Pulmonary

The Southwest Journal of Pulmonary and Critical Care publishes articles broadly related to pulmonary medicine including thoracic surgery, transplantation, airways disease, pediatric pulmonology, anesthesiolgy, pharmacology, nursing and more. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.

Rick Robbins, M.D. 4/1/18 Rick Robbins, M.D. 4/1/18

April 2018 Pulmonary Case of the Month

Ashely L. Garrett, MD

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 74-year-old woman with known chronic obstructive pulmonary disease (COPD) presented to emergency department on 2/4/18 with dyspnea. She had been hospitalized at another hospital from 12/29/17 - 1/30/18 for a COPD exacerbation and health care associated pneumonia described as a cavitary pneumonia. She was treated with various doses of systemic steroids and antibiotics. Her course was complicated by atrial fibrillation with a rapid ventricular response. She eventually was discharged to a skilled nursing facility.

Past Medical History, Social History and Family History

She has a known history of COPD with an FEV1 of 22% of predicted and is on 2L/min of O2 by nasal cannula. There is also a history of:

Hypertension.
Hypercholesterolemia.
Paroxysmal atrial fibrillation, not on anticoagulation.
Right 4 mm PICA aneurysm

She lives in rural Kingman, AZ with some dust and outdoor bird exposure.

Family history is noncontributory.

Medications

Alprazolam 0.25 mg p.o. b.i.d.
Symbicort two puffs inhaled b.i.d.
Diltiazem 120 mg p.o. q.12h
Disopyramide 150 mg p.o. q.6h
Furosemide 20 mg p.o. daily
Levalbuterol 0.31 mg q.6 days p.r.n.
Meperidine 50 mg p.r.n. pain
Metoprolol succinate 12.5 mg p.o. b.i.d
Prednisone 10 mg p.o. daily

Physical Examination

Vitals: BP 110/65 mm Hg, P 130 irregular beats/min, T 37° C, Respirations 20 breaths/min
General: Appears in mild respiratory distress
Lungs: Distant breath sounds
Heart: Irregular rhythm with distant tones
Abdomen: no organomegaly, masses or tendernesses
Extremities: No edema

Which of the following should be done at this time? (Click on the correct answer to proceed to the second of six pages)

Cite as: Garrett AL. April 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(4):174-82. doi: https://doi.org/10.13175/swjpcc050-18 PDF

Rick Robbins, M.D. 12/11/17 Rick Robbins, M.D. 12/11/17

Necrotizing Pneumonia: Diagnosis and Treatment Options

Brian D. Skidmore, BS¹ and Veronica A. Arteaga, MD²

¹College of Medicine and ²Department of Medical Imaging

Banner-University Medical Center

University of Arizona

Tucson, AZ USA

Abstract

We present the case of a patient who was initially diagnosed with community-acquired pneumonia that was later discovered to have necrotizing changes. The case illustrates the challenges in diagnosing necrotizing pneumonia and the preferred treatment methods.

Case Presentation

History of Present Illness

The patient is a 51-year old woman who presents with right upper lobe pneumonia and a failed outpatient regimen of levofloxacin. She returned one week after being seen in the emergency department with worsening dyspnea, productive cough, and fever in addition to new symptoms of right chest pain and post-tussive emesis. The chest pain is stabbing in quality and constantly present. She denied any calf pain/swelling, previous history of deep venous thrombosis, or long trips or travels.

Physical Exam

Upon admission, blood pressure was 103/56 with a pulse of 114 and respiratory rate of 18. Her temperature was 38.1 °C (100.5 °F) but spiked at 39.5 °C (103.1 °F) and her SpO₂ was 94.0% on room air. Her breathing was unlabored and her lungs were clear to auscultation bilaterally except for crackles in the right upper lung field. The remainder of the exam was unremarkable.

Laboratory and Imaging

A chest radiograph was initially obtained and showed a right upper lobe consolidation consistent with community-acquired pneumonia (Figure 1).

Figure 1. Chest radiograph showing right upper lobe consolidation with possible volume loss.

One week later, a contrast-enhanced chest CT was performed and revealed a heterogeneously enhancing right upper lobe consolidation with cavitation and foci of air diagnostic of necrotizing pneumonia (Figure 2).

Figure 2. Contrast-enhanced chest CT showing right upper lobe pneumonic consolidation with peripheral enhancement, central necrosis, and small foci of air.

Laboratory studies revealed a markedly elevated C-reactive protein of 16.61 mg/dL and a white blood cell count of 18,000 cells/ μL. In addition, the red blood cell count, hemoglobin, and hematocrit were all reduced with values of 3,390,000 cells/ μL, 10.0 g/dL, and 31.0% respectively.

Hospital Course

A chest CT was ordered and the patient was diagnosed with necrotizing pneumonia. She was given IV vancomycin and piperacillin-tazobactam as empiric therapy. Tylenol was administered for fever management and steroids were deferred because her CURB-65 score for pneumonia severity was 0.

Attention was then given to identifying the infectious agent. Blood and respiratory cultures were obtained and a TB test was ordered. The cultures showed no growth and the TB test was negative. A bronchoalveolar lavage showed a highly neutrophilic cell count, however no pathogen was ever identified.

Given improvement with empiric therapy, during her hospital course she was discharged on oral amoxicillin and clavulanate until follow up with pulmonary in outpatient 6 weeks later. Imaging at that time showed post inflammatory changes and no evidence of infection.

Discussion

Necrotizing pneumonia is a rare complication of bacterial lung infections affecting 4% of all patients with community-acquired pneumonia (1). The infection can be patchy, segmental, or involve the entire lung. While the pathogenesis of necrotizing pneumonia is not clearly defined, most studies indicate that it is either an inflammatory response to toxins produced by the pathogen or it is the result of associated vasculitis and venous thrombosis. Patients typically present with common symptoms of pneumonia such as fever, cough, shortness of breath, and chest pain but can also rapidly develop hemoptysis, septic shock, and respiratory failure as the necrosis progresses (2). Because necrotizing pneumonia is associated with increased morbidity and mortality, it is important to distinguish it from non-necrotizing cases (3).

The diagnosis of necrotizing pneumonia may be difficult to make because of its similar presentation to non-necrotizing pneumonias and the limitations of standard chest radiographs. Chest radiographs may show an area of consolidation but are limited in identifying the extent of parenchymal disease (Figure 1) (2). Therefore, contrast-enhanced chest CT is an optimal exam for diagnosing necrotizing pneumonia. Disease may first appear as an in-homogeneously enhancing consolidation with focal areas of low attenuation (Figure 2). Foci of air may subsequently develop in these areas of hypo-enhancing necrotic tissue indicating cavitation (4).

Laboratory studies may also be helpful in diagnosing necrotizing pneumonia. When compared to pneumonias without a necrotizing component, patients with necrotizing pneumonia show more elevated white blood cell counts and inflammatory markers (1). In one study, patients with necrotizing pneumonia had an average WBC count of 14,970/μL, an average ESR of 70 mm/h, and an average CRP of 18.8 mg/dL. Average values for patients with non-necrotizing pneumonia were significantly lower at 10,130/μL, 48 mm/h, and 11.4 mg/dL respectively (p<0.001) (3). These changes are also evident in the presented case with elevated WBC and CRP values of 18,000/μL and 16.61 mg/dL.

Necrotizing pneumonia is initially treated with intravenously administered broad-spectrum antibiotics that should target pathogens that commonly cause necrotizing changes. The most common microbes are Staphylococcus aureus, Streptococcus pneumoniae, and Klebsiella pneumoniae, however several other bacteria species may also cause necrosis (Table 1) (2).

Transition to oral antibiotics may be considered for patients that show improvement (1). A more focused treatment plan should be initiated once a specific pathogen is identified, however this is only accomplished in approximately 26% of cases (3).

Surgical resection may also be considered for patients who show no progress on antibiotic therapy and continue to decline. However the optimal timing and indications for surgery are not clearly defined. The extent of the resection should always be as conservative as possible and commonly involves debridement or segmentectomy of the damaged tissue. In cases where the parenchyma is extensively affected, lobectomy or pneumonectomy may be required (2).

References

Nicolaou EV, Bartlett AH. Necrotizing pneumonia. Pediatr Ann. 2017;1;46(2):e65-e68. [CrossRef] [PubMed]
Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med. 2012;18(3):246-52. [CrossRef] [PubMed]
Seo H, Cha SI, Shin KM, et al. Clinical relevance of necrotizing change in patients with community-acquired pneumonia. Respirology. 2017;22(3):551-8. [CrossRef] [PubMed]
Walker CM, Abbott GF, Greene RE, Shepard JO, Vummidi D, Digumarthy SR. Imaging Pulmonary Infection: Classic Signs and Patterns. AJR Am J Roentgenol. 2014;202(3) 479-92. [CrossRef] [PubMed]

Cite as: Skidmore BD, Arteaga VA. Necrotizing pneumonia: diagnosis and treatment options. Southwest J Pulm Crit Care. 2017;15(6):274-7. doi: https://doi.org/10.13175/swjpcc137-17 PDF

Rick Robbins, M.D. 10/7/17 Rick Robbins, M.D. 10/7/17

Treatment of Lymphoma and Cardiac Monitoring during Pregnancy

Stella Pak, MD

Yan Yatsynovich, MD

Damian Valencia, MD

Calvert Busch, MD

Emily Vannorsdall, MD

Department of Medicine

Kettering Medical Center

Kettering, OH USA

Abstract

Limited data is available regarding fetal-maternal outcomes with chemotherapy during pregnancy, including cardiovascular toxicity and evaluation thereof. Early cardiovascular evaluation and initiation of cardioprotective therapies should be considered. Herein, we report a case of a 33-year-old woman treated with R-CHOP chemotherapy for large B-cell lymphoma found to have some degree of reversible cardiac strain.

Introduction

There are no guidelines specific for cardiotoxicity monitoring in pregnant patients undergoing chemotherapy. Pregnant patients are more vulnerable to cardiovascular complications, such as congestive heart failure, from chemotherapy as their cardiovascular system is under considerable stress from increasing physiological demands in pregnancy. With elevated cardiac output and circulatory volume from baseline, these patients do not have much cardiopulmonary reserve to compensate for cardiac strains from chemotherapy side effects (1). Therefore, it would be critical for clinicians to be aware of increased risk of cardiovascular adverse effect from chemotherapeutic agents in pregnant patients. Herein, we report a case of a 33-year-old woman treated with R-CHOP chemotherapy for large B-cell lymphoma found to have some degree of reversible cardiac strain.

Case Presentation

An otherwise healthy 33-year-old Caucasian female, G2P1 at 24 weeks gestation presented with a chief complaint of cough, chest pressure, and swelling in the neck and face. Physical exam was notable for a negative Pemberton’s sign, two lymph nodes in the right supraclavicular region measuring approximately 2 cm without axillary or groin lymphadenopathy. Cardiac exam demonstrated distant heart sounds with a faint I-II/VI systolic murmur in the left second intercostal space, without presence of bruits or lower extremity edema. Lung exam was positive for occasional wheezing in the left lower lobe. Breast exam was normal. Initial chest x-ray (Figure 1) and computed tomography (CT) scan (Figure 2) of the chest revealed a mediastinal mass (11 x 9.2 x 8.7 cm) and a moderate sized pericardial effusion.

Figure 1. Roentgenogram of chest demonstrating a large mass on left lower lobe and pericardial effusion.

Figure 2. Computerized tomography of chest revealing a large homogeneous left mediastinal mass (92.1 mm X 87.1 mm).

Follow up CT-guided biopsy yielded a diagnosis of large B-cell lymphoma. Bronchoscopy done at that time demonstrated diffuse tracheal and bronchial involvement, likely pointing to primary mediastinal derivation of the tumor. Interestingly, the patient had a history of lymph node biopsy of two areas on her right lateral neck and right medial supraclavicular node; pathology reports were consistent with granulomatous disease at that time. Due to pregnancy, baseline positron emission tomography (PET)/CT was not performed, however, the patient did undergo staging with a CT scan of the chest and abdominal/pelvic and magnetic resonance imaging (MRI), both of which were negative for metastatic disease. Bone marrow biopsy obtained was negative for malignancy as well. Dose-adjusted R-EPOCH (rituximab, etoposide, prednisone, oncovin, cyclophosphamide, hydroxydaunorubicin) was replaced with R-CHOP (rituximab, cyclophosphamide, hydroxydaunomycin, oncovin, prednisolone) due to the teratogenic effects of etoposide. Embryologic toxicity has previously been observed with etoposide including skeletal abnormalities, exencephaly, encephalocele and anophthalmia. Monitoring of cardiac function was performed before, during and after treatment. Initial echocardiogram demonstrated preserved ejection fraction (EF) of 60% with a large pericardial effusion and early signs of tamponade. No strain studies were done prior to initiation of chemotherapy. The patient had undergone a total of six cycles with a good response. Upon treatment completion fluoro-D-glucose (FDG)-PET/CT did show persistent uptake mostly in the manubrium as well as a persistent mediastinal mass with a low standardized uptake values (SUV).

The patient had initially considered radiotherapy in her post-delivery course, but given her most recent PET scan with a Deauville score of less than 4, the patient decided to avoid radiation and opted for close follow-up with repeat imaging. The Deauville 5-point scoring system is an internationally accepted point based scale used to characterize fluorodeoxyglucose (FDG) avidity of malignant tumor mass as seen on FDG positron emission tomography (PET) scan. Scores between 1 and 2 are considered negative, a score of 3 is typically paired with other studies and clinical signs to determine progression of disease, a score of 4 and 5 are considered positive for malignancy progression. Her pericardial effusion had resolved with chemotherapy.

Echocardiographic cardiac strain evaluation performed during follow-up evidenced a drop in her longitudinal strains from 22.8 to -15% just prior to delivery. Ejection fraction remained preserved at >60%. Low-dose carvedilol was considered during treatment however patient was not agreeable. The patient had an uneventful delivery and strain studies post-delivery showed a stable -15% strain. Echocardiogram performed 6 months post-chemotherapy demonstrated an ejection fraction of 72% and normalization of longitudinal strain. In the light of chemotherapy with known cardiotoxic adverse effects, as well as pregnancy strain on cardiac function, the patient did well and underwent an uneventful course.

Discussion

The majority of data on maternal and fetal cardiotoxic effects of chemotherapy during pregnancy is based on case reports and retrospective data collection (2).

Registry data seems to suggest that the incidence of toxic side effects is not significantly increased during pregnancy and in the current literature there is no mention of an increased frequency of heart failure or left ventricular dysfunction during pregnancy (3-5). A study by Van Calsteren et al. (6), suggested that serum levels of chemotherapy, including anthracyclines, measured in pregnant women, were lower compared with those in nonpregnant women although the differences were not statistically significant. Despite the lower serum levels, cardiotoxicity might have a more significant impact on the maternal cardiovascular system in a context of increased hemodynamic loading. The use of cardiotoxic medications during pregnancy requires further attention, however no standard cardiac follow-up protocols are currently in place (7).

There may be a need for clinical cardiac assessments and an echocardiographic functional evaluation, including cardiac strain monitoring, prior to starting chemotherapy and repeat echocardiographic evaluation prior to every dose. If changes in cardiac function are observed, less cardiotoxic treatments might be considered or cardioprotective agents could be used. In this particular patient population, baseline echocardiography with strain study is crucial. Evidence of abnormal strain study during any part of the treatment should prompt initiation of cardioprotective therapy as per standards of the current heart failure guidelines. In addition, we suggest consideration for close cardiac follow-up monitoring, including a repeat echocardiogram study at 12 months post completion of chemotherapy/radiotherapy treatment. It is still unclear whether prophylactic therapy with cardioprotective agents would be safe and beneficial in these patients. Though we may be able to extrapolate data from trials performed on non-pregnant patients undergoing therapy and apply it to this particular niche of patients. The 2013 ACC/AHA heart failure guidelines state that it may be reasonable to evaluate those who are receiving (or who have received) cardiotoxic chemotherapy agents for left ventricular dysfunction as well as use echocardiographic techniques or biomarkers to identify increased heart failure risk in those receiving chemotherapy (8). In addition, the 2012 European Society of Medical Oncology (ESMO) guidelines stress on importance of serials cardiac function monitoring at baseline, 3, 6 and 9 months during treatment and then at 12 and 18 months after initiation of treatment (9).

Today, there is still no clear consensus with regards to cardioprotective therapy in patients exposed to cardiotoxic agents. As of 2016, the ACC/AHA guidelines did not reflect any change in recommendations in this particular field. Risk-stratification and prophylactic cardioprotective therapy remain an ultimate goal in pregnant patients undergoing chemotherapy, but how that should be done is still being studied. Early cardiology involvement and possible early initiation of prophylactic heart failure therapy should be considered.

References

Fadol AP, Lech T, Bickford C, Yusuf SW. Pregnancy in a patient with cancer and heart failure: challenges and complexities. J Adv Pract Oncol. 2012 Mar;3(2):85-93. [PubMed]
Gziri MM, Amant F, Debiève F, Van Calsteren K, De Catte L, Mertens L. Effects of chemotherapy during pregnancy on the maternal and fetal heart. Prenat Diagn. 2012 Jul;32(7):614-9. [CrossRef] [PubMed]
Cardonick E, Dougherty R, Grana G, Gilmandyar D, Ghaffar S, Usmani A. Breast cancer during pregnancy: maternal and fetal outcomes. Cancer J. 2010;16(1):76-82. [CrossRef] [PubMed]
Van Calsteren K, Heyns L, De Smet F, et al. Cancer during pregnancy: an analysis of 215 patients emphasizing the obstetrical and the neonatal outcomes. J Clin Oncol. 2010 Feb 1;28(4):683-9. [CrossRef] [PubMed]
Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol. 2004 May;5(5):283-91. [CrossRef] [PubMed]
Van Calsteren K, Verbesselt R, Ottevanger N, et al. Pharmacokinetics of chemotherapeutic agents in pregnancy: a preclinical and clinical study. Acta Obstet Gynecol Scand. 2010 Oct;89(10):1338-45. [CrossRef] [PubMed]
Ewer MS, Ewer SM. Cardiotoxicity of anticancer treatments: what the cardiologist needs to know. Nat Rev Cardiol. 2010 Oct;7(10):564-75. [CrossRef] [PubMed]
Yancy CW, Jessup M, Bozkurt B, et al. 2013 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15;128(16):1810-52. [CrossRef] [PubMed]
Curigliano G, Cardinale D, Suter T, et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. Ann Oncol. 2012 Oct;23 Suppl 7:vii155-66. [CrossRef] [PubMed]

Cite as: Pak S, Yatsynovich Y, Valencia D, Bushch C, Vannorsdall E. Treatment of lymphoma and cardiac monitoring during pregnancy. Southwest J Pulm Crit Care. 2017;15(4):154-8. doi: https://doi.org/10.13175/swjpcc106-17 PDF

Rick Robbins, M.D. 10/1/17 Rick Robbins, M.D. 10/1/17

October 2017 Pulmonary Case of the Month

Eric A. Jensen, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 56-year-old woman presented with 3 days of non-productive cough, low-grade fever and severe right-sided pleuritic chest pain.

Past Medical History, Social History and Family History

She was diagnosed with coccidioidomycosis 5 years previously. She reports that she has had pneumonia every 6 to 12 months since her diagnosis with valley fever. She does not smoke. Family history is noncontributory.

Physical Examination

Her vital signs were unremarkable and she was afebrile but did cough frequently during the examination. Her lungs were clear and the rest of the physical examination was unremarkable.

Chest Radiography

She brings in two prior chest x-rays, one from 2011 (Figure 1, Panels A & B) and another from 2012 (Figure 1, Panel C).

Figure 1. Chest radiograph from 2011 (A & B) and from 2012 (C).

Which of the following best describes the chest x-rays? (Click on the correct answer to proceed to the second of five pages)

Cite as: Jensen EA. October 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;15(4):125-30. doi: https://doi.org/10.13175/swjpcc115-17 PDF

Rick Robbins, M.D. 9/1/17 Rick Robbins, M.D. 9/1/17

September 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 67-year-old woman with history of chronic lymphocytic leukemia (CLL) was referred due to a 6-week history severe cough. Her CLL had recently relapsed and she was begun on ibrutinib (a small molecule drug that binds permanently to Bruton's tyrosine kinase) in addition to acyclovir, sulfamethoxazole/trimethoprim and allopurinol.

Past Medical History, Social History and Family History

Her CLL was initially diagnosed in 2009 and had responded to fludarabine, cyclophosphamide, and rituximab. She had no other chronic medical diseases. She smoked ½ pack per day but quit with the development of her cough. Family history was noncontributory.

Physical Examination

Her vital signs were unremarkable and she was afebrile but did cough frequently during the examination. There were shoddy small lymph nodes noted in both supraclavicular and axillary areas. Lungs were clear and the rest of the physical examination was unremarkable.

Laboratory Evaluation

Her complete blood count revealed her to be mildly anemic with a hemoglobin of 9.0 g/dL, an elevated white count of 33,700 cells/mcL with 88% lymphocytes, and a low platelet count of 60,000 cells/mcL. Her electrolytes were within normal limits and her blood urea nitrogen was 20 mg/dL, creatinine 1.1 mg/dL and uric acid 7.1 mg/dL.

Chest Radiography

A chest x-ray was performed (Figure 1).

Figure 1. Initial chest x-ray.

Which of the following is true? (Click on the correct answer to proceed to the second of five pages)

Cite as: Wesselius LJ. September 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;15(3):94-9. doi: https://doi.org/10.13175/swjpcc108-17 PDF

Rick Robbins, M.D. 7/1/17 Rick Robbins, M.D. 7/1/17

July 2017 Pulmonary Case of the Month

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

The patient is a 19-year-old woman who went to a local Emergency Room 12/23/15 for chest pain she described as pleurisy. She was told she had pneumonia and a chest x-ray was reported to show a lingular infiltrate (Figure 1).

Figure 1. PA (A) and lateral (B) chest radiograph taken 12/23/15.

She was treated with antibiotics and improved. She was well until 9/2/16 when she again returned to the emergency room complaining of hemoptysis. A chest x-ray was reported as showing a lingular infiltrate (Figure 2).

Figure 2. PA (A) and lateral (B) chest radiograph taken 9/2/16.

She was treated with azithromycin but her cough persisted sometimes with a small amount of blood in her sputum. She was referred because of her persistent symptoms and her abnormal chest x-ray.

Past Medical History, Social History and Family History

She is now taking fluoxetine daily.
She has a history of pediatric autoimmune neuropsychiatric disorder associated with Group A Streptococcus and was treated with antibiotics for 4-5 years.
Nonsmoker.

Physical Examination

Her physical examination was unremarkable.

Which of the following are true? (Click on the correct answer to proceed to the second of five pages)

Cite as: Viggiano RW. July 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;15(1):1-6. doi: https://doi.org/10.13175/swjpcc082-17 PDF

Rick Robbins, M.D. 6/1/17 Rick Robbins, M.D. 6/1/17

June 2017 Pulmonary Case of the Month

Robert Horsley, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 61-year-old woman presented to the emergency department for 3 days of fevers up to 102º F, malaise, and progressive shortness of breath. Her symptoms started immediately after he last naltrexone injection for alcohol use disorder.

Past Medical History, Social History and Family History

Alcohol use disorder
Treated with monthly naltrexone injections, received 3 doses total, and gabapentin
No other previous medical issues
Nonsmoker

Physical Examination

Vital signs: Pulse 100, BP 108/90, respiratory rate 34, SpO2 93% 10L non-rebreathing mask
Cyanotic on room air
Lungs clear

Radiography

A portable chest x-ray was performed in the emergency department (Figure 1).

Figure 1. AP chest radiograph taken in the emergency department.

A thoracic CT scan was performed (Figure 2).

Figure 2. Representative images from thoracic CT in lung windows.

Laboratory

CBC showed a white blood cell count of 12,000 cells/mcL.
The differential showed a left shift.
Lactate was 5.2 mmol/L

Which of the following is (are) true? (Click on the correct answer to proceed to the second of five pages)

Cite as: Horsley R, Wesselius LJ. June 2107 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(6):255-61. doi: https://doi.org/10.13175/swjpcc063-17 PDF

Rick Robbins, M.D. 5/1/17 Rick Robbins, M.D. 5/1/17

May 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 69-year-old man with known heart failure, COPD and prostate cancer with presented with increased shortness of breath. He denied any fever, chills, cough or sputum.

Past Medical History, Social History and Family History

Diastolic heart failure with a preserved ejection fraction
Prostate cancer with bone metastasis treated with leuprolide (Lupron^®)
COPD treated with salmeterol/fluticasone and tiotropium
He is married, retired and had quit smoking a number of years ago.
Family history was unremarkable

Physical Examination

Oxygen saturation (SpO2) was 93% on room air.
Physical examination showed jugular venous distention (JVD), bilateral lung rales a laterally displaced pulse of maximal impulse (PMI) and 1+ pretibial edema.

Radiography

A chest x-ray was performed (Figure 1).

Figure 1. Admission chest x-ray.

Based on the history and chest x-ray which of the following is the most likely diagnosis? (Click on the correct answer to proceed to the second of six pages)

Cite as: Wesselius LJ, Viggiano RW. May 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(5):185-91. doi: https://doi.org/10.13175/swjpcc052-17 PDF

Rick Robbins, M.D. 4/1/17 Rick Robbins, M.D. 4/1/17

April 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 63-year-old woman with a prior diagnosis of possible rheumatoid arthritis was referred for dyspnea with more vigorous activities in Prescott where she now lives (elevation 5367 ft.). She is receiving hydroxychloroquine 400 mg/day.

Past Medical History, Social History and Family History

She has a past medical history of hypertension. She smoked about a pack per day from age 20 to 40. There is a history of colon cancer in her mother and lung cancer in a sister.

Physical Examination

Vitals: BP 155/102, SpO2 93% on room air
Chest: slightly decreased breath sounds but clear
Cardiovascular: regular rhythm without murmur
Extremities: no cyanosis, clubbing or edema
The remainder of the physical examination is normal

What testing would you perform at this time? (Click on the correct answer to proceed to the second of five pages)

Cite as: Wesselius LJ. April 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(4):129-33. doi: https://doi.org/10.13175/swjpcc040-17 PDF

Rick Robbins, M.D. 1/1/17 Rick Robbins, M.D. 1/1/17

January 2017 Pulmonary Case of the Month

Jamie Bering, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

The patient is a 53-year-old woman transferred for acute respiratory failure and hemoptysis. She has a prior history of antiphospholipid syndrome and recurrent diffuse alveolar hemorrhage (DAH). She was admitted to another hospital about 2 weeks prior to transfer with hypoxic respiratory failure which ultimately required intubation. Bronchoscopy revealed a bloody aspirate raising concerns for recurrent DAH. She was started on high-dose solumedrol and extubated after 4 days. One week later, her respiratory status decompensated and her chest x-ray showed worsening diffuse bilateral opacities concerning for recurrent DAH. She was transferred to the Mayo Clinic Arizona for further evaluation. Upon arrival, she required 50% FiO2 by face mask to maintain adequate oxygenation and was started on broad-spectrum antibiotics. Her corticosteroids were tapered to 20 mg prednisone daily.

Past Medical History, Social History and Family History

She has a history of a mitral valve replacement with a St. Jude’s mechanical mitral valve and was on chronic anticoagulation with warfarin. In addition, there was a history of moderate aortic stenosis with moderate aortic insufficiency.

She had a history of diffuse alveolar hemorrhage, antiphospholipid antibody syndrome and possible systemic lupus erythematosus.

Medications

Dapsone 100mg daily
Ethacrynic acid 75mg daily
Gabapentin 900mg QHS
Lisinopril 20mg daily
Meropenem 1g Q8 hrs
Metoprolol 50 mg BID
Prednisone 20mg daily
Simvastatin 40mg QHS
Vancomycin 1.5g Q12 hrs
Warfarin 4mg T,F; 3mg SMWRSa

Physical Examination

Vitals: T 36.3^◦ C; HR 79 beats/min; BP 100/63 mm Hg; RR 26 breaths/min; SpO2 99% face mask
Gen: no acute distress
HEENT: hematoma on chin
Lungs: clear to auscultation and percussion
Cardiac: Mechanical valve click

Laboratory

CBC: WBC 15,900 cells per microliter (mcL); Hemoglobin 9.1 g/dL; hematocrit 29%; platelet count 156,000 cells per microliter.
Electrolytes: within normal limits.
BUN and creatinine: within normal limits.
Blood sugar: 220 mg/dL.

Radiography

Her initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of four pages)

Cite as: Bering J, Wesselius LJ. January 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;14(1):1-5. doi: https://doi.org/10.13175/swjpcc146-16 PDF

Rick Robbins, M.D. 12/1/16 Rick Robbins, M.D. 12/1/16

December 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

Correctly interpret and identify clinical practices supported by the highest quality available evidence.
Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 29-year-old man who presented to the emergency room with right-sided pleuritic chest pain, fever, cough, and progressive dyspnea over 2 weeks.

Past Medical History, Social History and Family History

He had no prior significant medical issues and had been well until 2 weeks ago. A native of India, he has been in the US for about 5 months and works at American Express. He is a nonsmoker. Family history is noncontributory.

Physical Examination

Vitals signs: Temperature 38.0^◦ C, Blood Pressure 155/85 mm Hg, Heart Rate 140 beats/min, Respirations 24 breaths/min
General: Appears to be in moderate pain and respiratory distress
Lungs: Decreased breath sounds on the right
Heart: regular rhythm with a tachycardia
Abdomen: unremarkable
Extremities: unremarkable
Neurologic: unremarkable

Radiography

His initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of seven pages)

Cite as: Wesselius LJ. December 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(6):268-75. doi: https://doi.org/10.13175/swjpcc122-16 PDF

Rick Robbins, M.D. 10/1/16 Rick Robbins, M.D. 10/1/16

October 2016 Pulmonary Case of the Month

Coya T Lindberg, BS¹

Ryan R Nahapetian, MD²

F Zahra Aly, MD, PhD, FRCPath³

¹University of Arizona College of Medicine Tucson, Tucson, AZ

²Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona, Tucson, AZ

³Brody School of Medicine at East Carolina University, NC

Pulmonary Case of the Month CME Information

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Coya Lindberg, BS. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

Correctly interpret and identify clinical practices supported by the highest quality available evidence.
Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

A 49-year-old man presented with chest discomfort to an outside medical facility in Arizona. He was previously healthy and had no chronic medical diseases. Physical examination was unremarkable and he was afebrile. A chest X-ray was performed (Figure 1).

Figure 1. Initial chest x-ray

Which of the following is most likely? (Click on the correct answer to proceed to the second of five panels)

Cite as: Lindberg CT, Nahapetian RR, Aly FZ. October 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(4):152-8. doi: http://dx.doi.org/10.13175/swjpcc096-16 PDF

Rick Robbins, M.D. 8/1/16 Rick Robbins, M.D. 8/1/16

August 2016 Pulmonary Case of the Month

Anjuli M. Brighton, MB, BCh, BAO

Kathryn E. Williams, MB, BCh, BAO

Lewis J. Wesselius, MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Anjuli M. Brighton, MB. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

Correctly interpret and identify clinical practices supported by the highest quality available evidence.
Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is 54-year-old man with type 1 diabetes mellitus admitted for diabetic ketoacidosis (DKA). He complained of somnolence, nausea and vomiting and right foot pain. He had been admitted 2 weeks earlier for right foot gangrene. He had been receiving daptomycin for his right foot gangrene.

PMH, SH and FH

He had a previous history of osteomyelitis, perianal abscess, maxillary abscess, Candida esophagitis, transient ischemic attack, and peripheral vascular disease. He had previous amputations along with thrombectomy/ embolectomy/bypass. He was a former Marine and construction worker with ongoing cigarette use. Family history was noncontributory.

Physical Examination

Febrile to 38.2ºC
Crackles bilaterally
Transmetatarsal stump with dry gangrene

Radiography

An admission chest x-ray was performed (Figure 1).

Figure 1. Admission portable AP of chest.

Which of the following are appropriate at this time? (Click on the correct answer to proceed to the second of four panels)

Cite as: Brighton AM, Williams KE, Wesselius LJ. August 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(2):40-5. doi: http://dx.doi.org/10.13175/swjpcc070-16 PDF

Rick Robbins, M.D. 2/1/16 Rick Robbins, M.D. 2/1/16

February 2016 Pulmonary Case of the Month

Ashley Garrett, MD

Karen Swanson, DO

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 77-year-old woman presented with dyspnea on exertion which was progressive for several years. She remains active but is "winded" with vigorous exercise or altitude. She denied cough, orthopnea , paroxysmal nocturnal dyspnea, chest pain or a prior history of pulmonary infections.

Past Medical, Social and Family History

She has a history of a seizure disorder and fibromyalgia. She has never smoked or drank and has no history of occupational exposures. There was no family history of respiratory disease.

Physical Examination

Her physical exam was unremarkable.

Current Medications

Topamax and alprazolam.

Radiography

A chest radiograph was performed (Figure 1).

Figure 1. Initial chest radiography.

Which of the following describe the initial chest x-ray? (Click on the correct answer to proceed to the second of five panels)

Cite as: Garrett A, Swanson K. February 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;12(2):34-40. doi: http://dx.doi.org/10.13175/swjpcc012-16 PDF

Rick Robbins, M.D. 1/1/16 Rick Robbins, M.D. 1/1/16

January 2016 Pulmonary Case of the Month

Kathryn E. Williams, MB

Karen L. Swanson, DO

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 64-year-old man was seen in June 2015 with a nonproductive cough.

Past Medical History, Social History and Family History

He has no significant past medical history. He is a former smoker. Family history is positive for coronary artery disease

Physical Examination

Decreased breath sounds over the right hemithorax with dullness to percussion. Otherwise, the physical exam is unremarkable.

Radiography

A chest radiograph was performed (Figure 1).

Figure 1. Initial PA chest radiograph.

The chest radiograph shows which of the following? (Click on the correct answer to proceed to the second of five panels)

Cite as: Williams KE, Swanson KL. January 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;12(1):1-5. doi: http://dx.doi.org/10.13175/swjpcc158-15 PDF

Rick Robbins, M.D. 12/1/15 Rick Robbins, M.D. 12/1/15

December 2015 Pulmonary Case of the Month

Zachary M. Berg, MD

Kashif Yaqub, MD

Brian Wojek, MD

Khang Tran, MD

Karen L. Swanson, DO

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

The patient is a 70-year-old man with a history of a chronic dry cough for 5 years, who presented to the emergency department with worsening cough and shortness of breath.

Two weeks prior to symptom onset, was on trip in the United Kingdom, he developed gastroenteritis which spontaneously resolved.

Past Medical History, Social History, and Family History

Old healed TB scar with positive PPD at 17 years of age prior to joining Air Force. No treatment given and patient was asymptomatic from a pulmonary point of view since then.
Squamous cell carcinoma of the skin on the scalp, status post excision complicated by osteomyelitis, status post surgical graft from hip with prolonged course of IV antibiotics in 2010.
Fractured left clavicle, status post repair 20 years ago.
Hay fever.
Hyperlipidemia.
Squamous cell carcinoma removed from left arm.
Varicose veins, lower extremity.
Married. Retired police officer. Does not smoke.
Family history is noncontributory

Physical Examination

General: In moderate respiratory distress.
Vitals: SpO2 on room air of 65%, 94% on high flow oxygen. Blood pressure 124/84, afebrile
Lungs: Fine bibasilar crackles posteriorly.
Heart: Regular rhythm without murmur.
The remainder of the physical examination was normal.

Laboratory Evaluation

CBC: unremarkable except white blood cell count 20.5 x 10³ cells/ɥL, neutrophil predominant
BNP: 366 pg/mL
Mycobacterium Quantiferon: Positive
Mycoplasma IgM: Positive at 1.18 U/L

Radiography

Initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest x-ray.

What is the best next step in the patient's evaluation? (Click on the correct answer to proceed to the second of five panels)

Cite as: Berg ZM, Yaqub K, Wojek B, Tran K, Swanson KL. December 2015 pulmonary case of the month. Southwest J Pulm Crit Care. 2015;11(6):240-5. doi: http://dx.doi.org/10.13175/swjpcc146-15 PDF

Rick Robbins, M.D. 10/29/15 Rick Robbins, M.D. 10/29/15

Why Chronic Constipation May be Harmful to Your Lungs: A Case Report and Review of Lipoid Pneumonia and Mycobacterium fortuitum Leading to Acute Respiratory Failure and Septic Shock

Sandra Till, DO

Manoj Mathew, MD

Da-Wei Liao, MD

Christina Ramirez, MD

Banner University Medical Center

Phoenix, AZ

Case Report

A 43 year-old female with a past medical history of right-sided hemiparesis secondary to motor vehicle accident 17 years prior presented a two week history of cough, fever and right-sided pleuritic chest pain. Her baseline status included using a wheelchair, living alone at home and working as a teacher.

On admission she had a temperature of 39.6º C, was tachycardia and hypotensive requiring vasopressors. Labs were remarkable for a white count of 25,000 cells/mcL. Chest x-ray showed right-sided infiltrate and pleural effusion (Figure 1).

Figure 1. Chest x-ray on presentation.

Bronchoscopy and thoracentesis was performed upon admission. The pleural fluid wasexudative with a glucose of 78 and no suggestion of loculations on chest x-ray or ultrasound. The patient was started on therapy for community-acquired pneumonia.

On day 4 after admission, the patient had increasing sinus tachycardia, hypotension and was worsening despite being on antimicrobial therapy. A CT angiogram of the chest was performed (Figure 2).

Figure 2. Initial CT scan on day 4 of admission. Panel A: axial view showing pneumonia and right pleural effusion. Panel B: coronal view.

CT angiogram was negative for pulmonary embolism and a percutaneous chest tube was placed on day 4 for drainage of pleural effusion due to development of loculations. On day 7, the pleural fluid from initial thoracentesis grew acid-fast bacteria identified as Mycobacterium fortuitum.

Bronchoscopy was performed on day 8 and there was no endobronchial obstruction.

Bronchoscopic alveolar lavage cultures grew Mycobacterium fortuitum. She had no history of bronchiectasis, skin infection, or immunoglobulin deficiency. Treatment with amikacin and levofloxacin was initiated based on susceptibilities.

The pleural chest tube was removed on day 14 (Figure 3). At this time the patient was transferred to a skilled nursing facility.

Figure 3. CT scan on day 13 prior to chest tube removal. Panel A: axial view. Panel B: coronal view.

The patient continued antibiotic treatment for Mycobacterium fortuitum with amikacin and levofloxacin, however, serial sputum cultures remained positive. On day 25, in the skilled nursing facility, the patient developed respiratory failure due to increased right effusion and worsening pneumonia. She was transferred to our facility were she was intubated and a new right-sided chest tube was placed. After placement of chest tube and drainage the right lung did not expand. Decompensation was felt to be related to the inadequate evacuation of the empyema with plans to solely continue antimicrobial therapies by the outside facility.

Figure 4. CT scan on day 30 showing trapped lung. Panel A: axial view. Panel B: coronal view.

Repeat pleural fluid cultures and BAL once again grew Mycobacterium fortuitum. She was taken for decortication and right middle and lower lobe resection by thoracic surgery. Due to extensive disease the patient required right thoracotomy, decortication, parietal pleurectomy, right middle lobectomy, and wedge resection of a right lower lobe lung abscess.

The lung pathology is shown below and was consistent with lipoid pneumonia (Figure 5).

Figure 5. Panels A & B: CD 163 stains showing lipid present within histiocytes. Panels C & D: histology demonstrating severe lipoid pneumonia. Panels E & F: Granulomatous inflammation with giant cells. Panel G: pleura. Panel H: abscess.

There were no mycobacteria cultured on the lung biopsy. There were areas of both acute and chronic fibrosis noted on pathology report along with areas of acute interstitial pneumonitis and granulomatous inflammation.

During post-operative phase the patient confirmed that she was drinking mineral oil chronically for treatment of constipation. Repeat sputum cultures 7 days post operatively were negative for Mycobacterium fortuitum. She continued to improve with treatment of Mycobacterium fortuitum and postoperative cultures remained negative. She was able to liberate from the ventilator and returned home at after a prolonged course of rehabilitation.

Lipoid Pneumonia and Associated Mycobacterial Infection

The association between acid-fast bacteria and lipoid pneumonia was first reported in 1925 and since case reports have been noted. In 1953, a case report and literature review documented six cases of “saprophytic” mycobacteria was noted in conjunction with lipoid pneumonia. It was observed at this time that the fatty environment of lipoid pneumonia might assist with the growth of mycobacterium (1). Since then, intermittent case reports have been published reporting lipoid pneumonia with atypical mycobacteria.

There are two main categories of lipoid pneumonia, endogenous and exogenous. The endogenous form is also known as cholesterol pneumonia or golden pneumonia. It is associated with lysis of lung tissue distal to obstruction due to malignancy, fat storage disease such as Neiman-Pick or Gaucher's, medications and therapies including chemotherapeutic agents, amiodarone and radiation therapy. Pulmonary alveolar proteinosis has also been reported in idiopathic cases with granulomatosis with polyangiitis and connective tissue diseases (2-4). In polarized light microscopy after staining with sulfuric and acetic acid, the sample reveals cholesterol crystals, which is diagnostic of endogenous lipoid pneumonia (3).

Exogenous lipoid pneumonia occurs when external substances enter the lungs due to inhalation or aspiration (3). Cases have been reported from mineral oil, paraffin use, oil based nasal drops, total parenteral nutrition, mineral oil nose drops, black fat tobacco smoking, milk, and liquid hydrocarbons used by flame blowers (2-6). The pulmonary reaction to each substance varies. For example, mineral oils are fairly inert and less likely to produce alveolar inflammation, where milk fats are hydrolyzed by lung lipases leading to a significant inflammatory response (2).

The clinical presentation and appearance of lipoid pneumonia is variable from consolidation to effusion to nodule. Nodules from lipids may have elevated standardized uptake value (SUV) on positron emission tomography (PET) scan. The BAL from lipoid pneumonia may demonstrate lipid laden foamy macrophages (2). Mineral oil granuloma (paraffinoma) also can present as a spiculated mass mimicking malignancy.

Mineral oil is notorious for causing lipoid pneumonia by aspiration for several reasons. First, it floats on the column of undigested material in the esophagus so it is first to be aspirated (5); secondly, it impairs phagocytosis at the alveolar level; and lastly, it inhibits the cough reflex and motor function of ciliated mucosa (7).

The impairment of phagocytosis associated with lipoid pneumonia is thought to be a contributing factor in why atypical mycobacterium strives in the lipid rich environment of lipoid pneumonia (5,6). Malnutrition is also thought to be a component of risk as it due to impairment in cell mediated immunity (6). Lipid acts as mechanical protection for the mycobacteria favoring tissue necrosis facilitating secondary infection. Also it is thought that lipids may activate the cell walls of the atypical mycobacteria leading to increased virulence of the mycolic acids within the wall of the bacteria (8).

Mycobacterium fortuitum rarely causes pulmonary disease unless associated with lipoid pneumonia. This is often related to gastroesophageal disease and chronic vomiting and aspiration of contents. It is typically associated with skin and soft tissue infections and is a rapid growing mycobacterium and most frequently found in water and soil (2,8,9)

This case demonstrates an atypical presentation of lipoid pneumonia and Mycobacterium fortuitum infection leading to septic shock and ventilator failure. Although the association of lipoid pneumonia and mycobacterial infections is well documented, the rapid and acute decline in this patient’s clinical status is unusual. This can be attributed to incomplete drainage of the initial empyema prior to transfer to the skilled nursing facility.

The etiology of the lipoid pneumonia was chronic aspiration of mineral oil producing an ideal environment for growth of Mycobacterium fortuitum. The absence of bronchiectasis, immunoglobin deficiency, skin infections should prompt further evaluation for abnormal lung architecture serving as a nidus for Mycobacterium fortuitum Infection. In our case, failure to improve is attributed to a persistent nidus for infection. We advocate resection of diseased lung segments of lipoid pneumonia to facilitate successful treatment of Mycobacterium fortuitum. In conclusion, if a patient has lipoid pneumonia with signs of clinical infection, the possibility of rapidly growing mycobacterium such as M. fortuitum should be considered.

References

Gibson JB. Infection of the lungs by saprophytic mycobacteria in achalasia of the cardia, with report of a fatal case showing lipoid pneumonia due to milk. J Pathol Bacteriol. 1953;65(1):239-51. [CrossRef] [PubMed]
Hasan A, Swamy T. Nocardia and Mycobacterium fortuitum infection in a case of lipoid pneumonia. Respiratory Medicine CME 2011: 75-78. [CrossRef]
Betancourt SL, Martinez-Jimenez S, Rossi SE, Truong MT, Carrillo J, Erasmus JJ. Lipoid pneumonia: spectrum of clinical and radiologic manifestations. AJR Am J Roentgenol. 2010;194(1):103-9. [CrossRef] [PubMed]
Harris K, Chalhoub M, Maroun R, Abi-Fadel F, Zhao F. Lipoid pneumonia: a challenging diagnosis. Heart Lung. 2011;40(6):580-4. [CrossRef] [PubMed]
Hughes RL, Freilich RA, Bytell DE, Craig RM, Moran JM. Clinical conference in pulmonary disease. Aspiration and occult esophageal disorders. Chest. 1981;80(4):489-95. [CrossRef] [PubMed]
Tranovich VL, Buesching WJ, Becker WJ. Pathologic quiz case. Chronic pneumonia after gastrectomy. Pathologic diagnosis: chronic aspiration lipoid pneumonia with Mycobacterium abscessus. Arch Pathol Lab Med. 2001;125(7):976-8. [PubMed]
Jouannic I, Desrues B, Léna H, Quinquenel ML, Donnio PY, Delaval P. Exogenous lipoid pneumonia complicated by Mycobacterium fortuitum and Aspergillus fumigatus infections. Eur Respir J. 1996;9(1):172-4. [Pubmed]
Couto SS, Artacho CA. Mycobacterium fortuitum pneumonia in a cat and the role of lipid in the pathogenesis of atypical mycobacterial infections. Vet Pathol. 2007;44(4):543-6. [CrossRef] [PubMed]
Vadakekalam J, Ward MJ. Mycobacterium fortuitum lung abscess treated with ciprofloxacin. Thorax. 1991;46(10):737-8. [CrossRef] [PubMed]

Cite as: Till S, Mathew M, Liao D-W, Ramirez C. Why chronic constipation may be harmful to your lungs: a case report and review of lipoid pneumonia and mycobacterium fortuitum leading to acute respiratory failure and septic shock. Southwest J Pulm Crit Care. 2015;11(4):193-9. doi: http://dx.doi.org/10.13175/swjpcc118-15 PDF

Rick Robbins, M.D. 10/15/15 Rick Robbins, M.D. 10/15/15

Traumatic Hemoptysis Complicating Pulmonary Amyloidosis

Erwan Oehler, MD¹

Charlotte Courtois, MD²

Florent Valour, MD¹

¹Department of Internal Medicine

²Department of Pulmonary Medicine

French Polynesia Hospital Center

98716 Pirae, Tahiti

French Polynesia

Case Presentation

We present a 74-year-old man admitted to hospital for a fall occurring at home. His past medical history included histologically-proven pulmonary amyloidosis followed for fifteen years (Figure 1A), without involvement of other organs.

Figure 1A. Frontal chest radiography shows bilateral confluent, somewhat nodular and dense-appearing opacities with a background of faint linear and reticular opacities.

At admission, he complained of left chest pain related to a rib fracture (Figure 1B, arrow).

Figure 1B. Detail radiograph of the left upper thorax shows a fracture (arrow) of a posterolateral rib, superimposed on the background of dense-appearing linear and nodular parenchymal disease.

The next day, he presented with moderate hemoptysis, prompting performance of thoracic CT (Figure 1C and D) which showed a cavity filled with material of soft tissue attenuation.

Figure 1C and D. Axial thoracic CT displayed in soft tissue windows shows extensive bilateral nodular hyperattenuating tissue consistent with alveolar septal / diffuse pulmonary parenchymal amyloidosis. A cystic lesion with internal, dependent soft tissue attenuation (arrow, D) is present, consistent with a hematoma.

This soft tissue-filled cavity was located at the same level as the rib fracture, surrounded by calcified tissue, and presumably reflected a pulmonary parenchymal hematoma resulting from traumatically induced laceration of the inelastic calcified lung tissue.

Discussion

Pulmonary amyloidosis is a rare disease resulting from the extracellular deposition of insoluble fibrillar proteins aggregating in a β–pleated sheet configuration (1). Amyloidosis is classified according to the chemistry of the amyloid protein as AA secondary amyloidosis (SAA protein) -often related to chronic inflammatory disease- AL amyloidosis (monoclonal immunoglobulin light chains of the lambda or kappa type)-secondary to B lymphoproliferative disorders-and hereditary or familial amyloidosis (transthyretin and gelsolin). Dialysis-associated amyloidosis (βR₂R microglobulinemia) and “senile” amyloidosis SAA (wild-type transthyretin) are also recognized. Pulmonary amyloidosis may occur in three forms: tracheobronchial, nodular parenchymal and alveolar septal / diffuse parenchymal patterns (2). The two first forms (which include primitive pulmonary amyloidosis) are often remain localized to the respiratory system, whereas the alveolar septal / diffuse parenchymal form of amyloidosis, whose prognosis is more severe, often presents in a systemically. Parenchymal amyloid nodules grow slowly and generally remain asymptomatic but patients may also present with dyspnea, cough, hemoptysis or recurrent pneumonia (3).

References

Chu H, Zhao L, Zhang Z, Gui T, Yi X, Sun X. Clinical characteristics of amyloidosis with isolated respiratory system involvement: A review of 13 cases. Ann Thorac Med. 2012 (4):243-9. [CrossRef] [Pubmed]
Gilmore JD, Hawkins PN. Amyloidosis and the respiratory tract. Thorax. 1999;54:444-51. [CrossRef] [PubMed]
Vieira IG, Marchiori E, Zanetti G, Cabral RF, Takayassu TC, Spilberg G, Batista RR. Pulmonary amyloidosis with calcified nodules and masses - a six-year computed tomography follow-up: a case report. Cases J. 2009;2:6540. [CrossRef] [PubMed]

Cite as: Oehler E, Courtois C, Valour F. Traumatic hemoptysis complicating pulmonary amyloidosis. Southwest J Pulm Crit Care. 2015;11(4):173-5. doi: http://dx.doi.org/10.13175/swjpcc133-15 PDF

Rick Robbins, M.D. 9/1/15 Rick Robbins, M.D. 9/1/15

September 2015 Pulmonary Case of the Month: Holy Smoke

Samir Sultan, DO

David M. Baratz, MD

Banner University Medical Center Phoenix

Phoenix, AZ

History of Present Illness

A 43-year-old woman presents to the office for second opinion of her dyspnea. She has very mild dyspnea with exertion which she notices when she cannot keep up with people going up stairs. She also has a "smoker’s cough".

Past Medical History, Family History, Social History

Her past medical history, family history and social history are unremarkable other than she smokes 1 ppd for the past 20 years and had a "collapsed lung" about 15 years ago.

Physical Examination

Her physical examination was unremarkable except for a small scar on her right chest.

Radiography

A chest x-ray (Figure 1) was performed.

Figure 1. PA (Panel A) and lateral (panel B) chest radiography.

Which of the following are true regarding the chest x-ray? (Click on the correct answer to proceed to the second of five panels)

Cite as: Sultan S, Baratz DM. September 2015 puilmonary case of the month: holy smoke. Southwest J Pulm Crit Care. 2015;11(3):90-6. doi: http://dx.doi.org/10.13175/swjpcc112-15 PDF

Rick Robbins, M.D. 7/1/15 Rick Robbins, M.D. 7/1/15

July 2015 Pulmonary Case of the Month: A Crazy Case

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 23-year-old woman presented in 2008 at outside institution with dyspnea and diffuse pulmonary infiltrates. She required intubation. After a surgical lung biopsy, she was transferred to the Mayo Clinic Hospital for further care.

Past Medical History

She has had a history of progressive dyspnea for several months, otherwise negative

Physical Examination

Vital signs are stable. SpO2 94% on FiO2 of 0.4. She is intubated and there is a chest tube in her right chest. Otherwise the physical examination is unremarkable.

Radiography

A thoracic CT scan was performed (Figure 1).

Figure 1. Representative images from the thoracic CT in lung windows.

Which of the following are present on the thoracic CT scan? (click on the correct answer to proceed to the second of five panels)

Reference as: Wesselius LJ. July 2015 pulmonary case of the month: a crazy case. Southwest J Pulm Crit Care. 2015;11(1):3-10. doi: http://dx.doi.org/10.13175/swjpcc079-15 PDF