Ambulatory Intrapleural Fibrinolytic Therapy in Highly Viscous Recurrent Malignant Pleural Effusion

Malignant pleural effusion (MPE) is common in lung cancer. We report a case of highly viscous recurrent MPE associated with lung cancer. The viscosity prohibited gravity-dependent drainage initially with a 6-Fr aspiration catheter and subsequently with a 12-Fr intercostal drain. The effusion was eventually evacuated after a single dose of intrapleural fibrinolytic therapy. This process was repeated a total of 13 times over a 12-month period in an ambulatory setting. No bleeding complications were observed. This case highlights the feasibility and safety of repeated intrapleural fibrinolysis in the management of highly viscous recurrent MPE in an ambulatory setting.

Interventions to support Choosing Wisely for coagulation studies in the emergency department

OBJECTIVE

To evaluate the effectiveness of two different strategies designed to facilitate implementation of Choosing Wisely Australia guidelines, aiming to reduce unnecessary coagulation study blood tests in patients presenting to a metropolitan hospital ED.

METHOD

In this real-world quality improvement study, the first intervention tested was an education strategy. The second intervention was physically removing coagulation pathology tubes from the bedside trolleys in the ED. Data were collected about clinical appropriateness of testing, as per the Choosing Wisely Australia guideline and total volume of coagulation studies ordered.

RESULTS

No reduction in inappropriate coagulation testing was observed following the education intervention whereas a significant reduction in inappropriate coagulation testing was seen after the second intervention (inappropriate testing reduced from 73.8% to 53.0%).

CONCLUSION

Physically removing coagulation pathology tubes from the trolleys was found to be effective at reducing unnecessary testing.

Autoimmune pulmonary alveolar proteinosis prior to myelodysplastic syndrome

We report the first case of autoimmune pulmonary alveolar proteinosis (PAP) associated with and preceding myelodysplastic syndrome. A 74-year-old female with a history of polymyalgia rheumatica presented with six months history of progressive exertional breathlessness. Examination revealed bilateral chest crackles and exertional desaturation. A diagnosis of autoimmune PAP was made based on the presence of autoantibodies to granulocyte-macrophage colony-stimulating factor and characteristic findings on chest computed tomography, bronchoalveolar lavage, and transbronchial biopsies. Bilateral whole lung lavage was performed with prompt improvement in symptoms. Fourteen months later, she presented with new breathlessness and was diagnosed with myelodysplasia on bone marrow biopsy. No recurrence of alveolar proteinosis was detected. This case highlights the importance of follow-up and screening of patients with autoimmune PAP for haematological conditions.

Endobronchial tuberculosis polyps

Endobronchial tuberculosis (TB) is an uncommon manifestation of Mycobacterium tuberculosis. We report a case of endobronchial TB polyps in a patient from India presenting with cough, loss of weight and night sweats. Computed tomography chest revealed enlarged mediastinal lymph nodes, endobronchial invasion, and nodular infiltrates in the right lower lobe. Flexible bronchoscopy revealed two endobronchial polyps at the carina and left main bronchus which were biopsied. Histopathology showed non‐caseating granulomas. Both the biopsy and bronchial washings did not identify acid‐fast bacilli on Ziehl‐Neelsen stain and had negative TB complex DNA polymerase chain reaction. One month after bronchoscopy, M. tuberculosis was cultured from the bronchial washings. Following six months of TB treatment, there was full resolution of symptoms and significant radiological improvement. We highlight the diagnostic challenges in endobronchial TB which may impact on the timely institution of treatment.