Assessing the Safety and Clinical Impact of Thoracoscopic Lung Biopsy in Patients with Interstitial Lung Disease.

INTRODUCTION: The clinical relevance of surgical lung biopsy in Interstitial Lung Disease (ILD) is supported in the literature. Yet most reports reflect institutional or personal bias. AIM: To evaluate the validity of radiologic diagnosis and clinical impact of lung biopsy to help clarify which patient benefit most from biopsy. MATERIALS AND METHODS: We performed a retrospective analysis of a prospectively managed database. All patients who had a surgical lung biopsy for ILD within a period of four year (2009 to 2013) were included. Data included patient demographics, peri-operative variables and outcomes. Preoperative Computed Tomography (CT) imaging was reviewed by a thoracic radiologist blinded to the original report and pathologic information. RESULTS: A total of 47 patients were included. Lung tissue was obtained via a thoracoscopic approach in all but two that had mini-thoracotomy. Mean operating time was 51.1 minutes (18-123), median hospital stay was two days (1-18). Most (87.2%) of the patients were discharged within 72 hours. Thirty day mortality for elective surgery was 4.5% (2/44). Post-operative complications occurred in about one third of the patients. Complications in elective procedures included pneumothorax (10.4%), re-intubation (5.4%) and prolonged intubation (2.7%). Full concordance of radiographic diagnosis with the final diagnosis was significantly higher when reviewed by a cardiothoracic radiologist (60.5% vs. 21.3%). The preoperative clinical diagnosis was fully concordant with the final diagnosis in only 28.2% of cases. In 13.0% of patients the preoperative diagnosis was incorrect. Malignancy was the final diagnosis in two (4.3%) patients. In 51.1% of the patients, results of the biopsy did alter therapy. CONCLUSION: Diagnosis of specific ILD by a cardiothoracic radiologist is more specific and accurate and will probably lead to more appropriate therapy. Elective thoracoscopic surgical lung biopsy is a safe procedure, leads to a more accurate diagnosis of ILD and impacts therapy.

Pulmonary Artery Dimensions as a Prognosticator of Transplant-Free Survival in Scleroderma Interstitial Lung Disease.

BACKGROUND: Systemic sclerosis is a chronic debilitating autoimmune disease characterized by endothelial dysfunction and multi-organ fibrosis. Interstitial lung disease, a common manifestation of SSc, is termed scleroderma-related interstitial lung disease (SSc-ILD) and along with pulmonary hypertension contributes to a majority of deaths in SSc. SSc-ILD patients frequently develop pulmonary hypertension, which prognosticates a poorer outcome. We investigated pulmonary artery dimensions as an outcome predictor in patients with SSc-ILD. METHODS: A retrospective chart review abstracting data from SSc-ILD patients evaluated at a large tertiary care center was performed. HRCT imaging was reviewed and pulmonary artery (PA) and ascending aorta (Ao) diameters were measured for calculation of the PA:Ao ratio. Additionally, demographics, vital signs, spirometric parameters, comorbidities, and mean pulmonary artery pressures were collected when available. Outcome analysis with lung transplant or death events within 4 years based on pulmonary artery size as well as PA:Ao ratio was performed. RESULTS: 70 SSc-ILD patients were identified. Mean pulmonary artery diameter and PA:Ao ratio was 31.17 and 1.07 mm, respectively. Patients with a pulmonary artery diameter ≥32 mm had higher risk of lung transplantation or death (p < 0.001) within 4 years. Patients with a PA:Ao ratio ≥1.1 also had higher risk of lung transplantation or death (p < 0.001) within 4 years. Unadjusted outcomes analyses also identified PA:Ao ratio ≥1.1 as an independent outcome predictor (hazard ratio 3.30, p < 0.001). CONCLUSIONS/CLINICAL IMPLICATIONS: In SSc-ILD patients, a PA:Ao ratio ≥1.1 is associated with higher risk of lung transplant or death. These data suggest that PA:Ao dimension may be used for prognostication in SSc-ILD.

Pulmonary Artery Invasion Caused by Mycobacterium tuberculosis.

Extrapulmonary tuberculosis refers to Mycobacterium tuberculosis involving organs other than the lungs (eg, pleura, lymph nodes, genitourinary tract, abdomen, skin, joints and bones, or meninges). In non-HIV-endemic areas, where reactivation is the predominant mechanism of tuberculosis, pleural involvement occurs in 4% of cases. We present an extremely rare case of a 62-year-old immunocompetent patient with pleural tuberculosis confirmed by surgical pleural biopsies, who presented with a large mediastinal mass and evidence of pulmonary artery invasion on CT scanning and endobronchial ultrasonography imaging, highlighting a unique and malignant-like character of the disease.

Biphasic Malignant Pleural Mesothelioma Masquerading as a Primary Skeletal Tumor.

Biphasic malignant pleural mesothelioma is a rare malignant tumor, usually presenting as a pleural-based mass in a patient with history of chronic asbestos exposure. We herein report a case of a 41-year-old man who presented with chest pain and had a chest computed tomography (CT) scan suggestive of a primary skeletal tumor originating from the ribs (chondrosarcoma or osteosarcoma), with no history of asbestos exposure. CT-guided core needle biopsies were diagnosed as malignant sarcomatoid mesothelioma. Surgical resection and chest wall reconstruction were performed, confirming the diagnosis and revealing a secondary histologic component (epithelioid), supporting the diagnosis of biphasic malignant mesothelioma.

Pneumocystis Pneumonia Presenting as an Enlarging Solitary Pulmonary Nodule.

Pneumocystis pneumonia is a life threatening infection that usually presents with diffuse bilateral ground-glass infiltrates in immunocompromised patients. We report a case of a single nodular granulomatous Pneumocystis pneumonia in a male with diffuse large B-cell lymphoma after R-CHOP therapy. He presented with symptoms of productive cough, dyspnea, and right-sided pleuritic chest pain that failed to resolve despite treatment with multiple antibiotics. Chest X-ray revealed right lower lobe atelectasis and CT of chest showed development of 2 cm nodular opacity with ground-glass opacities. Patient underwent bronchoscopy and biopsy that revealed granulomatous inflammation in a background of organizing pneumonia pattern with negative cultures. Respiratory symptoms resolved but the solitary nodular opacity increased in size prompting a surgical wedge resection which revealed granulomatous Pneumocystis pneumonia infection. This case is the third documented report of Pneumocystis pneumonia infection within a solitary pulmonary nodule in an individual with hematologic neoplasm. Although Pneumocystis pneumonia most commonly occurs in patients with HIV/acquired immunodeficiency syndrome and with diffuse infiltrates, the diagnosis should not be overlooked when only a solitary nodule is present.

A Rare Case of Streptococcus alactolyticus Infective Endocarditis Complicated by Septic Emboli and Mycotic Left Middle Cerebral Artery Aneurysm.

To date, S. alactolyticus endocarditis complicated by middle cerebral artery aneurysm has not been reported. We describe the case of a 65-year-old female with a history of hypertrophic cardiomyopathy with left ventricular outflow tract obstruction presenting with confusion and a apical holosystolic murmur. Angiography of the brain identified new bilobed left middle cerebral artery aneurysm. Serial blood cultures grew S. alactolyticus, and aortic and mitral valve vegetation were discovered on transesophageal echocardiography. The patient was treated with antimicrobial therapy, mitral and aortic valve replacements, and microsurgical clipping of cerebral aneurysm. This case serves to highlight the pathogenicity of a sparsely described bacterium belonging to the heterogenous S. bovis complex.