the presence of at least 2 of the following criteria within 90 days after PFA: 1) pleuritic chest pain; 2) friction rub; 3) new widespread ST-elevation or PR depression on ECG; 4) pericardial effusion. Suspected acute pericarditis was diagnosed if 1 criterion was fulfilled. Results A total of 388 patients with AF (median age 67.5 years, 32% female) underwent pulmonary vein isolation using PFA. 0 (0%) patients fulfilled ≥ 2 ESC criteria required for diagnosis of acute pericarditis. Suspected acute pericarditis within 90 days after the procedure was found in 17 (4.4%) patients. 29 (7.5%) patients reported some sort of cardiothoracic symptoms (chest pain, chest tightness, chest discomfort, shortness of breath or pleuritic chest pain). Among them, 6 (1.5%) patients received anti-inflammatory drug treatment due to suspected pericarditis. 0 (0%) patients had a friction rub, 6 (1.5%) patients showed PR depression (no ST-elevation) and 5 (1.3%) patients demonstrated pericardial effusions. None of the pericardial effusions required drainage. Conclusion In this large cohort of patients undergoing PFA for AF, no patients suffered acute pericarditis according to current ESC criteria. Any type of cardiothoracic symptoms after PFA were noted in 7.5% of patients with 1.5% of patients requiring drug therapy.Graphical Abstract

Bilateral adrenal hemorrhage in a postpartum woman with multiple thromboemboli: A case report

BackgroundBilateral adrenal hemorrhage is a rare but often a fatal cause of primary adrenal insufficiency that can result in adrenal crisis if not identified and managed appropriately.Case presentationWe present a case of a 27-year-old Caucasian female who was admitted to the hospital 17 days postpartum with pleuritic chest and flank pain, shortness of breath and nausea. Computed tomography imaging confirmed multiple thromboemboli including pulmonary emboli and noted bilateral bulky adrenal glands. She was managed for infection and pulmonary emboli; however, she complained of persistent headaches, nausea, and vomiting despite appropriate management. Radiology re-review found the computed tomography imaging was consistent with bilateral adrenal hemorrhage in hindsight. Subsequent endocrine evaluation with hypothalamic–pituitary–adrenal axis interrogation and adrenocorticotropic hormone (Synacthen) stimulation testing confirmed resultant primary adrenal insufficiency. She required urgent intravenous hydrocortisone and was subsequently discharged on oral adrenal replacement therapy and anticoagulation.ConclusionsDelay in identification and treatment of adrenal insufficiency can lead to catastrophic outcomes. This case highlights the challenge of diagnosing bilateral adrenal hemorrhage and resultant adrenal insufficiency as patients may not present with the classic risk factors, signs, symptoms, and electrolyte derangements.

Anakinra-Dependent Recurrent Pericarditis: The Role of the R202Q Variant of the MEFV Gene.

Background: the role of the R202Q (c.605G>A, p.Arg202Gln) missense variant of the MEFV gene has been debated as either a benign polymorphism or a potentially pathogenic mutation. We report and discuss here the case of a young female with corticosteroid-dependent recurrent pericarditis carrying the homozygous R202Q variant, exhibiting distinctive clinical features possibly influenced by this genetic variant. Methods: a 30-year-old woman with a previous diagnosis of cancer and recent respiratory infection presented with severe pleuritic chest pain, hypotension, tachycardia, and fever. Initial diagnostic evaluation indicated cardiac tamponade, and emergent pericardiocentesis was performed. Despite initial treatment with NSAIDs, colchicine, and corticosteroids, the patient experienced multiple recurrences. Genetic testing identified homozygous R202Q variant in the MEFV gene. Given the corticosteroid dependency and recurrent nature of her condition, IL-1 inhibitor anakinra was introduced, leading to significant improvement, although tapering below 150 mg per week failed to prevent recurrences. Results: the introduction of anakinra resulted in rapid symptom relief and resolution of pericardial effusion. However, attempts to taper or discontinue anakinra led to pericarditis recurrences. Ultimately, a maintenance dose of 50 mg every three days was established, which maintained remission for 18 months without recurrence. Despite multiple tapering attempts, further reduction in anakinra dosage was unsuccessful without triggering relapses. Conclusions: the R202Q variant, although typically considered benign, may contribute to an autoinflammatory phenotype resembling familial Mediterranean fever. This case underscores the potential pathogenicity of the homozygous R202Q variant in recurrent pericarditis and its responsiveness to IL-1 inhibition. In patients with corticosteroid-dependent recurrent pericarditis, genetic testing for the R202Q variant should be considered when anti-IL-1 drugs cannot be withdrawn. Further studies are warranted to elucidate the variant's role in pericardial inflammation and guide personalized treatment strategies.

The diagnostic value and validation of IL-22 combimed with sCD40L in tuberculosis pleural effusion

BackgroundThere is substantial evidence indicating that cytokines play a role in the immune defense against tuberculosis. This study aims to evaluate the levels of various cytokines in pleural effusion to ditinguish between tuberculosis pleurisy and malignant pleurisy.MethodsA total of 82 participants with pleural effusion were included in the training cohort, and 76 participants were included in the validation cohort. The individuals were divided into tuberculosis and malignant pleurisy groups. The concentrations of interleukin-1β (IL-1β), IL-4, IL-6, IL-10, IL-17 A, IL-17 F, IL-21, IL-22, IL-25, IL-31, IL-33, interferon-γ (IFN-γ), soluble CD40 ligand (sCD40L) and tumor necrosis factor-α (TNF-α) in pleural effusion were measured using a multiplex cytokine assay. The threshold values were calculated according to the receiver operating characteristic (ROC) curve analysis to aid in diagnosing tuberculosis pleurisy. Furthermore, the combined measure was validated in the validation cohort.ResultsThe levels of all 14 cytokines in pleural effusion were significantly higher in participants with tuberculosis compared to those with malignant pleurisy (all P < 0.05). The area under the curve (AUC) was ≥ 0.920 for the IL-22, sCD40L, IFN-γ, TNF-α and IL-31, which were significantly increased in tuberculous pleural effusion (TPE) compared to MPE in the training cohort. Threshold values of 95.80 pg/mL for IFN-γ, 41.80 pg/mL for IL-31, and 18.87 pg/mL for IL-22 provided ≥ 90% sensitivity and specificity in distinguishing between tuberculosis pleurisy and malignant pleurisy in the training cohort. Among these, IL-22 combined with sCD40L showed the best sensitivity and specificity (94.0% and 96.9%) for diagnosing tuberculosis pleurisy, and this finding was validated in the validation cohort.ConclusionWe demonstrated that the levels of IL-1β, IL-4, IL-6, IL-10, IL-17 A, IL-17 F, IL-21, IL-22, IL-25, IL-31, IL-33, IFN-γ, sCD40L and TNF-α in pleural effusion had significant difference between tuberculosis pleurisy and malignant pleurisy. Specifically, IL-22 ≥ 18.87 pg/mL and sCD40L ≥ 53.08 pg/mL can be clinically utilized as an efficient diagnostic strategy for distinguishing tuberculosis pleurisy from malignant pleurisy.

8528 An Unusual Case Of Adrenal Hemorrhage As An Initial Manifestation Of Castleman Disease In A 29 yo Male With Unsuspected Late-Onset Congenital Adrenal Hyperplasia

Abstract Disclosure: L.M. Martel: None. F. Mercier: None. S. Parisien-La Salle: None. A. Lacroix: None. A. Liberman: None. N. Bettache: None. H. Olney: None. I. Bourdeau: None. Background: Castleman disease is a lymphoproliferative disorder with no clear etiology. We report the case of a 29 yo man presenting with an adrenal hemorrhage as initial manifestation of Castleman disease and unsuspected late-onset congenital adrenal hyperplasia. Clinical case: A 29-year-old male with no significant past medical history except for unilateral orchiectomy at 1 year-old for a possible testicular mass was referred to our adrenal clinic for a 6,2x7,5 cm left adrenal mass showing at CT scan necrosis and an hemorrhagic component (HU52). The patient presented initially with acute left abdominal pain. The adrenal mass showed at peripheral high uptake at PET-FDG (SUVmax 5,3) with no central uptake. His physical exam was unremarkable except for obesity. The hormonal work-up for the adrenal mass revealed normal metanephrines, and normal 1mg-dexamethasone suppression test with morning cortisol of 18 nmol/L (N&amp;lt;50). Further hormonal investigations based on the high adrenal mass uptake and possible adrenocortical carcinoma included: 17-OH Progesterone: 7.7 nmol/L (N:1.1-7.0), Androstenedione: 14.1 nmol/L (N: 1.5-9.0), Testosterone: 11.3 nmol/L (N: 9.0-28.3) and DHEAS: 3.6 umol/L (2.3-18.7). The ACTH levels were increased at 21.2 pmol/L (N:2-11) with morning cortisol of 220 nmol/L. During the consultation, the patient reported a pleuritic chest pain and underwent an urgent CT pulmonary angiography showing a pulmonary embolism with lung infarction in addition to mediastinal lymphadenopathy (biopsy negative) and a mass in his thymus. He underwent thymectomy and the pathology report described Castleman disease (hyaline vascular type). Taking into account the increased level of 17-OH progesterone, we performed an ACTH stimulation test (250 mcg) that showed an increase of cortisol levels from 333nmol/L to 874nmol/L at 60 minutes and of 17OH Progesterone levels from 5.2nmol/L to 44.2nmo/L excluding adrenal insufficiency, but confirming the diagnosis of late-onset congenital adrenal hyperplasia. Genetic analyses: After written consent, the patient underwent genetic analysis of the CYP21A2 gene by direct sequencing and MLPA. The analyses revealed a heterozygous pathogenic variant in the CYP21A2 gene (c.293-13A/C&amp;gt;G). No other genetic variant was identified in the gene. Follow-up: Subsequent adrenal MRIs showed decreasing size of the left adrenal mass; 3 cm at 3 months, 2 cm at 6 months and no residual mass was seen at 9 months supporting the diagnosis of adrenal hemorrhage. Conclusion: To our knowledge, we report a first case of Castleman disease presenting with adrenal hemorrhage as initial symptom with the association of late-onset congenital adrenal hyperplasia. The possible link between these diseases remains to be explored. Presentation: 6/3/2024

Acute Hypoxic Respiratory Failure Secondary to Pulmonary Nocardiosis: An Unusual Presentation in the Emergency Department

Background: Nocardiosis, a rare but serious infection caused by Gram-positive, aerobic actinomycetes, primarily affects immunocompromised individuals. This report highlights an uncommon case of pulmonary nocardiosis in an immunocompetent patient leading to acute hypoxic respiratory failure. Case Presentation: A 45-year-old male gardener with no significant past medical history presented with acute dyspnea, pleuritic chest pain, fever, night sweats, and weight loss. Physical examination revealed respiratory distress and hypoxia. Imaging showed bilateral alveolar infiltrates and cavitary lesions. Sputum analysis identified Gram-positive branching filamentous bacteria, and Nocardia species were cultured. HIV test was negative. Management: The patient was admitted to the ICU and treated with high-flow oxygen therapy and empirical antibiotics (trimethoprim-sulfamethoxazole [TMP-SMX] and meropenem). Upon culture results, TMP-SMX was continued, and meropenem was discontinued. The patient showed significant improvement and was discharged on oral TMP-SMX for a six-month course. Discussion: This case underscores the importance of considering pulmonary nocardiosis in acute respiratory failure, even in immunocompetent patients. Early diagnosis and appropriate treatment are crucial for favorable outcomes. Conclusion: Pulmonary nocardiosis can cause severe respiratory symptoms in otherwise healthy individuals. Prompt recognition and treatment are essential to manage this potentially life-threatening condition effectively.

Spontaneous Pleuritic Chest Pain In An Otherwise Healthy 22 Year Old Collegiate Athlete

Spontaneous Pleuritic Chest Pain In An Otherwise Healthy 22 Year Old Collegiate Athlete

Pulmonary Embolism and Right Ventricular Dysfunction: Mechanism and Management.

Pulmonary embolism (PE) occurs when thrombi from deep vein thrombosisdislodge and obstruct pulmonary arteries, raising pulmonary artery pressure and straining the right ventricle. This strain can lead to right ventricular dysfunction (RVD), characterized by reduced cardiac output, impaired contractility, and potential development of chronic thromboembolic pulmonary hypertension. Clinically, PE may present with symptoms such as dyspnea, pleuritic chest pain, and tachycardia. Diagnosis is typically confirmed through computed tomography pulmonary angiography, biomarkers like D-dimer and cardiac troponins, and clinical scoring systems. Acute management focuses on hemodynamic support, including intravenous fluids and vasopressors, and may involve anticoagulation with low-molecular-weight heparin or direct oral anticoagulants. Severe cases may require systemic anticoagulation, catheter-directed techniques, and surgeries like pulmonary endarterectomy. Long-term management involves continued anticoagulation tailored to individual risk factors, with ongoing monitoring to prevent recurrence. Effective early diagnosis and management are crucial, as severe PE can significantly increase mortality and lead to serious complications. This review explores the pathophysiology, diagnosis, and management of PE and RVD.

Tolerability and Safety of Miltefosine for the Treatment of Cutaneous Leishmaniasis.

Miltefosine, an orally administered drug, is an important component of the therapeutic arsenal against visceral and mucosal forms of leishmaniasis. However, data regarding the safety and tolerability of miltefosine treatment for cutaneous leishmaniasis (CL) are relatively limited. The aim of this study was to evaluate the tolerability, safety, and adverse events (AEs) of miltefosine treatment in patients with CL. In this cohort study, we reviewed the medical records of all miltefosine-treated patients between 1 January 2016 and 31 December 2022, at Israel Defense Forces military dermatology clinics and the dermatology and Tropical Medicine Clinics at Chaim Sheba Medical Center, Ramat-Gan, Israel. A total of 68 patients (54 males, 79%) with a median age of 30.3 ± 15.6 years (range: 18-88) were included in this study. Leishmania species were identified as L. major (n = 37, 54.4%), L. tropica (n = 12, 17.6%), L. braziliensis (n = 18, 26.5%), and L. infantum (n = 1, 1.5%) using polymerase chain reaction (PCR). Miltefosine tablets were administered orally at a dose of 50 mg, three times daily, for 28 days. Overall, 44 patients (65%) completed the 28-day treatment, and the remaining patients required dose reduction or early discontinuation of treatment. AEs (of any degree) were common, reported in 91% of patients. Both previously reported and previously unreported AEs were documented. Gastrointestinal symptoms (66.1%) and malaise (23.5%) typically occurred during the first two weeks of treatment and tended to subside. Other AEs, including acute renal failure (20.6%), sudden and severe pleuritic chest pain (7.6%), acne exacerbation (11.8%), suppuration of CL lesions (17.8%), and AEs related to the male genitourinary system (39.6% of males), typically occurred towards the end of treatment. The latter included testicular pain, epididymitis, diminution or complete absence of ejaculate, inability to orgasm, and impotence. Severe AEs necessitated treatment discontinuation (29.4%) or hospitalization (10.3%). URTI-like symptoms, arthritis, cutaneous eruption, pruritus, and laboratory abnormalities were also observed. Overall, the cure rate (for all patients combined) evaluated 3 months after the completion of treatment was 60%. The tolerability of miltefosine treatment for CL is low. Close clinical and laboratory monitoring is required during treatment, as severe AEs are not uncommon. As new insights regarding its toxicities emerge, further studies are required to define the role of miltefosine in the treatment of CL.

Purulent pericarditis and cardiac tamponade in HIV: a case report on a dreaded complication of streptococcus pneumoniae

Introduction and importance: Purulent pericarditis is an uncommon complication of Streptococcus pneumoniae, which commonly occurs in an immunocompromised state such as HIV and can lead to life-threatening complications such as cardiac tamponade and potentially death if untreated. Early identification, pericardiocentesis, and general measures such as antibiotics and anti-inflammatory medications can be life-saving. Case presentation: We present a case of a 64-year-old male with HIV who presented with clinical symptoms suggestive of pericarditis. Chest imaging revealed multifocal airspace diseases and moderate pericardial effusion. He had worsening lactic acidosis, and bedside point-of-care ultrasound showed pericardial effusion with features suggestive of cardiac tamponade. His lactic acidosis improved with emergency pericardiocentesis. Blood and pericardial fluid cultures revealed Streptococcus pneumoniae. He was further treated with intravenous antibiotics, colchicine, and ibuprofen. Clinical discussion: Although Streptococcus pneumoniae is a common etiology of community-acquired pneumonia (CAP), it has not been cited as the leading cause of pericarditis or pericardial effusion. In immunocompromised patients, it is necessary to consider a broad differential diagnosis as an etiology of acute chest pain, as it may be challenging to differentiate pleuritic and pericarditic chest pain from clinical presentation only. Moreover, infectious etiology of acute pericarditis and pericardial effusion should be considered in this patient population, especially those with HIV. At the same time, it is crucial to promptly identify and treat cardiac tamponade to prevent further deterioration. Conclusion: Our case provides insight into the diagnosis and management of CAP and its potential complication of purulent pericarditis and cardiac tamponade in immunocompromised patients.

Incidental pulmonary embolism: A Case Report

Pulmonary embolism (PE) is a common clinical condition that generally presents with acute dyspnea, pleuritic chest pain, cough, hemoptysis, tachypnea, tachycardia and hypoxia. Incidental pulmonary embolism (IPE) is defined as an unsuspected filling defect in the pulmonary arteries identified on CT imaging performed for another indication. This report describes a case of Incidental pulmonary embolism (IPE) detected by CT imaging during the follow-up of a 34-year-old male patient who applied to the internal medicine outpatient clinic with weight loss and gastrointestinal system complaints

A robust ensemble deep learning framework for accurate diagnoses of tuberculosis from chest radiographs.

Tuberculosis (TB) stands as a paramount global health concern, contributing significantly to worldwide mortality rates. Effective containment of TB requires deployment of cost-efficient screening method with limited resources. To enhance the precision of resource allocation in the global fight against TB, this research proposed chest X-ray radiography (CXR) based machine learning screening algorithms with optimization, benchmarking and tuning for the best TB subclassification tasks for clinical application. This investigation delves into the development and evaluation of a robust ensemble deep learning framework, comprising 43 distinct models, tailored for the identification of active TB cases and the categorization of their clinical subtypes. The proposed framework is essentially an ensemble model with multiple feature extractors and one of three fusion strategies-voting, attention-based, or concatenation methods-in the fusion stage before a final classification. The comprised de-identified dataset contains records of 915 active TB patients alongside 1,276 healthy controls with subtype-specific information. Thus, the realizations of our framework are capable for diagnosis with subclass identification. The subclass tags include: secondary tuberculosis/tuberculous pleurisy; non-cavity/cavity; secondary tuberculosis only/secondary tuberculosis and tuberculous pleurisy; tuberculous pleurisy only/secondary tuberculosis and tuberculous pleurisy. Based on the dataset and model selection and tuning, ensemble models show their capability with self-correction capability of subclass identification with rendering robust clinical predictions. The best double-CNN-extractor model with concatenation/attention fusion strategies may potentially be the successful model for subclass tasks in real application. With visualization techniques, in-depth analysis of the ensemble model's performance across different fusion strategies are verified. The findings underscore the potential of such ensemble approaches in augmenting TB diagnostics with subclassification. Even with limited dataset, the self-correction within the ensemble models still guarantees the accuracies to some level for potential clinical decision-making processes in TB management. Ultimately, this study shows a direction for better TB screening in the future TB response strategy.

MEDIASTINITIS, WHAT SHOULD WE KNOW: A CASE REPORT OF PNEUMOPYOTHORAX WITH SUSPECTED MEDIASTINITIS IN A 67-YEAR-OLD MALE

Mediastinal disease consists of various diagnoses that have different characteristics, and the severity is not the same. The mediastinal disease diagnosis is often delayed because of the non-specific and sometimes vague presentation and clinical symptoms. One of the commonly missed diagnoses is acute mediastinitis, which is usually presented with fever, pleuritic or retrosternal chest pain, and an inflammatory syndrome. Careful clinical evaluation and radiological correlation are essential when diagnosing mediastinitis, as well as the need to differentiate it from mediastinal infiltration due to malignancy. In this case report, we describe a 67-year-old male, who was referred with pyothorax, cough, and 10 kg of weight loss in the last 1 month. The patient then underwent a CT examination with contrast to establish the diagnosis. Finally, the patient was diagnosed with pneumopyothorax with suspicion of mediastinitis and abscess formation. The lessons learned from this case include the need for recognizing features of mediastinitis, such as fat stranding and fluid collection, which may contain gas locules, in the mediastinal region. The aim of this case report is to increase awareness of early signs of mediastinitis so that prompt management can be initiated as early as possible. Keywords: Mediastinitis, pneumopyothorax, CT thorax

A Study on the Etiology and Clinical Manifestations of Community-Acquired Pneumonia in Adults in Western India.

Community-acquired pneumonia (CAP) is an acute lung infection affecting the alveoli in individuals who have not had recent exposure to healthcare settings. It is characterized by newly detected pulmonary infiltration on a chest X-ray or computed tomography scan, accompanied by at least two of the following symptoms: a new or worsening cough, shortness of breath, increased sputum production, fever or hypothermia, pleuritic chest pain, hypoxia, confusion, or an abnormal WBC count (either leukopenia or leukocytosis). It is a major contributor to global mortality and morbidity, especially in elderly populations. This study aims to investigate the etiology of CAP in our region and analyze the clinical characteristics of patients diagnosed with CAP. This prospective, hospital-based study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, a 2,011-bed multispecialty hospital. The study included 100 patients over 18 years old, diagnosed with CAP, and hospitalized between January 2023 and January 2024. All patients underwent a thorough clinical assessment, and sputum cultures were collected on the day of admission. Patients under 18 years old, those who had been hospitalized within the preceding two weeks, individuals with pneumonia caused by tuberculosis oraspiration pneumonia, patients with compromised immune systems, and pregnant women were excluded. The study included 100 patients with a mean age of 53.13 years (±18.31). The most common age group was 59-68 years, which included 25 (25%) cases, followed by the 69-78 yearage group with 18 (18%) cases and the 18-28 yearage group with 15 (15%) cases. The majority were male, with 61 (61%) cases. Common symptoms included fever in 78 cases (78%), chest pain in 69 cases (69%), dyspnea in 65 cases (65%), and cough in 51 cases (51%). Sputum cultures showed growth in 65 cases (65%), with Klebsiella pneumoniae being the most prevalent pathogen in 28cases (43%), followed by Streptococcus pneumoniae in 18 cases (28%). Together, these two pathogens accounted for 46 out of 65 positive samples (70%). This study highlights the clinical profile and rising etiology of K. pneumoniae in CAPin adults in Western India, particularly in the elderly. These findings underscore the need for periodic updates on CAP etiology to inform empirical treatment strategies effectively. Future research should use advanced diagnostics and diverse samples to refine CAP management, with continuous monitoring to update treatment protocols.

Lung cancer in females from nonsmoker families in India: Observations and inferences in 5 years.

e20610 Background: Incidence in lung cancer in last two decades has been changing drastically in terms of gender, age, smoking behaviour of patients, stage at presentation, histopathology, genetic abnormalities, operability at presentation and survival. More perplexing is the increase in its occurrence in females from non smoker families, mitigating the sole importance of the traditional risk factors of tobacco and smoking in the recent times. This highlights the need to investigate other risk factors like radon exposure from indoor pollution where females stay most of the time, exposure to arsenic and other chemicals in daily life, particle pollution, physical inactivity and inflammatory diseases of airways. Methods: It was an observational study of patients who were diagnosed and treated at a high volume cancer centre in Karnataka state of India. 89 never smoker female patients under 50 years of age from non smoker families with no obvious exposure to second hand or third hand smoke were enrolled from October, 2018 to June, 2023. It was a longitudinal prospective cohort study where the demographic data, symptoms with duration, histopathology including genetic abnormalities, treatment details and survival were noted. Results: 89 never smoker females from non smoker families with ages ranging from 36 to 50 years had a median age of 46 years. About 70% of the ladies were from houses closely associated with farm in past or present. 55% of them had overweight and obese body habitus. Most common presenting symptom was dry cough with median duration of about 3 months in about 89%. Other symptoms were pleuritic chest pain(39%), breathlessness (19%), generalized body ache(9%) and jaundice(2%). Stage of disease was IV(69%), IIIC(12.3%), IIIB(11.2%), IIIA(5.6%) and II in just one patient. Most common sites of metastasis were contralateral lung(45%), bone(20%), liver(20%), adrenal glands(10%) and brain (15%). Most common histopathology was adenocarcinoma(87.6%), adenosquamous carcinoma(7.8%), squamous cell carcinoma(3.3%), large cell neuroendocrine carcinoma in just one patient. EGFR was mutated in 56(62.9%) with deletion 19( 33%) and L858R(21%) being the most common abnormalities. ALK rearrangements and ROS1 fusion were seen in about 9(3.3%) and 3(3.3%) patients respectively. Surgery was done in only 3 patients and chemoradiation after neoadjuvant chemotherapy was given in 8(8.9%) patients. Median overall survival was about 42 months in stage IV patients. Conclusions: Changing demographic profile of lung cancer warrants more research into the other causes of lung cancer. More stage IV disease highlights the emphasis on prevention and screening for the disease.

Multiple Immune Dysregulation Conditions with a Single Underlying Root Cause of NRAS Gene-Positivity: A Case Report

Hematological malignancies in particular are recognized to be linked to immunological dysregulated disorders such hematolytic anemia, immunodeficiency, and autoimmune illnesses. We describe a rare case that had multiple immune dysregulation symptoms and was subsequently found to be positive for the NRAS gene. A male, 29, complained of pleuritic chest pain. On the ECG, he showed broad PR depression and elevated PR in aVR, along with elevated troponin. He received colchicine and NSAIDs as treatment with a good response and resolution of his symptoms. After four weeks, he developed a fever which thought to be secondary to perianal abscess, and a surgical incision and drainage along with broad spectrum antibiotics was used to treat a perianal abscess. Despite receiving extensive medical and surgical care, his fever persisted. His blood film started to show circulating blast cells. Following an immediate bone marrow aspiration and biopsy, there were no notable abnormalities seen, and a 1% blast was present, which was assumed to be the result of stress or infection. Later, a weak positive +1 Coombs (DAT) test is developed and caused active hemolytic anemia required blood transfusion. Along with the anemia, a wrist expanding wound was discovered in the previous IV cannula site. Clinically wound appears as a pyoderma gangrenosum. Histopathology showed purulent dermal inflammation including many neutrophils and macrophages. This feature of micro abscess formation was consisting with the diagnosis of pyoderma gangrenosum. An intravenous steroid (1 mg/kg) was administered in response to a positive Coombs test and pyoderma gangrenosum. The patient's condition greatly improved overall. His wound began to heal as his white blood cell count dropped. After being given oral steroids with a titration-down plan, the patient was sent home. A whole genome sequence was performed on him because he had peri myocarditis, pyoderma gangrenosum, and hematolytic anemia. The results show that he is NRAS gene positive. He was attentively observed clinically with regular out-patient follow-ups as this gene is strongly associated with hematological cancers. He developed symptomatic normocytic anemia a few months later, and a bone marrow aspiration and biopsy were performed to confirm the presence of Myelodysplastic syndromes (MDS). He was transferred to another facility and underwent chemotherapy and bone marrow transplant. In otherwise healthy individuals, the idea of offering a single explanation—Occam's razor—must be considered and investigated. Finding the underlying reason could improve patient care, enable precision therapy, and alter the course of events.

Listeria pericarditis as a paraneoplastic presentation

Introduction: Pericarditis is a common cause of chest pain. It has many etiologies, which are classified into infectious and non-infectious causes. The majority of cases follow a benign course. Case summary: A 66-year-old female presented with pleuritic chest pain following a febrile illness. She was diagnosed with acute idiopathic pericarditis, and standard treatment was initiated. In the following weeks she returned to the hospital multiple times due to unresolved symptoms. Pericardiocentesis was done and cultures from the fluid grew Listeria monocytogenes. CT scan uncovered metastatic pancreatic malignancy. Rapid symptom resolution was observed following the initiation of appropriate antibiotic treatment. Discussion: While most cases of pericarditis follow a benign course, the presence of high-risk features warrants a thorough investigation. In cases resistant to standard treatment, less common causes of pericarditis should be sought.

Point-of-care ultrasound in necrotizing pneumonia: A case report in an adult

Case presentation: A 49-year-old woman returned to the emergency department for respiratory distress and pleuritic chest pain one day after influenza diagnosis. Chest X-ray was consistent with pneumonia. Point-of-care ultrasound showed dynamic air bronchograms and computed tomography revealed necrotizing pneumonia. Discussion: Emergency physicians should suspect necrotizing pneumonia in patients with rapidly progressive community-acquired pneumonia. Point-of-care ultrasound can aid in quick diagnosis of pneumonia. Emergency physicians should be familiar with ultrasound and computed tomography findings in necrotizing pneumonia to trigger appropriate treatment.

Epipericardial Fat Necrosis and Covid-19.

Epipericardial fat necrosis (EFN) is a rare and self-limiting cause of acute chest pain. We describe a case of EFN in a patient with a recent coronavirus disease (COVID-19). A 55-year-old male presented with a sudden onset of left-sided pleuritic chest pain for the past two days. The patient was diaphoretic, tachypneic, and tachycardic. Acute coronary syndrome was ruled out. A computed tomography (CT) pulmonary angiogram revealed an ovoid encapsulated fatty mass surrounded by dense appearing tissue. Patient symptoms improved remarkably with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). EFN typically presents with a sudden onset of excruciating chest pain. Misdiagnosis, under-diagnosis, and mismanagement are unavoidable. EFN is incidentally diagnosed on CT scan. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects visceral adipose tissue and appears to increase the risk of EFN by promoting inflammatory cytokine production and death of adipocytes. EFN is a rare cause of acute chest pain. SARS-CoV-2 is likely to induce EFN. This rare clinical entity should be considered in the differential of acute chest pain especially in patients with active or recent COVID-19. Epipericardial fat necrosis (EFN) is a rare cause of acute pleuritic chest pain that is often misdiagnosed and mismanaged.SARS-CoV-2 can possibly increase the risk of EFN and this entity should be considered in the differential of chest pain, especially in patients with active or recent coronavirus disease (COVID-19).Clinician awareness of EFN and its potential association with COVID-19, can reduce unnecessary testing and emotional distress.

Diagnosis and Management of Hepatic Hydrothorax.

Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).