A 40-year-old woman with multiple pulmonary nodules. Pulmonary hyalinizing granuloma

A 40-year-old woman (a nonsmoker) with history of idiopathic thrombocytopenic purpura and a platelet count > 90,000 cells/μL without specific medication was referred to pulmonary clinic for evaluation of multiple pulmonary nodules. The patient presented to an outside hospital with fatigue, lack of energy, and dyspnea on exertion for 2 years. She denied fever, cough, chest pain, or weight loss. An initial chest radiograph showed bilateral multiple pulmonary nodules. A chest CT scan revealed multiple nodular lesions, varying in size, in all lobes of both lungs. There was no mediastinal lymphadenopathy or pleural effusion. There was no significant hypermetabolic activity on a subsequent fluorodeoxyglucose PET scan/CT scan, and there had been no significant change. She underwent CT scan-guided percutaneous transthoracic biopsy and bronchoscopy with transbronchial biopsies, all of which were inconclusive. An open lung biopsy was considered.

Anterior Mediastinal Desmoid Tumor With CT and MR Imaging

Desmoid tumors, or aggressive fibromatoses, are rare, histologically benign tumors with biologic behavior that is intermediate between benign fibrous proliferations and low-grade fibrosarcoma. These tumors can cause significant morbidity and mortality by their propensity for local invasion and recurrence following surgical excision. A case of an anterior mediastinal desmoid tumor in a 67-year-old woman is reported with computed tomography and magnetic resonance imaging findings.

Retrospective study of pulmonary function tests in patients presenting with isolated reduction in single-breath diffusion capacity: implications for the diagnosis of combined obstructive and restrictive lung disease

OBJECTIVE

To examine the frequency and spectrum of diseases associated with isolated reduction in the diffusing capacity of lung for carbon monoxide (D(Lco)).

PATIENTS AND METHODS

We retrospectively identified all potentially dyspneic patients who had pulmonary function tests (PFTs) performed at the Mayo Clinic in Jacksonville, Fla, between January 1, 1990, and June 30, 2000, that showed reduced D(Lco) (< 70% of predicted), normal lung volumes (total lung capacity and residual volume > 80% and < 120% of predicted, respectively), and airflow variables (forced expiratory volume in 1 second and forced vital capacity values > 80% of predicted and forced expiratory volume in 1 second/forced vital capacity ratio > 70% of predicted). Only patients who had also undergone chest computed tomography (CT) and echocardiography within 1 month of PFTs were studied.

RESULTS

Of the 38,095 patients who underwent PFTs during the study period, 179 (0.47%; 95% confidence interval [CI], 0.40%-0.54%) had isolated D(Lco) abnormalities. The 27 patients (15.1%; 95% CI, 10.2%-21.2%) who had also undergone chest CT and echocardiography within 1 month of PFTs form the study cohort reported herein. Their mean D(Lco) was 50% +/- 15% (95% CI, 45%-56%) with average normal pulse oxygen saturation at rest and mild hypoxemia with activity. Thirteen of the 27 patients (48%; 95% CI, 28.7%-68.1%) had underlying emphysema evident on CT. Eleven of these 13 patients had emphysema associated with a restrictive lung process. The 14 patients without emphysema had interstitial lung disease, pulmonary vascular disease, and other isolated findings. Six patients with combined emphysema and idiopathic pulmonary fibrosis accounted for the largest percentage (22%) of patients with Isolated D(Lco) reduction. The mean +/- SD smoking history of the 27 patients in the study cohort was 36 +/- 33 pack-years (range, 0-116 pack-years).

CONCLUSION

Dyspneic patients with respiratory symptoms and normal lung volumes and airflows associated with Isolated reduction in D(Lco) should be evaluated for underlying diseases such as emphysema, with or without a concomitant restrictive process, and pulmonary vascular disease.

Clinical relevance of time of onset, duration, and type of pulmonary edema after liver transplantation

We investigated the clinical significance of time of onset, duration, and type of pulmonary edema after orthotopic liver transplantation by retrospectively reviewing 93 consecutive recipients. Pulmonary edema was diagnosed by means of radiographic criteria and Pao(2)/Fio(2) ratio <300. Type was identified by pulmonary artery wedge pressure (hydrostatic, >18 mm Hg; permeability, < or =18 mm Hg). Of 91 evaluable patients, 44 (48%) had no pulmonary edema, 23 (25%) had immediate pulmonary edema resolving within 24 hours, 8 (9%) had late pulmonary edema (developing de novo in the first 16 to 24 hours), and 16 (18%) had persistent pulmonary edema (developing immediately and persisting for at least 16 hours). At 16 to 24 hours, mean arterial pressure was lower with persistent permeability-type edema than without pulmonary edema (75 versus 87 mm Hg, P <.01). Patients with persistent permeability-type edema had higher mean pulmonary arterial pressure (23 versus 16 mm Hg, P <.01) and higher pulmonary vascular resistance (103 versus 53 dyn. second. m(-5), P <.05), consistent with a resistance-dependent mechanism. Patients with persistent hydrostatic-type edema did not differ from those without edema in mean arterial pressure (84 versus 87 mm Hg, P >.05) or pulmonary vascular resistance (67 versus 53 dyn. second. m(-5), P >.05), but had increased mean pulmonary arterial pressure (27 versus 16, P <.01), suggesting a flow volume-dependent mechanism. Duration of mechanical ventilation, intensive care, and hospital stay were prolonged in patients with late or persistent permeability-type edema but not in patients with immediate pulmonary edema of any type. In conclusion, immediate pulmonary edema resolving within 24 hours after liver transplantation had little clinical consequence; persistent permeability-type pulmonary edema portended a worse outcome.