Spontaneous resolution of a giant pulmonary bulla: what is the role of bronchodilator and anti-inflammatory therapy?

Spontaneous resolution of giant pulmonary bullae occurs infrequently. The mechanisms responsible for the natural elimination of giant bullae are variable. We report a patient who experienced spontaneous total regression of his giant bulla following intensification of his inhaled bronchodilator and airway anti-inflammatory therapies. This occurrence suggests that smoking cessation and optimization of inhaled bronchodilator and anti-inflammatory therapies should be undertaken before referral for surgical bullectomy. These relatively simple measures may obviate the need for an invasive procedure.

Hemoptysis and respiratory failure following sildenafil use for pulmonary hypertension.

Sildenafil, usually a well-tolerated drug traditionally used for erectile dysfunction (ED), was recently approved for pulmonary arterial hypertension. In the literature, there are few cases of hemoptysis following sildenafil use for ED; however, to our knowledge, we are reporting the first case of hemoptysis following sildenafil use for pulmonary hypertension. We are documenting a case of a 90-year-old male patient who was admitted to the intensive care unit with hemoptysis and respiratory failure two weeks after he was started on sildenafil.

Veillonella as a cause for septic pulmonary emboli.

We are reporting a case of a 63-year-old-male patient with an unusual presentation of multiple lung abscesses. The patient likely had septic pulmonary emboli secondary to periodontal disease. The implicated organism was Veillonella species. Veillonella are anaerobe bacteria that traditionally been considered nonpathogenic flora.

Case report and review of the literature: spontaneous aortobronchial fistula.

We present a fatal case of aortobronchial fistula due to ruptured atherosclerotic aneurysm of the aorta into the left lower lobe, bronchus. Also, review of the pertinent literature is presented. Fistulas between the aorta and tracheobronchial tree are rare but usually lethal if not treated promptly and timely, as they can cause fatal hemoptysis. Aortobronchial fistulas occur most often in patients who have a history of thoracic vascular surgery. Nevertheless, few cases without previous thoracic surgery, trauma or infectious process of the aorta have been described in the literature. [corrected].

A case report of vinorelbine monotherapy-related acute bronchospasm and non-ST elevation acute coronary syndrome.

Vinorelbine is a semi-synthetic vinca-alkaloid with a broad spectrum anti-tumor activity. The dose-limiting toxicity of vinorelbine is neutropenia and leucopenia which is seen in majority of the patients. The previous case reports on the cardiac toxicity occurred mainly in combination therapy of vinorelbine with cisplatin or carboplatin. We offer evidence that acute coronary syndrome and resultant diastolic heart failure developed as a result of acute bronchospasm due to intravenous vinorelbine monotherapy.

Respiratory failure in a 70-year-old veteran.

In Western countries the incidence of amyotrophic lateral sclerosis (ALS) is 1.89 per 100,000 per year and the prevalence is 5.2 per 100,000. The incidence of ALS is lower among African, Asian, and Hispanic ethnicities when compared to Caucasians. The mean age of onset for sporadic ALS is about 60 years and there is a slight male predominance (male to female ratio of 1.5 to 1). Approximately two thirds of patients with ALS have the spinal form of the disease with symptoms presenting in the extremities. Patients typically have evidence of both lower motor neuron degeneration (atrophy, weakness, and fasciculations) and upper motor neuron degeneration (spasticity, weakness, and hyperreflexia). Patients with limb onset ALS typically complain of focal muscle weakness and wasting. The symptoms may start either distally or proximally in the upper and/or lower limbs. Gradually spasticity develops in the weakened atrophic limbs, affecting manual dexterity and gait. Patients with bulbar onset ALS typically present with dysarthria and dysphagia for solid or liquids. Limb symptoms can develop simultaneously with bulbar onset. In the vast majority of patients, limb weakness will occur within 1-2 years of bulbar onset ALS symptoms. A case of bulbar and sporadic limb ALS in a 70-year-old veteran, presenting with right diaphragmatic paralysis and respiratory failure, is presented.

The association between obstructive sleep apnea syndrome and microvascular complications in well-controlled diabetic patients.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) may promote hyperglycemia and insulin resistance. OBJECTIVE: We studied the link between sleep apnea and microvascular diabetic complications in veterans with type 2 diabetes mellitus (DM-2). DESIGN: A retrospective electronic chart of all veterans referred for sleep studies over a 1-year period was reviewed. Ninety-eight patients with a glycosylated hemoglobin < 6.5% were included in the study. The degree of glycemia (HbA1c) and presence of macro- and microvascular complications were compared with OSAS variables. METHOD: Statistical analysis examined bivariate associations between OSAS variables and metabolic syndrome parameters. RESULTS: The apnea hypopnea index was significantly related to diabetic microvascular complications, particularly retinopathy. Oxygen desaturation was significantly and inversely related to microalbuminuria, microvascular complications, retinopathy, and HbA1c. CONCLUSIONS: Sleep apnea is associated with microvascular complications even in well-controlled DM-2 veterans. CLINICAL IMPLICATIONS: Screening for OSAS should be considered in patients with DM-2.

Peritoneal tuberculosis: modern peril for an ancient disease.

Extrapulmonary manifestations of Mycobacterium tuberculosis (MTB) in general, and tuberculous peritonitis (TBP) in particular, have posed complex diagnostic challenges for centuries. Peritoneal tuberculosis is a very rare manifestation of MTB with subtle clinical findings that may result in a significant diagnostic delay, often of more than four months. As the incidence of tuberculosis is declining in developed nations, clinicians may overlook the need to establish an early diagnosis and prompt therapy for this disorder. We present a case of peritoneal tuberculosis and a review of the literature.

Acute pulmonary edema associated with direct current cardioversion in a structurally normal heart.

The transthoracic application of synchronized direct current cardioversion (DCC) is widely used to terminate atrial fibrillation, atrial flutter, and other supraventricular tachyarrhythmia. DCC is a highly effective method for acute restoration of sinus rhythm. Although DCC is a relatively safe and frequently performed procedure, data on potential side effects are very rarely reported in the literature. The most serious complications associated with DCC are thromboembolism and intracranial hemorrhage. The true incidence of postcardioversion pulmonary edema is not known, but it is estimated to occur in 1% to 3% of patients, particularly those with coexistent heart disease. We report on a patient with a structurally normal heart who developed acute pulmonary edema after undergoing DCC. The patient had no evidence of myocardial injury according to an electrocardiogram and cardiac biomarkers. The patient was treated with intravenous diuretics. After 4 days, the pulmonary edema resolved.

Strongyloides hyperinfection syndrome complicating (ectopic) Cushing syndrome.

Strongyloidiasis can present with a wide variety of symptoms and can lead to a potentially fatal hyperinfection. Although any factors that suppress the host defense mechanisms can potentially trigger hyperinfection, prolonged steroid use has been quite well described. A patient with disseminated small cell lung cancer suffered a Strongyloides stercoralis hyperinfection syndrome complicating ectopic adrenocorticotropic hormone (Cushing syndrome). Evaluation revealed lymphopenia, elevated levels of adrenocorticotropic hormone in the setting of elevated cortisol levels, a normal pituitary, and metastatic malignancy. S. stercoralis larval forms were seen in the stool and sputum. At autopsy, S. stercoralis larval forms were seen in the lung along with evidence of metastatic small cell lung carcinoma.

Fatal iatrogenic hyperphosphatemia.

Hypertonic sodium phosphate enemas are available for relief of constipation. They are widely used as colorectal laxatives because of their efficacy and because most patients tolerate the preparation well. Nevertheless, their use has been associated with decreases in intravascular volume as well as measurable changes in serum phosphorus and calcium levels. Usually these effects are transient and cause no ill effects. Severe toxicity may occur when the osmotically active hypertonic phosphate enema is retained or when it is administered to a patient with a decreased glomerular filtration rate. We report an elderly patient with previously normal renal function who developed severe hyperphosphatemia, hypocalcemia, and cardiac arrest after the administration of hypertonic sodium phosphate enemas for the treatment of an ileus. We review the patient characteristics that increase the risk of adverse effects from hypertonic sodium phosphate enemas and emphasize the danger that moderate dehydration poses when considering the use of these cathartics.

Dacryocystitis: an unusual form of Mucorales infection.

Mucormycosis is an acute fungal infection in humans that is often fulminant and potentially fatal. It occurs most frequently in immunocompromised individuals. We report a diabetic patient who presented in ketoacidosis with lacrimal sac infection from this organism. To the best of our knowledge, this is only the second patient with dacryocystitis caused by this fungus described in the medical literature. Our patient is unique in that she had no evidence of concurrent sinus involvement. Surgical debridement and antifungal therapy were combined to ensure a successful outcome.

Cyanosis following transesophageal echocardiogram.

Topical anesthesia is routinely employed to facilitate diagnostic and therapeutic procedures that involve the oropharynx. Although this practice is usually safe, there is always the potential that methemoglobinemia might be induced by the topical anesthetic agent. The clinician should consider this possible complication when the patient experiences signs or symptoms of oxygen desaturation in the absence of another explanation. Because methemoglobinemia can be life-threatening, early recognition and treatment are extremely important.

IgA nephropathy and small cell lung carcinoma.

The occurrence of glomerular disease as a paraneoplastic manifestation of malignancy is well documented in the medical literature. The strongest association is between membranous glomerulonephritis and solid tumors. We report a patient with IgA nephropathy associated with small cell lung cancer. To our knowledge, this is the second documented occurrence of an IgA nephropathy with a casual association with small cell bronchogenic cancer. This observation leads to the hypothesis that IgA nephropathy might be a paraneoplastic manifestation of this histiologic type of lung cancer.

Septic pulmonary emboli due to periodontal disease.

Septic pulmonary embolization (SPE) is a rare but serious disorder. It is a well-recognized potential problem in the settings of tricuspid valve endocarditis, septic thrombophlebitis, infected central venous catheters, and postanginal septicemia. Less well documented is the occurrence of SPE in patients with periodontal disease without suppurative thrombophlebitis of the great vessels of the neck. We report a patient with SPE in whom periodontal disease was the only identifiable nidus of infection and review the literature regarding the four other patients reported to have suffered this complication.

Pulmonary nocardiosis: an unusual cause of a solitary pulmonary nodule.

Nocardiosis is an infection caused by a soil-borne aerobic micro-organism. The pathogen is most commonly introduced in humans by inhalation into the respiratory tract. This infection may be transient and subclinical or may result in an acute or chronic bronchopulmonary process. Although an unusual cause of pulmonary infection in immunocompentent individuals, human nocardiosis is now documented more often in patients whose cell-mediated immunity is compromised by immunosuppression from comorbid disease or as a result of modern medical intervention. The diagnosis is often elusive unless a high index of suspicion is maintained. We present a patient with localized pulmonary nocardiosis who was immunosuppressed by virtue of a myeloproliferative disorder.

Streptococcus intermedius: an unusual cause of a primary empyema.

Despite the evolution of modern antibiotics, pleural space infection remains a common illness with significant morbidity and mortality. Every year up to 60 percent of the 1.2 million patients in the United States who present with community-acquired pneumonia develop parapneumonic pleural effusions. Few of these parapneumonic effusions progress to an empyema. Interestingly, in about 10 percent of the cases of empyema, no underlying pulmonary infection can be identified. These pleural space infections are called primary empyemas. We present a patient with a primary empyema caused by Streptococcus intermedius. Relatively few studies have investigated primary empyema caused Streptococcus intermedius. This case presentation serves as a reminder to the clinician about primary empyema caused by this micro-organism.

Post-traumatic thoracic arteriovenous fistulas.

Post-traumatic arteriovenous fistulas (AVF) between vascular structures in the thorax rarely occur. We present an unusual case of the delayed diagnosis of two post-traumatic thoracic AVF in a 70-year-old male. He had abnormal communications between an intercostal artery and an intercostal vein as well as an intercostal artery and a pulmonary vein. He has remained asymptomatic and has not developed a complication from these abnormal vascular structures in a three-year follow up.

Phrenic nerve involvement in Charcot-Marie-Tooth disease.

Diaphragmatic weakness in Charcot-Marie-Tooth (CMT) disease may be more common than generally acknowledged. Recognizing diaphragmatic weakness in a patient with CMT is important since recognition of this process may help explain the symptoms of breathlessness and orthopnea, as well as the development of hypercarbia. Although most patients with CMT have a normal lifespan, the subset of patients with diaphragmatic weakness may be at a higher risk of pulmonary morbidity and early mortality. Elevation of one or both hemidiaphragms on chest roentgenogram should raise the suspicion of diaphragmatic dysfunction and prompt further investigation.