Repeat Chest Computed Tomography Research Articles

Abstract 13553: Traumatic Right Atrium Perforation Causing Pneumopericardium and Pneumothorax, Treated Conservatively

Background: Pneumopericardium after pacemaker implantation is an extremely rare complication. Patients can present with symptoms such as chest pain, shortness of breath, or be completely asymptomatic. We present a case of a 68-year-old male who underwent dual chamber pacemaker implantation complicated by a pneumopericardium and contralateral pneumothorax. Case Report: A 68-year-old male with a past medical history of coronary artery disease status post percutaneous coronary intervention to the obtuse marginal artery and left circumflex, hypertension and benign prostatic hyperplasia presented with syncope while driving. Telemetry showed symptomatic long pauses up to 6.2 seconds and a dual chamber pacemaker implantation was recommended via the left subclavian vein approach. It was noted that the patient had multiple attempts to place the right atrium lead. Two days after the procedure, the patient developed severe right-sided chest pain and an electrocardiogram showed diffuse ST segment elevations consistent with pericarditis. A chest computed tomography (CT) showed a large right-sided pneumothorax and pneumopericardium and a chest tube was placed. The pacemaker was interrogated and showed a stable function and the patient was managed conservatively. A repeat CT chest showed significant improvement in both the pneumopericardium and the pneumothorax and the patient did well on follow up. Discussion: Ipsilateral pneumothorax and cardiac perforation are not uncommon following pacemaker implantation; however, contralateral pneumothorax and pneumopericardium are extremely rare. In our patient, it appears that the right atrium lead perforated through the right atrium into the right pleural space creating a fistula between the pericardial and pleural spaces. This was not detected on the initial chest x-ray and was only seen on subsequent CT chest imaging. Treatment of pneumopericardium usually involves lead revision or extraction; however, conservative therapy can be successfully attempted with close monitoring, as in our case.

BRONCHOSCOPIC LOCALIZATION OF PERIPHERAL LUNG LESION TO GUIDE SURGICAL RESECTION IN A TODDLER

BRONCHOSCOPIC LOCALIZATION OF PERIPHERAL LUNG LESION TO GUIDE SURGICAL RESECTION IN A TODDLER

SEVERE PULMONARY BLASTOMYCOSIS IN A PATIENT WITH A COVID-19-POSITIVE TEST: A DANGEROUS ANCHORING BIAS

SEVERE PULMONARY BLASTOMYCOSIS IN A PATIENT WITH A COVID-19-POSITIVE TEST: A DANGEROUS ANCHORING BIAS

65-Year-Old Man With Weight Loss and Dyspnea on Exertion

65-Year-Old Man With Weight Loss and Dyspnea on Exertion

Successful treatment of an 82-year-old COVID-19 delta variant-infected patient with haemorrhagic stroke and active prostate cancer brain metastasis.

Successful treatment of an 82-year-old COVID-19 delta variant-infected patient with haemorrhagic stroke and active prostate cancer brain metastasis.

48-Year-Old Woman With Dyspnea and Chest Pain

48-Year-Old Woman With Dyspnea and Chest Pain

Comprehensive Health Assessment 3 Months After Recovery From Acute Coronavirus Disease 2019 (COVID-19).

BackgroundLong-term health sequelae of coronavirus disease 2019 (COVID-19) may be multiple but have thus far not been systematically studied.MethodsAll patients discharged after COVID-19 from the Radboud University Medical Center, Nijmegen, the Netherlands, were consecutively invited to a multidisciplinary outpatient facility. Also, nonadmitted patients with mild disease but with symptoms persisting >6 weeks could be referred by general practitioners. Patients underwent a standardized assessment including measurements of lung function, chest computed tomography (CT)/X-ray, 6-minute walking test, body composition, and questionnaires on mental, cognitive, health status, and quality of life (QoL).Results124 patients (59 ± 14 years, 60% male) were included: 27 with mild, 51 with moderate, 26 with severe, and 20 with critical disease. Lung diffusion capacity was below the lower limit of normal in 42% of discharged patients. 99% of discharged patients had reduced ground-glass opacification on repeat CT imaging, and normal chest X-rays were found in 93% of patients with mild disease. Residual pulmonary parenchymal abnormalities were present in 91% of discharged patients and correlated with reduced lung diffusion capacity. Twenty-two percent had low exercise capacity, 19% low fat-free mass index, and problems in mental and/or cognitive function were found in 36% of patients. Health status was generally poor, particularly in the domains functional impairment (64%), fatigue (69%), and QoL (72%).ConclusionsThis comprehensive health assessment revealed severe problems in several health domains in a substantial number of ex–COVID-19 patients. Longer follow-up studies are warranted to elucidate natural trajectories and to find predictors of complicated long-term trajectories of recovery.

RARE COMPLICATION OF BILATERAL BRONCHOESOPHAGEAL FISTULAS DUE TO INVASIVE MUCORMYCOSIS AFTER RENAL TRANSPLANTATION

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchoesophageal fistula (BEF) is a rare pathological connection between the esophagus and bronchi. Most are acquired due to esophageal or lung cancer. A small subset is caused by opportunistic infections in the immunocompromised. To our knowledge, this is the first case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. CASE PRESENTATION: 67 year old male with hypertension, diabetes, ESRD status post kidney transplant one month prior presents with two weeks of dysphagia, cough, and fatigue. Initial labs were significant for leukocytosis. Computed Tomography (CT) of the chest showed nonspecific pulmonary nodules and a mediastinal mass contiguous with the esophagus concerning for malignancy. EGD revealed an esophageal ulcer that was biopsied. Flexible bronchoscopy with bronchoalveolar lavage and EBUS of subcarinal lymph node was also obtained. Over the course of 72 hours, patient’s clinical status deteriorated. His oxygen requirements increased from nasal canula to high flow in a matter of hours and was ultimately intubated due to hypoxic respiratory failure. After intubation, patient had persistent air leak and remained hypoxic despite being on 100% FiO2. His ET tube was upsized from 7.5mm to 8.5mm due to concern for tracheomalacia. At this time, BAL cultures and esophageal cultures grew mucor. Amphotericin B was initiated. Repeat chest CT showed possible BEFs. Bedside bronchoscopy revealed bilateral white exudate at the level of the right and left mainstem bronchi. Gas bubbles from the esophagus were visible, confirming the bilateral BEFs. During this time patient developed septic shock requiring multiple pressors and persistent hypoxia despite maximal ventilatory settings. Cardiothoracic surgery team offered last-resort surgery including total esophagectomy and lobectomy with reconstruction of BEFs. However, given the extremely high mortality risk, the family declined. The patient passed away shortly after. DISCUSSION: Invasive mucormycosis is a rare, opportunistic fungal infection that presents in immunocompromised patients with underlying diabetes mellitus. Rhino-orbital-cerebral and pulmonary infections are the most common sources. Diagnosis can be made by tissue histopathology with culture confirmation. Due to its aggressive nature, local invasion often leads to multi-organ dysfunction. BEFs are extremely rare complications of invasive mucormycosis. Unfortunately, even with aggressive anti-fungal and surgical intervention, invasive mucormycosis carries extremely high mortality rate. CONCLUSIONS: To our knowledge, this is the first reported case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. Our EGD and bronchoscopy images illustrate the aggressive nature of this fungi. Due to its high mortality rate, early detection, anti-fungal therapy, and surgical debridement are critical. Reference #1: Lee et al. Rare complication of bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia: a case report. Journal of Medical Case Reports (2016) 10:195 DISCLOSURES: No relevant relationships by Dafang Chen, source=Web Response No relevant relationships by Keith Killu, source=Web Response No relevant relationships by Brett Lindgren, source=Web Response No relevant relationships by Neha Mehta, source=Web Response

Haemophilus influenzae Conjunctivitis Secondary to Pneumonia in the Setting of Lymphoplasmacytic Lymphoma

Haemophilus influenzae Conjunctivitis Secondary to Pneumonia in the Setting of Lymphoplasmacytic Lymphoma

Clinical and radiologic features of the first cured Coronavirus disease 2019 (COVID-19) patient in Guangzhou City, China.

To determine changes in clinical and radiologic findings associated with Coronavirus disease 2019 (COVID-19) from diagnosis to recovery, we retrospectively reviewed the diagnosis and treatment records of the first patient cured of COVID-19 in Guangzhou. A 55-year-old woman from Wuhan was admitted to the hospital isolation ward with the chief complaint of “cough for 11 days and once fever 8 days ago” on January 22, 2020. COVID-19 was laboratory confirmed by reverse transcription polymerase chain reaction (RT-PCR) assay, and she received conventional antiviral therapy, such as moxifloxacin, traditional Chinese medicine, and arbidol. Repeat chest-computed tomography (CT) scans were performed on days 13 and 19 of her illness. The former showed radiologic findings, including ground-glass opacities (GGOs), which revealed viral pneumonia; the latter revealed that the previous lesions had been significantly absorbed. The lesions on CT scans were consistent with the changes in the course of disease. Some drugs, such as traditional Chinese medicine and arbidol, might play an important role in the recovery of COVID-19 patients. This study provides some new insights into the formulation of a timely and effective diagnostic and therapeutic strategy to cure patients with COVID-19.Electronic supplementary materialThe online version of this article (10.1007/s42058-020-00045-z) contains supplementary material, which is available to authorized users.

PULMONARY VEIN THROMBOSIS VISUALIZED BY ENDOBRONCHIAL ULTRASOUND (EBUS): A RARE FINDING

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Endobronchial ultrasound (EBUS) offers a minimally invasive tool to allow for visualization and histopathological diagnosis of mediastinal and hilar lymph nodes or masses. Simultaneously, it allows for visualization of major vasculature surrounding the tracheobronchial tree such as the pulmonary veins and arteries. Limited report exists regarding pulmonary vein thrombosis (PVT) visualization with EBUS with only one case being found after conducting a PubMed search. We are presenting an additional case of PVT incidentally diagnosed by chest computed tomography (CT) and later visualized by EBUS. CASE PRESENTATION: A 66-year-old female with a history of 30 pack-year smoking and COPD stage IVB, was found to have a sub-centimeter left lower lobe (LLL) nodule on lung cancer screening. CT chest with contrast was performed revealing new right and left hilar lymphadenopathy without extra-thoracic involvement. Due to claustrophobia PET scan was not tolerated. Repeat CT with contrast revealed that the presumed left hilar mass was actually an occlusive pulmonary vein thrombosis in the superior pulmonary vein. Few weeks later patient was admitted to the hospital with worsening fatigue and right side pleuritic chest pain. Exam was unremarkable. She was managed with therapeutic anticoagulation and antibiotics for possible infectious thrombosis. EBUS-transbronchial needle aspiration of station R10 revealed small cell lung carcinoma. Incidentally the pulmonary vein thrombosis visualized by EBUS (Figure1&2) and confirmed with Doppler mode was comparable with CT images. Chest CT repeated after 6 weeks showed minimal change in the PVT and the patient was continued on therapeutic enoxaparin without complication. DISCUSSION: PVT is a rare and fatal condition with non-specific presenting symptoms making diagnosis a challenge. There have been several case reports on PE diagnosis by EBUS, but to the best of our knowledge there has been only one other case report of PVT visualized on EBUS. No guidelines exist for the diagnosis of PE and PVT with EBUS and much of literature are the case reports only. We are presenting this case to demonstrate that EBUS could be an option to diagnose or confirm PVT when other modalities are contraindicated (e.g. CT pulmonary angiography in the presence of renal impairment or contrast allergy). Although EBUS visualization of PVT may not be applicable to the general population due to cost and invasiveness it could be considered as an alternative diagnostic modality in the right sub-population. CONCLUSIONS: PVT is a rare condition which could prove fatal if diagnosed late. Due to its nebulous presentation, diagnosis can be challenging. EBUS could be considered for the diagnosis or confirmation of PVT in the right sub-population. Reference #1: MacEachern P, Dang B, Stather D, Tremblay A. Tumor invasion into pulmonary vessels viewed by endobronchial ultrasound. J Bronchol 2008; 15:206–207. Reference #2: Swartz MA, Gillespie CT. Pulmonary emboli detected by endobronchial ultrasound. Am J Respir Crit Care Med 2011; 183:1569. Reference #3: Mohammad R. Al-Ajam et al. Endobronchial Ultrasound. When to Venture into the Vasculature. ll AnnalsATS Issues. Vol. 10, No. 4 | Aug 01, 2013. DISCLOSURES: No relevant relationships by Muhammad Bilal, source=Web Response No relevant relationships by Cynthia Callahan, source=Web Response No relevant relationships by Ameet Kumar, source=Web Response No relevant relationships by Benedicta Nnodum, source=Web Response

DIFFUSE ALVEOLAR HEMORRHAGE ASSOCIATED WITH FLECAINIDE

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) occurs as a result of endothelial alveolar-capillary cell injury. Although there are many etiologies for DAH, up to 10% of cases are due to drug toxicity. To our knowledge, we describe a rare case of flecainide-associated DAH likely with underlying diffuse alveolar damage (DAD). Dyspnea and hypoxia improved after cessation of flecainide and initiation of glucocorticoids. CASE PRESENTATION: A 59-year-old female with atrial fibrillation on chronic flecainide presented with a history of dyspnea and dry cough. Vital signs on admission showed hypoxemia with oxygen saturation of 89% on room air. Exam revealed diffuse expiratory wheezing. Chest radiograph showed diffuse interstitial disease with bibasilar lung opacification. She was managed as a case of community acquired multifocal pneumonia, however, remained hypoxemic requiring high flow nasal cannula refractory to antibiotics. Chest computed tomography (CT) demonstrated multifocal areas of ground glass opacities with superimposed interlobular septal thickening in a “crazy paving” pattern (Image 1). During hospitalization, patient developed worsening hypoxemia requiring BiPAP and was transferred to the ICU. Infectious, rheumatologic, and cardiac workup were negative. She was started on intravenous methylprednisolone while in the ICU for presumed ILD. Bronchoscopy was done and bronchoalveolar lavage (BAL) revealed progressively more bloody return in different aliquots consistent with DAH. A literature search showed flecainide linked to DAH and this was discontinued. Steroids were tapered down during a lengthy hospital course with progressive improvement in hypoxemia. Repeat CT of the chest showed significant improvement of ground glass opacities (Image 2). Patient was seen in outpatient clinic after she had a third CT chest performed. This showed further improvement in the ground glass opacities with bibasilar distribution of subpleural reticulation suggestive of underlying DAD with resultant fibrosis (Image 3). PFT’s further confirmed this with a significantly reduced diffusing capacity of 26%. DISCUSSION: There are numerous reports of drug-induced lung injuries and DAH. There have been a few case reports of lung toxicity associated with flecainide, which is felt to be secondary to a cell-mediated immunologic reaction, and is a diagnosis of exclusion. In our case, the patient presented with hypoxemic respiratory failure while on flecainide. Improvement was achieved after withdrawal of flecainide and initiation of steroids, supporting a drug-induced etiology over others. CONCLUSIONS: Our case highlights a rare but potentially lethal manifestation of flecainide-induced pulmonary toxicity. Early recognition of this may prevent irreversible damage leading to pulmonary fibrosis. Reference #1: Hanston P, Evrard P, Mahieu P, Wallemacq P, Friob M, Hassoun A: Flecainide-associated interstitial pneumonitis. Lancet 1991;337:371–372. DISCLOSURES: No relevant relationships by Tracy Ashby, source=Web Response No relevant relationships by Nimeh Najjar, source=Web Response No relevant relationships by Tiara Ong, source=Web Response No relevant relationships by Vandana Seeram, source=Web Response

Abstract 17257: Does Repeat Imaging Validate Visual Coronary Artery Calcium Scoring on Non-Electrocardiogram Gated Chest Computed Tomography?

Aim: To investigate if estimation of the amount of calcium in the coronary system utilizing a visual coronary artery calcium scoring (CACS) system (Kirsch et al. Detection of coronary calcium during standard chest computed tomography correlates with multi-detector computed tomography coronary artery calcium score) in non - electrocardiogram (ECG) gated chest computed tomography (CT) scans maintains its strong correlation with the Agatston CACS on dedicated ECG gated cardiac CT exams across two or more points in time per patient. Methods: A visual scoring system (Weston score, WCS) was previously developed assigning a score (0-3, total score 0-12) for each coronary vessel including the left main trunk. Predetermined score cutoffs in both Agatston and Weston scoring methods were designated for risk stratification. Following institutional review board approval, we retrospectively analyzed 127 total body CT scans on 53 low-risk patients referred by executive health who had received repeat CT scans between 2007 and 2018 and compared the traditional Agatston CACS with the Weston score. Analysis: The data were gathered from a total of 53 executive health patients ages 33 to 71, with an average age of 51. 83.6% were male and 16.4% were female. 118 scans were examined, taken between 307 and 2,792 days apart, with an average of 937 days between scans. The Weston and Agatston scores predicted the same risk classification for 79.7% of the first set of scans, with 10.2% uprisked and 10.2% downrisked by their Weston scores. For the second set of scans, 78.0% had the same classification, with 10.2% uprisked and 11.9% downrisked by their Weston scores. Weston scores predicted 100% of scans within one risk classification of the corresponding Agatston score across all pairs of scans.The average CACS utilizing the Agatston scoring method was 54.3, with a standard deviation of 148.6 due to a large positive skew in the data. The corresponding Weston scores had an average of 1.1, with a standard deviation of 2.14. Conclusion: A visual CACS system (WCS) performed on non-gated CT scans allows risk stratification for cardiac events in a similar manner as the Agatston CACS on ECG-gated CT scans even at separate points in time.

Tracheobronchitis With Stridor in a Patient With Ulcerative Colitis

Bronchopulmonary involvement is a rare but well documented extra-intestinal manifestation of inflammatory bowel disease (IBD). IBD related pulmonary disease can range from subglottic-glottic stenosis to tracheobronchitis to interstitial lung disease and is often misdiagnosed on initial presentation. Symptoms often do not correlate with IBD activity and can even manifest in those with undiagnosed IBD. We present a case of Ulcerative Colitis (UC) related tracheobronchitis in a patient who presented with stridor to emphasize the importance of maintaining a clinical suspicion for pulmonary manifestations of IBD. A 23 year-old woman with UC, who had recently been treated for pneumonia, returned to the emergency department due to worsening respiratory distress and stridor. Past medical history was significant only for UC for which she had self-discontinued mesalamine as she was symptom free. Tracheobronchitis was evident on computed tomography (CT) of the neck and thorax which showed diffuse circumferential nodular tracheal and central bronchial thickening. Flexible bronchoscopy showed papilomatous-like lesions, lending to initial concern for tracheobronchial papillomatosis with parenchymal involvement. Ulcerated tracheal mucosa with fibropurulent exudate was seen on biopsies. Pathology was negative for papillomatosis, viral cytopathic changes, evidence of fungal organisms or malignancy. The patient was empirically started on high-dose corticosteroids with rapid improvement of her respiratory status. Extensive workup for alternative infectious or autoimmune etiologies was negative. The patient remained symptom free at discharge with plans to undergo repeat chest CT four weeks after initiation of steroids to monitor for resolution of pulmonary findings. Extraintestinal manifestations of IBD develop in 21-41% of patients with a higher incidence in those with UC as compared to Crohn's Disease (CD). Pulmonary involvement is rare, occurring in only 0.21% of patients and is often misdiagnosed as asthma on initial presentation. A wide variety of bronchoscopic findings have been reported including severe tracheal narrowing, ulcerated mucosa, a cobblestone appearance and pus. Systemic corticosteroids led to rapid improvement in symptoms in most reported cases of large airway involvement. As seen with the above case, pulmonary manifestations of IBD can be fatal but prompt diagnosis and early intervention can lead to improved outcomes.Figure: Tracheal papilomatous-like lesions found on flexible bronchoscopy in a patient who presented with stridor.Figure: Diffuse tracheobronchial thickening consistent with tracheobronchitis in a patient with inflammatory bowel disease.

Inflamed Bowels, Now Inflamed Lungs: A Case Report of Pulmonary Necrobiotic Nodules in Crohn's Disease

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary necrobiotic nodules have been described as a rare extraintestinal manifestation of Crohn’s disease. We report imaging and pathological findings of this rare disease entity. CASE PRESENTATION: A 21-year-old gentleman with a longstanding history of Crohn’s disease presented with 2 weeks of right-sided pleuritic chest pain, associated with a dry cough. He did not report fevers, night sweats, abdominal pain or diarrhea. The patient had achieved remission of his Crohn's disease for 11 years with adalimumab, which was discontinued 2 months prior to presentation due to concerns of developing secondary lymphomas. He was then transitioned to mesalamine, after which he experienced a self-limited episode of Crohn’s disease exacerbation. On presentation, he was hemodynamically stable. Physical examination was notable for right-sided chest tenderness. Laboratory investigations showed an elevated erythrocyte sedimentation rate of 33 mm/hr and D-dimer of 535 µg/mL. A computed tomography (CT) scan of the chest showed multiple nodular appearing opacities bilaterally (figure 1). Lung biopsy revealed areas of parenchymal necrosis with necrotizing granulomas. The necrosis was basophilic, which contained nuclear debris and eosinophils with the surrounding inflammatory infiltrates (figure 2). Gram stain, acid-fast bacilli stain, fungal stain and tissue culture were all negative. Angiotensin-converting enzyme level was normal. Cytoplasmic antineutrophil antibodies titer was 1:40, myeloperoxidase and proteinase-3 antibodies were not detected. The differential diagnosis was primary vasculitis versus Crohn’s disease associated necrobiotic nodules. The lack of systemic manifestations lowered the suspicion for active vasculitis. The patient had an uneventful recovery. Mesalamine was changed to vedolizumab. Repeat chest CT scan 2 months later showed marked reduction in size and number of the pulmonary nodules. 5 months after presentation chest CT showed complete resolution of the previously noted pulmonary nodules. DISCUSSION: Our case demonstrates a rare pulmonary complication related to Crohn’s disease exacerbation, which is the development of pulmonary necrobiotic nodules. We suspect that this was the consequence of therapy de-escalation. Our hypothesis is supported by the complete resolution of pulmonary nodules following therapy re-escalation. CONCLUSIONS: Even after achieving Crohn's disease remission for a long period of time, therapy de-escalation still carries the risk of triggering unexpected pulmonary manifestations. Physicians should consider risks versus benefits of alternate therapy. In clinical practice, it is important to maintain a broad differential diagnosis, especially in patients with conditions affecting multi-organ systems. Reference #1: Warwick, G., Leecy, T., Silverstone, E., Rainer, S., Feller, R., & Yates, D. H. (2009). Pulmonary necrobiotic nodules: a rare extraintestinal manifestation of Crohn's disease. European Respiratory Review, 18(111), 47-50. DISCLOSURE: The following authors have nothing to disclose: Mahmoud Ahmed, Laurie Lerner No Product/Research Disclosure Information

Acute Respiratory Failure Caused by Hepatopulmonary Fistula in a Patient with Hepatocellular Carcinoma.

A 59-year-old man presented with acute dyspnea following sudden productive cough and expectoration of a full cup of "blood-tinged" sputum. He had been diagnosed with hepatitis B virus–related hepatocellular carcinoma and had received transarterial chemoembolization 5 years ago for a 20-cm hepatic mass; he denied any history of hematemesis and the last esophagogastroduodenoscopy from a year ago showed absence of varix. Chest computed tomography (CT) with angiography showed new appearance of right basal lung consolidation but no bleeding focus. Despite the use of systemic antibiotics, the patient developed respiratory failure on day 7 of hospitalization. After intubation, a massive amount of brown sputum with anchovy-paste-like consistency was suctioned via the endotracheal tube. Bronchoscopic toileting was performed and the patient was extubated. In the ward, he continued to expectorate the brown sputum. On day 25 of hospitalization, a repeat CT scan showed simultaneous disappearance of the pneumonic consolidation and the necrotic fluid within the hepatic mass, suggesting the presence of a fistula. He has continued to receive systemic antibiotics, sorafenib, and entecavir, and follow up by respiratory and hepato-oncology specialists.

Clinical and Immunological Factors in Emphysema Progression. Five-Year Prospective Longitudinal Exacerbation Study of Chronic Obstructive Pulmonary Disease (LES-COPD).

Cross-sectional studies of T-cell responses to self-antigens correlate with baseline emphysema severity. We investigated whether clinical and/or immunological factors could predict disease progression, such as emphysema, FEV1, and 6-minute-walk distance (6MWD), in former and active smokers in a 5-year prospective study. We recruited 224 ever smokers over 40 years of age and with greater than a 15 pack-year smoking history. Repeated spirometry, 6MWD, and peripheral blood T-cell cytokine responses to lung elastin fragments were measured. Baseline and repeat chest computed tomography (CT) scans (34 to 65 mo apart) were used to quantify emphysema progression. Of the 141 ever-smokers with baseline and repeat CT scans, the mean (SD) annual rate of change in percent emphysema was +0.46 (0.92), ranging from -1.8 to +4.1. In multivariable analyses, the rate of emphysema progression was greater in subjects who had lower body mass index (BMI) (+0.15 per 5-unit decrease in BMI; 95% confidence interval, +0.03 to +0.29). In active smokers, increased IFN-γ and IL-6 T-cell responses had a positive association with the annual rate of emphysema progression. Male sex and IL-6 T-cell responses to elastin fragments were significantly associated with annual 6MWD decline, whereas IL-13 was associated with an increase in annual 6MWD. The rate of emphysema progression quantified by CT scans among ever-smokers was highly variable; clinical factors and biomarkers explained only some of the variability. Aggressive clinical care that targets active smokers with autoreactive T cells and low BMI may temporize progression of emphysema.

Benign metastasizing leiomyoma of the lung: A case report and literature review.

Pulmonary benign metastasizing leiomyoma (BML) is a rare event characterized by benign soft-tissue tumors that occur when uterine leiomyomas metastasize to the lung. The present study reports the case of a 47-year-old female patient who presented with multiple bilateral pulmonary nodules on a chest X-ray during a health checkup nine years after a hysterectomy due to uterine fibroids. Chest computed tomography (CT) revealed multiple well-defined nodular shadows in the lung. One tumor of the left upper lung was resected by thoracoscopic surgery. Pathologically, the resected lesion consisted of benign spindle cells and was diagnosed as BML. The post-operative course was uneventful. Other lung nodules have been meticulously monitored at follow-up, and repeat CT two years later showed that these nodules had not increased at all in size and that no new lobe nodules had appeared. The present study indicates that pulmonary BML occurs in a low proportion of female with a history of uterine leiomyoma and treatment methods for it are diverse and controversial.

Clot in Bovine Arch Diagnosed by Transesophageal Echocardiography

Clot in Bovine Arch Diagnosed by Transesophageal Echocardiography

Cytomegalovirus Viremia, Pneumonitis, and Tocilizumab Therapy

Cytomegalovirus Viremia, Pneumonitis, and Tocilizumab Therapy