Methotrexate-induced pleuropericarditis and eosinophilic pleural effusion.

A 41-year-old man developed widespread skin rash involving his knees, elbows, and gluteal region. He received methotrexate for approximately 1 month and later developed dyspnea and a left-sided eosinophilic pleural effusion. He was transiently placed on oral steroids. Subsequent skin biopsy showed psoriatric arthritis. Methotrexate was restarted and 8 weeks into the treatment, he developed dyspnea, a hemorrhagic pericardial effusion, and a right-sided eosinophilic pleural effusion. Methotrexate was discontinued, but patient developed dyspnea with a recurrent right eosinophilic pleural effusion, 2 weeks later. Pleural biopsies were obtained through medical pleuroscopy that revealed mild chronic inflammation with prominent eosinophils and no evidence for malignancy. Oral steroids were restarted with significant improvement in his symptoms.

Endobronchial ultrasound-guided needle aspiration of a bronchogenic cyst to liberate from mechanical ventilation: case report and literature review.

An 86-year-old man developed stridor and acute respiratory failure after being treated for a chronic obstructive pulmonary disease exacerbation and a urinary tract infection that required mechanical ventilation. A contrast computed tomography of the chest revealed a 4.2×5.7×7 cm homogeneous mass in the thoracic inlet, consistent with a bronchogenic cyst producing mass effect over the trachea. Patient was deemed a poor surgical candidate given significant comorbidities. We performed endobronchial ultrasound-guided transbronchial needle aspiration successfully to drain the bronchogenic cyst, allowing successful extubation within hours after the procedure.

Lymphangioleiomyomatosis screening in women with tuberous sclerosis.

BACKGROUND: Lymphangioleiomyomatosis (LAM) occurs in at least 40% of women with tuberous sclerosis complex (TSC), as diagnosed based on chest CT scan findings. Early identification may inform lifestyle choices and treatment decisions. Here we report LAM prevalence in a large TSC clinic and propose an approach to CT scan screening for LAM in women with TSC. METHODS: We retrospectively reviewed initial chest CT scans of all female patients with TSC aged ≥ 15 years seen at our center over a 12-year period. Each CT image slice was manually scored for the presence or absence of characteristic thin-walled cysts, and the diagnosis of LAM was made if the sum of the cysts on all slices exceeded three cysts. RESULTS: Of 133 female patients with TSC, 101 had chest CT scans available for review. Forty-eight (47.5%) met criteria for TSC-LAM on the initial CT scan. The risk of LAM was age dependent, rising by about 8% per year. The prevalence of LAM was 27% in subjects < 21 years of age and 81% in subjects > 40 years of age. Among asymptomatic subjects with LAM, 84% had cysts present in the single image at the level of the carina. Most subjects with LAM eventually developed pulmonary symptoms (63%), and 12.5% died from LAM. CONCLUSIONS: These results suggest that most women with TSC ultimately develop cystic changes consistent with LAM and that most cases can be identified from a single CT imaging slice at the level of the carina. TSC-LAM was associated with appreciable morbidity and mortality in this referral population. An age-based approach using limited CT scanning methods may facilitate screening and subsequent treatment decisions with decreased radiation exposure in this at-risk population.