Thoracic endometriosis presenting as hemopneumothorax

Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and hemoptysis. Common manifestations include pneumothorax, hemothorax, and pulmonary or pleural nodules. In addition, symptoms and manifestations can be “catamenial” happening a few days after menstruation onset. This disease can be debilitating, causing a significant impact on the quality of life of young women. We present a case of a young female who was referred to our hospital with recurrent right-sided pleural effusions and pneumothoraces. Pleural fluid drainage was consistent with hemothorax. Transvaginal ultrasound showed mild intraperitoneal fluid in the Cul-de-Sac. Due to concerns for thoracic endometriosis, video-assisted thoracoscopic surgery was performed confirming the diagnosis by pathology. Therapeutic pleurectomy with diaphragmatic repair and pleurodesis was performed. The patient was started on medroxyprogesterone acetate injections two weeks after with great clinical response.

Swyer-James syndrome: A cause of adult-onset dyspnea in a patient with adult polycystic kidney disease

Swyer-James syndrome (SJS) is a rare lung condition characterized by abnormal lung growth secondary to childhood post-infectious bronchiolitis obliterans. Usually, one lung is affected more than the other leading to asymmetrical lungs with one lung being significantly smaller. The disease can lead to pulmonary obstructive airflow physiology, bronchiectasis, and fibrosis. Dyspnea usually presents early on in infancy and symptoms can mimic asthma, however, they can go unnoticed until adulthood. We present a case of SJS in a patient with adult polycystic kidney disease (ADPKD) and color vision deficiency. The patient presented to our clinic for evaluation for progressively worsening dyspnea and cough. His imaging revealed a hypoplastic left lung with fibrosis, cystic airway disease, and a small left pulmonary artery. His spirometry revealed an obstructive defect. A Ventilation-Perfusion scan (V/Q) showed a significant reduction of ventilation and perfusion to his left lung confirming the diagnosis of SJS. Both conditions - SJS and ADPKD-are not pathologically or genetically related and are very rare. Having both conditions is even rarer yielding interesting radiological imaging.

Severe drug-induced immune hemolysis due to ceftriaxone

Drug-induced immune hemolytic anemia (DIIHA) is a rare condition that results primarily due to drug-induced antibodies, either drug dependent or drug independent. For its diagnosis, specialized immunohematology laboratory is often required for performing complex serological tests. The exact incidence of DIIHA is not known, but as per data published by Garratty, the incidence of DIIHA is estimated to be one in million population.^[1] There are many drugs which are implicated in causing DIIHA ranging from antimicrobials, antineoplastics to anti-inflammatory drugs. Among antimicrobials, cephalosporins are commonly reported to cause hemolytic anemia.^[2] In this report, we present a life-threatening hemolytic reaction to cephalosporin (ceftriaxone) in a 15-year-old child, which was diagnosed and managed in a timely manner. Our patient was suddenly deteriorated after two doses of intravenous ceftriaxone, with increase in pallor, fatigue, and frank hematuria. Repeat laboratory investigations showed signs of hemolysis, presence of schistocytes, raised lactic dehydrogenase, and indirect bilirubin. Reticulocyte count was 3.4%. Direct antiglobulin test was strong positive (4+) with IgG and C3d positive. Testing for drug-dependent antibody confirmed the presence of ceftriaxone-dependent antibody. Drug was stopped immediately. There was a rapid improvement in patient's general condition after discontinuation of drug. Laboratory parameters were improved after 48 h, and the patient was stable with no further drop in hemoglobin and hemolytic episodes. We suggest the need for proper immunohematological services to diagnose and solve such complex cases promptly.

Pleural fluid glucose testing using a finger stick glucometer: a novel bedside test

Background

Pleural fluid glucose (PFG) has diagnostic and therapeutic implications for the management of pleural effusion. The literature examining point-of-care testing of PFG is limited, and no studies exist for the bedside measurement of PFG using a glucometer (B-PFG). In this study, we compared the accuracy of B-PFG measurement to standard in-lab measurement (Lab-PFG).

Methods

Patients undergoing thoracentesis or thoracostomy were enrolled. PFG was measured at the bedside with a finger stick blood glucometer (ACCU-CHEK^® Inform II, Roche) and in the laboratory. Two consecutive measurements were taken using the glucometer, and their mean was compared to the glucose concentration measured in the laboratory. Pearson correlation coefficient and Bland-Altman Plot analysis were used to compare the two measurements.

Results

Sixty patients were included. Mean age was 64.1 years. Forty-nine patients had exudative effusions (41% malignant, 26% parapneumonic, and 33% others). There was a significant correlation between the B-PFG and the Lab-PFG (r=0.98, 95% CI of 0.97 to 0.99; P<0.0001). There was good agreement between the B-PFG and the Lab-PFG with a mean difference of 14.8 mg/dL [95% limit of agreement (LOA) of -2.2 to 31.8 mg/dL]. This agreement was even better at glucose values less than 80 mg/dL.

Conclusions

PFG measured at the bedside with a glucometer closely correlates with the laboratory measurement. Further studies are needed prior to incorporating this test in clinical practice.

Mineralizing angiopathy presenting with recurrence of basal ganglia stroke following minor head trauma

Basal ganglia stroke secondary to mineralizing angiopathy of lenticulostriate arteries is a well-recognized clinical entity following minor head trauma in children. Recurrences are uncommon, and the majority of these recurrences occur within a few months of initial insult. We report a 2-year-old boy who developed recurrence of basal ganglia stroke after a latency of 18 months from the time of first unrecognized insult at 6 months of age. The case brings forth the need to recognize the condition of basal ganglia stroke secondary to mineralizing angiopathy considering the risk of recurrence to occur as far as 18 months after the first stroke.

Stenting of critical tracheal stenosis with adjuvant cardio-pulmonary bypass

Severe and critical central airway obstruction causing impaired ventilation and/or oxygenation can impose tremendous challenges on the interventional pulmonologist. Near total airway obstruction can rapidly evolve into potentially fatal complete airway occlusion during bronchoscopic airway manipulation under moderate sedation; as well as during the induction of the general anesthesia. Although there are currently interventional pulmonary procedures available to tackle the critical airway obstruction in extreme situations, cardio-pulmonary bypass should be considered prior to the intervention to maintain the adequate gas exchange during the procedure. Orotracheal intubation with mechanical ventilation in this situation can be fatal itself if the obstructing airway lesion functions as a “one way valve” allowing air to follow distally during inspiration but impeding expiratory flow leading to gas trapping, high intrathoracic pressure, tension pneumothorax, and ultimately a cardiac arrest.

ID: 58: ACUPUNCTURE THERAPY, AN UNDERREPORTED CAUSE OF PNEUMOTHORAX

Introduction

Acupuncture is usually portrayed as a risk-free therapy; but is it? We report a case of a tension pneumothorax following acupuncture therapy.

Case Presentation

A 70 year-old-man was receiving acupuncture therapy for right-sided post-herpetic neuralgia involving the 4th–7th intercostal nerves. Shortly after, he started complaining of severe dyspnea and pleuritic chest pain and was transferred to the emergency department. His SpO2 was 77% on room air, respiratory rate 38/min, heart rate 129/min and blood pressure 154/82 mm Hg. Absence of breath sounds was noted on the right side. Chest X-ray (CXR) revealed a right-sided pneumothorax with mediastinal shift (figure 1). A 14F chest tube was placed and a follow-up CXR showed resolution of the pneumothorax. On hospital day#2, the air leak resolved and the chest tube was clamped, but the patient developed subcutaneous emphysema requiring unclamping of the chest tube and attaching it to suction (–40 cm H2O). On day#4, the chest tube was removed. Serial CXRs were done showing stable subcutaneous emphysema and absence of pneumothorax. He was discharged home on day#7 only to be readmitted 48h later with recurrent pneumothorax requiring placement of another 14F chest tube. Due to persistent air leak on suction, a chest CT was done showing small anterior right-sided pneumothorax and right-sided subpleural bullae (figure 2). Thoracic surgery was consulted and a Video-assisted thoracoscopic excision of ruptured bullae with talc pleurodesis was performed. He was discharged home on hospital day#13. At one month follow-up, he remained asymptomatic.

Discussion

Acupuncture is one of the most popular of all alternative therapies, and is a relatively safe procedure. Although rare; pneumothorax is the most reported serious complication. In a prospective observational study in Germany, the incidence of acupuncture-related pneumothorax was 1/100000 patients (1). Unfortunately, this study included various acupuncture treatments and not only the ones where needling of the thorax occurred.

High quality studies are absent and most data come from case reports. In a review of the Chinese literature, 30 cases were reported between 1980 and 2013(2). In the English literature, 26 cases were reported between 1965 and 1999(3), and 13 cases between 2000 and 2011, with only 3 cases in the USA(4).

Most reported cases have in common the lack of an informed consent. We are reporting this case to increase the awareness toward recognizing pneumothorax as a potential complication of acupuncture, and reinforce the need of an informed consent where benefits and risks of acupuncture therapy are discussed.

Abstract ID: 58 Figure 1

Molecular targeted therapy to improve radiotherapeutic outcomes for non-small cell lung carcinoma

Effective treatments for non-small cell lung carcinoma (NSCLC) remain elusive. The use of concurrent chemotherapy with radiotherapy (RT) has improved outcomes, but a significant proportion of NSCLC patients are too frail to be able to tolerate an intense course of concurrent chemoradiotherapy. The development of targeted therapies ignited new hope in enhancing radiotherapeutic outcomes. The use of targeted therapies against the epidermal growth factor receptor (EGFR) has offered slight but significant benefits in concurrent use with RT for certain patients in certain situations. However, despite theoretical promise, the use of anti-angiogenics, such as bevacizumab and endostatin, has not proven clinically safe or useful in combination with RT. However, many new targeted agents against new targets are being experimented for combined use with RT. It is hoped that these agents may provide a significant breakthrough in the radiotherapeutic management of NSCLC. The current review provides a brief discussion about the targets, the targeted therapies, the rationale for the use of targeted therapies in combination with RT, and a brief review of the existing data on the subject.

Transudative chylothorax in a patient with liver cirrhosis: A rare association

Chylothorax is an unusual type of pleural effusion which results from the accumulation of chyle in the pleural cavity. High triglyceride content and presence of chylomicrons in the chyle give this fluid a characteristic milky appearance. Chylothorax most commonly results from the obstruction of the thoracic duct by a malignant lesion or from its traumatic disruption. Liver cirrhosis is an uncommon and frequently underappreciated cause of chylothorax. Pleural effusion in chylothorax is typically described as a lymphocytic predominant, exudative type and it is exceedingly rare to encounter a transudative type of chylothorax. To date, very few cases of transudative chylothoraces have been described in the literature, most commonly in association with liver cirrhosis. Only a limited range of other clinical settings have been linked to transudative chylothorax and timely recognition of these associations can prevent unnecessary, expensive and sometimes invasive workup in this patient population.

Recurrent pneumomediastinum in a patient with rheumatoid arthritis

Recurrent pneumomediastinum in a patient with rheumatoid arthritis. H. Bhardwaj, B. Bhardwaj, P.V. Carlile. Spontaneous pneumomediastinum (SPM); also known as mediastinal emphysema, is a rare and usually benign self-resolving appearance of extraluminal air in the mediastinum without any underlying trigger. This is an uncommon disorder mostly seen in the young males and classic clinical presentation is with chest pain, dyspnea, cough and appearance of subcutaneous emphysema. Although several connective tissue disorders have been reported in association with SPM, it is a rare occurrence in rheumatoid arthritis (RA) with only small number of cases reported in literature. We report a 69 years old male with RA who developed recurrent asymptomatic episodes of SPM detected over a period of one year. The recurrent but benign episodes of SPM in this patient reestablish the usual uncomplicated course of this unusual clinical entity even in the rare recurrent cases.

A case of spontaneous pneumothorax following radiation therapy for non-small cell lung cancer

Spontaneous pneumothorax (SPTX) is a potentially devastating rare complication of the thoracic radiation therapy. Most of the cases in the medical literature, have been described in lymphoma patients receiving radiation therapy. The pathogenesis of this adverse event remains undefined although different mechanisms have been proposed. We present a case of post-radiation therapy SPTX in a non-small cell lung cancer (NSCLC), following intensity modulated radiation therapy (IMRT), which to our knowledge is the first such reported case related to this newer mode of radiation therapy. This report highlights the importance of keeping a close eye for this complication as timely treatment with chest tube insertion and drainage of the pneumothorax can be a lifesaving in these patients.

Abducens nerve palsy in a patient with scrub typhus: a case report

Abducens nerve palsy is a known but rare complication of a few bacterial and viral infections like Mycoplasma pneumonia, cytomegalovirus, Epstein-Barr virus, Hanta virus, herpes zoster, and measles. Abducens nerve palsy due to scrub typhus is extremely rare and so far only one case has been reported in the literature. Scrub typhus is a febrile illness caused by rickettsia, Orientia tsutsugamushi, a gram negative intracellular obligate parasite which is endemic in Asia. This disease can present with wide range of clinical manifestations with involvement of any organ system, alone or in combination. Central nervous system involvement is very common and includes meningism, altered sensorium to focal neurological deficits. We present a rare manifestation of Scrub typhus in the form of sixth cranial nerve involvement which responded to the treatment with doxycycline.

An unusual case of pulmonary coccidioidomycosis presenting as pneumothorax

Coccidioidomycosis, although endemic to southwest regions of United States, has sporadic cases which can be encountered outside of the endemic areas. Clinicians must be aware of usual and unusual presentations of this disease entity and should keep a high level of suspicion for the diagnosis. We discuss an uncommon presentation for pulmonary coccidioidomycosis in a patient with a history of HIV/AIDS, who presented with pneumothorax due to a ruptured coccidioidal cavity. This report also illustrates the high importance of travel history in investigating rare disease presentations.

Ifosfamide-induced neurotoxicity reversal with continuous veno-venous hemodialysis. A case report

Ifosfamide is an alkylating agent used to treat different types of malignancies including lymphomas, sarcomas and germinal cell tumors. Symptoms of ifosfamide neurotoxicity can range from mild confusion, dizziness and hallucination to overt encephalopathy. Various treatment options like methylene blue, albumin infusion and rarely hemodialysis have been used to treat ifosfamide neurotoxicity. We hereby report a case of a patient with relapsed diffuse large B cell lymphoma who received methylene blue after experiencing acute renal failure and encephalopathy due to ifosfamide with no improvement. The prompt use of hemodialysis in this case has led to reversal of both renal failure and neurotoxicity.